Impact of natural disasters on health disparities in low- to middle-income countries

Abstract

Natural disasters, characterized by their ferocity and unpredictability, can cause a lot of damage to people's lives. These effects can last for many years and affect entire communities. After these huge events, the healthcare system faces numerous challenges. Smart planning and timely, clear actions are important to reduce and eventually overcome the bad effects of the events. It's particularly important to acknowledge the status of the healthcare system in low-and middle-income countries (LMICs). These countries have a tough time because their economies are often limited, with limited finances and resources. Hence, natural disasters can damage their healthcare system more. This review looks closely at how various natural disasters have caused big problems for LMICs and their healthcare systems. We carefully look at what happens after these disasters and how they worsen existing problems in these economies. The review also highlights how communities work hard to improve after these events. By showing how natural disasters affect healthcare systems in LMICs, this paper tries to make more people aware of these issues. It encourages everyone to work together to strengthen these important systems against nature's strong forces.

Full text

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Discover Health Systems
Review
Impact ofnatural disasters onhealth disparities inlow‑
tomiddle‑income countries
AbdulqadirJ.Nashwan1,2· SyedHassanAhmed3 · TahaGulShaikh3 · SummaiyyaWaseem3
Received: 4 July 2023 / Accepted: 24 August 2023
© The Author(s) 2023 OPEN
Abstract
Natural disasters, characterized by their ferocity and unpredictability, can cause a lot of damage to people’s lives. These
eects can last for many years and aect entire communities. After these huge events, the healthcare system faces
numerous challenges. Smart planning and timely, clear actions are important to reduce and eventually overcome the
bad eects of the events. It’s particularly important to acknowledge the status of the healthcare system in low- and
middle-income countries (LMICs). These countries have a tough time because their economies are often limited, with
limited nances and resources. Hence, natural disasters can damage their healthcare system more. This review looks
closely at how various natural disasters have caused big problems for LMICs and their healthcare systems. We carefully
look at what happens after these disasters and how they worsen existing problems in these economies. The review also
highlights how communities work hard to improve after these events. By showing how natural disasters aect healthcare
systems in LMICs, this paper tries to make more people aware of these issues. It encourages everyone to work together
to strengthen these important systems against nature’s strong forces.
Keywords Natural Disasters· Heath Disparities· LMICs· Climate Change
1 Introduction
Since the start of the Industrial Revolution, people’s actions driven by money goals have led to a big 47 percent increase in
the amount of carbon dioxide (CO2) in the air [1, 2]. Surprisingly, today’s CO2 levels are at a concerning 412 parts per mil-
lion (ppm), much higher than the 280ppm back in the late 1700s [1, 2]. The repercussions of such nancially-motivated
exertions have cast a dark shadow, with extreme weather events between 2000 and 2019 besieging over 475,000 souls
and engendering economic losses amounting to a jaw-dropping 2.56 trillion USD in purchasing power parity [3, 4].
The Global Climate Risk Index 2021 paints a harrowing picture. It shows that among the ten countries most severely
aected by climate change from 2000 to 2019, a big majority–specically seven–were low- to middle-income countries
(LMICs). These countries include Myanmar, Haiti, the Philippines, Mozambique, Bangladesh, Pakistan, and Nepal. The other
three–Thailand, the Bahamas, and Puerto Rico–are not in the LMIC group [3, 4]. This data illuminates the disproportionate
brunt borne by LMICs in the face of natural calamities.
Abdulqadir J. Nashwan, Syed Hassan Ahmed contributed equally to this work and are co-rst authors.
* Abdulqadir J. Nashwan, anashwan@hamad.qa; Syed Hassan Ahmed, syedhassanahmed99@gmail.com; Taha Gul Shaikh, tahagul946@
gmail.com; Summaiyya Waseem, summaiyyawaseem@gmail.com | 1Department ofNursing, Hamad Medical Corporation, P.O. Box3050,
Doha, Qatar. 2Department ofPublic Health, College ofHealth Sciences, QU Health, Qatar University, Doha, Qatar. 3Dow University ofHealth
Sciences, Karachi, Pakistan.

