Developing an International Standard for Disaster Epidemiology

In the aftermath of Hurricane Katrina, the Northern Armenian earthquake and the Indian Ocean Tsunami, regular epidemiologists stood by to help the cause, to save lives and prevent disability. Disaster epidemiology is a reactive school of public health in which only past experience, education and present colleagues serve as your guide and textbook for decision-making (Armenian, 2009). Disaster epidemiology is the often-unplanned application of epidemiological principles to the aftermath of natural disasters and war. Because disaster epidemiologists are traditionally recruited by the chance of their mere presence in ground zero, there are very few full time professional disaster epidemiologists.

Epidemiology provides as framework for effectively dealing with the resulting damages created by natural disasters. This framework includes the development of surveillance systems, which are intended to keep track of diseases incidence, deaths and general health data in the wake of disasters (Armenian, 2009). An additional part of this framework is the development of disease control strategies in response to health issues resulting from the event (Armenian). Assessment is a major epidemiological method that is used in disasters to determine the efficacy of health services administered throughout the event’s aftermath (Armenian). To determine the root of diseases and disasters, research on the etiologic causes should be conducted in an epidemiological review (Armenian). Finally, epidemiology serves as a valuable tool in the wake disasters as surveillance and investigation systems are developed for the long-term usage (Armenian).

An interesting event to look at within the framework of disaster epidemiology is the Indian Ocean Tsunami of 2004. The Indian Ocean Tsunami was considered one of the worst disasters ever to occur. The tsunami was created by a massive earthquake with energy the equivalent of 23,000 Hiroshima-type atomic bombs according to the US Geological Survey (National Geographic News, 2005).

Because these events, like infection, can lead to specific diseases and health conditions, systems for managing events must be designed in the interest of prevention and control. Due to the sudden nature of disasters, it is essential to collect initial data in order to better inform actions that can potentially head off disability and decrease the rate of mortality (Armenian, 2009). One of the early issues officials discovered in the wreckage of the tsunami was the hesitancy with which victims would speak to public health representatives (The International Labour Organization, 2005). Because of a fear of distressing victims, officials decided to refrain from asking them questions about the event, psychological data was not collected (Miller, 2005). The International Labour Organization replaced the representatives with young volunteers whose demeanor was received as relaxed and approachable by victims. These volunteers were then able to collect data through questionnaires to establish a baseline of prior economic and health status.

This ability to accommodate the delicate, and often-varied states of victims is essential in tailoring emergency response. This is because one of the results of living through a disaster can include resulting psychological. This psychological damage can result from forced isolation, personal injury, or the injury and death of others. To assess the psychological impact of the tsunami, mobile clinics administered mental health surveys, antidepressant and anti-anxiety medications throughout affected regions (Miller, 2005).

One of the differences between the psychological damage inflicted in this disaster, versus those that occurred in previous times is the use of the Internet. Immediately after the tsunami, many survivors used the Internet to communicate with friends and family. In addition, many of the survivors of the tsunami turned to the use of blogs where they dealt with the psychological stress created by the disaster (Handwerk, 2005). Blogs also serves as a massive source of news as eyewitnesses, known as “citizen journalists” were able to publish their own stories. The psychological benefits gained by producing these blogs resulted in enhanced feelings of camaraderie, social support as victims disclosed fears and shared experiences. Not only did these blogs provide a forum for psychological support and growth, but also they became a proper, up to date news source for the victims and their families.

The development of emergency monitoring systems and public health decision-making processes are some of the only ways to prepare for the unexpected. These systems can be designed based on experience from disasters elsewhere or relevant disasters that happened locally in the past (Armenian, 2009). One of the faults of this method is if the interval between disastrous events is too long or a natural disaster had never occurred in that region before. Lack of prior experience, resulting from lengthy disaster intervals or the absence of previous events, make it difficult to prepare a community for the potential occurrence of a disaster and even more difficult to prepare an action plan (Armenian).

An example of extreme intervals between events can be seen in the history of earthquakes in Armenia (Armenian, 2009). The first recorded earthquake was the destruction of Moz in which 10,000 died in the year 735 (Armenian). Over the next century, there were 7 more earthquakes throughout the country that resulted in the destruction of thousands of houses and villages. The most recent earthquakes occurred in 1859 and 1924 before the major earthquake in 1988. The length of these intervals gives evidence to the difficulty of learning from previous local events.

Because of the intrinsically unexpected nature of disasters, there should be a global approach to disaster management. This approach could be manifested as a global treaty designed in the image of the World Health Organization’s Framework Convention on Tobacco Control (WHO FCTC). Like the WHO FCTC, the evidence-based treaty could legally bind contracting countries to employ and tailor relevant disaster management systems. The treaty, entitled the World Health Organization’s Framework Convention on Disaster Management, could include a variety of pre-approved, effective surveillance, evaluation and disease control strategies and methods that could be applied in a matter of hours.

Disaster preparedness should be a necessary governmental practice internationally. Rather than accepting the haphazard approach to disaster control and disaster epidemiology, local governments should institute teams of academics who serve as specialized disaster epidemiologists and disaster management experts consistently on call in the event of an emergency. This conceptual system is reminiscent of the Southern California Earthquake Center whose central office is located beneath Los Angeles City Hall and remains in service 24 hours a day (Southern California Disaster Center, 2009).

Disaster management is a method of dealing with the unexpected that is frequently unorganized and slapdash. The institution of formal disaster management methodology will normalize disaster counteraction and enhance the efficacy of first and last responders.

References

Armenian, H. (2009). "Epidemiology in War and Disasters."

Handwerk, B. (2005 January 28). Tsunami blogs help redefine news and relief
effort. National Geographic News Retrieved March 3, 2009 from
http://news.nationalgeographic.com/news/2005/01/0126_0
50126_tv_tsunami_blogs.html.

Miller, G. (2005). The tsunami’s psychological aftermath. Science, 309(5737),
1030-4.

National Geographic News. (2005 January 7). The deadliest tsunami in history?
National Geographic News. Retrieved March 3 2009 from
http://news.nationalgeographic.com/news/2004/12/1227_041226_tsunami.html.

Southern California Earthquake Center. (2009). Major products and publications.
Southern California Earthquake Center. Retrieved March 28, 2009 from
http://www.scec.org/.

