Test 4

Critical Actions followings CHEs-safe/healthy environment

-15 L/day of water is recommended within 500 ft and with a max. wait time of 15 minutes -provide at least 1 toilet for every 20 ppl; should be within 50 ft; segregate toilets by sex to help protect women -provide MHM materials for women -educated people about the importance of soap and ensure soap os accessible -immediately provide shelter for people; in the wonder term, improve the quality of the shelter and ensure security for women

Overview of CHEs

-1975-1985: avg of 5 CHEs per year -end of 190s: avg of 40 CHEs per year -CHEs have generally had a greater impact than natural disasters during the past decade -UN: Yemen is the worst humanitarian crisis in 2018, and the worse since 1945

How many people worldwide are overweight/obese?

-2.1 billion people -nearly 30% of the world's population

Origins of Rwandan Genocide 1960-

-3 diff. groups of ppl lived in Rwanda: Hutus, Tutsis, and Twa -differences between the two largest groups weren't necessarily ethnic—they were defined by class, occupation, clan, etc (exploited by Belgian colonists) -the smaller of the two main groups were the Tutsis (~14%); they were generally cattle herders and had higher SES than Hutus, who made up ~85% of the pop -Belgian missionaries helped place Tutsis in power, thinking of them as being ethnically superior to Hutus (used facial features and other techniques similar to that what would be used by Nazis) -Rwandans had to carry ID cards identifying their ethnic group -1959-1960: revolution took place and Hutus won control of Rwanda in a subsequent election -Hutus lashed out at Tutsis, following decades of oppression -Tutsis began leaving Rwanda-many went to Uganda -~1960-1970, nearly 20k Tutsis were killed -Rwandad exiles in Uganda were training and coalescing, looking for an opportunity to return to Rwanda -1990: civil war broke out in Rwanda -Rwandan exiles from the Tutsi minority group (the Rwandan Patriotic Front, or RPF) were based in Uganda at the time -they staged an offensive against the current Rwandan leadership for failing to fix the problem of the refugees -all Tutsis in Rwanda were considered accomplices -Hutu moderates were considered traitors -1992: Peace agreement reached -4/6/1994: place carrying the Rwandan president and the Burundian president were shot down; both were killed

Treatment—MDR cases of TB

-4 second-line drugs taken in combo w/ pryazinamide: fluoroquinolone, parenteral agent, ethionamide/prothionamide, cycloserine/para-animosalicylic acid if cycloserine can't be used -expert opinion needed -drug susceptibility should be checked -treatment is 20 months if not previously treated patients, 30 months in previously-treated people

TB Burden

-8.7 million incident cases -13% wre co-infections w/ HIV -310k cases of MDR-TB -China and India have the largest number of cases -Sub-Saharan Africa has most active TB per capita -1.4 million deaths

Vaccine Efforts

-BCG vaccine: typically given to babies in endemic areas, not usually in non-endemic areas -about 50% in effective in preventing active TB in adulthood -BCG can cause disseminated TB in immunocompromised individuals (contraindicated) -currently: >30 vaccines in development, 12 in clinical trials

Mental Health in CHEs

-CHEs are associated with a range of social and psych shocks to affected people due to changes in their way of living, their loss of livelihoods, damaged social networks, and physical/mental harm to them, their families, and their friends -considerable disagreement among those working with CHEs about the validity of defining the impact on people affected by CHEs through the framework of a Western medical model of mental health -children who have been through conflict situations do suffer from high rates of both PTSD and depression -a number of those involved with the mental health impacts of CHEs believe that the stress placed by some on PTSD is not valid; small minority need psychotropic medication, most need to rapidly rebuild their lives and social networks

refugee (under int'l law)

-a person who is outside his/her country of nationality or habitual residence, has well-founded fear of persecution because of his or her race, religion, nationality, membership in a particular social group, or political opinion, and is unwilling to avail him/herself of the protection of that country, or to return there, for fear of persecution -subgroup of boarder category of displaced persons -CHEs cause people to migrate and become refugees -UN High Commissioner for Refugees is responsible for protecting the rights of refugees

z-score

-a statistical term, meaning the deviation of an individual's value from the median value of a reference population, divided by the standard deviation of the reference population

