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Archive for January, 2010

By Dr Mala Rao, Director of the Indian Institute of Public Health.

The harrowing accounts of the earthquake in Haiti are a reminder of the helplessness of humanity when faced with nature’s fury. And it isn’t only the developing world which can be overwhelmed by environmental calamities. Hurricane Katrina killed more than 1,000 Americans in 2005 and extreme levels of rainfall during the summer of 2007, the wettest in England since records began, resulted in the severest loss of essential services in the affected areas since the World War II.

Nevertheless, it is clear that the greatest human, economic and environmental losses following such disasters occur in socio-economically deprived communities with the least capacity to absorb such shocks and to recover quickly from them.  Such as in Haiti.

But the challenges are huge.  ‘Natural’ disasters are increasing in number and severity, and they are compounded by increasingly frequent extreme weather events, which result from anthropogenic climate change. The international effort to address disasters is usually reactive. All too often it is shaped by political agendas rather than what the recipients need. Local recovery efforts can also be hampered by well meaning and enthusiastic volunteers descending on disaster zones, offering impractical and sometimes insensitive interventions.  An Indian colleague recently recalled, with amusement and annoyance, a mountain of Western women’s clothes donated by a charity to a village devastated by the Indian Ocean tsunami.  A deeply conservative community in the Tamil Nadu region, these clothes were lying untouched and getting in everyone’s way.

Focus needs to be shifted to strengthening the affected region’s disaster response preparedness and to build the resilience of those communities most at risk. For it is multidisciplinary strategies, which anticipate and prevent or mitigate the effects of disasters, that have the best chance of reducing the carnage which accompanies so many environmental disasters.

This takes time, commitment and long-term collaboration.  Public health practitioners in the developing and developed countries have a crucial role in working together and with their partner organizations to help develop these strong, resilient communities, able to withstand such increasingly frequent shocks.

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By Dr Emilia Crighton, chair of the Scottish committee of the Faculty of Public Health.

So the government has decided to bring in a ban on pub and club drinking promotions that encourage people to drink fast and furiously. Licensees will face fines of up to £20,000 or face a prison sentence, under this new tougher code of practice.

This is definitely a step forward in attempting to tackle a British drinking culture that encourages people to see drinking large volumes of alcohol as an achievement to crow about to friends, rather than a threat to their health.

The introduction of the mandatory code of practice banning irresponsible promotions; the need for age verification policies; and ensuring smaller measures are available, acknowledges the failure of the voluntary arrangements that have been in place until now.

Making pub and clubs offer free tap water to customers, from April, should also be welcomed. Drinking water could help drinkers slow their consumption of alcohol and tackle dehydration.

As the FPH has regularly argued, alcohol consumption in the UK has doubled over the last 40 years and the average consumption of alcohol in the population is directly linked to the amount of harm. Increases in alcohol consumption have been driven by an increase in off sales, which now represents around 51% of alcohol volume sales, up from 24% in 1980. Consumption is strongly linked to affordability: as price has fallen, consumption has risen. Alcohol is now 69% more affordable than thirty years ago. The increased affordability of alcohol has been driven by the off sales sector.

Tackling price and availability are the most effective alcohol policies aimed at reducing alcohol related harm. Research produced by the team at Sheffield University which modelled the effect of different levels of minimum pricing on alcohol consumption indicates increasing impact on consumption with increases in price. For example the introduction of a minimum price of 40 pence per unit in Scotland would have a very small effect on consumption (-2.7 per cent), while at 50 pence and 60 pence, there would be significant changes in consumption (-7.2 per cent and 12.9 per cent respectively). The higher the price, the lower the consumption, and the lower the harm caused by drinking.

However, the government needs to go further. The introduction of a minimum price per unit of alcohol sold will have the highest financial impact on harmful drinkers.  People who drink within the sensible drinking guidelines will hardly be financially affected.   For example, if a 40p minimum price was introduced, it is estimated that a moderate drinker’s spend on alcohol would go up by £11 per year (21p per week), but that of a harmful drinker, who tends to buy more, cheap alcohol, would go up by £137. The increased prices in alcohol could be offset by lower prices for food and non alcoholic drinks by the supermarkets.

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By Dr Lucy Reynolds, Visiting Research Fellow, London School of Hygiene and Tropical Medicine, University of London

  • Dr Reynolds has worked in Haiti in 2006-07 and 2007-08, and in the aftermath of the Sichuan and Banda Aceh earthquakes.

