Increasing attention is being focused on the needs of vulnerable populations during humanitarian emergency response. Vulnerable populations are those groups with increased susceptibility to poor health outcomes rendering them disproportionately affected by the event. This discussion focuses on women's health needs during the disaster relief effort after the 2010 earthquake in Haiti.

The Emergency Department (ED) of the temporary mobile encampment in L'Hôpital de l'Université d'Etat d'Haïti (HUEH) was the site of the team's disaster relief mission. In February 2010, most of the hospital was staffed by foreign physicians and nurses, with a high turnover rate. Although integration with local Haitian staff was encouraged, implementation of this practice was variable. Common presentations in the ED included infectious diseases, traumatic injuries, chronic disease exacerbations, and follow-up care of post-earthquake injuries and infections. Women-specific complaints included vaginal infections, breast pain or masses, and pregnancy-related concerns or complications. Women were also targets of gender-based violence.

Recent disasters in Haiti, Pakistan, and elsewhere have challenged the international health community to provide gender-balanced health care in suboptimal environments. Much room for improvement remains. Although the assessment team was gender-balanced, improved incorporation of Haitian personnel may have enhanced patient trust, and improved cultural sensitivity and communication. Camp geography should foster both patient privacy and security during sensitive examinations. This could have been improved upon by geographically separating men's and women's treatment areas and using a barrier screen to generate a more private examination environment. Women's health supplies must include an appropriate exam table, emergency obstetrical and midwifery supplies, urine dipsticks, and sanitary and reproductive health supplies. A referral system must be established for patients requiring a higher level of care. Lastly, improved inter-organization communication and promotion of resource pooling may improve treatment access and quality for select gender-based interventions.

Simple, inexpensive modifications to disaster relief health care settings can dramatically reduce barriers to care for vulnerable populations.

BloemCM, MillerAC. Disasters and Women's Health: Reflections from the 2010 Earthquake in Haiti. Prehosp Disaster Med.2013;28(2):1-5.

The problems of pre-hospital care and training in the developing world are very similar – resource limitations and training deficiencies. Humanitarian conditions in the Sudan have been among the worst in the world including both man-made and natural disasters. Effectively responding to emergencies is of paramount importance.

The information was collected by a group of Sudanese physicians working in the emergency department at a large urban public hospital in Khartoum, Sudan and in the U.S. for the purpose of establishing structured training programs for pre-hospital responders.

There are currently 37 registered state operated mini-van ambulances serving ∼8 million people in the capital city of Khartoum. There is 1 central dispatching command center operated by the state Ministry of Health (MOH) that serves 29 hospitals. Services are available by calling a central “999” emergency response number. There are no private ambulances in Khartoum; however, most patients are transported by private or public transportation. Ambulance transport teams consist of ∼2 ambulance emergency assistants with limited medical training. Ambulance transport costs are covered either by insurance for the insured; however, the majority of patients are self paid. Emergencies are also managed by the Department of Civil Defense, which is a branch of the Sudanese MOH that responds to natural and man-made disasters. There are 2 layers of this team; 420 physician with masters degrees in DM and emergency rescue workers. These emergency rescue workers do not have formalized training. Other important findings are: lack of training centers for first emergency responders, no standardized practice guide lines among pre-hospital care personnel.

Emergency response in the Sudan is a relatively new practice but has shown a promising trend for the continued development of a highly advanced and functional pre-hospital/emergency response system. More structured training through collaborative efforts and substantial resources are needed.

To determine if instituting an Emergency Department (ED) fast-track area would increase efficiency in patient flow, improve utilization of limited resources, and identify critical versus non-critical patients during disaster relief in Port au Prince, Haiti.

A survey was conducted at L'Hôpital de l'Université d'Etat d'Haïti (HUEH) in Port au Prince, Haiti by Emergency physicians and nurses from SUNY Downstate Medical Center on a disaster relief mission following the 2010 earthquake. The following variables were obtained to assess ED effectiveness: number of patients, acuity level, chief complaints, critical interventions, waiting times, length of stay, specialty service coverage and physical plant space. Additionally, existing practitioners were surveyed regarding existing ED practices. ED operation flow maps were created.

The assessment revealed a large volume of low-acuity patients mixed with high-acuity patients without identification of acuity level, time of arrival, or designated area for treatment. Although literature reports routine use of START triage, this was not being implemented in this setting. Results of implementing a fast track area included: (1) Improved identification of patients needing immediate treatment. (2) Increased flow of low acuity patients in designated fast track areas. (3) Improved triage protocols maximized appropriate use of resources, and expedited subspecialty consultation.