Health burden of volcanoes

-about 90% of deaths from volcanoes due to mud and ash or from floods on denuded hillsides affected by the volcano -can arm health by displacing people, rendering water supplies unsafe, and causing mental health problems among affected population

Inter-Agency Standing Committee of WHO—guidelines on mental health and psychosocial support in emergency settings

1. human rights/equity 2. participation 3. do no harm 4. building on available resources/capacities 5. integrated support systems 6. multilayered supports

case fatality rate

the number of deaths from a specific disease in a given period, per 100 episodes of the disease in the same period

MDR-TB Partners in Health Video narrated by Brad Pitt

-DOTS created to cure all; best TB program in world but so many still suffering from TB -PIH found that DOTS wasn't working even though it was functioning effectively and people were taking their meds because so many cases were resistant -many healthcare officials were saying DOTS is curing everyone; resistance isn't an issue -authorities ignoring growing threat because they believed there was nothing that could be done; no drugs were donated -PIH showed that people could treat the MDR-TB to prevent the spread -85% of patients considered un-curable were disease-free -WHO now recommends MDR-TB treatment plan based on Peru

Haiti's 2010 Earthquake Relief Effort

-Dw/oB played a key role in the relief effort -the timeliness and scale of response strengthened by fact that it had already been providing health services in Haiti for 19 yrs prior to eh earthquake -providing emergency medical services was the first priority for MSF after the earthquake -to perform life-saving surgeries and wound care, MSF created new emergency facilities -MSF sent more surgical supplies and increased number of personnel on ground -creating sanitary conditions suitable for performing surgery was one challenge faced in this stage of the emergency response -nature of emergency care for earthquake-related injuries soon shifted with time, from lifesaving to treating infected wounds -provision of emergency obstetric care was also a priority, which is crucial to saving maternal life -psychological care was integrated with emergency care for trauma patients -providing primary health care was also a priority for MSD, which was addressed by setting up additional primary health clinics

Genocidaires in Goma, DRC

-Genocidaires fled Rwanda and settled near Lake Kivu, DRC -around 50k ppl died in the first month from cholera and dysentery -humanitarian aid began 3 weeks after the initial migration -an initial assessment blamed diarrheal disease for >90% of deaths -food shortages were prevalent -meningitis broke out -rocky, volcanic soil made it difficult construct latrines -food were not equitably distributed by Hutu leaders -some estimates suggest that 1/3 ppl in the refugee camps were murderers -the UNHCR coordinated a response in August -vaccinations, disease surveillance, vitamin A supplementation, water were provided -a number of lessons were learned

Rwandan Genocide

-President's death sparked immediate (within hours) violence against Tutsis and moderate Hutus -Hutus eliminated moderate leaders within a day -Tutsis and those suspected of ties to Tutsis were killed over the next few weeks -Hutu extremists took control of the country -lists of Tutsis to be killed were created by the government -government radio stations fueled campaigns based on hate and called for Hutus to Murder their Tutsi neighbors and even family members

complex emergency/complex humanitarian emergency (CHE)

-a complex, multi-party, intra-state conflict resulting in a humanitarian disaster which might constitute multi-dimensional risks or threats to regional and international security -frequently, state institutions collapse, law and order break down, banditry and chaos prevail, and portions of the civilian population migrate -situations affecting large civilian populations which usually involve a combo of factors, including war or civil strife, food shortages, population displacement, resulting in significant excess mortality -affect large numbers of people -severe impacts of availability of food, water, shelter -create refugees -e.g. war, civil conflict

Dr. Boghuma Kabisen Titanji: Ethical riddles in HIV research

-after finishing trial in which transportation costs and ART was provided, HIV+ treatment stopped going to clinic and got sicker -didn't no what drugs she had taken/needed or the goal of the trial had given informed consent but didn't understand the implications of being a participant or what would happen afterwards -HIV clinical trials in developing countries can be extremely useful tools and are needed to address burden -inequalities between richer/developing counties in terms of funding pose risk of exploitation (esp in externally funded research) a lot of studies conducted in developing countries would never be authorized in richer countries which fund the research -they are conducted in sub-Saharan Africa bc of high incidence of new infections -research easier to conduct there because of widespread poverty, endemic diseases, and inadequate health care systems, lower risk of litigation, less rigorous ethical reviews, pops that are willing to participate in almost any study that hints at cure -recommendations: appropriate/effective informed consent procedures -ppl in LMIC take almost any offer of medical assistance, standard of care that is relevant for context of study/most beneficial to participants, effective system for ethical review to protect participants independent of gov't and research sponsors, clear plan post-research