The International Labour Organization. (2005 March 23). After the
tsunami rebuilding lives: A first step to rebuilding a
community. The International Labour Organization. Retrieved
March 7, 2009 from http://www.ilo.org/global/About_the_ILO/Media
_and_public_information/Feature_stories/lang--en/WCMS_075556/index.htm.

Prioritizing the crowded Global Health Agenda

Prioritizing the crowded Global Health Agenda

The subject of the following paragraphs is the prioritizing the crowded global health agenda. I am going to use the nature of “blogging”, which is to share the most relevant information, to discuss the urgent priority of the current global health agenda, the Swine Flu.

First, it seems that not everyone around the world is happy with the name. Pork producers question whether the term “swine flu” is appropriate, given that the new virus has not yet been isolated in samples taken from pigs in Mexico or elsewhere. While the new virus seems to be most heavily composed of genetic sequences from swine influenza virus material, it also has human and avian influenza genetic sequences as well, according to the CDC. Some officials around the world have already started naming the virus by its so-called place of origin. Government officials in Thailand, one of the world’s largest meat exporters, have started referring to the disease as “Mexican flu.” An Israeli deputy health minister, an ultra-Orthodox Jew, said his country would do the same, to keep Jews from having to say the word “swine.” But it seems that hopefully the WHO will have the final say on this. On the 25^th of April, the organization issued a statement suggesting that the virus should be called the “North America Influenza”. It seems that there is a medical tradition of naming influenza pandemics for the regions where they were first identified. This has included the Spanish flu of 1918 to 1919, the Asian flu of 1957 to 1958 and the Hong Kong flu of 1967 to 1968. The debate is likely to continue as scientists and health authorities try to trace the disease. While all signs now point to Mexico as the epicenter, the genetic material in the virus there includes part of a swine influenza virus of Eurasian origin. And influenza viruses tend to emerge from Asia. Many medical historians believe that the Asian and Hong Kong flus started in southeastern China near Hong Kong, where very high densities of people live in close proximity to hogs and chickens in rural areas and can share their viruses. Some historians also suggest that the Spanish flu also started in southeastern China. Those who are trying to relate the virus origin to the southeast Asia have come up with some evidence as well. For instance, Millions of pigs died in China two years ago in an epidemic so severe that it pushed pork prices up 90 percent. Veterinarians attributed the deaths at the time mainly to blue-ear disease, which does not affect humans, but also to swine flu. The Chinese government did not issue a public report assessing the outbreak and provided very few details to international organizations.

But whatever the virus is called and wherever it has been originated from, people must know what they are dealing with. Swine influenza is originally referred to influenza caused by any strain of influenza virus endemic in pigs. Strains endemic in swine are called Swine Influenza Virus (SIV). Of the three human influenza viruses, two are endemic in swine as well; type A is very common, type C is rare, and type B has not been reported in Swine. Before the 2009 flu outbreak in humans, swine flu was very rare among humans, and those who are very closely exposed to pigs, such as the pig farm workers, used to be the only group at risk. The original virus is non-lethal, and not transmittable from human to human either. The symptoms of the swine flu in humans are similar to those of influenza, or influenza-like illness, namely chills, fever, sore throat, muscle pains, severe headache, coughing, weakness, and general discomfort. The 2009 flu outbreak in humans that is widely known as "swine flu" apparently is not due to a swine influenza virus. It is due to a new strain of influenza A subtype H1N1 that is derived from one strain of human influenza virus, one strain of avian influenza virus, and two separate strains of swine influenza viruses. The origins of this new strain are unknown, and the World Organization for Animal Health reports that this strain has not been isolated in swine. Unlike the original strain, it passes with apparent ease from human to human, an ability attributed to an as-yet unidentified mutation.

It is interesting to know that the common human H1N1 influenza virus affects millions of people every year. In yearly influenza epidemics 5-15% of the world population are affected with upper respiratory tract infections. This results 250000-500000 deaths around the world. However, most certainly, this flu epidemic started after the flu season, and is on the verge of becoming a worldwide pandemic. The outbreak is believed to have started in March. Local outbreaks of an influenza-like illness were first detected in three areas of Mexico, but the virus responsible was not clinically identified as a new strain until April 24^th. Following the identification, its presence was soon confirmed in various Mexican states and in Mexico City. Within days, isolated cases were identified elsewhere in Mexico, the U.S and several other northern hemisphere countries. By April 28^th, the new strain was confirmed to have spread to Spain, the UK, New Zealand, and Israel, and the virus was suspected in many other nations, with a total of over 3000 candidate cases, with 152 attributed deaths. As of now, there are 14 cases identified in California.

On April 27^th, the WHO raised their alertness level from 3 to 4 (on a scale of 6) worldwide in response to sustained human-to-human transfer of the virus. The situation was raised to level 5 on April 29^th. Here is a quick look at the WHO’s pandemic alert phases. Phase 1: A virus in animals has caused no known infections in humans. Phase 2: An animal flu virus has caused infection in humans. Phase 3: Sporadic cases or small clusters of disease occur in humans. Human-to-human transmission, if any, is insufficient to cause community-level outbreaks. Phase 4: The risk for a pandemic is greatly increased but not certain. The disease-causing virus is able to cause community-level outbreaks. Phase 5: Still not a pandemic, but spread of disease between humans is occurring in more than one country of one WHO region. Phase 6: This is the pandemic level. Community-level outbreaks are in at least one additional country in a different WHO region from phase 5.

Despite the scale of the alert, the WHO stated on April 29^th that the majority of people infected with the virus have made a full recovery without need of medical attention or antiviral drugs. But there are ways both to prevent and to treat the disease. The CDC reports that the swine influenza A (H1N1) virus is susceptible to the prescription antiviral drugs oseltamivir and zanamivir. In addition, the Federal Government and manufacturers have begun the process of developing a vaccine against this new virus. As far as prevention, the CDC suggests that Personal hygiene measures, such as avoiding people who are coughing or sneezing and frequent hand-washing, may prevent flu infection. Those who aren’t health professionals should avoid contact with sick people. People who get sick with flu symptoms should stay home. Studies have suggested that closing schools, theaters, and canceling gatherings in the early stages of a pandemic can limit its spread. Such measures would likely take place if health officials determine that the virus is spreading quickly enough and is deadly enough to cause a pandemic.

