Increases in morbidity and mortality due to non-communicable diseases are a common feature of many disasters. Injury is usually the major cause following acute onset natural disasters, such as earthquakes and hurricanes. Injury due to physical violence is also associated with all complex emergencies, and can be a major cause of excess mortality during such crises. The reproductive health (RH) needs of disaster-affected populations have received increased attention in recent years, especially in light of the greater awareness of problems such as HIV/AIDS, gender-based violence, emergency obstetric care needs and the poor availability of even basic RH services in many communities. The need for improved RH programmes has been especially recognised in association with complex emergencies, but it is also relevant to many other types of disaster.

Although difficult to quantify, mental health and psychosocial problems can be associated with any type of disaster and post-disaster setting. The horrors, losses, uncertainties and other stressors associated with disasters can place people at increased risk of various psychiatric, psychological and social problems. Finally, there is evidence to suggest that there is an increased incidence of acute complications from chronic diseases associated with disasters. These complications are generally due to disruptions of ongoing treatment regimens. However, a variety of other stressors may also precipitate an acute deterioration of a chronic medical condition.

Key indicators (to be read in conjunction with the guidance notes)

1. Prioritising trauma services: in most disasters, it is not possible to determine the number of injured persons who will require clinical care. Following acute onset disasters such as earthquakes, 85-90% of those rescued alive are generally extracted by local emergency personnel or by their neighbours and families within 72 hours. Therefore, in planning relief operations in disaster-prone regions the major emphasis should be on preparing local populations to provide the initial care. It is important to note that priority health interventions are designed to reduce preventable excess mortality. During armed conflict, most violent trauma deaths occur in insecure regions away from health facilities and therefore cannot usually be prevented by medical care. Interventions that aim to protect the civilian population are required to prevent these deaths. Health interventions implemented during conflict should emphasise community-based public health and primary care, even in situations where there is a high incidence of violent injury.

2. Triage: triage is the process of categorising patients according to the severity of their injuries or illness, and prioritising treatment according to the availability of resources and the patients' chances of survival. The underlying principle of triage is allocating limited resources in a manner that provides the greatest health benefit to the greatest number. Triage does not necessarily mean that individuals with the most serious injuries receive priority. In the setting of multiple casualties with limited resources, those with severe, life-threatening injuries may, in fact, receive lower priority than those with more survivable injuries. There is no standardised system of triage, and internationally several are in use. Most systems specify between two and five categories of injury, with four being the most common.

3. First aid and basic medical care: definitive trauma and surgical care may not be readily available, especially in resource-poor settings. But it is important to note that first aid, basic resuscitation and non-operative procedures can be life-saving for even severe injuries. Simple procedures such as clearing the airway, controlling haemorrhage and administering intravenous fluids may help to stabilise individuals with life-threatening injuries before transfer to a referral centre. The quality of the initial medical management provided can therefore significantly affect a patient's chances of survival. Other non-operative procedures, such as cleaning and dressing wounds, and administering antibiotics and tetanus prophylaxis, are also important. Many severely injured patients can survive for days or even weeks without surgery, provided that appropriate first aid, medical and nursing care are provided.

4. Trauma and surgical care: all health-care providers should be able to provide first aid and basic resuscitation to injured patients. In addition, life-saving triage capacity at strategic points, with a linkage to a referral system, is important. However, definitive trauma care and war surgery are specialised fields that require specific training and resources that few agencies possess. Inappropriate or inadequate surgery may do more harm than doing nothing. Only organisations and professionals with the relevant expertise should therefore establish these sophisticated services.