LAUSR

Since the beginning of this decade, all countries have faced serious health emergencies, whether due to wars, earthquakes, cyclones, floods, industrial explosions, fires or the global coronavirus disease 2019 (COVID-19) pandemic. These events tragically continue to kill many people; however, the number of people experiencing injury or impairment that require acute and ongoing rehabilitation is far higher – and increasing. Between 2010 and 2019, available data show the number of people injured in disasters (6.7 million) was four times more than those killed (1.5 million).1 We do not have a true picture of rehabilitation needs in emergencies due to a lack of research and little or no monitoring of health outcomes in emergencies other than mortality. However, health emergencies create significant surges in pressing and often unmet rehabilitation needs. Improved emergency, surgical and critical care are also now saving more lives, and with more survivors, rehabilitation needs may further increase. Early rehabilitation in emergencies is therefore essential: it can maximize the impact of medical and surgical interventions; speed up recovery; optimize functioning; and enhance quality of life of survivors.2 Additional health service benefits include reduced length of stay in hospital, decreased readmissions, and the prevention of costly and potentially fatal complications.3 When rehabilitation needs are not quickly addressed, individuals, their families and communities face farreaching consequences. For example, a lack of early rehabilitation for a patient with burns after a tanker explosion may result in preventable contractures and a subsequent loss of function and income. A child who loses a limb during a conflict and does not have access to early rehabilitation may develop complications or not receive a prosthesis, and therefore find their participation in education restricted. A patient hospitalized with COVID-19 leaves hospital still dependent on their family for care due to a low prioritization of rehabilitation. In each of these examples, people directly affected by emergencies suffer unnecessarily and have a suboptimal recovery. Moreover, their families and communities are affected as well. The origins of modern rehabilitation are in emergencies; it developed as a treatment strategy in part due to a surge in needs as a result of war and polio epidemics in the early 20th century. More recently, key humanitarian operational2 and clinical guidelines4,5 have included rehabilitation as an essential component of care. Such guidelines include the World Health Organization (WHO) Emergency Medical Teams: minimum technical standards and recommendations for rehabilitation.6 Despite its origins, and although many response guidelines exist, rehabilitation is rarely prioritized early in emergencies and a misconception exists that rehabilitation comes later in the continuum of care. Too often, responders cite the humanitarian imperative, with the priority being to save lives. However, this conception is a false dichotomy: the humanitarian imperative includes the prevention or alleviation of human suffering, in which rehabilitation plays a critical role. Response challenges are not just attitudinal; existing rehabilitation services are often under-resourced, poorly integrated into health systems and quickly overwhelmed in emergencies. Such underlying weaknesses and barriers underscore the importance of preparedness to best utilize scarce rehabilitation resources. Research on health system preparedness is lacking, specifically on the status and impact of rehabilitation preparedness. Notwithstanding, rehabilitation appears to be almost universally absent from health emergency preparedness. Data from WHO’s work to strengthen rehabilitation in health systems showed that only one of 19 lowand middle-income countries involved had integrated rehabilitation into health emergency preparedness. The example of Nepal is a key outlier, where specific rehabilitation preparedness, including training of staff, development of protocols and stockpiling of equipment, improved the ability of service providers to respond.7 Evidence from responses in high-income settings indicate that the situation is not much different there – a lack of rehabilitation preparedness has repeatedly been a key barrier to an early effective response – with the example of Japan being one positive exception.8 An overall approach to rehabilitation in health systems strengthening will improve access to rehabilitation in emergencies, but specific steps must be taken to better prepare rehabilitation services. Preparedness must also be allhazard, that is, with plans to maintain essential services as well as specific considerations for hazards that may cause a surge in rehabilitation needs, including but not limited to natural hazards such as earthquakes, cyclones, floods and disease outbreaks; societal hazards, such as conflict and terrorism; and technological hazards such as major explosions, fires and chemical or radiological events. The COVID-19 pandemic has provided a stark example of the need for rehabilitation in outbreak preparedness. Rehabilitation services were needed for acute hospitalized patients, patients with post-intensive care syndrome and those with post COVID-19 condition.9 However, a WHO survey of 105 countries between March and June 2020 showed that rehabilitation was among the most disrupted services in the early months of the pandemic.10 Polio, measles, severe acute respiraEmergency preparedness and readiness; anticipating the need for rehabilitation Pete Skelton,a Flavio Saliob & Nedret Emiroglub