 

Resources

http://www.cdc.gov/h1n1flu/index.htm

http://www.nytimes.com/2009/04/29/world/asia/29swine.html?_r=1&scp=6&sq=swine%20flu&st=cse

http://www.bloomberg.com/apps/news?pid=20601087&sid=aLdy2aZer5fM&refer=home

http://www.nytimes.com/2009/04/27/world/27flu.html?scp=16&sq=swine%20flu&st=cse

http://www.webmd.com/cold-and-flu/news/20090429/swine-flu-one-step-closer-to-pandemic?ecd=wnl_nal_042909

http://www.nytimes.com/2009/04/29/opinion/l29flu.html?scp=12&sq=swine%20flu&st=cse

 

 

 

 

Kiran Gadani
Prioritizing the Global Health Agenda
“So much to do, so little funding!”—is probably the motto on many public health professionals’ lips these days. Looking at the tremendous global health agenda, one is forced to ask the questions: Where should we start? Where is the funding? What is priority? What country is important?—the answers to these and many other questions are very close to unanswerable. So then what do we do?
Much of the world is suffering from what is called the “double burden of disease”—meaning that there is a great prevalence of communicable diseases in addition to the epidemic of chronic non-communicable diseases (CNCDs), which disproportionately impacts the developing world. The number of deaths from these diseases [CNCDs] is double the number of deaths that result form a combination of infectious diseases (including HIV/AIDS, tuberculosis, and malaria), maternal and perinatal conditions, and nutritional deficiencies (Daar et al. 2007). With increasing globalization and urbanization, the prevalence of Type II Diabetes, cardiovascular disease, cancers, etc. have risen. In the developing world, for example, in India, the prevalence of Type II Diabetes is the highest in the world and it’s population still suffers from infectious diseases such as pneumonia and malaria. Besides their direct threat to global health, diseases such as HIV/AIDS, TB, and malaria have a disastrous impact on the development of the poorest countries (Kaul and Faust, 2001).
Developed nations also face a rising epidemic of chronic diseases. 66% of the U.S. Adult population is considered overweight or obese, which drives the rising incidence of associated chronic diseases (diabetes, CVD, hypertension, stroke, etc.). The high incidence and prevalence of these types of chronic diseases put a great deal of strain on health care systems and health care professionals. With rising medical costs and technology, comes the need for better, more sustainable health care systems. But what is the most important? Is it the annual death of 2.04 million people due to HIV/AIDS (WHO 2004)? Or the 7.20 million deaths due to coronary heart disease (WHO 2004)? Or the deaths due to other conditions such as lower respiratory diseases, diarrheal diseases, cancers, influenza, and the list goes on.
Most funding is driven by emotional, high-visibility events, including large-scale natural disasters such as the Asian tsunami; diseases that capture the public’s imagination such as HIV/AIDS; or diseases with the potential for rapid global transmission such as hemorrhagic fever, severe acute respiratory syndrome, or pandemic influenza. These funding streams skew priorities and divert resources from building stable local systems to meet everyday health needs. (Gostin 2007).
This shows that funding is lacking in many situations and most funding goes to the “high-profile” diseases. What about road traffic accidents? The obesity epidemic? Or perinatal conditions? All these question marks behind these threats to health and other threats poses the critical urgency of planning the global health agenda in the most effective way possible. As Gostin suggest, a sustainable local system of health care is definitely needed, in order to provide basic health care services, which, for the most part, will prevent many risk factors and diseases. However, merely providing health care services will not tackle all of these questions. Rather, a combination of a healthy built environment and access to sustainable health care would prevent many diseases. Although treatment of HIV/AIDS is extremely important, it is more important to build sustainable systems to prevent these types of diseases. Putting funding into more preventative programs will be more beneficial than trying to treat people. Ethically, it is not right to ignore the treatment portion of health care programs. So, in addition to treatment, preventative programs should be placed.
For example, investing funds into programs that prevent risk factors such as adiposity, high blood pressure, smoking, poor diet, sedentary lifestyle—would reduce the incidence of chronic diseases such as Type II Diabetes, cancers, hypertension, CVD, stroke, just to name a few. Furthermore, basic health goods should be in place, such as safe drinking water and sanitation regulations, which would greatly reduce the incidence/prevalence of infectious diseases and breed healthier individuals.
What is truly needed, and what richer countries (although not always adequately) do for their citizens, is to meet what can be called “basic survival needs.” Basic survival needs include sanitation and sewage, pest control, clean air/water, diet nutrition, tobacco reduction, essential medicines and vaccines, and well-functioning health systems (Gostin 2007).
“Meeting basic survival needs can be disarmingly simple and inexpensive and should rise to the top of the agenda of the world’s most powerful countries” (Gostin 2007). Gostin’s suggestions on what should be priority and what should be at the top of the global health agenda do not require extensive technology and biomedical research, they are basic survival needs, which will foster healthier individuals, and in the long-run reduce deaths due chronic and infectious disease. Furthermore, by providing these basic needs will enhance the overall health of a population, in the long run, increasing productivity and positively contributing to economic stability.
Prioritizing the global health agenda is one of great controversy about health care professionals, politicians, and citizens of all countries. As stated before, much of the funding and resources go toward diseases and other conditions that are visibly apparent and many diseases/conditions are ignored. What about mental health conditions? And road traffic accidents? Tobacco control? Gostin suggests a Framework Convention on Global Health as a model for all states (nation-states) to provide citizens with basic survival needs. He describes this framework as a bottom-up model, in which a global health governance scheme is formed to do the following: build capacity (which will contribute to building sustainable health systems), set priorities (so international assistance can be geared toward providing basic survival needs), involve stakeholders (in which relevant resources and expertise can be allocated and made us of), coordinate activities, and evaluate/monitor progress. Just as in the Framework Convention for Tobacco Control, an international treaty which takes into account global health, will be one step forward in setting priorities and effectively reducing disease burden around the globe.
Resources
Gostin, L.O. (2007). Meeting the survival needs of the world’s least healthy people. Journal of the American Medical Association; 298: 225-228.

Kaul, I., Faust, M. (2001). Global public goods and health: taking the agenda forward. Bulletin of the World Health Organization, 79 (9).

World Health Organization. (2008). The World Health Report 2008. WHO: Geneva, Switzerland.

