Welcome everyone, to this discussion of providing health services in disasters. And by the end of this module, you'll be able to list the key health and health service indicators that should be part of an initial assessment in an emergency. You'll be able to explain how disasters affect the structure of health services and the need for health services which a population has. You'll be able also to list the health services components that are critical in providing health services in emergencies and the types of services that should be provided to an affected population. In the next slide, we'll look at the importance of an initial health assessment. And I'm going to refer here again to the Sphere Standards, which I hope you have downloaded from www.sphereproject.org and we're going to look at the core standards. And standard number three in the core standards is the assessment. And as you can read here, the priority needs of a disaster-affected population are identified through a systematic assessment of the context, the risks to life with dignity and the capacity of the affected population and relevant authorities to respond. So the assessment not only looks at the needs of the affected population but also the capacity of health services to respond to the disaster or emergency. In the next slide, we'll look at the initial assessment measures and the kind of things that it looks at to determine what are the appropriate services for a population. So we would want to know something about the existing health status of a population. We'd want to know something about the health facilities and services. And in the photo you can see a hospital that's been destroyed in Zenica in the Balkans. This is a photo from my colleague Paul Bolton. We'll look at the existing access to services. So even if services are present, we want to know who has access to them and what are potential barriers that we may have to address? We'll look at environmental issues, as well. What are the factors in the environment? Not only the physical environment, but also areas of security and possible injuries, and difficulties which people have because of conflict situations. We'll look at the disease ecology in the disaster location. So what are the common diseases? What are the times of year that they appear? How do they affect population? And then finally, I've listed population structure. What is the basic demographic structure of this population? So it can help us to identify who would be important users of the services that we provide. In the next slide, we have an example of a population pyramid. And these are very critically important to the understanding of what population needs would be. So a high fertility population would have perhaps 15% of that population under the age of 5. And perhaps 40% to 45% under the age of 18. Young children require a disproportionate share of the health resources. So even if the population of children under age 5 might be 15% or 18%, they may require 45% or 50% of the services from a health facility. Now in the population pyramid, which I've obtained from the Jordanian government. We see how the Syrian population have added to the existing population pyramid for Jordan. And I should note this was 2013, so this is a few years old, and you can see where this additional load on the health services have been, primarily in the younger population. So this indicates how the additional resources would be deployed and what potential numbers would be required for health workers and supplies to meet this increased population from the displaced Syrian population. And, of course, this would apply in other situations as well. Here we want to look at two fundamentals of health care in disasters. The first fundamental is the need for health services are increased following a disaster, while the resources are diminished. So this means that the functioning facilities and access are less. The amount of medicines and supplies and utilities for providing services are decreased. And the human resources, here we see a loss from migration, from injury, from death, from demoralization, and this is a common circumstance in disasters. The second principle is that clinical services without a public health component prove to be futile. So while clinical services are important, and they're very critical to addressing the needs of the population. These benefits may be only temporary if the population returns to circumstances where they're, again, at risk of the diseases that they had sought treatment for in the formal sector. So, a strong formal public health approach protects the population, and benefits the clinical services by reducing the stress on these services. Environmental health services are an important part of health services. So it's not just the treatment of disease, but also looking at the environmental issues. This can be sanitation, this can be water issues. But this can be dangerous circumstances from buildings that have collapsed or electric lines that are lying live in the ground, and other potential risks from the nature of the disaster. And finally, I want to emphasize that security situations often constrain health services. So even if the health services are there, but people are unable to access them because of either dangerous environmental issues or because of fighting or conflict going on, then these services are really not benefiting the population. In this diagram that you see here, we see actually two diagrams. And on the left hand side, we see a diagram of the necessary resources for addressing health needs. So there are conditions which can be treated at home by mothers or grandmothers or family members and these actually consist of the bulk of the type of diseases that one sees. There are some conditions that require a health center, and then there are a smaller number of conditions that require a hospital to provide the required services. But then if we look at the resources that are necessary to supply these, the resources necessary to address home treatment is fairly small. The resources needed to support a health center, to provide health needs, is larger, but it is much less than the resources required for a hospital. So when we think about disasters, we can see that the resources being constrained in disaster situations affect much more the formal side of things than they do the informal side. So here we see a diagram that illustrates that, we can see a collapsed structure on the right. And this helps illustrate the fact that the capacity to provide services are shrinking in a disaster situation. In a disaster, we can see that the conditions that require treatment would be increased and these will be increased at all levels. So this contrast is important when we think about how do we establish the services, knowing that our demands are going to increase and yet our resources are going to be decreased in the formal sector. And we may have to look at alternative approaches to increase those access to resources. This is a fly that reminds us that the various diseases that we see, that come to the formal health sector, that require treatment. When people with these diseases return to an environment of polluted water, insufficient food, unhealthy environments, overcrowding, the diseases that they've been treated for are returned. So if we're going to take the stress off the formal sector, we have to look at a public health approach that will address many of these circumstances that are causing, or at the root anyway, of the diseases that are being treated in the formal health sector. The curative services without a public health measure are futile. And these photographs illustrate the difficult circumstances that displaced populations have. The difficulty with waste and garbage and rubbish that are created by these circumstances. You can imagine the kinds of diseases that are bred here. The rodent and insect population, and these are things that drive people to return to the health facilities for treatment. Only then to have to return