After a 7.0 earthquake with 30 aftershocks, close to the surface and to the capital city, much of Port-au-Prince is now rubble.  Although this just attains the category of major quake, in terms of destruction and casualties, it is one of the worst ever.  This is partly because of the lack of implementation of construction standards: Port-au-Pierre’s mayor estimated a year ago that 60% of its buildings were unsound.  Haiti’s development has followed a model which stresses private-sector actors and has not built a state apparatus equipped to undertake such functions to protect the population.  Corruption is another major reason for unsafe building practices: appropriate construction materials are substituted for inferior to increase profits, some of which are then available to arrange that regulations will not be enforced.  Such problems were blamed for the high death toll among schoolchildren in Sichuan in the 2008 earthquake.  In Banda Aceh, 2004-5, few buildings escaped damage other than mosques and Dutch colonial dwellings, both of which had, for different reasons, been soundly built.

TIME IS RUNNING OUT

The International Federation of the Red Cross has an active disaster preparedness programme in Haiti, and they were among the first responders for the rescue effort. They have now been joined by teams from many countries, but an almost complete lack of heavy equipment such as cranes has prevented many rescues.  Although presumably the US military could import such equipment, soon it will be too late for most of those still trapped; dehydration and/or crush syndrome will result in such severe renal damage that recovery is impossible.  Those whose limbs or torsos are trapped should be freed under medical supervision, in order to protect their kidneys.

INADEQUATE HEALTHCARE SERVICES

Many of those injured continue to wait for medical attention, and by now, are developing infections in open wounds.  Eight of Port-au-Pierre’s eleven hospitals collapsed, including one previously supported by a Médecins Sans Frontières mission, and several field hospitals have been set up as part of the international aid effort.  In Haiti, most health care is either costly private sector provision or malfunctioning because health staff are irregularly paid and supplies of medications and consumables are intermittent and inadequate.  Because of gang warfare, parts of the city are too dangerous for providers other than international NGOs and faith-based organisations. So, while international health interventions will be well funded for now, after the emergency phase health care provision is likely to be even more inadequate than previously, which could have ongoing public health consequences in the city.

WATER SHORTAGES

By the 17th, the issue of drinking water had emerged as the most urgent need for most people affected.  At the best of times much of Port-au-Prince lacks access to piped water.  In Haiti, the state is not in a position to provide services to households, and the private sector solution for ordinary Haitians is to sell drinking water in small plastic pouches containing about 200ml/time; people can also buy drinking water by the gallon for their homes.  As many of the 300,000 newly homeless have come from plumbed-in buildings, and will now be forced to depend on this system, there could be significant shortages.  It can be assumed that since a market solution has been put in place for drinking water, if demand increases price is likely to increase in the short term, before other supplies come on stream through existing vendors and relief efforts. Action on sanitation is also needed, for those in temporary shelter now, and in the future for those whose homes are defunct.

DEATH TOLL

The Red Cross estimated 3 million people displaced and 50,000 dead, but by the 16th 50,000 bodies had already been retrieved. The estimated death toll is rising toward 200,000.  Bodies have been put out in the street for relatives to collect, but the MINUSTAH peacekeepers are now moving them to a central collection point.  Some are by now unrecognisable, and some will have no relatives to collect them due to death, injury, displacement or penury.  In general, there are not usually major health consequences from the presence of corpses, but some risks exist as decomposition proceeds; fortunately it is winter in Haiti.  Social repercussions could result if corpses attract rats, wild dogs or carrion birds.  Sooner or later mass graves are needed.

OVERCROWDING INCREASES DISEASE RISK

While the dead may not create much disease, the same cannot be said of the 300,000 now homeless people in Port-au-Pierre, much of which is a shanty town with inadequate services.  Overcrowding carries risks of measles, diphtheria, whooping cough and meningitis outbreaks, as well as the threat of water-borne and water-scarce infections, and enhanced spread of TB. At least cholera is not endemic to the island!  An immunisation programme for key disease threats, particularly measles is urgently needed, because its interaction with malnutrition boosts rates of consequent blindness and death.