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A natural disaster, which is a catastrophic event caused by natural processes of the Earth, compounds the challenges
in LMICs. These events include earthquakes, hurricanes, oods, and wildres. They often result in widespread destruction
and can have long-lasting impacts on communities.
In addition to these problems in LMICs, there are also existing challenges and economies that are barely managing to
avoid nancial trouble. Plus, the not-so-great living conditions in these countries make their people easily aected by
many health problems. When natural disasters hit these places, it makes things even worse, increasing the chances of dis-
eases spreading and making the problems that come with them even harder on these societies. LMICs, which are already
dealing with a lot of diculties, end up struggling even more when natural disasters happen. This shows how important
it is for focused help and support to make these countries stronger and more able to handle these unavoidable forces.
2 Impact ondisease burden
Natural disasters in low- to middle-income countries often magnify existing health disparities. These events can lead to
an unequal distribution of disease burden, disproportionately aecting vulnerable populations. Lack of access to medical
care, clean water, and sanitation exacerbates the spread of diseases, placing marginalized communities at a higher risk.
Natural disasters frequently unleash devastation, characterized by the loss of infrastructure, mass movement of popu-
lations, and the drop in hygiene standards. These events expose the aected populace to a labyrinthine matrix of public
health quandaries [5, 6]. A slow respoense exacerbates the situation, setting the stage for massive outbreaks and a grim
toll on human life. A trainof disease transmission pathways and their associated risk factors can give rise to complex
shifts in health patterns [7].
Waterborne diseases (WBD) stand as towering adversaries in the aftermath of disaster-aicted outbreaks [8]. The
amalgamation of compromised water supplies, contamination of water sources, the disintegration of sewage systems,
overcrowding, and declining hygiene conditions creates a fertile breeding ground for WBD. This includes diseases such
as acute diarrhea, cholera, typhoid, and hepatitis A and E. A testament to this is the data emerging from a refugee
camp, which witnessed a 42% surge in diarrheal diseases post the 2005 earthquake in Pakistan [9]. In a parallel vein, a
staggering 85% of survivors ensconced in Calang grappled with diarrhea in the wake of the 2004 tsunami in Indonesia
[10]. Over 1200 cases of hepatitis A and E were reported following the 2005 earthquakes in Pakistan, with comparable
surges witnessed in India and Sudan [10, 11]. Norovirus was entrenched as the second most frequent diarrheal pathogen
after cholera from 1988 to 2004, in the aftermath of ooding in Bangladesh. Escherichia coli (E. coli) and cholera were
the culprits behind nearly 17,000 cases of diarrhea during the deluge of 2004 [11, 12]. Likewise, a spate of leptospirosis
outbreaks has been chronicled in the wake of oods and typhoons across diverse geographical landscapes, including
India, Thailand, Tanzania, and Taiwan [10, 13].
On February 6, 2023, a devastating earthquake of magnitude 7.8 hit Turkey in close proximity to the Syrian border
[14]. The tremor, which occurred at 4:17 a.m. local time, had its epicenter near the town of Pazarcık, situated in Turkey’s
Kahramanmaraş province. It was felt across a wide region, impacting not only Turkey but also neighboring countries
including Syria, Iraq, and Iran. This catastrophic event was accompanied by multiple aftershocks, one being as strong
as magnitude 7.5. There was extensive damage to buildings, infrastructure, and triggered consequential hazards such
as landslides and ooding. The human toll was staggering, with the death toll in Turkey reaching 50,783, and in Syria,
it amounted to 8476 fatalities. Furthermore, millions were rendered homeless [14]. This calamity marked the deadliest
natural disaster to strike Turkey in more than eight decades, leading to an extensive humanitarian crisis. Relief and reha-
bilitation eorts have been ongoing to address the immediate needs and to rebuild the aected communities.
A sudden increase in exposure to mosquitoes, stagnant water bodies, and overcrowded habitats fuels susceptibil-
ity to vector-borne diseases, with malaria and dengue fever became the prime disease causing agents [10, 15]. Brazil,
reeling from oods in 2008, reported 57,010 dengue fever cases. Northern Peru’s oods in 2017 were the precursor to
outbreaks of dengue fever and chikungunya, with dengue fever suspected in 19,000 cases. Pakistan’s oods in 2010 were
followed by almost 21,000 dengue fever cases [11]. Iran’s deluge between March and April 2019, which inundated 140
rivers, resulted in catastrophic damage. Reports by the International Federation of Red Cross and Red Crescent Societies
highlight that this event aected 3800 cities and towns [16]. A conuence of overcrowding, impaired sewage disposal,
agging hygiene, malnutrition, rudimentary sanitation, and human interactions among refugees fosters the transmission
of infectious maladies, with the potential to ignite epidemics [17].

