This is Paul Spiegel and I'll be speaking on The Role of Public Health and Humanitarian Emergencies. We'll describe the role of public health professionals in humanitarian emergencies. And we'll discuss the essential components of the humanitarian emergency, or often what's called the disaster management cycle. Basically, what should public health professionals do, and when should they do it? So, overall public health is concerned with protecting the health of populations. Unlike clinical care, which is primarily focused on individuals. Public health, therefore, takes a population based view. For example, what interventions can help the most amount of people at the lowest cost? Preventive interventions, such as immunizations, are often very cost effective. But we need to be able to provide a wide range of responses that vary over context and time. So it is clear that there will not be one's set of interventions that will help all persons. How one responds to a large scale epidemic in a conflict setting, maybe quite different compared to slow onset drought. However the principles are still similar, we need to use existing capacities and resources to help the most amount of people, and that is the public health approach. I would like to discuss the Sphere Handbook, which is a very important tool that was developed, and includes the Humanitarian Charter, as well as, Minimum Standards. The Sphere Handbook is designed for planning, implementation, monitoring, and evaluation during humanitarian responses. There are many public human health humanitarian interventions and standards in Sphere. For example, the one that commonly quoted is the quantity of water needed in emergency situations. Which is generally 15 liters per person, per day. However, as with all standards, one has to take into account the context. There may be standards where the local populations do not have 15 liters per person, per day. There may be other situations where there is an abundant supply of water. Therefore, these standards are meant to be indicative and context-specific. Another example is the provision of food. Which is generally 2,100 kilocalores per person, per day. Again, this may depend on the population and the context. But Sphere standards have been very important, particularly in a public health sense. To be able to allow public health professionals to have an idea of the minimum standards that should be provided to a population. I was involved in 2011, in an emergency response of Somali refugees fleeing conflict, and famine like conditions, into Ethiopia and Kenya. Tens of thousands, actually, were fleeing the border. So what are some of the issues in this situation that a public health professional must address? Some examples include, the establishment of a surveillance system. We need to know and respond to mortality rates, to morbidity rates, to diseases of epidemic potential. If we don't have such a surveillance system, we will not know which events are occurring, and then how best to respond. Another important issue relates to community and facility based healthcare, we need to assure that they're established. And often people concentrate more on the clinical care, or the, let's say the health facilities, and they don't concentrate enough on the community aspects. But if you can imagine, a population that has been displaced may not have its social networks, are living in a situation, whether it's a camp, or out of camp situation. And are not familiar with their surroundings, community-based workers are extremely important. Another example is food and security, and even famine like conditions, which was an issue then and is actually an issue as we speak in East Africa. We need to be able to establish treatment for severe and moderate acute malnutrition. And to ensure that the needs are addressed not just for those that are acutely malnourished, but for those that are vulnerable. Among the many other issues to address is a strong coordination system, both within the health sector, but also among various sectors beyond health. Because health is not a sector onto its own. We need to think about other areas such as energy, food, a shelter that also have very strong health effects. These are just a few of the many issues that must occur to ensure a strong public health response. I'm going to discuss now the Humanitarian Emergency Management Cycle. A previous speaker has also discussed this in a different format, but called, the disaster cycle. However, it's very similar and is comprised of four phases. Mitigation, Preparedness, Response, and Recovery. Throughout all these phases, public health is an essential component. However, it cannot and should not, be considered separately, as I mentioned. Rather, public health must be considered together in conjunction with all the other sectors. Because health and the health of a population will affect livelihoods, will affect the environment, and conversely, those sectors will have a major effect on the health of populations. Why is it difficult to work amongst the different sectors in a common manner. It is not uncommon for public health and other professionals to work in a vacuum. One reason is that many of the experts feel most comfortable working among persons with similar expertise. It can be more complicated when working with other experts in different sectors. There can be differences of opinion, and prioritization amongst the sectors can be quite controversial. And it is often very difficult to agree upon. What is more important for example? Planning for water, planning for health, food, for shelter, when you have a limited number of resources and a limited number of people. Who makes those decisions and how does one prioritize? As I mentioned previously, one must be aware of the inter-linkages among the sectors. If there is not safe water and sufficient sanitation. If there is insufficient food, insufficient wood, or electricity, to cook food, and to stay warm. If there is insufficient shelter to protect families, how can the health of individuals, families, and communities be secured. As you can see, this can become quite complicated. All of these important interactions, and many more, including protection, nutrition, education, all need to be considered together. They need to be costed and, eventually, they need to be prioritized accordingly. This is often dealt with through various coordination mechanisms and planning. This has been discussed further in another module. I'm now going to lead you through the four phases of the cycle and give examples of what a public health practitioner should know and can do. The first phase is Mitigation. Previous slides in this module have discussed the components of a disaster, such as hazards, as well as, risks and vulnerability. The international community has reinforced its response to emergencies through concerted efforts at disaster risk reduction, or what's commonly called DRR. Efforts have been made to reduce exposure to hazards, to reduce vulnerability