World Health Organization. (2009). Top 10 causes of death. WHO: Geneva, Switzerland. http://www.who.int/mediacentre/factsheets/fs310/en/index.html

Disaster Relief - Analysis of 2005 South Asian Earthquake

It’s hard to imagine a more devastating disaster than a powerful earthquake. They come without notice; completely unpredictable even in our age of technology. They last barely seconds but manage to level cities centuries old. The destruction left by earthquake is often irreparable and rebuilding of structures, restoring of power and water, etc may take months or years to complete. However, more devastating then the lack of shelter, power, etc is the disruption of health care. Those injured in major earthquakes can number in the hundreds of thousands and most likely, health care in the area is heavily disrupted if not shut down altogether. Those with minor injuries who otherwise would have received treatment may have to wait days before being seen by doctors and even longer before receiving care. Most vulnerable in earthquake disasters, or any disasters for that matter, are developing countries with poor infrastructure, remote populations, and difficult terrain. The 2005 major earthquake that shook the mountains of Kashmir was the third deadliest disaster in the last quarter century. The 7.6 magnitude quake leveled the cities of Muzaffarabad, Balakot, and Abbottabad and destroyed innumerable villages in those and neighboring regions.

The earthquake struck Northern Pakistan just northeast of the capital of Azad Kashmir district, Muzaffarabad. Muzaffarabad is a large city with a population of over 750,000, located in a river valley and surrounded by mountain villages. On the morning of the earthquake, October 8, 2005, most men were at work in the open fields, while majority of women and children were at home and school respectively. When the earthquake hit at 9 am that morning, children in their classrooms experienced their schools collapsing on them, while shelter homes in the mountains crumbled and fell. In a report put together by the Spinal Cord Injury Project for Pakistan Earthquake Rehabilitiation (SCIPPER), children reported hearing a “deafening sound and forceful shaking” which sent them tumbling down. The walls of their school collapsed, killing hundreds of children instantly and trapping the rest of them. Confusion and panic spread as they lay injured under the rubble, surrounded by dead classmates and screaming. The injured children lay for hours until they were rescued by family or community members. Many sustained spinal cord injuries which left them paralyzed from the neck or waist down. The shock of being unable to move their arms and leg was horrifying; just earlier that day they were “running and playing with their friends.” Far from being cared for or comforted, the paralyzed victims of the earthquake were left lying outside for days until helicopters came and took them to care facilities. Because of the mountainous terrain, most affected villages and cities were already difficult to access because of poor roads and weather conditions. After the earthquake, landslides essentially blocked all access to the region, making care even more difficult to access.

In addition, Pakistan was not properly prepared to manage such a huge natural disaster and didn’t have the means to respond quickly and efficiently. It took weeks to reach most of the affected villages and because of the quake, most proximal health care facilities were destroyed so victims had to be airlifted elsewhere. It was reported that of the nearly 512 healthcare facilities in the affected area, approximately 300 of them were completely destroyed while nearly 75 were seriously damaged. The lack of facilities and competent doctors was exacerbated by the landslides and road blockages which made most villages accessible only by helicopter. The condition worsened in the following days as the few health care facilities that were still open became extremely overcrowded as victims were flown in. The immediate priority of the doctors was surgical care for patients that were severely injured. However within days it became clear that lack of access to clean water, sub par sanitation conditions, and overcrowding were of greater concern. Patients who received surgical care continued to suffer from life-threatening infections due to unhygienic conditions. The overburdened care facilities could not provide follow-up care for many patients post-operatively simply due to the sheer volume, which indirectly resulted in lives lost.
The level and nature of the training of much of the medical provider was not adequate to prepare them to treat affected patients. Many senior medical students, in their fourth year, were sent to the mountain region to help the rescue efforts. Not only had they received no formal training in disaster relief medicine, they were hardly accustomed to making independent decisions without the approval of their attending physicians. When they finally arrived in the affected regions, it had been a few days since the quake and people were desperate for medical attention. The burden of having to prioritize patients by severity of condition and treating them independently was overwhelming for the untrained and unprepared medical students. In addition, the majority of them had never had to practice medicine without the facilities of a hospital or even more basic needs such as anesthesia, clean water, or proper prescription medicines. The adaptability required of those treating earthquake victims definitely hindered relief efforts and better preparation of medical students would have been invaluable in making them more efficient first responders to this disaster situation.
An unexpected crisis that arose after the quake was the outbreak of infectious disease in the shelter camps. The state of Pakistan’s development in terms of availability of water, power, and safe road conditions was unreliable even before the quake. Afterwards, approximately 144 camp settlements were established to shelter nearly 144,000 residents. The close proximity in which masses of people lived caused huge outbreaks of disease, with nearly 65% of all clinic visits being to treat infections. Generally, acute respiratory disease, such as pneumonia, and diarrhea were among the chief complaints, especially once the winter set in. The tents set up in these settlements were not meant to be used in the harsh cold of Kashmir’s winter, and the death toll continued to rise through the first winter season. Winterization of the tents became increasingly important to enable the survival of the displaced village populations. Even now, three years after the earthquake, access to food and water continue to remain unreliable, especially since the initial influx of international aid dropped steeply after the first few months. Many people are still living in prefabricated homes which are unable to protect residents from the elements and could most definitely not withstand another earthquake. Roads have not been permanently rebuilt yet either, forcing patients with lifelong conditions to travel for hours or even days to receive proper medical attention when needed.
Death caused by a natural disaster is unfortunate and unavoidable. However, every effort to reduce the number of deaths and the injuries sustained by a population must be made. The time lag in reaching the affected regions, the consistently poor access to basic needs such as clean water and the lack of disaster preparation of the medical teams all contributed to the enormous death toll of nearly 75,000 and those injured numbering 100,000. Although international aid is of invaluable help in facing these kinds of disasters, ultimately it is the responsibility of every nation to prepare themselves against disasters which pose the largest threats in their regions.

