Building resilience | CRIMEDIM’s health systems lens

In conversation with Monica Trentin and Martina Valente from CRIMEDIM, we discuss the importance of building resilient health systems and focusing on every step of disaster preparedness and response.

CRIMEDIM ( Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health) is a university-wide academic center that conducts research, education, and training in the field of disaster medicine and humanitarian health. The center is committed to promoting innovative research projects and fostering learning and training programs using state-of-the-art technologies to enhance the resilience of health systems in emergency, disaster, and humanitarian crises. 

In the context of MSI’s theme of Post-Pandemic Recovery and Resilient Health Systems, what topics or experiences from CRIMEDIM’s work could be particularly insightful and relevant for medical students to learn from?

Martina: One of the main focuses of CRIMEDIM when it comes to disasters, global health issues, or humanitarian crises is to always have the health system perspective and to consider a whole-of-health system approach to disaster response and preparedness. Quite often this perspective is either absent or restricted. CRIMEDIM considers having this holistic perspective of great importance. We are not only trying to understand the impact on the community and the general population, but also the impact on the health system, health system performance, health system functioning, and considering the health system in its broadest perspective. So not only hospital response, which is perhaps a bit more common when it comes to disasters but also the pre-hospital system and primary care system. It also means understanding that there are other actors that work for the well-being of the communities, such as non-governmental organizations and the third sector. They play a huge role in disasters, especially when it comes to vulnerable and marginalized populations. 

When it comes to COVID-19, we can share our experience based on the recent studies that we have conducted, which actually adopted this health system lens. We wanted to explore the main strategies that were implemented during COVID-19 and how those strategies and lessons learned could improve future health emergency and disaster risk management. We conducted a case study based in Italy, involving a broad spectrum of stakeholders from different levels of the health system. We included representatives of the hospital sector, of pre-hospital, and primary care, people from the third sector, NGOs, community members, but also representatives of the public administration, politicians, policymakers, and so on. The view we could grasp from them was very comprehensive and we really managed to understand all the different perspectives on what is a health system response.

Could you share with us your personal experiences and impactful moments during your involvement in disaster medicine and humanitarian aid that have shaped your perspective on the importance of building a resilient health system?

Martina: Personally, I’m not a medical doctor, I’m a global health researcher and therefore my involvement is always from a research perspective. I can share my recent experience regarding health system perspectives and health system strengthening. I was recently deployed and involved in a project in the field in Afghanistan to explore how access to health care changed following the government change in August two years ago. It was in collaboration with the non-governmental organization EMERGENCY, which has been working in Afghanistan for a very long time. We had the opportunity to explore from both a health system and community perspective, whether there were some changes in access to care following the change of government and all the sociopolitical changes that Afghanistan went through in recent years. It was very interesting to see that while, at times, disaster researchers might expect drastic changes when a crisis or disaster happens, they may be confronted with chronic challenges instead. So besides the disaster, many times the health system has some chronic issues or problems, some institutional barriers that are the real problem even when there are no disasters.  It also inspires us to take into account long-term health system-strengthening interventions rather than only focusing on intervening in disaster situations. Many times the limitations, problems, and challenges are really structural in certain contexts.

At times, disaster researchers might expect drastic changes when a crisis or disaster happens, but they may be confronted with chronic challenges instead. Many times the health system has some chronic issues or problems that are the real problem even when there are no disasters.

Monica: I’m a Ph.D. candidate at CRIMEDIM, but besides my research activities, I’m also the coordinator of the TDMT project, Training Disaster Medicine Trainers. The opportunity to coordinate such a huge project that reaches medical students all around the world made me understand very well, very clearly the importance of preparedness when it comes to medical students. One week ago, one student from TDMT told me that she was in contact with authorities in her country and she’s planning with them for a refugee camp to be opened. And she’s putting into practice the principles she learned from the training. You, medical students, will be the key actors in health systems in the next few years. So for me coordinating such a huge project helped in understanding the importance of preparedness and training in disaster medicine and global health. This is a very enlightening experience.

Let’s also talk a little bit about how the COVID-19 pandemic highlighted the health disparities and health inequalities within and also between the countries. How does CRIMEDIM address those disparities in disaster medicine and humanitarian aid efforts? Could you tell us about your efforts to ensure equitable access to health care for vulnerable populations?