of people and property, to improve management of land and environment, and improve preparedness for adverse events. In terms of mitigation, I'll provide some examples of such measures for both natural disasters, and for conflict. So they can vary. For example, engineering issues. Ensuring infrastructure, such as, roads and bridges, as well as, buildings are constructed to withstand earthquakes. As we saw recently, this was a major issue in Nepal as certain standards were insufficient and other standards were simply ignored. Conflict resolution is another very important issue that's often ignored in these situations. Differences among persons and communities exist everywhere. I imagine that you can think about some examples within your own community. Conflict resolution attempts to use dialogue to reduce tensions amongst communities before they ignite to cause a conflict, such discussions are always context specific. And they can revolve around various issues such as land and natural resources, political systems, power sharing, among many other issues. Who undertakes such dialogue? And how it is undertaken is very important. For example, we have internally displaced persons or refugees, who are hosted by national populations. These national populations are living in very difficult conditions as well. However, the assistance is generally provided to those directly affected by the conflict. In this case, these displaced persons. If the assistance that is provided to displaced populations is not planned for and provided in a wider sense to include those that are hosting those displaced persons conflict may occur amongst these communities. More and more, we are looking at how to ensure displaced populations will benefit as well as those that are hosting to reduce conflict. And hopefully provide a conducive environment to those refugees and internally displaced persons. Another example is economic, such issues as diversification of economic activity. Economic incentives such as grants and loans and even issues such as insurance looking at now drought insurance or even health insurance. And this is relatively new trying to invest and develop insurance that will help people that are affected by natural disasters but also to include refugees into national health insurance programs. Where refugees will be able to pay premiums into a larger risk pool, so in theory, the refugees should benefit as well as the national populations. Finally, another issue is spatial planning where displaced persons settle can have a serious effect on relations with the government in the host community. I took some photos of Dollo refugee camp in 2011. One can see an aerial photograph of how the camp is situated in a very remote area with sparse vegetation. One can also see a water access point with a pump surrounded by hundreds of jerrycans and people waiting to fill up their Jerrycans and to get their water. How a camp is established in terms of location and layout has repercussions for years and possibly decades. Site planners need to take this into account and move away from military-like setups to better understand where the national population is located, where are the sources of water, where are the markets, where are the schools and health centers. And also look at the development plans of the district in order to allow the establishment of refugees or IDP sites that will eventually benefit the population in the future as it grows. The next phase I wish to discuss is preparedness in humanitarian emergencies. The primary difference between preparedness planning and emergency operations planning is the potential nature of the plan for a situation. Unlike emergency operations planning, which is done in response to a known emergency situation, preparedness planning is done before the event happens, in a state of uncertainty. This means that much of the planning for the conditions, the scale of the emergency, the timing, the different scenarios, must be based on predictions. And assumptions about the potential crisis rather than a real time assessment. For example, there are many emergencies that are predictable and often repeat themselves. Meningitis in the meningitis belt of Sub-Saharan Africa that stretches from Senegal in the West to Ethiopia in the east, is one such example. Another examples, are the recurrent food insecurity or food crises, that often lead to acute malnutrition and rarely famine. Which is happening as we speak now in east Africa, but happens rather consistently in different parts of West and East Africa. For these, and other situations, contingency planning occurs, and can be effective, if done correctly. Situations of conflict are often more difficult to plan for, as they are often, but not always, less predictable than some of the emergencies described above. However, such preparedness planning has been found to be helpful among partners even when an emergency does not occur, because people get to know each other, their organizations, the different ways of planning, amongst many other issues. A final issue with respect to preparedness is the funding that often is not available particularly funding for stockpiles. The counter factual is very difficult to explain to donors and to the public however, funding for a stock pile in case a disaster may occur is very cost effective, particularly if the disaster does occur and the stock pile is used. However, with proper stockpile planning and careful rotation of resources before their due dates. This can be done effectively and have a major and positive cost effective effect on disaster preparedness and response. I am now going to talk about health responses and humanitarian emergencies. So you are a public health professional and arrive ten days after a large scale displacement has occurred in a low income country with minimal resources. How will you go about assessing the needs of the population and prioritizing those needs? This is one of the most difficult aspects of humanitarian response. And frankly, there's no simple answer, it's very context specific, and it also depends on the resources available. An initial assessment is very important and is often not done very well. One must undertake these assessments in a coordinated manner with questions and tools that are harmonized in terms of data collection and analysis. Initial assessments should be done jointly amongst sectors and organizations that should eventually lead into a single report, the so-called common assessment. In reality, this often doesn't occur because organizations do not arrive at the same time, and there may be many security constraints. For example, when I was in Côte d’Ivoire or Ivory Coast in 2011, it was difficult at the beginning of the crisis to know who was doing what, where and when. Furthermore, the security concerns made it difficult to have all sectors represented when we undertook our initial joint assessments. So we had to prioritize who was doing what and we had to have sectoral experts that could