References
1. Suharwardy, Sanaa. Personal interview. 10 Apr 2009. Interview.
2. Brennan , Richard J., and Ronald J. Waldman. "The South Asian Earthquake Six Months Later - An Ongoing Crisis." The New England Journal of Medicine (2006): 1769-1771. Print.
3. Sabri, Ahmed A., and Muhammad A. Qayyum. "Why Medical Students Should be Trained in Disaster Management: Our Experience of the Kashmir Earthquake." PLoS Medicine 3(2006): 1452-1453. Print.
4. Vanek, Zeba. "SCIPPER-Medical Neuro-Rehabilitation and Creating an Ongoing Sustainable System of Medical Care." RealMedicineFoundation.org Oct 2007 1-5. Web.11 Apr 2009. .

Swine Flu

            Introduction

 

There has been much media attention given to “swine flu,” a flu outbreak that began in Mexico and has had confirmed cases in the last few weeks in California, Texas, New York and a number of other states. This blog will examine the history of swine flu and the current responses to its development from an epidemiology of infectious diseases perspective. Saker et al.’s “Infectious disease in the age of Globalization” article highlights one important consequence of globalization on infectious disease: the ability for rapid transmission of diseases all over the world. Flights can reach from one point to any other point in the world, usually in less than 36 hours, while the incubation period for most illnesses and for swine flu, specifically, is significantly longer than 36 hours (6). Thus, disease can be spread before carriers are even aware of their own sickness. Perhaps because of this fact, swine flu has been identified in Canada, Israel, France, New Zealand, Costa Rica and South Korea (8).

 

History

 

Surveillance in Mexico began registering cases of swine flu starting from March 18. As of April 23, there were 854 reported cases from Mexico City and more than 50 cases reported from other cities in the country. The total mortality is estimated at 62 deaths as of the time of the WHO report (9). Strains identical to those found in patients in Mexico were seen in patients in California meaning that the same virus had spread to inside of the United States. One alarming fact cited in the report was that flu generally afflicts the very young, very old or immunocomprised, however, the majority of the cases from the swine flu epidemic have been in otherwise healthy young adults. The Mexican health secretary recently released a report that identified the case fatality rate of swine flu at 6 or 7% (2). His analysis was completed by dividing the number of deaths by the suspected number of cases, yet if his analysis is correct, the case fatality for swine flu would be even higher than the 1918 flu pandemic – one of the most devastating in recent history. Other officials argue that the number of suspected cases could be significantly higher and may be underreported because the afflicted either did not need to go to the hospital or the cases were not reported in general. If this is true, the case fatality may be much smaller. What is certain is that Mexico has seemingly been plagued much more by the virus than the United States. No indigent case fatalities have been reported yet from Americans who caught the disease. (2)

            Reports from Mexico indicate that the effects of the virus may be waning as the number of new suspected cases declined from 141 on Saturday, to 119 on Sunday and 110 on Monday. In keeping with the 1918 flu analogy though, the assistant director-general of the WHO warned governments not to become complacent as the 1918 flu began with a mild epidemic in the spring of 1918 that withdrew only to come back with full force in the fall of the same year (2).

            A number of press reports have asserted that the swine flue may have begun in China – an allegation that Chinese officials vehemently deny. The reports stem from the fact that a blue-eared pig disease began in China in 2007 which, perhaps in conjunction with a swine flue, led to the deaths of 80,000 pigs and the slaughtering of an additional 235,000 pigs. The large number of killed pigs led to a spike in pork prices last year of almost 90 percent (7).

 

Naming the Flu

 

One interesting controversy regarding the epidemic is deciding upon the official name of the virus. Because the flu has not as of yet been isolated in any pigs, officials are questioning whether it can properly be referred to as swine flu, an idea many pork producers are strongly backing. In meetings all over the world officials have been meticulous about naming the disease anything from “Mild flu-like illness” to “H1N1” to “Mexican Flu” and “North American Flu.” The CDC has also discouraged using the name “swine flu”, although the most recent fact sheets that have been released in hospitals and airports by the institution still refer to the disease as “swine flu.” Others argue that identifying the origin of the disease and from there deciding on a proper name is a secondary concern as all efforts now should be concentrated on preventing and treating the disease (5).

 

National Response

 

President Obama recently asked congress for 1.5 billion dollars in funds for treatment of swine flu. Additionally, the FDA authorized emergency use authorizations of important diagnostic and therapeutic tools for surveillance and treatment of the disease. This action effectively declares a state of emergency and allows the FDA to approve the use of uncleared medical devices and drugs for treatment provided certain criteria are met. The CDC has also begun issuing reports to the media, to hospitals and to airports to spread awareness about the disease and try and control its spread in the US (3). Furthermore, Carnival Cruise Lines and Royal Carribean Cruise have both stopped docking in Mexico indefinitely.

 

International Response

 

Cuba ordered a suspension of all flights to and from Mexico for a period of 48 hours on Tuesday, becoming the first nation to suspend travel to Mexico. Argentina later followed suit cancelling all flights to and from Mexico for the next 5 days. While other countries have not suspended flights, the United States has sent health officials to Mexico to aid in the investigation of swine flu. China offered 5 million dollars in aid to Mexico and the World Health Organization has also sent officials to the country in order to assist with the epidemic (7) (1).

 

Conclusion

 

Responses to the epidemic have taken a global scale only very recently, but all involved parties have echoed the desire to improve surveillance and engage in early detection, early response efforts to prevent further escalation of the disease.

 

 

 

 

 

Works Cited

1. "AFP: China rejects reports as origin of swine flu." Google. 30 Apr. 2009 .

2. "The Associated Press: Scientists struggle to understand swine flu virus." Google. 30 Apr. 2009 .

3. "CDC - Influenza (Flu) | Swine Influenza (Flu)." Centers for Disease Control and Prevention. 30 Apr. 2009 .

4. "FDA Authorizes Emergency Use of Influenza Medicines, Diagnostic Test in Response to Swine Flu Outbreak in Humans." U S Food and Drug Administration Home Page. 30 Apr. 2009 .

5. "The Naming of Swine Flu" The New York Times - Breaking News, World News & Multimedia. 30 Apr. 2009 .

6. Saker, Lance, Kelley Lee, and Barbara Cannito. "Infectious Disease in the Age of Globalization."

7. "Swine flu: California declares state of emergency; cruise ships avoid Mexico -- chicagotribune.com." Chicago News, Chicago Weather, Chicago Sports and Politics -- chicagotribune.com. 30 Apr. 2009 .