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Furthermore, an insidious rise in dermatological aictions, such as scabies and skin infections, has been reported in
the wake of natural disasters. After the 2010 oods in Pakistan, 2377 scabies cases were reported in four aected regions
of Baluchistan. Lin etal. underscore that individuals with limbs submerged in oodwaters faced a 6.2-fold greater risk of
developing lower limb cellulitis. Additionally, skin infections, urticaria, and eczema have been reported in the aftermath
of oods and hurricanes. Ocular aictions, such as conjunctivitis and trachoma, can also manifest due to the scarcity of
safe washing water, spawning sight-threatening morbidities [12].
Populations in LMICs, already skating on thin ice due to heightened risk factors and a heavy burden of communicable
diseases, as depicted in Fig.1 [18], nd themselves in the crosshairs of natural catastrophes which could exacerbate the
chasm that separates LMICs from high-income nations.
3 Impact onhealthcare infrastructure
LMICs nd themselves in a vulnerable position with healthcare budgets that are woefully inadequate, shackled by the
constraints of their fragile economies. This culminates in a lamentable dearth of prompt provision of treatments and
accessibility to medications. The already dire circumstances are further exacerbated by meager wages, overwhelmed
healthcare facilities, and a scarcity of indispensable resources, all of which severely undermine the motivation and
adherence to disease management protocols by healthcare workers (HCWs). The World Health Organization (WHO)
paints a grim picture, highlighting a staggering decit of 4.3 million HCWs on a global scale, with LMICs in South Asia
and Africa shouldering the brunt of this crisis [19]. Natural disasters serve to exacerbate this shortage, as corroborated
Fig. 1 Risk Factors and
Disease Burden Disparity
between LMICs and High-
Income Countries

