Then I want to look at the various parts of health services. If we're in a situation where we need to provide services, what are the various components that we would need to address? And this fear of standards in their section of minimum standards and health action, which is an important section that you should become acquainted with, it lists six components. And those of you who studied health systems will not be surprised to see these are the basic six WHO building blocks. Starting with delivery, human resources, drugs and medical supplies, health care financing, which we often forget when we think about providing services. How do we deal with information management, and then finally, leadership and coordination. So, we'll start with the first one which is health service delivery. And then we'll go through these, one by one, to bring out some important points. Here, the important point is that services are readily available to the affected population, and that these meet international standards. So, this is not a time to look for shortcuts or light level healthcare. This is healthcare that's the same kind of standard that we see in an unaffected population. Now of course, as you can see, this is a substantial challenge because we're dealing with limited resources and yet we don't want to compromise our standards. Here we see that the second health standard, which is human resources and you can read there about what the sphere standards for human resources are stressing the train and competent to health workers. But, finding the health worker as the right people in an emergency can be difficult. Because if you hire a new staff, these new staff may be depleting existing services. They may be coming from another hospital and they may be attracted by the fact that you're promising that you're going to pay them more than their existing rate. And this is not an uncommon situation. If you expect people to leave their homes and go into new, and difficult, and sometimes dangerous situations, it's reasonable to expect an increased payment for these kind of situations. So some people might go as volunteers but for our local population, they have family, they have their own financial commitments they need to address. Now increasingly, we're looking at the use of vouchers and cash to provide assistance and emergencies. So far this trend toward cash or vouchers that has been mostly confined to food and nutritional supplements. But now we're starting to see this in other areas as well, and so it's still an open question about how cash will increase access to health services in the private sector. So, a number of research studies are going on to address this at the moment but we see this as a trend that's coming and we can expect that in the future we're going to look at people seeking healthcare outside of a special system setup for disasters but, in the general private sector in the affected population. We have a third standard, which is to drugs and medical supplies and that standard is that, as you can read, people have access to a consistent supply of essential medications. So, we have what's known as emergency drug kits and these are kits that can be dispatched just about any place in the world in 24 to 48 hours. And in the photograph you can see the emergency health kit or a drug kit. And this has gone through a number of different names and now it has even further new names. This has two components. It has a basic kit, which has the medicines needed for 10,000 persons for three months. And then it has a supplementary kit, which has injections, and fluids, and the things that would be used at a first referral level, they might not be at health post but a first referral level. The initial shipment is ten of these basic units and one supplemental kit, this is what's known as a push system. So we have an emergency, we send these medicines, we don't try to match the medicines necessarily to a specific situation. But as soon as we can, we want to replace this push system, which you can see is a fairly inefficient system with a lot potential waste in it, to a pull system and that's where the health systems understand their situations and they can order the supplies they need to better meet what the demands are from the the patients that are using their services. Now at this point I might add that we've had some further differentiations so we can use these basic kits with little supplemental kits for a specific situation. So, if we're dealing with an area where there is a lot of, say malaria, we can be sure that these kits are supplemented with the appropriate malaria medication for this certain area. Now with the Ukraine situation and the crisis there, we've developed a supplemental system that meets the needs for treatment of non-communicable diseases. And so increasingly as we're using just in time distribution systems, it gives us the opportunity to fine tune some of these kits with some supplementation for a special health needs and health situation. Our fourth health system standard is that of health financing, and that's the access to free primary health care services for the duration of the disaster. Now in countries that have universal health coverage, and that's many countries in the world, this could probably work all right. There might be increased demands, there might be issues of health resources, and so forth. But the system is in place to assist people through a universal coverage mechanism. In privatized situations, this can be a real problem. An example of this is Lebanon where Syrian and Palestinian refugees have great demands for services and yet the bulk of services in the country are highly privatized, particularly at the referral level. So, even when healthcare is free, if it's seen by the affected population to be of an inferior quality people are still willing to pay out-of-pocket. So even having the service in place free of charge, if it's a poor quality really hasn't eased the burden of disease on the population and the financial sector. But paying for secondary and tertiary care for non-communicable diseases is often beyond the capacity of international assistance. So international assistance can help supplement the costs of providing care, if we're looking at primary health