8. "Swine flu continues to spread; Obama asks $1.5 billion to fight it -- baltimoresun.com." Baltimore, Maryland breaking news, sports, blogs, video, classifieds and weather | baltimoresun.com -- baltimoresun.com. 30 Apr. 2009 .

9. "WHO | Influenza-like illness in the United States and Mexico." World Health Organization. 30 Apr. 2009 .

 

Abandoning Failed Global Health Ideologies & Practices: the Most Vital Step for a New Global Health Agenda

            As the purview of global health’s mission, goals, priorities, and responsibilities is constantly being defined and redefined, we can no longer allow politics, disjointed interdisciplinary efforts, and ill-informed practices set the standards for the future global health agenda. Millions of patients’ lives in both the developing and developed world depend on the agenda-setting decisions that are often based on outdated ideologies and pressure from insincere stakeholders. In order for the future generation of global health leaders to approach global health commitments through an ethical and evidence-based lens, I have listed below what I believe to be the most necessary and yet neglected global health priorities that should define the future global health agenda.

Priority I: Global health inequities must be approached through a human rights framework that becomes fully integrated with public health ideology and practice.

Dr. Paul Farmer, MD, PhD, one of the world’s most committed prophets of social justice, argues that while the emerging global health and human rights movement has reduces many inequities that plague the disease landscape of the developing world, the orthodox lens through which we view both public health and human rights approaches are essentially flawed (2008). Today, global health policies are popularly constructed around cost-effectiveness and sustainability, which possess genuine motives, but are devoid of the commitment required to not only cease epidemics, but address social and economic inequities, such as poverty, in impoverished countries (Farmer, 2008). In terms of human rights ideology, only civil, legal, and political rights are prioritized, and the much more dire issues of food, health, and education are regarded as an after-thought (Farmer, 2008). Dr. Farmer argues that both these theoretical approaches serve a neoliberal political and economic agenda set by domineering governments and international financial institutions, rather than the public health needs of the world’s most neglected communities (Farmer, 2008). Chidi Anselm Odinkalu, one of Africa’s leading human rights lawyers, astutely proclaims, “In Africa, the realization of human rights is a very serious business indeed. In many cases it is a life and death matter. From the child soldier, the rural dweller deprived of basic health care, the mother unaware that the next pregnancy is not an inexorable fate…and the activist organizing against bad government…people are acutely aware of the injustices inflicted upon them. Knowledge of the contents of the Universal Declaration will hardly advance their condition. What they need is a movement that channels these frustrations into articulate demands that evoke responses from the political process. This the human rights movement is unwilling or unable to provide. In consequence, the real-life struggles for social justice are waged despite human rights groups, not by or because of them, by people who feel that their realities and aspirations are not adequately captured by human rights organizations and their language” (Farmer, 2008).

One of the most telling examples of the salience of prioritizing an evidence-based human rights approach to the global health agenda is that of financing AIDS treatment in the developing world. The health and human rights community has successfully framed access to life-saving medications as a public good rather than a commodity (Farmer, 2008). This has compelled public health experts to rethink their traditional funding strategies that are adopted from international financial entities, such as capping health expenditures and prioritizing cost recovery in resource-poor countries (Farmer, 2008). After it was discovered that implementing user fees and selling AIDS therapy to poor African patients who could not afford treatment, diagnosis and care transformed from commodities with a market value to rights, driven by a framework of ethics and dignity (Farmer, 2008). It is promising to note that human rights and social justice were once the roots of public health action, and now are reemerging as priorities in the future global health agenda (Farmer, 2008). G8 countries must build on these recent encouraging responses and “move toward explicit endorsement of a rights based approach, backed up by firm long-term commitments to the redistribution of resources across national borders” (Labonte et al., 2005).

Priority II: Human, information, and material resources must be responsibly delivered and monitored to developing countries whose primary health care systems are experiencing crippling shortages of both health professionals and medical supplies.

As the brain drain of health professionals and dearth of medical supplies, ranging from gloves to HIV medications, threatens the delivery of care to millions of patients in the developing world, the long-term strengthening of human and material resources seems to fall at the bottom of the global health agenda each year. In sub-Sahara Africa alone, one million more health workers are needed just to provide basic primary care to its citizens (Labonte et al., 2005). The most unacceptable tragedy is that under-resourced health systems in most developing countries are unable to retain the nurses and physicians trained by their own professional schools (Labonte et al., 2005). The medical training of these health professionals is supported not only by private financing, which includes tuition, but by the local impoverished communities, who are taxed indirectly (Labonte et al., 2005). In order to reverse the brain drain, investments must be made medical universities and hospitals, health professionals must receive sufficient salaries and benefits that will incentives them to stay in their home country, such that they not only serve as clinicians, but public health leaders as well (Labonte et al., 2005). However, salaries alone cannot convince health professionals in the developing world to commit their professional lives to communities plagued by war, genocide, and social injustice. One study found that young physicians in urban Kenya were mostly unsatisfied with their working conditions simply due to the lack of diagnostic tools and medications needed in order to treat their patients (Labonte et al., 2005). Dr. Farmer once questioned, “How long can African doctors and nurses tolerate being little more than spectators to the grisly parade of suffering and premature death within the walls of that continent’s public hospitals?” (Farmer, 2008). In addition, the training and integration of community health workers is the most promising means by which to deliver care to the most neglected and isolated patient communities who possess the smallest chance of ever seeing a health professional in their lifetime.

It has been agreed upon by the global health community that since the most affluent countries benefit the most from this brain drain, these countries should begin negotiations on the multilateral agreement on migration of health professionals (Labonte et al., 2005). In addition to holding wealthy nations accountable for their intake of health professionals from the developing world, private foundations and donors must be encouraged to prioritize health information and human-resource development in their funding considerations (Labonte et al., 2005). The enhancement of health information systems can enable developing countries to “quantify health problems, set spending priorities, improve health care delivery, and measure the effects of interventions” (Okie, 2006).

Priority III: The funding decisions made by international institutions, national governments, non-profit organizations, and private foundations must follow standards of accountability, transparency, need, and sustainability.