Monica: This question is particularly relevant to us and to me specifically since my PhD is about this topic. Its title is „Being a migrant woman during disasters” and with this project we also recently won a research grant from Fondazione Cariplo, a philanthropic foundation in Italy, to specifically investigate inequalities We are conducting a mixed-method study to address and explore the impact of the COVID-19 pandemic on migrant women in Milan, in Italy. When it comes to disparities and inequalities, at CRIMEDIM we try to always adopt an intersectional lens. This is paramount to not consider groups of people as silos. We are aware that multiple identities that people have may increase their vulnerabilities when it comes to disasters, and this has been shown by the COVID-19 pandemic. So in this project, we are going to intersect the vulnerability arising from being a migrant and from being a woman to see how this community was impacted. We are already exploring this phenomenon through different sources of data and information. And we think this is very important when it comes to understanding vulnerabilities and disparities.

So for example, we analyze data coming from the emergency department, as this is the first access point, especially for migrants seeking care. But we also seek data and information from NGOs. This helps us understand what happens to all these people who can’t make it to the emergency department, who have difficulties in accessing care at the emergency department, or who can’t access care from the general practitioner. In general, and then when it comes to vulnerabilities, disparities, and inequalities, we always want to hear from the affected communities. We are going to conduct many interviews with migrant women to hear directly from them. In general, we always try to implement approaches such as participatory research, and transdisciplinary research to hear from different stakeholders and communities. 

Martina: I just want to point out that in general the understanding, assessment, and monitoring of inequalities may be quite challenging. Oftentimes we’re talking about marginalized communities or groups that tend to be hard to reach. And understanding inequalities through the lens of access to care can be quite useful. Many times when a disaster happens the inequalities are seen as a lack of access. 

Besides this recent project, we also have other projects, such for example a PhD project that looks at how different factors such as migration, conflict, and the COVID-19 pandemic have affected the continuity of maternal and child health care for refugee women in a particular area of Pakistan. It is quite useful to check how a specific service has been disrupted by the COVID-19 pandemic, and how a vulnerable population like migrant women in the postpartum period or mothers with children under five are experiencing disruption of care.

Monica: I would like to add one last thing. It’s very important to explore and study disparities and inequalities in ordinary times because disasters and public health emergencies exacerbate those disparities rather than create new ones. For example, we have also conducted a review of the literature exploring inequalities between migrant and non-migrant populations when it comes to access to the emergency department to analyze what happens in ordinary times, and which inequalities are there. We can also tailor some interventions that can be effective during a crisis. So, we always try to not improvise during a disaster or crisis, but rather to explore vulnerability in ordinary times.

Digital health technologies also played a significant role during the pandemic. Can you share how CRIMEDIM utilizes those innovations to support your work?

Martina: CRIMEDIM considers technology as a useful tool to improve disaster preparedness and disaster response. One case that comes to my mind is the involvement of  CRIMEDIM in a project called NIGHTINGALE, funded by the European Commission. The main aim is to improve the health response in major emergencies, in particular, to develop, test, and deploy an integrated toolkit for medical emergency response, which is also aimed at improving pre-hospital triage and interventions and overcoming the outdated technologies and methodologies that are employed in these circumstances. Technology plays a very important role and we have a great team at CRIMEDIM focusing on this specific project.

Monica: When it comes to the use of technology for training at CRIMEDIM, we must mention the European Master in Disaster Medicine (EMDM), which is an advanced master, but also the TDMT and Disaster SISM, which Is the Italian version of the TDMT project in collaboration with SISM Italy. We always expose students to computerized simulations, for example using XVR, which allows conducting simulations in a virtual setting, where students can play like they are conducting the response to a large-scale disaster or a mass casualty incident.

So for example, when it comes to XVR, students have triage cards on the screen and they have to decide very quickly what to do. So that’s very realistic. You feel like diving into the response. In this case, technology and software can support us in delivering training and making students feel prepared. Because when a disaster occurs, there’s not enough time to prepare ourselves. Using this very realistic software is very, very useful for students. And this is also feedback that we receive a lot.

We already discussed TDMT, training, and their impact on how students use those skills in real life. Can we expand on this topic? How can medical students play a role in disaster preparedness and response, both within their communities, but also on a global level?

Monica: I think that the most important aspect is Preparedness. Think about COVID. Many students were asked by their universities or hospitals to be deployed and to respond to the COVID-19 crisis without any preparation at all. And this can be very, very harmful to their mental health, also when it comes to making very important, sensitive decisions that would require ethical preparation.