assess multiple sectors. The types of assessment will also depend on the contacts and the phase of emergency. For example, initial assessments are often more superficial compared with the in-depth assessments that occur later. Some of the important health information that needs to be collected includes population size and demographics. Mortality and morbidity data, the functioning of the various health posts, health centers and hospitals. The available heath care personal in place, as well as the available medical supplies and equipment. Again, what will be collected will depend upon the context and the phase of the situation. I'd like to also discuss emergency response plans. Emergency response plans often come early and may sometimes be used more as a donor tool than an actual guide to a response. This is because they often have to be done very quickly And insufficient data are available to make in depth decisions. There are many types of plans available to use as guides. The insufficient amount of data and detail to go into a plan may make many healthcare responders anxious, as the specifics are often not known. However, these emergency response plans should be iterative and continuously approved as more information becomes available. Beyond the initial assessment and the emergency response plan, other very important components include health service delivery. Which will be discussed in another module. As well as communicable disease and non-communicable disease interventions, again, discussed in another module. The last component in the health response for in humanitarian emergencies, that I'll discuss, is monitoring and evaluation, or M&E. This aspect is often insufficiently implemented in most humanitarian emergencies. It is important to know if the response has been successful. And more and more, we have an obligation to use the money most effectively and to measure our response to make sure that the precious money that we have is used effectively. Furthermore, we can learn a lot of lessons that will help us improve future responses. One of the biggest problems when doing a monitoring and evaluation program, is that there is a lack of baseline data available to be able to compare before and after. This component is important to address in the assessment phase when proper baseline data could and should be made available after being collected. Therefore, often the monitoring and evaluation component is based more on process indicators, such as how many people were reached by a specific intervention, than actually what was the impact of that intervention? For example, it is not unusual to see a report that states that 10,000 people have received primary healthcare services, or 1,000 persons have been referred to a hospital over a certain period of time. However, that really doesn't tell us anything other than healthcare services were provided or people were referred to a hospital. If we had the actual impacts of health intervention, such as the number of deaths due to measles or diarrhea, for example, this would allow us to really understand what our response and the impact of that response has been. Again, that is difficult to collect, but it is being required more and more as we try to professionalize the humanitarian response, and assure donors that we are using their money effectively. The last component of the humanitarian emergency planning cycle, is the transition recovery and development. Transition refers to the period when the conflict appears to end, stabilization increases, and early reconstruction and recovery efforts may be able to begin. Recovery is the next phase, and that's the process of restoring capacities of governments and communities to rebuild and prevent relapses. Transition and recovery in reality can be very complex. A recent positive example, until Ebola occurred and showed the fragility of the health systems, was Liberia. After a horrible and prolonged war in the 1990s, Liberia was recovering. Working with its international partners, the government had turned on electricity and piped water to many parts of the capital city. Had started to rebuild roads and bridges, increased primary school enrollments. And reached 95% of children under five with a measles vaccination all before Ebola struck in 2014. Liberia, unlike Haiti, is a good example of how transition and recovery from a disaster, can occur successfully, when there is strong government leadership and international support that works with the government, to support local capacity. However, Ebola did show how fragile recovery can be. And how easy it is to slip back into nonfunctioning health systems with a severe external stressor. And this is, unfortunately, what we saw in Liberia when Ebola struck. The last phase I want to discuss is development, which relates to longer term objectives and presumes security and a functioning administration. Development is often seen as quite different and separate to a humanitarian response, transition and recovery. Although there needs to be some sort of categorization of phases to help one conceptualize, the reality is more messy. And it's not unusual to see different, so called phases, occurring all at once in different parts of a country. For example, the Democratic Republic of Congo, or DRC, is a good example, particularly in the east of the country. It has been constantly moving back and forth between emergency, transition, recovery, development, often at different phases within different districts. And constantly moving back and forth amongst each other, depending upon the complexity and the instability of the settings. A future module will discuss the humanitarian development nexus, which is an attempt to join the phases and not think in linear terms, but rather, see how humanitarian, transition, recovery, and development can occur or at least be considered at the same time. Here are some of the main messages of the module combined. Number one, a disaster has a risk or a probability of loss to a population. Number two, a disaster has a hazard or an event. And number three, a disaster has vulnerabilities. Vulnerabilities related to public health are commonly concerned with dynamic pressures, underlying conditions and unsafe circumstances. Public health addresses vulnerabilities by building capabilities at national, provincial or state, and local levels. Displacement, whether internal or external, or from natural disaster or conflict, has many social, economic, and health consequences. Other main messages include the following. A public health approach emphasizes prevention and response at a population level over an individual level. The Sphere Project and its handbook provide minimum standards and accountability for humanitarian emergencies. The humanitarian emergency management cycle consists of four parts, mitigation, preparedness, response, and then transition, recovery, and development. The public health of populations is affected by all sectors and cannot be considered in isolation. [MUSIC]