Lessons in cost-effective ways for external partners to help in addressing the disasters

-although many countries send search and rescue teams to assist the victims of natural disasters, the effort of such teams are not cost effective -by the time these teams arrive, most victims will have been safe or dead -many countries will send field hospitals to disaster areas but by the time they arrive, they are of little value in addressing the most urgent trauma cases -more cost effective to have fewer field hospitals but to have a few that will remain in place for some time, in addition to building some temporary but durable buildings that can also serve as hospitals -countries send diff. kinds of goods to disaster-affected places but these goods can be inappropriate to the needs of the problem -better results occur when the affected country clearly indicates what it needs and other countries send only those goods -providing cash/building materials to affected families allows them to rebuilt as quickly as possible, in a manner in line with their cultural preferences

CHEs—Assessments and Surveillance

-among the first things that needs to be done in emergency phase is assessment of the displaced population and establish a system for disease surveillance -assessment would try to immediately gather info on the number of people who are displaced, their age and sex, their ethnic and social backgrounds, and their state of health and nutrition -it is difficult to get this info in the chaotic movements of an emergency, it is impossible to rationally plan services for displaced people without this info -surveillance system must be simple but still give a robust sense of the health of the affected community -given importance of nutrition and likelihood for undernourishment, it is essential that the weight for height of all children younger than 5 be checked -it is also important to have surveillance for diseases that cause epidemics among displaced persons, such as measles, cholera, and meningitis -goal in a public health emergency is to keep rate below 2/10 per day

disaster

-any occurrence that causes damage, ecological destruction, loss of human lives, or deterioration of health and health services on a scale sufficient to warrant an extraordinary response from outsize the affected community area -an occurrence, natural or man made, that causes human suffering and creates human needs that victims cannot alleviate without assistance -some are rapid onset; others are slow onset -although long-term effects can be substantial, often characterized by an initial event and then its aftereffects

Critical Actions Following CHEs

-asses the health situation -set up a disease surveillance system

Addressing Health Effects of CHEs

-avoidance of conflict lies in political realm, rather than measures that are directly health related -primary prevention means stopping the violence -early warning systems for natural disasters don't exist for political disasters -some groups carry out analyses of political vulnerability in countries, corruption, and the risk of political instability, these analyses aren't used to prepare contingency plans for civil conflict -it would be prudent if orgs, countries, and int'l bodies would cooperatively establish contingency plans for areas of likely conflict -it would be prudent to stage near such areas the material needed to address displacement and health problems that would occur if conflict breaks out

low birthweight

-birthweight less than 2500 grams

anemia

-body has insufficient RBCs or quality of RBCs is poor -RBCs are generally produced in the bone marrow -healthy RBCs last for ~3-4 months and then are replaced -low level of hemoglobin in the blood, as evidenced by a reduced quality or quantity of red blood cells

body mass index (BMI)

-body weight in kilograms divided by height in meters squared

Lessons learned from Response to Earthquake in Pakistan

-buildings in rural areas in seismic zones should be built or designed to decrease human injury -governments should analyze existing risks to their ability to rapidly respond to emergencies and prepare emergency plans in advance that take those risks into account -donations of materials and supplies should be managed carefully so that they fit real needs -the expertise of nongovernmental organizations can be very helpful in addressing natural disasters, particularly if the involved organizations already have a presence in the affected country

Critical Actions followings CHEs-disease surveillance system

-consider nutritional monitoring for kids -consider disease that may become epidemic

Features of CHEs

-generally long-lasting -are increasingly civil wars -relief workers often not allowed -humanitarian workers increasingly targeted by fighters -civilians often purposely targeted by fighters -human rights violations often pursued as tools of war (rape, sexual abuse, torture) -health facilities often purposely destroyed -people often forced or choose to flee -food and water insecurities likely -health systems break down -migrating pops often exposed to new diseases or bing diseases to new areas