MALNUTRITION AND FOOD AID

Malnutrition is likely to be a major issue in the weeks to come: Haiti has been receiving food aid for so long that its indigenous agricultural base has fallen away, unable to compete with free produce. This has led to a dependence on imports which may be a difficulty as damaged port infrastructure may require development of new supply lines, at the same time as aid deliveries tie up functioning transport routes and vehicles.  Road condition within Haiti and to the Dominican border is dreadful, and so private sector food provision may not cope with the demand, meaning that food aid could be critical for more than those made destitute by the earthquake.

HIV RISK

Haiti has the highest HIV prevalence in the Western hemisphere, and population risk in an emergency situation will usually increase due to more mixing of people from different communities  and to a psychological reaction to disaster and bereavement which resulted in a baby boom nine months after the Asian tsunami.  In addition, displaced people living with HIV may suffer interruption to their antiretroviral treatment, thus becoming not only more vulnerable to infections including TB, but also more infectious to others.  A condom distribution and HIV education intervention in displaced camps would be timely. It is to be hoped that someone will think to provide formula milk and clean water to HIV+ new mothers, otherwise vertical transmission could increase also.

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The Faculty of Public Health today publishes our joint manifesto on public health, alongside the Royal Society of Public Health. 12 Steps to Better Public Health offers a dozen practical recommendations that, if adopted by the next government, will improve the UK’s health and well-being for the new decade.

The joint public health manifesto calls for:

  1. A minimum price of 50p per unit of alcohol sold
  2. No junk food advertising in pre-watershed television
  3. Ban smoking in cars with children
  4. Chlamydia screening for university and college freshers
  5. 20 mph limit in built up areas
  6. A dedicated school nurse for every secondary school
  7. 25% increase in cycle lanes and cycle racks by 2015
  8. Compulsory and standardised front-of-pack labelling for all pre-packaged food
  9. Olympic legacy to include commitment to expand and upgrade school sports facilities and playing fields across the UK
  10. Introduce presumed consent for organ donation
  11. Free school meals for all children under 16
  12. Stop the use of transfats

The full manifesto is available to read here, and the front-page Guardian story, with an accompanying podcast from our President Alan Maryon-Davis, is available to read here.

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As the full tragedy of the Haiti earthquake and its aftermath emerges, there will be many very painful lessons to be learned. Why were so many key public buildings so vulnerable? Why weren’t there sufficient stockpiles of food, bottled water, sterile bandages, antibiotics, painkillers? Nor enough fuel for generators, transport and heavy lifting equipment? Why so little public education about what to do? Why was there such an apparent lack of contingency planning?

One underlying problem is that Haiti is such a poor country with a relatively fragile infrastructure at the best of times. The government can’t afford all the stockpiling, set-aside and duplication needed for really robust resilience. Another problem is the chronic underinvestment in its health service – hospitals, health centres and preventive programmes.

The massive inpouring of aid and expertise will help to get Haiti back on its feet in the coming days, weeks and months – although the shadow of suffering will remain for generations. Hope for the people must come in the knowledge that, as the rawness of this tragedy slowly fades, there could arise from the rubble a new stronger Haiti. An opportunity to rebuild the nation’s communities, public services, government and economy.

An essential part of this renaissance must be Haiti’s health system. The global health community will do what it can to help in this new beginning. We at the UK Faculty of Public Health, directly and through our members, will willingly work with the people of Haiti, its public health leaders, its government and international agencies, to help develop a more robust and resilient public health system and more effective public health programmes in the years ahead.

To help us turn this intention into action please contact our Head of International Development: rosyemodi@fph.org.uk

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Micaela Serafini, Medical Coordinator of Merlin’s Emergency Response Team, is flying to Haiti today to help survivors of the earthquake. In a 3 minute podcast, she talks about the three phases of an emergency response, and outlines Merlin’s immediate priorities once the team hits the ground.

Merlin is a health charity aiming to provide health care for people at times when they are most in need.

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Haiti earthquake

The scenes of devastation and suffering in Haiti are truly horrific, and the international emergency reponse has been agonisingly slow in getting help through to where it’s most needed. But beyond the immediate essentials, with hospitals and health centres wrecked and many staff killed or injured, Haiti will struggle to rebuild its public health infrastructure and services.

This will take time. But the the UK Faculty of Public Health, with over 3000 public health specialists, has expertise and experience which I’m sure could be brought to bear in helping Haiti recover from this dreadful setback. We stand ready, willing and able to help in whatever way we can.

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