care. But if people need to have cardiac bypass surgery, they need to have more detailed and involved, and expensive surgery. Then this is not something that might be possible for a displaced population. The fifth standard is that of health information management. And that reminds us that the design and delivery of health services are guided by the collection, analysis, and interpretation, and most importantly, the utilization of relevant public health data. Of course, this is the kind of message that we at a school of public health would think would be number one in that list of key standards. But it's critical that we're collecting information, we can monitor what the needs of populations are as they change. And they will certainly change through various phases of an emergency. And that we can adjust our services based upon these data. To meet those changing needs. Now, in one picture here, labeled Kabul, you can see a very informal settlement. I photographed this among a series of warehouses and shops and other facilities. So you can see in this picture, that collection of data might be a bit difficult if these residences or shelter are hidden behind other building, and collecting information from these on a representative basis, might be a bit difficult. In Kurdistan, we can see this settlement for a population that's been displaced from Mosul, and very neat, organized electricity, street lights, everything you need. And collection of data here might be really straightforward, not difficult at all. And it could be a very representative sample taken from here. These data that I collected are combined, analyzed and put out in an epidemiologic bulletin. And this comes out on a regular basis, and it tells us the health status of the population. What are new needs? What are services? What are trends, and what are patterns that are seen? So every place in an emergency, you will find some place an epidemiologic bulletin, or something of its equivalency. The sixth standard is leadership and coordination. A humanitarian response is often marked by chaos, duplication and gaps in services. This goes without saying at the beginning of many emergencies. Now, the test of leadership is how quickly we can get these under control, how quickly we can get these managed. Now, as an attempt to move this forward, a cluster system was created by the UN to bring the responders together by sectors. So there's a cluster sector for water sanitation, there's a cluster for food and nutrition and there's a cluster for health services. The purposes of these 11 clusters are to coordinate assessments, to conduct joint analysis, to set priorities, to agree goals, to share resources and those resources mean information as well. As human resources, and sometimes medicines and other resources, to create a coordinated health sector strategy and implementation. So not everybody is working independently, but we have a joint pattern that people are working through. And then, this initial activity is then followed through by thorough monitoring and evaluation procedures, so we can keep track of what's happening and it makes the leadership, the coordination and the management much easier. Now, it goes without saying that a very independent group of non government organizations and most of them are very independent in emergency situations, sometimes have some difficulty in the coordination process. Now, I think we're moving along from where we were before so people see the importance of the sharing and this importance of the coordination, but we still have problems and emergencies, sometimes sharing data. Especially, if this data are linked to applications for additional grant funding, some sensitivities there. Now, underneath these various essential services and structures and standards. Then we have the basic listing of the types of services that need to be provided from, as you can see here, the conduct of communicable diseases. Child health issues, sexual and reproductive health issues, injury problems, mental health issues and, increasingly, the non communicable diseases. Now, we'll show some examples of these. So, for the communicable disease program, we're not just looking at the diagnoses and treatment and case management, which is the second one, but we're focused, number one, on prevention. So this is these informal settlements. Is there enough space? Is rubbish and refuse being managed appropriately? Are rodents being handled appropriately? Are we dealing with vector borne diseases and so forth. Those are important components in the prevention. But, also, we need to have in place an information system that helps detect outbreaks at the first sign, not waiting until they become well established. And give us the necessary data for control. And then, also, in this list of common conditions, we have the non communicable diseases. A few years ago, we didn't have this on the list because many of the countries that were affected by disasters were countries with not an older population and not a population heavily affected by non communicable diseases. But now, we're in that world and having some type of standards and having the appropriate medicines and the appropriate laboratory test that are necessary for treatment of non communicable diseases is now a critical component of the treatment program and are addressed by standards in this sphere approach to the provision of services. Then, we have child health issues. These can be summarized in a few points. One of them is halting vaccine preventable diseases. So that's really critical. Populations that are affected by disasters may not have had the same level of immunization coverage that we might have seen in more stable populations. Then we need, particularly, to look at newborn and child illnesses, and how do we address these? The access to services for newborns in an emergency situation is really poor. And we need to make a special effort to look at this sector of the population and address these. Measles is one that we often think about, although much of the world is now well immunized against measles. This is a condition that has a very high case fatality rate, particularly, in children who are malnourished, so this is the important. And then, we need to look at the