Haiti's 2010 Earthquake

-given the magnitude of the earthquake, the poor quality of construction, and the exceptionally poor living conditions, the earthquake caused major devastation -country's already weak health system was ill equipped to handle the overwhelming health needs -60% of existing health facilities destroyed -10% of medical staff killed or absent from the country

CHEs—Disease Control

-control of communicable diseases is one of the first priorities in the emergency phase of a disaster, especially a complex humanitarian emergency -important priority in the emergency phase of a CHE is to prevent an epidemic of measles (vaccination all all children from 6 months to 15 yrs) -priority to ensure that children up to 5 get vitamin A -systems need to be put in place so that other epidemics that sometimes occur in these situations can be detected and urgently addressed -proper management of diarrhea in children and the appropriate diagnosis and treatment for malaria (in prevalent zones) -health education and hygiene promotion must take place continuously to try to help families prevent the onset of disease -measures need tone in place to handle injuries and trauma, first to stabilize people and then to refer them to receive additional medical help -immediate need for reproductive health services bc there will almost always certainly be pregnant women among the displaced people -care of noncommunicable diseases will be a lower priority in emergency situations than addressing communicable diseases -some psychiatric problems require urgent attention and need to be treated as effectively as possible with counseling and continuation of meds -as emergency recedes, greater attention can be paid to long-term treatment, counseling, and psychosocial support for dealing with mental health and the many disruptions people have faced

TB-Symptoms

-coughing up mucus -coughing up blood -night sweats -fatigue -fever -weight loss -possibly breathing difficulty, chest pain, wheezing

Addressing the Health Effects of CHEs

-currently, there are some predictions about the likelihood of political instability, but they're not used to create contingency plans -contingency plans should be created -materials to respond to CHEs should be located near potential conflict sites

Broth culture

-diagnose sputum-smear false-negatives -check for drug resistance -get bacteria to grow under treatment -phenotypic assessment

New Yorker's Spector TB article

-disease of urban poverty, passed easily in poorly ventilated spaces -the leading cause of death among people between fifteen and forty-five—the most productive age group in any country and the key to India's prospects forcontinued economic growth. -Public hospitals are so overcrowded that people are forced to rely on inaccurate tests dispensed at private labs/clinics -private sector are unregulated enterprises, and peddle blood tests that are responsible for tens of thousands of misdiagnoses every year. -In India, China, and Africa, at least two billion people have latent infection -every day thousands are told,mistakenly, that they are sick and need treatment -TB is the source of misguided stereotypes, including the association of consumption with creativity and brilliance - most serious toll on the industrial-labor class (grew with rise of industry) -1994, the W.H.O. instituted a program called DOTS, which stands for "directly observed treatment, short course -GeneXpert, allows doctors to diagnose TB in under two hours (very expensive)

Weather-related natural disasters

-droughts -heavy rains -hurricanes, typhoons, and cyclones (same weather phenomenon) -causes of weather conditions: pre-existing weather disturbance, warm tropical oceans, moistures, relatively light winds

Non-weather-related Natural Disasters

-earthquakes: generally kill more people that other types of natural disasters -tsunamis: a series of ocean waves generated through natural processes in the ocean floor -volcanoes

TB—Risk groups and factors

-elderly -infants -immunocompromised individuals -undernourished people -crowded conditions -close proximity to those with active TB -people experiencing homelessness (due to nutrition, environment)

Lessons from Rwanda Genocide Health Response

-establish early warnings for CHEs -prepare in advance for CHEs -strengthen the existing nongovernmental groups with capability to respond to CHEs

What is the guiding principle that PIH uses?