             In terms of sustainable financing, it has been estimated that most developing nations will not be able to achieve the Millennium Development Goals by 2015 that were set by G8 countries, unless these G8 countries increase their long-term funding commitments to these countries (Labonte et al., 2005). The G8 countries account for almost half the world’s economic output and govern the agenda-setting processes of the World Bank and International Monetary Fund, and yet only provided one-third of the estimated minimum health care needs of developing countries (Labonte et al., 2005). G8 countries must also specify mechanisms to ensure the affordability and availability of any vaccines, essential medicines, and diagnostic tools developed, as well as commit to ensuring access to and reduced prices of treatments (Labonte et al., 2005).In addition, the funding of research for diseases that afflict the wealthiest populations the most, disproportionately outweigh the many more millions of people who are dying of neglected and tropical diseases in impoverished countries due to the lack of market value incentives for researchers (Labonte et al., 2005). In order to reconstruct the funding agenda for global health, development aid must not undermine equity, such that health and education expenditures are capped or user fees are required for cost recovery (Labonte et al., 2005). Patients in the developing world do not wish for “cost-effective” solutions to their problems; they simply desire effective solutions (Farmer, 2008). Shirin Ebadi, a Nobel Peace Prize winner and human rights lawyer in the Middle East, recently encouraged the United Nations to cut off its funding to all nations who spent more on their military than on health and education for their people.

Private foundations, most notably the Bill & Melinda Gates Foundation, have arguably “energized research and forged partnerships among academia, governments, and industry much more effectively than most other institutions have” (Okie, 2006). The world’s largest charitable foundation, the Bill & Melinda Gates Foundation provides approximately $3 billion, or approximately one dollar per year for every person in the poorer half of the world’s population, solely to global health innovations, projects, and campaigns (Okie, 2006). “I think people watch what the Gateses do and assume that if they’re doing it, it’s not only a smart humanitarian move, but a smart business move,” said Helene Gayle, a former official at the Centers for Disease Control and Prevention (Okie, 2006). While the size of the foundation’s grants have largely shaped the current global health agenda, critics have argued that such monopolizing power instills long-term threats to global health needs (Okie, 2006). “The foundation’s grant making may not always reflect the priorities of recipients in developing countries, and its choices may influence the decisions of other funding agencies, potentially steering money away from basic science and toward product development” (Okie, 2006). Thus, Gates Foundation advisors must become more fully integrated into the communities they serve so that funding is responsibly distributed to the issues and patients who need it the most.

Priority IV: We must resurrect the priority public health once placed on primary health care infrastructure and we must ensure that our current disease-specific approach does not undermine the sustainability of these health systems

             Due to the detrimental impact infectious diseases have had on impoverished patient communities throughout the world, disease-specific initiatives have institutionalized a vertical, “stovepipe” approach to the global health agenda. This has partly been due to the relative ease of raising media attention, garnering resources, and securing financing for disease-specific actions, as opposed to the less glamorous public health issue of broad health system strengthening (Smith & MacKellar, 2007). For instance, the world’s two most largely endowed funding sources, the Global Fund and PEPFAR, are allotted specifically for HIV/AIDS, tuberculosis, and malaria. However, the impacts that funding and attention for infectious diseases are belittled by widespread health system weaknesses, such shortages of skilled personnel and insufficient resources for operating hospital vehicles (Smith & MacKellar, 2007). “Although disease-specific interventions are important, assuring real change will require attention to environmental, political, and social actions that target the root causes of disease as envisaged at Alma Ata” (Magnussen et al., 2004). As a result, the seemingly short-fix solutions to our current global health crises pose as our largest threat, as it steals the spotlight away from the long-term systemic issues that need the attention the most.

Our future global health agenda can easily prioritize primary health system strengthening alongside current disease-specific programming in such a way that the two do not cancel each other our. First, the Ministry of Health of each country must work intimately alongside leaders from their fellow departments of agriculture, housing, sanitation, education, and food distribution  (Magnussen et al., 2004). Second, health care system strengthening can no longer be placed in the hands of distant policymakers and top-down officials. The Alma Ata Declaration of 1948 requires that interventions are derived from the needs of the community, and are expressed and led by community members themselves (Magnussen et al., 2004). Furthermore, it is implied from this notion that programs need to be founded and researched in the locality in which they will be applied, rather than in universities and think tanks halfway across the world  (Magnussen et al., 2004). Finally, accessibility to health services and resources to rural populations in both the developing and developed world must be ensured through the creation of community clinic networks, rather than on building acute, tertiary hospitals in booming urban centers (Magnussen et al., 2004).

 

Works Cited

Farmer, P. (2008). Challenging Orthodoxies: The Road Ahead for Health & Human Rights. Health and Human Rights, 10 (1): 5-19. Retrieved April 19, 2009, from < class="Apple-tab-span" style="white-space:pre"> article/viewFile/33/102>.

 Labonte, R., Schrecker, T., & Gupta, A.S. (2005). A global health equity agenda for the G8 summit. British Medical Journal. 330, 533-536. Retrieved April 19, 2009, from www.bmj.com/cgi/reprint/330/7490/533>.

Magnussen, L., Ehiri, J., & Jolly, P. (2004). Comprehensive Versus Selective Primary Health Care: Lessons for Global Health Policy. Health Affairs, 23 (3): 167-176.

Okie, S. (2006). Global Health- The Gates-Buffet Effect. New England Journal of Medicine, 355 (11):  1084-1088.

Ollila, E. (2005). Global health priorities- priorities of the wealthy? Globalization and Health, 1(6): 1-5.

Smith, R.D., & MacKellar, L. (2007). Global public goods and the global health agenda, problems,  priorities, and potential. Globalization and Health, 3(9): 1-7. Retrieved April 19, 2009, from www.globalizationandhealth.com/content/pdf/1744-8603-3-9.pdf>.

