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Archive for the ‘Disaster relief’ Category

Gelada baboons
Move along there: Gelada baboons

By Dr Jackie Spiby

We are still here in Addis Ababa. We have survived the rainy season and the sky is blue again.

Many of you will have seen the news about the famine in the south east of Ethiopia where it borders Sudan and Kenya. Sitting in Addis, it is as difficult to understand the whole story here as it is at home. We pick up the news and some of the debate from the BBC when the internet is working. When we travelled to the south recently, everywhere looked really fertile and verdant as it was just after the rains. But at work I do hear about problems with food-aid delivery and families that can’t feed their children.

As recipients of Global Fund money, my organisation has to have pristine financial arrangements. The management audit letter we received recently could have been one found in any PCT. By the way do PCTs still exist? The only difference was that they were querying why a goat had been bought. I recently found myself on an appointments committee for an internal auditor – something I have managed to avoid in the UK. Amazingly my interviewing instincts rose to the fore. I was delighted that my first choice was the same as the finance director’s. It did help that the interviews were in English. So, another country another culture but actually much is the same.

We took a few days off to travel north to trek in the Simien mountains. Ethiopia lies in the East African Rift Valley so much of the north and central areas are hilly in stark contrast to the desert areas bordering Sudan and Somalia. We were walking at three to four thousand metres and were surprised that it was still scattered with villages, and, wherever we went, small children were keeping an eye on the cattle and sheep. They said they went to school but I wasn’t really convinced.

Walking into a BBC crew filming the gelada baboons was quite surreal. We had just stopped to put on our macks as it was raining when we heard a very posh voice asking if we could move please as they were trying to film the baboons running down that particular hill. If you ever see a documentary on these baboons in the Simiens we were there, and we saw the locals on the other side of the hill ‘encouraging’ the baboons to move.

One of my areas of work is developing a volunteers’ strategy. Not international volunteers but local volunteers. PLHIV associations are similar to charitable organisations in the UK so their boards are all volunteers and most of the programmes workers are also volunteers. However they do get expenses. The latter get 206 birr a month for travel. That is £7.60. In the focus groups they tell me they do it for humanitarian reasons. However when I asked if they also had paid work, they said it was hard to get work as they were HIV+. So what is a volunteer? I really enjoy the focus groups: however formal I try to make them, we have to have a coffee ceremony, and they usually end with music and dancing. The highlight last week was meeting a 22-year-old woman who finished school at grade 6 but was carrying a beautiful, chubby smiling baby who everyone proudly told me was HIV negative.

Am I making any difference? Not an unusual question for anyone in public health. I’ve been asking it my entire career. I’d better get back to work and make sure that I am.

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By Andy Beckingham, ex-DPH and public health consultant now living and working in India

Indian back street

Indian back street

I spent much of 2010 in South India on sabbatical with Indian Institute of Public Health. Would my UK experience be useful? Or irrelevant in India? I made new friends and networks, loved the food, the heat and the work. I was incredibly lucky to find a great boss. Found myself helping identify the ‘burdens of disease’ for one state (pop c80 million) and working with the Indian government to focus primary care and work on social determinants, to address health needs – and often failing too. I worked on maternal mortality and discovered how hard it is to change things when social determinants are complex and women undervalued. My boss and I were asked by the government to assess the impact of climate change on the country’s health, and our contribution went into Climate Change and India: a 4×4 Assessment. It helped that I’d been a DPH in England, but getting this kind of work experience was mostly just luck. I returned briefly to a snowy UK, its NHS workforce shell-shocked to find their skills on the Government’s scrapheap. Hmmm – back to India…