-everybody deserves access to best quality treatment

overweight

-excess weight relative to height -commonly measured by BMI among adults -25-29.99 for grade I (overweight) -30-39.99 gor grade II (obese) ->40 for grade III -for children, overweight is measured as weight-for-height two z-scores above the international references

obesity

-excessive body fat content -commonly measured by BMI -the international references for classifying an individual as obese is a BMI greater than 30

Treatment—Extensively Drug Resistant Cases

-extremely difficult to diagnose and treat -case fatality can be -~98% w/ HIV-coinfections -some drugs are in clinical trials

Causes of Malnutrition

-food availability and utilization -disease prevention -quality of maternal and child care

CHEs—Food

-food rations should be distributed by family units -special care needed to ensure that female-headed households and children w/o families get their reactions -vitamin A should be given to all children -most severely malnourished children may also need urgent nutrition supplementation

Treatment—Non-MDR cases of TB

-for active cases, drugs must always be taken in combination, never alone -first-line drugs taken as a combo of 4 (~90 cure rate): isoniazid, rifampin, pyrazinamide, ethambutol -adhering to a treatment schedule is essential

Lessons Learned from Past Natural Disasters

-foreign search and rescue operations: generally not cost-effective -send fewer field hospitals, but plan for them to remain for a longer period of time -construct other "temporary but durable buildings that can also serve as hospitals" -instead of erecting a lot of tents, send cash and building materials to families to help them rebuild as quickly as possible

Shortcomings of Rwanda Genocide Response

-general lack of preparedness for dealing with this type of emergency, despite well-known political instability at the time -medical teams on ground didn't have the physical infrastructure or the experience needed for a task of this magnitude -the work of the military forces that joined the effort wasn't integrated into the planning fo the other efforts

Links Between Nutrition & Health of Mothers/Children

-good maternal nutrition and avoiding obesity is essential for good outcomes of pregnancy for mother/child -EBF for 6 months promotes better health and better cognitive development for infants than mixed breastfeeding with other foods during that period -nutritional deficits in fetuses and in children under 2 years of age may produce growth and development deficits in infants and young children that can never be overcome -about 45% of all deaths in children under 5 yrs worldwide are assoc. with nutritional deficits -underweight and micronutrient deficiencies in children make those children more susceptible to illness, cause illnesses to last longer, and can lead to deaths from diarrhea, measles, pneumonia, and malaria that might have been prevented -rapid weight gain in children who were underweight is assoc. later in life with obesity and noncommunicable diseases -obesity and women and men is assoc. with a range of noncommunicable diseases, such as heart disease, stroke, and diabetes

Response to Earthquake in Pakistan

-gov't created Federal Relief Commission and Earthquake Rehabilitation and Reconstruction Authority that offered short/long-term recovery efforts -a week after, the gov't presented a relief plan that included compensation for survivors -World Bank and Asian Development Bank conducted assessments to identify vulnerable groups and areas that might hinder early recovery -South Asia Earthquake Flash Appeal created to receive donations for the recovery effort -Doctors w/o Borders an integral part of the interventions, as it provided emergency relief within a day of the earthquake, given that MSF medical teams were already on ground in Kashmir -these teams focused on hygiene promotion, administer 30k measles vaccines, and later redirected attention to rebuilding medical infrastructure -despite national/international efforts to mobilize an effective response, injured indivs flooded hospitals that were still intact but didn't have the personnel or the equipment to respond effectively -many patients suffered more severe secondary complications due to prolonged waiting for medical treatment, a common occurrence when earthquakes significantly affect the medical system -small, remote villages remained inaccessible bc of significant road damage

Addressing Health Effects immediately after Natural Disasters

-health effects of rapid-onset natural disasters occur in phases, starting with immediate impact and then continuing for some time until displaced ppl can be resettled -it is important that health situation be assessed immediately after disaster has occurred; this will set basis for initial relief effort -immediately after, care must begin for those injured in the disaster -once immediate trauma cases are taken care of, relief workers and health service providers can turn their attention to other injured people in need of early care/treatment -in early stages, public health functions: establishment of continuous disease surveillance among the affected populations and provision of water, shelter, and food -ensure access to WASH including MHM -ensure that external actors coordinate their efforts, work together, and involve the affected communities

Disaster preparedness for natural disasters can be formulated to...