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by existing data revealing that in the wake of a ood, over 50% of hospital sta nd themselves incapacitated in fulll-
ing their duties [20].
Earthquakes, bearing the distinction of being the most devastating form of natural disasters, alongside other calami-
ties, can wreak havoc on hospital infrastructures and healthcare materials. In the aftermath of an earthquake in Nepal,
an astonishing 90% of medical facilities in the impacted regions were reduced to rubble. This catastrophic event was
coupled with a ve-fold spike in hospital admissions, exerting an unbearable strain on hospitals, patient care, manage-
ment systems, and, ultimately, the healthcare infrastructure at large [21]. In a parallel vein, the catastrophic ooding in
Malaysia unleashed an estimated 1100 million Malaysian Ringgit worth of logistical and medication losses. Six of the
most eminent hospitals bore the brunt of this disaster, with one witnessing an 80% collapse in its operational capacity,
culminating in the dislocation of over 200 patients [20].
Furthermore, it is imperative to recognize that in LMICs, agriculture often emerges as the bedrock of economic sta-
bility, with minimal bolstering from the fruits of the industrial revolution. The specter of ooding and other disasters
looms large, possessing the capacity to inict colossal damage to crops. This, in turn, can cast a pall over the countries’
economies, fanning the ames of the already Herculean challenges faced by healthcare facilities.
4 Impact onmaternal health
The global landscape has witnessed cosniderable problemes related to maternal health and infant mortality rates. Nev-
ertheless, such progress remains an elusive mirage for LMICs, where maternal mortality rates are always at alarming
levels. Despite persistent endeavors to rene healthcare, the maternal mortality ratio in LMICs stands at 253 per 100,000
live births. Nigeria, in particular, bears the most burden of the highest rate, with a staggering 917 maternal deaths per
100,000 live births [22, 23].
Pregnancy is a delicate time during a woman’s life, lled with vulnerabilities. The scarcity of resources can precipitate
a cascade of complications, especially when the unforgiving natural disasters happen. Scholarly literature illuminates
the dire repercussions, including premature births, miscarriages, low birth weights, and severe mental health aictions
among women negotiating the crucible of childbirth during natural calamities [24–26].
The ooding that engulfed Pakistan serves as a testament to the fragility of maternal health during disasters. The del-
uge led to the shutdown of healthcare access for 650,000 expectant mothers, a harrowing period during which at least
73,000 deliveries were of an emergent nature [27, 28]. A study from Africa corroborated this vulnerability, documenting
a 0.5% dip in female fertility in the aftermath of a natural disaster. This was attributed to the deleterious impact on the
mental and physical health of mothers [29]. In an incisive study, Baten and colleagues demonstrated that in ood-ravaged
regions of Bangladesh, accessibility to antenatal and postnatal care was severely aected compared to unaected regions
(OR = 0.76) [30]. Almeida etal. shine a light on the somber reality that, in the wake of the 2015 earthquake in Nepal, hos-
pital admissions for pregnancy-related concerns lingered around 13.8% to 11.5%. The contraction in these critical health
services was attributed to the formidable barriers to healthcare facilities and birthing centers [31].
5 Impacts onmental health
The psychological toll of natural disasters introduces another layer of health disparities. Vulnerable populations, including
those with pre-existing mental health conditions and limited access to mental health services, are disproportionately
aected. This sad situation is even worse in less wealthy countries, where women, due to their roles and societal fac-
tors, are especially aected. A review encompassing 58 studies in Asia, Latin America, and the Caribbean, found that
more people had mental health problems after climate-related disasters. Climate-related disasters. PTSD, depression,
and anxiety emerged as the triad of the most pervasive mental health outcomes, reported in (45), [30], and [25] studies,
respectively [32].
The precarious plight of LMICs is thrown into sharp relief in a study emanating from Nepal in the wake of the devastat-
ing 2015 earthquake. A staggering 34% of individuals battled the specter of depression and anxiety. Additionally, 11%
thought about ending their lives, and 20% had problems with drinking too much alcohol. These numbers were much
higher than what the World Health Organization usually estimates. It’s worrying how Nepal’s mental health situation is
similar to places dealing with long periods of civil unrest, as shown in a study from 2007–2008.

