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

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.


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 (CO 2 ) in the air [1,2].Surprisingly, today's CO 2 levels are at a concerning 412 parts per million (ppm), much higher than the 280 ppm back in the late 1700 s [1,2].The repercussions of such financially-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 affected by climate change from 2000 to 2019, a big majority-specifically 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.

Review
Discover Health Systems (2023) 2:23 | https://doi.org/10.1007/s44250-023-00038-6 1 3 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, floods, and wildfires.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 financial trouble.Plus, the not-so-great living conditions in these countries make their people easily affected by many health problems.When natural disasters hit these places, it makes things even worse, increasing the chances of diseases spreading and making the problems that come with them even harder on these societies.LMICs, which are already dealing with a lot of difficulties, 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.

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 affecting 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 populations, and the drop in hygiene standards.These events expose the affected 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-afflicted 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 flooding 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 floods 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 flooding.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 rehabilitation efforts have been ongoing to address the immediate needs and to rebuild the affected communities.
A sudden increase in exposure to mosquitoes, stagnant water bodies, and overcrowded habitats fuels susceptibility to vector-borne diseases, with malaria and dengue fever became the prime disease causing agents [10,15].Brazil, reeling from floods in 2008, reported 57,010 dengue fever cases.Northern Peru's floods in 2017 were the precursor to outbreaks of dengue fever and chikungunya, with dengue fever suspected in 19,000 cases.Pakistan's floods 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 affected 3800 cities and towns [16].A confluence of overcrowding, impaired sewage disposal, flagging hygiene, malnutrition, rudimentary sanitation, and human interactions among refugees fosters the transmission of infectious maladies, with the potential to ignite epidemics [17].Furthermore, an insidious rise in dermatological afflictions, such as scabies and skin infections, has been reported in the wake of natural disasters.After the 2010 floods in Pakistan, 2377 scabies cases were reported in four affected regions of Baluchistan.Lin et al. underscore that individuals with limbs submerged in floodwaters 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 floods and hurricanes.Ocular afflictions, 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], find themselves in the crosshairs of natural catastrophes which could exacerbate the chasm that separates LMICs from high-income nations.

Impact on healthcare infrastructure
LMICs find 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 deficit 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 by existing data revealing that in the wake of a flood, over 50% of hospital staff find themselves incapacitated in fulfilling their duties [20].Earthquakes, bearing the distinction of being the most devastating form of natural disasters, alongside other calamities, 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 five-fold spike in hospital admissions, exerting an unbearable strain on hospitals, patient care, management systems, and, ultimately, the healthcare infrastructure at large [21].In a parallel vein, the catastrophic flooding 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 stability, with minimal bolstering from the fruits of the industrial revolution.The specter of flooding and other disasters looms large, possessing the capacity to inflict colossal damage to crops.This, in turn, can cast a pall over the countries' economies, fanning the flames of the already Herculean challenges faced by healthcare facilities.

Impact on maternal health
The global landscape has witnessed cosniderable problemes related to maternal health and infant mortality rates.Nevertheless, such progress remains an elusive mirage for LMICs, where maternal mortality rates are always at alarming levels.Despite persistent endeavors to refine 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, filled 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 afflictions among women negotiating the crucible of childbirth during natural calamities [24][25][26].
The flooding that engulfed Pakistan serves as a testament to the fragility of maternal health during disasters.The deluge 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 flood-ravaged regions of Bangladesh, accessibility to antenatal and postnatal care was severely affected compared to unaffected 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, hospital 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].

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 affected.This sad situation is even worse in less wealthy countries, where women, due to their roles and societal factors, are especially affected.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 devastating 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 2007-2008.6 Food shortage and insecurity The specter of food insecurity casts a long shadow over approximately 12% of the global population, an alarming figure 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, floods, and storms, which wreak havoc on the agricultural lifelines of LMICs, and in turn, fan the flames of food insecurity [35].This creates barriers and undermines the tireless efforts 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 barrier of food unaffordability, which paves the way for malnutrition.This, in turn, spawns a higher risk of chronic ailments, and the financial 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 financial reserves, thereby perpetuating this infernal cycle.
In Pakistan, chronic hunger has caught over 3.4 million children in its chilling grip.Post-flood 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 flood-ravaged families.The population bereft of adequate access to food ballooned from 5.96 million pre-flood to a grim 8.62 million in the aftermath [37][38][39][40].As winter is close, the looming threat to hundreds of thousands of lives intensifies 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 financial 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 disaster 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.

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 afflictions, 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 proactive 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, prevailing 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 unaffected territories.Safer grounds, with the residents armed with their prized possessions, should be contructed in advance of the looming disaster.Moreover, safeguarding an uninterrupted flow of healthcare, food, and the bare necessities is paramount to stave off the shortages and the financial albatross of post-disaster transportation costs.Likewise, deploying skilled rescue brigades from surrounding areas can bolster the capacity for a swift and efficient response to the unfolding crisis.

Review
Discover Health Systems (2023) 2:23 | https://doi.org/10.1007/s44250-023-00038-6 1 3 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, allocating 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 staff.
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.