-identify vulnerabilities -develop scenarios of what might happen and its likelihood -outline the role that different actors will play in the event of an emergency -train first responders and managers to deal with such emergencies

Complex Emergencies and Health

-impact on health over last decade has been considerable greater than that of natural disasters -go on for long periods of time -common that one or more of groups that are fighting will not allow humanitarian assistance to be provided to other groups -humanitarian workers have increasingly been the targets of those who are fighting, despite what should be their protected status -combatants often intentionally target civilians for displacement, injury, and death -many fighters engage in systematic abuse of human rights, including torture, sexual abuse, and rape as a weapon of war -disruption of society leads to foot shortages -common that publicly supported health system may break down entirely -damage to water supply and sanitation systems -migration of large numbers of people, some of whom will live in camps, brings with it a number of problems -diseases can spread faster among refugee pops than normally bc of large number of people living in crowded conditions, often w/o appropriate hygiene and sanitation -large numbers of migrants need care from health systems that were weak before and now may be nonexistent after suffering the effects of civil conflict -many factions in civil conflicts use landmines

Causes of deaths in CHEs

-in early states of dealing with large numbers of displaced ppl in CHEs, most deaths occur from diarrheal diseases, respiratory infections, measles, or malaria -diarrheal diseases are generally the most common cause of death in refugee situations -epidemics of dysentery and cholera have occurred in refugee games -measles has also been a major killer in camps for displaced persons (esp. significant in populations that are malnourished and not-immunized) -malaria is also a significant contributor to death in refugee camps (esp. when refugees move from countries in which there is rel. little malaria to places in which it is endemic) -acute respiratory infections are also major causes of deaths in refugee camps -outbreaks of meningitis and hepatitis E have also occurred in refugee camps -the pops that are affected by CHEs are generally poor and not well nourished, and nutritional issues are always of grace concern during CHEs, when there may also be problems of food scarcity -the relationship of infection and malnutrition also poses risks to discalced populations -underlying nutritional status of refugees or internally displaced people is often poor and micronutrient deficiencies can also be very important in CHEs -women and children who are in the camps w/o a male adult are at particular risk of not getting enough food in camps and of suffering acute protein-energy malnutrition and micronutrient deficiencies

Underlying Causes of Malnutrition

-inadequate access to food -poor health services and environment -inadequate care for child and women

Tuberculosis

-infectious bacterial disease caused by Mycobacterium tuberculosis -contracted by breathing droplets from a cough/sneeze from an infected person with active disease -about 1/3 of all people are infected -TB cases on the rise in some areas -infection may remain dormant for years -there can be a long lag-time between infection and symptoms -symptoms tend to be non-specific -most infected people lack access to appropriate diagnostic testing -drug resistance is increasing: 84 countries have extensively drug-resistance TB

CHEs—Safe and Healthy Environment

-it is critical in camps and other situations with large numbers of displaced people that efforts be made to ensure that environmental and personal hygiene are maintained -key to avoiding the potentially serious effect of diarrheal disease -providing appropriate sanitation in situations of displaced people is also very challenging -goal is one toilet every 20 people, separated by sex, not more than 50 m from dwellings -many displaced ppl poor w/ little educations and poor hygiene practices -important to make community aware of the importance of good hygiene and to see that soap is available to all families and used -in short-term, goal is to have families be sheltered temporarily with other families -whenever possible, local and culturally appropriate building materials should be used -short run, aim to get people into covered areas

Health burden of earthquakes

-kill many people quickly -cause a substantial number of injuries in very short period of time -in longer term, earthquake survivors face increased risks of permanent orthopedic disabilities, mental health problems. and increase in rate of heart disease and other chronic disease -indirect effect of earthquakes on health depends on the severity and location of the earthquake and the extent to which it damages infrastructure and forces people out of their homes

Preemptively Create Natural Disaster Preparedness Plans

-known the geographic regions of the world prone to natural disasters -determine vulnerabilities before the disaster strikes -develop scenarios and consider their likelihood -prior to the disaster, identify roles and responsibilities of the major actors who will respond to an emergency -train first responders and managers to response appropriately -during construction, seek to make critical infrastructure (e.g. WASH, healthcare facilities) less vulnerable to damage

stunting

-low height-for-age -indicates long-term, cumulative nutrient deficiencies -failure to reach linear growth potential because of inadequate nutrition or poor health -stunting is measured as height-for-age two z-scores below the international reference

underweight

-low weight-for-age -two z-scores below the international reference for weight-for-age -implies stunting or wasting -indicator of undernutrition

wasting

-measures weight-for-height -indicates acute undernutrition -weight, measured in kilograms, divided by height in meters squared, the tis two z-scores below the international reference