treatment of common diseases and these are common in the sense that there'll only be 10 or 12 of them, and that's the bulk of our work. But we need to be sure that everybody knows how to treat these diseases appropriately. So the algorithms that we use, such as the integrated management of childhood illness, are very important in emergency situations. Then, there's standards for reproductive health. Making reproductive health services available from the beginning of an emergency. And we have to be reminded that pregnancies occur in disaster situations. And it becomes very difficult sometimes to address the needs of pregnancies in emergencies that have heavily affected a health service. HIV and AIDS, prevention diagnosis and management is critically important, and many disasters occur in populations that already have a high risk of these conditions. Early prevention of STIs, sexually transmitted infections, and unwanted pregnancies is critical, and there is a Minimal Initial Service Package, sometimes called the MISP. And this is something that can be put into place in any emergency very early on and provide care and prevention for sexually transmitted infection. And then, providing antenatal, delivery, and postnatal care. This can be a real challenge in places where there are insufficient midwives, insufficient obstetricians, and the population is not in the habit of using these services for pregnancies. Then, there are standards on injury prevention. Injuries can be fairly common in emergency situations. People are working in the informal employment sector and this might be a dangerous sector because Often in a displaced population, especially crossing an international border, they ostensibly may not be allowed to work. So, formally they cannot get work permits, they are forbidden to work as they're seen to be in competition for employment with the local population. And yet, they do work because they do need to have resources. And, they often work in very dangerous circumstances. In displaced populations there are a lot of tensions and these often give rise to domestic violence. We need to be aware of that and we need to be sure that in some way your health service can address this. And informal settlements, as you can see in this picture, here, may increase risks, risks of burns or mechanical injuries, or violence from interpersonal events. Then, we have sphere standards for mental health issues. And here we're divided into two sectors. We're divided into one sector, which deals with people who have preexisting mental conditions. They had this before the disaster happened and they've been dependent upon major tranquilizers or other medications for treatment and, suddenly, they are now in a situation where they don't have the access. The other population we need to think about, are those who are developing mental health consequences as a result of the events that have occurred. Family members have been lost, livelihoods have been lost, the future is very uncertain and this causes a lot of mental health problems as well. So, there are some existing programs to treat post traumatic stress disorders and other types of trauma. And there is evidence that some of these work. Cognitive behavioral therapy is one of those things that has been found to work very well and found to work through very rigorous clinical and research trials. There's a lot of other things that are done out there and there is no evidence that they work, but there's no evidence that they don't work, as well. There's a lot of play therapy, there's a lot of drama, there's even film therapy. So, what's the evidence for these working? Well, it's not really very strong. So, as we mentioned, there may be limited resources for addressing the mental health needs of a population. And even if there are the people there, there may not be the psychotropic medications available for treatment, and this is a challenge. So, recently, we've been putting a lot more emphasis on what we call psychological first aid, which is really just being supportive to a population affected. This doesn't necessarily mean you have to have a degree in anything to provide this. It just means that you're empathetic, you're helping them, and allowing people to return as closely as possible to normal situations. And these normal situations are very important in restoring psychological function. Then we have a question about how much of what do we need. We've already alluded to this by the referral population. But, in general, in a stable situation, 1% to 2% of a population will seek outpatient services everyday. And of these, as we've mentioned, 1% may require hospital referral. This could be higher in children, and both of these numbers could be higher in the onset of an emergency, especially if health services haven't been functioning so well in the past and there's a lot of demand for services that have not been met. We must be reminded that distance affects utilization. So if people have to walk a mile or one and a half kilometers, this may reduce, by 50%, the number of people from a specific location that may seek health care. So having health posts and community health workers are a way that we get around this problem with distance in emergencies. Then, there are finite limits to the number of patients that health professionals can see during a day and to maintain the quality of treatment. So under ideal circumstances, nurses or doctors should not be expected to see more than 50 patients in a day. And you can back up a bit and look at this percentage of a population that needs services and think about your health workers, and work out how many staff you'd need to address these type of issues. But, in addition to trying to figure out how many staff you need, we must remember that there are other things that take people's time, rather than just seeing patients. So they may need training time. Especially, if you're setting up an operation in a disaster, you have people that maybe are not familiar with integrated management of childhood illness or local medications. So there's some training time. And everybody needs time off from time to time. And, many people need time for family obligations as well. So many things take time besides just seeing patients.