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6 Food shortage andinsecurity
The specter of food insecurity casts a long shadow over approximately 12% of the global population, an alarming gure
that translates to a staggering 924 million souls, as reported by the WHO. A worrisome trend of an ever-widening gender
gap reveals that 31.9% of women are in the throes of moderate to severe food insecurity, compared to 27.6% of men [33,
34]. This is further fueled by the escalating intensity and frequency of natural calamities, such as droughts, oods, and
storms, which wreak havoc on the agricultural lifelines of LMICs, and in turn, fan the ames of food insecurity [35]. This
creates barriers and undermines the tireless eorts to end hunger and poverty and charts a tumultuous path towards
sustainable development. Food shortages arise not only from the ravages of natural disasters depleting food reserves
and systems, but also from the loss of assets and livelihoods.
There is a conenction between food shortages and chronic diseases. The labyrinth begins with the formidable bar-
rier of food unaordability, which paves the way for malnutrition. This, in turn, spawns a higher risk of chronic ailments,
and the nancial resources consumed in their wake bleed household budgets dry. Natural disasters serve as a veritable
powder keg in this volatile mix, augmenting stress, exacerbating malnutrition, and depleting nancial reserves, thereby
perpetuating this infernal cycle.
In Pakistan, chronic hunger has caught over 3.4million children in its chilling grip. Post-ood estimates paint a dire
picture where 76,000 children are facing severe food shortages and teeter on the brink of acute malnutrition [36]. The
deluge has caused damage to agricultural tracts and livestock, resulting in a food shortfall. Consequently, the price of food
commodities has skyrocketed, pushing them out of reach for ood-ravaged families. The population bereft of adequate
access to food ballooned from 5.96 million pre-ood to a grim 8.62 million in the aftermath [37–40]. As winter is close,
the looming threat to hundreds of thousands of lives intensies unless urgent interventions are mobilized.
Adding to this disparity, a qualitative study by Pradhan etal. sheds light on a surge in illness, domestic violence, and
sexual abuse against women in the throes of natural disasters [41]. Flood-ravaged roads and immobilized transport
systems stymied outreach endeavors in disaster-stricken areas. The tenuous nancial fabric, coupled with a disrupted
supply chain for essential medications and supplies, compounded the crisis. Furthermore, the dearth of female medical
professionals in disaster response training exacerbated the losses.
Given this harrowing landscape, a multi-pronged approach is vital to fortify agricultural resilience, ensure equitable
food distribution, and proper healthcare infrastructure and training, particularly in LMICs. Proactive engagement in dis-
aster preparedness and response, coupled with social safety nets and support for the most vulnerable, is indispensable
in navigating the stormy waters of food insecurity and its associated problems.
7 Conclusions & future directions
In essence, natural disasters cause double blow to the already fragile healthcare systems of LMICs, both in the throes
and the aftermath of these calamities. The repercussions are a complex woven strands of escalating diseases, illnesses,
chronic aictions, surging mortality and morbidity rates, and infrastructures reduced to rubble. The proverb "an ounce
of prevention is worth a pound of cure" rings particularly true in this context, underscoring the imperativeness of proac-
tive measures. For LMICs, it is crucial to gauge the magnitude, the probable timespan, and the geographical epicenters
most vulnerable to the impending problem.
Embarking on the jpurney of the target areas is pivotal; this entails assessing infrastructure, population density, pre-
vailing disease patterns, and resource availability to spotlight the potential hurdles that lie in wait. This reconnaissance
sets the stage for charting a cogent action blueprint tailored to address these challenges. Seamless coordination is of
the essence—this blueprint should be disseminated across all the pertinent departments and ministries, and rescue
personnel should be equipped with the requisite training to spring into action at a moment’s notice.
Additionally, local governing bodies should take the lead in providing relief and asking for help from neighboring
unaected territories. Safer grounds, with the residents armed with their prized possessions, should be contructed in
advance of the looming disaster. Moreover, safeguarding an uninterrupted ow of healthcare, food, and the bare neces-
sities is paramount to stave o the shortages and the nancial albatross of post-disaster transportation costs. Likewise,
deploying skilled rescue brigades from surrounding areas can bolster the capacity for a swift and ecient response to
the unfolding crisis.

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In the long-term, governments must champion the cause of fortifying infrastructures with resilience woven into their
very fabric, especially in regions that are perennially in the crosshairs of natural disasters. Tackling the behemoth that is
climate change is indispensable, and this entails revisiting existing policies through a critical lens. Additionally, allocat-
ing a more generous slice of the national budget to the healthcare sector is imperative to ensure its armor is reinforced
with cutting-edge equipment and a battalion of well-trained sta.
In conclusion, as the intricate web of challenges posed by natural disasters in LMICs unravels, a proactive, coordinated,
and multifaceted approach, both in the short and long term, is the important in minimizing the devastation that these
events can wreak on healthcare systems and the communities they serve.
Acknowledgements Open Access funding was provided by the Qatar National Library.
Author contributions AJN and SHA: Conceptualization. AJN, SHA, TGS, and SW: writing- original draft, and editing, review- nal draft. All
authors read and approved the nal manuscript.
Funding This research received no external funding.
Data availability Not applicable.
Declarations
Ethics approval and consent to participate Not applicable.
Informed consent Not applicable.
Competing interests The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article
are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ lic en ses/ b y/4. 0/.
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