2011 – I woke as the dawn appeared as a thin orange line over the Arabian Sea and the plane flew in over the Western Ghats. In 2010 I had met the CEO of a maternity hospital who’d asked if I’d like to set up midwifery training. Are you kidding?? Yes!! So In 2011 I find myself working in a hospital seriously dedicated to improving clinical quality. And in a world of private health care, nevertheless providing free health care for the poorest women. Our Consultant Obstetricians work 7am-9pm and sleep in the hospital when on call, to be quickly available when women have difficulties. A small village hospital 100 km away and run by nuns needed doctors, so our CEO is lending them two registrars for free and I’m helping them plan cervical screening and incontinence counselling to complement their obs & gynae sessions. Public health work here is like…  SO interesting, Dude…  I’ve made links with an NGO in the city’s biggest slum (estimated population… a million? We have no demographic nor epidemiological data) with no primary health maternity care there. Pregnant women walk 3km in 90ᵒF to the nearest private hospital. We plan to provide a free doctor. They’ll have their work cut out…

The maternity hospital I work for managed 5,000 births last year, 65% of them ‘high risk’. We’re developing a programme to train nurses to become professional midwives who will manage the normal births and free the obstetricians up to do the risky ones. India doesn’t really have midwives, so we will pilot their training and work, and evaluate whether they contribute to better maternal outcomes. So in 2011 I find myself writing the curriculum, setting up the training, plus a midwifery exchange programme with South Africa, London and Toronto. Almost every week another really interesting health issue arises. I love it here… want to come too?

PS: Spot the health inequality issues in the photo to win free biryani, bangles and a public health internship.

PPS: No salary available, find your own plane fare.

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By Matthew Kilgour

What are the difficulties encountered when planning for and responding to natural disasters and adverse weather conditions in the UK?  This was the topic of discussion at the FPH Annual Conference session on Wednesday 7 July,  featuring contributions from Lucy Reynolds from the London School of Hygiene and Tropical Medicine, Wayne Elliott, Head of the Health Programme at the Met Office, Shona Arora, NHS Director of Public Health for Gloucestershire, and Andy Wapling, NHS Head of Emergency Response for London.

The three key environmental factors affecting UK emergency planning and response were outlined as excessive cold, heat and flooding.  All the speakers were keen to point out that the implications of these factors stretch beyond immediate and physical dangers, and stressed the need to understand the social and mental health implications of events like floods or heatwaves. Andrew Wapling, discussed the need to conflate the public health and emergency response agendas saying, “the quicker an effective response is mounted, the lesser the impact on individuals.“  He cited early response to disasters as a key determinant in minimising longer-term implications.   He also stressed the need to identify critical infrastructure and the events that could potentially ground services and impede response.

Shona Arora discussed her involvement with the response to 2007’s flooding in Tewkesbury, Gloucestershire. The flooding heavily disrupted day-to-day patterns of life, and vulnerable individuals and groups like the poor, the elderly or those with learning difficulties did not, in many cases, have access to the information or resources to protect themselves.  Lucy Renolds stressed this same issue in her closing remarks by saying, “it is always the poorest communities who are affected the worst”.  Large percentages of individuals affected by the flooding did not have sufficient insurance, and many were left without access to serviceable kitchens.  Ms Arora admitted that the evidence base for pre-empting eventualities like these was thin, and placed emphasis on the need to address this factor.

Lucy Reynolds highlighted the key role that mass media can play in information sharing and raising public awareness in response to disasters.  She stressed the need for reliable communications networks when dealing with disaster relief, as public phone network can become overloaded and unreliable.  The need for effective and reliable communication between departments was emphasised repeatedly throughout the session. Wayne Elliott from the Met Office said that “unless you communicate at the right time, and in the right manner, nothing will get done.”

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Morning parallel session, at the Faculty of Public Health annual conference, on Wednesday 7 July.

Chaired by Professor Alan Maryon-Davis (former President, UK Faculty of Public Health), and panel members Lucy Reynolds (London School of Hygiene and Tropical Medicine), Wayne Elliott (Head of the Health Programme, Met Office) and Shona Arora (Director of Public Health, NHS Gloucestershire) and Andy Wapling (Head of Emergency Preparedness, NHS London).

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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 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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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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