By instituting well-accepted, validated patient flow systems and reinforcing communication regarding resources available and the use of geographic space, better management of incoming emergency patients was achieved.

There has been increased international awareness and a need to provide accessible and essential emergency preparedness training in developing countries that has resulted in the recognition of new teaching needs and number of new initiatives to meet these needs.

These teaching methods have been applied in Haiti before and after the 2010 earthquake. They include: - Established a “Train the trainer” model - Established civilian first responder training - Basic Life Support (BLS) and First Aid - Implemented medical training using the Meti Simulator models - Conducted post-training Disaster drill - Conduction of post training assessment - Succession model of training.

A total of 54 people completed a BLS course and 67 completed a First Aid course. 12 participants completed the First Aid and BLS Instructors course. 95 program participants completed an end of course survey. 41 participants had no prior BLS/First Aid training or exposure. The course participants included 2 physicians, 22 students, 8 nursing students, 7 nurses, 20 teachers, 12 health workers, 5 drivers, and 14 laborers. 92 of those surveyed stated they would recommend this course to a friend. 88 participants stated that hands on learning helped them better learn the course material.

This training model has been well received in rural Haiti and can be applied in other developing countries. We would like to standardize training protocols that will serve as a foundation for self-sustaining higher-level emergency, pre-hospital, disaster training and management. This will improve the general quality of health care delivery. Our next pilot of this program will be in other parts of Haiti and in Khartoum, Sudan.

Upon arrival of the SUNY Downstate Medical Center team for their disaster relief mission in Port au Prince, Haiti, it was observed that obstacles to patient care were directly related to difficulty in locating supplies and medications in a timely manner. In addition, staffing schedules had not been correlated to patient flow patterns.

A survey was conducted at L'Hôpital de l'Université d'Etat d'Haïti (HUEH) in Port au Prince, Haiti by Emergency physicians and nurses from SUNY Downstate Medical Center. The following variables were obtained to assess existing resources: number and types of providers available, provider staffing schedules, medication/supply inventories and management systems. Basic ED operation and supply system flow maps were created.

The assessment revealed a large volume of patients presenting in the early morning. Night shifts were inconsistently staffed with ED physicians. Although medications and supplies were reported to be available on-site, they were not tracked, inventoried, or centrally managed. As a result, this increased time to treatment and practitioner fatigue. Process improvements included: (1) Institution of swing and night shifts accommodated peak patient volumes, decreased waiting times, provided care for critical patients during off-peak hours, and decreased physician fatigue. (2) Identification and labeling of existing medications/supplies facilitated more accurate management of inventories and decreased time to treatment and disposition.

Process improvement through systematic analysis led to better disaster resource utilization in this tent hospital.

Recent reports have highlighted the health disparities that women and other vulnerable populations experience following disasters. Humanitarian groups have struggled to implement effective measures to mitigate such disparities during subsequent disasters.

To analyze and provide practical solutions to mitigate barrier's to women's health encountered in Haiti following the 7.0 magnitude earthquake in January 2010.

In February 2010, a New York based team of emergency and international medicine specialists staffed the mobile emergency department in Port au Prince at L'Hôpital de l'Université d'Etat d'Haïti.

Common presentations included infectious diseases, traumatic injuries, chronic disease exacerbations, and follow-up for earthquake-associated conditions. Female gender-specific problems included vaginal infections, breast pain or masses, pregnancy-related concerns, and the effects of gender-based violence. Identified barriers to effective gender-specific care included communication, camp geography, supply availability, and poor inter-organization communication.

Recent disasters in Haiti, Pakistan, and elsewhere have challenged the international health community to provide gender-balanced healthcare in sub-optimal environments. Much room for improvement remains. Although our assessment team was gender-balanced, improved incorporation of Haitian personnel may have enhanced patient trust, and improved cultural sensitivity and communication. Camp geography should foster both patient privacy and security during sensitive examinations. This could have been improved upon by geographically separating men's and women's treatment areas and using a barrier screen to generate a more private examination environment. Women's health supplies must include an appropriate exam table, emergency obstetrical and midwifery supplies, urine dipsticks, and sanitary and reproductive health supplies. A referral system must be established for patients requiring a higher level-of-care. Lastly, improved inter-organization communication and promotion of resource pooling may improve treatment access and quality for select gender-based interventions.

Simple inexpensive modifications to organized post-disaster medical relief settings may dramatically reduce gender-based healthcare disparities.