Natural Disaster

Public Health during a Natural Disaster
It is amazing how we sometimes take certain necessities for granted. While I was in high school which was also a boarding school in Cape Coast, the central region of Ghana, West Africa, there was water shortage for about four weeks. The worst experience I had to face within the three years in high school. We had to walk about three miles, wait a couple of minutes in a line to fetch a bucket of water which we used for bathing, washing our utensils, washing our cloths and for cleaning the bath and restrooms. I was fortunate because my parents sent me filtered bottle water to drink, and not everyone was fortunate enough to have that privilege, but I still had to go for two to three trips before I would be able to get enough water to do all my other chores. Some of the students found other ways like cleaning their plates with tissues other than cleaning it with water and soap. It was frustrating and stressful and due to the fact that, we had to wake up very early to make our journey for water, we slept in class most of the time because we were tired. The water shortage which was caused by lack of rainfall and excessive heat dried the source from which our water came from. The water in my school’s reservoirs got finished. The experience was terrible and eventually, we were all sent home until the supply of water was restored. We had five minutes prayer session each time we met for assembly where we prayed for rainfall. In our geography class we were encouraged to plant more trees than to destroy them and were taught that these were some of the problems caused by global warming. Some students got ill, others had heat rushes on their skin due to the excessive heat, body odors and we all faced serious sanitation problems forcing the school authorities including the health department to send us all home. When we were called back to school my classmates and I decided to each bring a tree which we planted on our school property to help in the evaporation process for the future rainfall process. The experienced taught me to appreciate the flow of water in our various homes and caused me to understand some of the trouble and problems these natural disasters such as excessive heat and lack of rainfall causing drought and other social problems that individuals living in other countries face for a long time.
Many countries especially developing countries remain significantly great with impact of natural disaster such as earthquakes, volcanoes, extreme heat, famine, drought, hurricanes, tsunamis, wildfires, etc. This disasters cause about 90 percent of deaths in low and middle-income areas (1) due to the continuous lack and inadequate access to basic amenities such as running water, food, shelter and health care after the disaster strike. The poor even before the disaster strikes already live in conditions which are not very conducive making them vulnerable even before they are hit with natural environmental problems. Whether it is natural or man-made disaster, it caused damage, loss of lives, ecological destruction and major health problems (1). Before a situation may be classified as a disaster, there are not many resources available to handle the that particular situation thus expert extra support and response from outside to that particular area or country. Man-made disaster such as war can have great impact on human lives. There was 13 years of civil war in Liberia from 1990 to 2003, the country suffered an enormous amount of death and disability. It killed more than 200,000 people (3), and about 500,000 people were forced to leave their homes and became internally displaced refugees who had to flee to other countries (1). The UN High Commission for Refugees (UNHCR) who is in charge of protecting the rights of refugees reported 42, 000 Liberians living in the Budumbura Refugee Camp in neighboring Ghana, including 18,000 children and over 4,000 of these children were born in the camp. Their human rights were violated and they had to live their entire lives as refugees (3). Some of the refugees arrived in boats, canoes, helicopters and a few on cars. I remember watching the news and constantly seeing casualties and young children holding guns on the news in Liberia. One of my Liberian friend mentioned that another way to survive was to join the civil war movement and fight for that particular group, in that sense they could be able to arm and protect themselves. As he mentioned, it was just another way to survive. Perch my Liberian friend suffered cuts and a gunshot in his arm but he is now married to a Ghanaian woman, with two beautiful children. It is possible that, his initial plan wasn’t to work as a car mechanic but situation in which he found himself made him decide to do and get the best out of his life in Ghana. A lot of people who suffer from such a disaster do not always have it as Perch had; they sometimes die and mostly have psychological problems. To help the refugees who came to settle in the Buduburam Refugee Camp in Ghana, they created the Liberian Dance Troupe project which uses theatre and dance to maintain Liberian culture, and to teach the youth within the camp about HIV/AIDS, teen pregnancy and drug abuse. Adult leaders were able to train over 100 children and youth in theatre, the arts, oral and written literature, dance and music. Youth who receive cultural training carry out weekly cultural training seminars in primary schools located in the camp which have provided support to over 1000 children (3). This project has also enhanced the literacy skills of young members of the LDT and supports their psychosocial rehabilitation. They are able to raise awareness about important health and social issues while the youth are encouraged to participate in this project to build their self-confidence, acquire dignity and develop renewed sense of identity and to continue with practicing their culture even a different community and not their own country (3).
Drought another serious disaster which is mainly caused by lack of precipitation, a natural climate cycle thus causing an extended dry period (2). Drought leads to serious shortage in water and food. Shortage of water leads to shortage of food, no water to cultivate and harvest food crops to eat. In 2005, Niger suffered an agricultural problem locust outbreak and drought which lead to famine. The drought affected more than 3.6 million people and put them at risk of starvation (4) thus they seek international aid for food.
Natural and man-made disasters are all major problem to our health and to the entire environment in which we live in. It is indeed true that most of the natural disasters, we as human can not always prevent them but as little as we can such as using more green products can also help in taking little steps and trying to be rational on issues to prevent conflicts can go a long way in saving life and preventing some man-made disaster as wars. I know its not as easy as it sounds but as an African, I know in a developing country such as Ghana when there is conflicts which can spark to a major problem, the governments do not only handle the issue themselves but involves the local leaders who are mostly opinion leaders in that particular region. Involving these opion leaders are able help solve regional conflicts for example which goes a long way because they eventually after a long process compromise and then resolve the issue. It makes these opinion leaders feel important and also they serve as a better channel for the group who are dissatisfied in sometimes very minute misundersatnding. The culture of a group of people are to be respected when trying to help and bring peace among people in a particular palce or even a country. I think its best for local leader and government in most developing countries to give basic education to its people, in doing that, certain basic things that contribute to misunderstanding may be solved by knowing the facts and practicing to live a better and healthy life styles. Education goes a long way because it does not only expalin basic concepts but goes a long way by helping people become more rational on issues and open minded on things they might have not thought of and due to past expereinces they might learn to tale some approaches that other countries took to make their nation a better one. Wars pull us back especially with the health sector because it spoils a nation rather than fixes the nations. Since we all want to move forward in having better life styles and increasing our life span its important to discourage any man-made disaster and try not to pull back in increasing factors that would contribute to natural disater. There is great impact on disasters, nations suffers when thre is one, so we must all move forward by not encouraging any form of disaster among ourselves and in our various countries.




References

Skolnik R. Natural Disaster and Complex Humanitarian Emergencies. Essentials of Global Health. Sudbury, MA: Jones and Bertlett Publishers; 2008: 247-262.

World Health Organization, 2009. Retrieved
http://www.who.int/hac/techguidance/ems/drought/en/

Liberian Trauma Recovery and Cultural Awareness, 2009. Retrieved
http://www.warchild.org/projects/WC_Canada/Liberia_Ghana/liberia_ghana.html

Niger, country, African: History, 2009. Retrieved
http://www.infoplease.com/ce6/world/A0860001.html