to a living environment where they are at risk again of acquiring these conditions. Here we have a diagram that looks at a kind of a pathway for health services following a disaster. So the first one we see is a rapid onset disaster. So this might be something like an earthquake or a volcanic eruption. Or something where there was very little warning that this occurred, this happened fairly quickly, and there was a quick response that was critical for saving lives. People had to be extracted from buildings that had collapsed, people had to be rescued from rising water from storms. Those major needs are fairly quickly dispensed with. So the waters recede, buildings are either leveled or reconstructed, and there will still be some long term needs remaining. So if these events heavily affected the health system in some way, then reconstruction of the health system might be required. I might point out that, also, this is an opportunity for addressing some of the problems in the health system that have been neglected in the past. But now that we're looking at some reconstruction activities, many of these long standing, or long term issues can be addressed as well. And in the photograph, we see people living in temporary housing two years after the earthquake in Port-au-Prince. An example that although many needs have been addressed, some of them continue for a long period of time. There are other options, as well. And here is a diagram of a slow onset disaster. And this is something we often see with a complex humanitarian emergency, often abbreviated as CHE. There's a quick response needed for a short period of time, but there is a long term response that continues to be needed. And in these circumstances, it's common for separate health facilities to be constructed to address the needs of populations that have been displaced or have been affected by these slow onset disasters or these conflicts. At the end of the period of time that these events have affected the population, then the services can be closed or they can be integrated with existing health services as the emergency ends. And two illustrations here, one is Balsam Hospital in a Palestinian refugee camp in Lebanon. This hospital was originally set up with the flow of refugees out of Palestine into Lebanon in 1948. And this photograph I took a couple years ago, and you can see that community is still alive and well and needing the services of a hospital. Now this might not look like your image of a refugee camp, but in fact, many refugee camps turn out to be very long term situations. And so these type of permanent looking buildings are common features in refugee camps that have been present for 10 or 20 years. Now in the small inset photograph, we see a clinic that was set up for Burmese that had crossed into Thailand to evade the fighting that was occurring in Eastern Burma or Myanmar. This was a long term situation because the refugees found many reasons not to go back into Burma and they were also followed by large numbers of labor migrants. People leaving from Burma to seek employment in Thailand. These were unofficial or illegal migrants, but they were important for the economy of Thailand. And many of these used these clinics originally set up for the refugees but now are providing services for these migrant laborers coming into Thailand. Then we need to look at the various levels of care in an emergency. Now in an emergency, we have a very strong emphasis on the community. So community health workers, community health volunteers, or other groups working in the community. And there are a variety of names for these, are critically important. Because many of the needs of a community are at the household level. And there may be reasons, there may be barriers why these people cannot seek care in facilities. So providing these at the household level is critically important. And furthermore, these community workers are important for sensitization, for mobilization of the community, for spreading information about access to services, for very short term sudden activities or emergencies that are occurring. These community health workers, are very good communicators there. The next level up is the health post and this is a facility that has minimal amount of curative services but it's important for immunization programs. So if people need to be bringing their children for measles immunization or hepatitis immunization then this is a location very close to the community. This staff, perhaps on an intermittent basis, but provides the services that are needed close to the households. The centerpiece for primary health care is the health center and this is a facility that staffs with health professionals. Some countries, this might include doctors. Other countries, this would be clinical officers or nurses that can provide curative care for the common diseases in a community. When one looks at the type of diseases that affect a disaster affected population, the bulk of these diseases are probably 10 or 12 diseases, which can be easily managed by people working in these health centers. At the same time, there needs to be a first referral backup hospital to refer people who need further care or perhaps with trauma issues, or perhaps obstetrical emergencies. These are referred to the first referral hospital. And we have some data that tells us of that of the people who come to a health center, perhaps 1% or 2% will need to be sent on to a referral hospital. So when you're planning health services for a disaster-affected population, be sure that there's a smooth and easy referral system in place. Now we often wonder about the specific types of services that are needed for various disasters. And in this matrix, we can look at on the left-hand side, the various types of care that would be provided. And then along the top, we can see some of the types of disasters that might affect a population. So let's just take for an example, an earthquake, which would be in the third column. So in an earthquake, the demand for mass casualty care might be fairly high. The demand for primary health care would also rise. Because this earthquake is likely to affect health facilities as well as health workers. So there'll be a demand that will not be able to met by a health service that has been severely damaged by things as well. Hospital care, absolutely, there's going to be lots of fractures, open fractures, multiple fractures, compound fractures, that need assistance. Disease surveillance may be an issue as well. If populations are displaced from their homes, we're going to see potential outbreaks of disease. Certainly, shelter issues are important. Food issues may not be so critically important in the beginning, because we are unlikely to have a lot of malnutrition related to this earthquake. But if this earthquake occurs in a location where nutritional status is not good already, then access to food is really important. Security may be a concern, but it's not the kind of concern that one might see with a conflict, a situation. There's a lot of concern about looting, but much of this concern about looting after disasters is misplaced. Because while looting may occur, as we saw following Hurricane Katrina in New Orleans, this is really not a common situation. And then we can look at some of the other issues. I won't go through all of these in great detail. But you can imagine that in a flood situation, the need for mass casualty care is not great. The flood may affect some health facilities, but may not affect all of the health facilities. Disease surveillance in floods is important, because the one communicable disease that we see after natural disasters is commonly diarrhea, and that occurs in flooding situations. Security may not be a major concern, but certainly shelter could be a concern if large numbers of people were displaced from their home because of flooding. Usually, flooding retreats fairly quickly, so people can return to homes fairly soon. So long-term housing may not be a major issue in flooding.