So the first thing that I would like to mention is the importance of being prepared in advance. We cannot improvise during a disaster. At CRIMEDIM we try to do our part in this with the TDMT project that we mentioned earlier. We try to fill the gap because as you may know, universities around the world often do not offer courses in disaster medicine. Every time I meet TDMT students, they underline this gap. Oftentimes our project is the only opportunity to do courses on this topic. So, we try to fill this gap by training students to become disaster medicine trainers, who after obtaining the final certification, can go to their universities but not only to deliver courses in disaster medicine. And this is already a significant outcome. When it comes to building students’ roles in their communities or at the global level, we think that it’s very important to rely on authorized, well-known entities or organizations to start a collaboration.

Martina: I also wanted to mention the role not only of medical students but each and every one of us in the disasters. It’s important to consider all the phases of disasters, not only disaster preparedness or disaster response. At times we forget about mitigation and that’s something that very easily everyone can play a role in. And if we think about mitigation it’s just a matter of a sustainable lifestyle as well as a sustainable diet in the long term. It’s really impressive how much behaviors we have today can bring change in the future and perhaps at least decrease the disasters caused by natural hazards and climate change-induced disasters.

So let’s look into the medical students’ future for a bit. What would be your recommendations to medical students who in the future want to work in disaster medicine, humanitarian aid, or global health based on your experience in the field and lessons learned from COVID-19?

Martina: In terms of being involved in research which definitely plays a big role in disaster medicine, global health, and humanitarian aid, being informed about courses and opportunities within CRIMEDIM and other organizations might be a starting point. At CRIMEDIM TDMT orEMDM are excellent opportunities to deepen knowledge in the field. A bit more advanced, but the same goes for Ph.D. program opportunities or starting research in these fields. 

And of course, they must have an idea of a topic they might want to go more in-depth with so that they can refer to professors or institutions that might endorse the idea. So reach out to institutions that can collaborate with students and support them. Going into the field, collecting data, and being operational in the research can advance disaster medicine research and increase the chances of collaboration in bigger projects and institutions. Try joining International projects, as this is also a way to build experience and gives you more opportunities to have a say in terms of disaster medicine.

Monica: Another thing that medical students could do is conduct research projects, and training activities in many countries around the world to deepen their knowledge and broaden their perspectives. I’m sure this could be very beneficial for their careers and daily work. To see and learn from other communities, and what they do to learn best practices from each other, is a very beneficial approach.

So we mentioned international collaboration and its importance in responding to disasters and humanitarian aid. Building on that, how can we as medical students contribute to the promotion of international collaborations, but also information sharing, as it’s also very important in times of crisis?

Martina: I want to underline the importance of opening communication channels with important institutions. For example, the WHO or other international bodies might be very helpful in enhancing international collaborations. Participating in various projects can also be an opportunity for different partners and organizations to join their efforts toward a common goal. In terms of information sharing, advocacy projects can be a good way to start spreading information.

Do you have any final message to share with the medical students worldwide?

Monica:   You as medical students should be brave and make your voices heard. Don’t be afraid to push communities, governments, your professors, research centers, universities. If you think there is an opportunity that you want to take, don’t be afraid to push, go there and fight for it.

Martina: And do not wait until there’s a disaster to focus on disasters, but consider disasters also in peacetime in terms of research, in terms of preparedness, in terms of training and preparation, because otherwise, it would be too late. We tend to focus on disasters only when one is happening, but we need to remember that this is and should be an ongoing process.

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Monica Trentin and Martina Valente in conversation with Olga Wdowiczak

Photos by Nour Assaf

Monica Trentin joined CRIMEDIM in 2020 as a research fellow. Her research interests include, among others, vulnerable population’s disaster preparedness, the relationship between gender and disasters, and menstrual health during disasters. In 2021, Monica began her PhD in Global Health, Humanitarian Aid and Disaster Medicine, with a project focused on the impact of the COVID-19 pandemic on migrant women. She is also the Principal Investigator of the project „Being a Migrant Woman During Disasters: A Mixed-method Study Exploring Multidimensional Inequalities During the COVID-19 Pandemic in Northern Italy”, funded by the Fondazione Cariplo. Monica is also the coordinator of the Training Disaster Medicine Trainers (TdmT) project, an educational program in disaster medicine for medical students, organized in partnership with IFMSA.

Martina Valente works at CRIMEDIM as a postdoctoral research fellow. She is mainly involved in the Doctoral Program in Global Health, Humanitarian Aid and Disaster Medicine: she provides lectures on research methods, collaborates with the coordination and organization of the PhD program, and provides ongoing support to PhD students throughout their research projects. She obtained a PhD at the Athena Institute (Vrije Universiteit Amsterdam), and she gained experience in research, education and supervision of students in the field of global health. Besides that, Martina is involved in other research-related activities and lectures at CRIMEDIM, and she contributes to designing new research directions.