Genocide in Rwanda

-nearly 1 million Hutus tried to escape persecution from the newly established gobv't of Rwanda led by Tutsis -borden town of Goma in what is now the DRoC became entry point for majority or the refugees -almost 50k ppl died in the first month after the start of the influx, largely result of epidemic of cholera, followed by epidemic of bacillary dysentery -crude mortality rate the highest by a considerable margin over rate found in any previous CHE -diarrheal disease affected young children and adults alike, whereas normally young children are more severely affected than adults -diarrheal disease contributed to 90% of deaths -food shortages were prevalent, esp. among female-headed households -acute malnutrition afflicted up to 23% of the refugees -meningitis epidemic arose -circumstances complicated by the large number of people who fled in such a short period of time -Hutu leaders given control over distribution of relief, but this didn't provide for the equitable distribution of food that was hoped for

Rwandan Genocide—Health Consequences

-nearly 100k children are orphaned, abducted, or abandoned -26% of the Rwandan population currently suffers from PTSD

Natural Disasters

-number is increasing -affect more people in the past (partly bc of larger pop) -smaller proportion go people die as a result, but >90% of deaths occur in LMIC (better preparedness, response, not bc of preparedness) -poorer people are more likely: to live in areas prone to natural disasters, have houses lacking structural stability, lose a greater proportion of assets -climate change may exacerbate natural disasters

Earthquake in Pakistan

-over 3 million homeless -many indivs buried under rubble or injured in debris -88k lost lives from instantaneous death, such as severe head injury or internal bleeding, or delayed death, such as wound infections -80k ppl injured -65% of all previously existing healthcare facilities failed to withstand the seismic forces and collapsed

Elizabeth Pisani:Sex, drugs and HIV — let's get rational

-people get HIV not just because they do stupid things -For most of them, when they are doing stupid things, they have perfectly rational reasons -Most of the people in Africa know sex and blood can transfer HI -they also know where to buy clean needles, but because of gender inequality and poverty, sometimes people choose to "rationalize" things even though they know there is a great chance that they may get HIV. -everyone has a duty to demand our politicians to make policy based on scientific evidence and on common sense

internally displaced people (IDP)

-people who flee or are forced to migrate during a disaster or complex humanitarian emergency and leave their homes but stay in the country where they were living -someone who has been forced to leave their home for reasons such as religious of political persecution or war, but has not crossed an international border -subset of more general displaced person -no legal definition -legal status of IDP is not as well defined as that for refugees -unlike the case for refugees, no agency or org is responsible for IDPs; their own gov't is responsible for them, but that gov't is often part of problem as to why they are fleeing

Treatment Challenges (non-MDR-TB)

-poor/patchy drug quality -need for directly-observed treatment -need for additional patient support -treatment discontinuations -side-effects -drug toxicity -interactions with other drugs -compliance over a long time-period

Implications of improved surveillance

-possibility of treating more people appropriately -possibility of treating fewer people who do not need treatment -"possibility" because having data doesn't mean having resources to provide treatment -TB treatment costs tens to hundreds of dollars per patient -MDR-TB treatments costs thousands of collars and requires specialized drugs and skills

Characteristics of CHEs

-potentially massive displacement of people -the likelihood that displaced people will live in camps for some time -the need in camps for adequate shelters are water, sanitation, and food -the importance of security in the campus, especially for women -the need to address early in the crisis the potentially worst health threats, which are malnutrition, diarrhea, measles, pneumonia, and malaria -the need to avoid other epidemic diseases, such as cholera and meningitis -the need as one moves away from the emergency phase of a CHE to deal with longer term mental health issues, primary health care, TB, and some non-communicable diseases

Primary goals of humanitarian response to disasters

-prevent and reduce excess morbidity and mortality -promote a return to normalcy

TB Diagnosis via Sputum Smear Microscopy

-pros: inexpensive, available in many lab worldwide, fast, highly specific -cons: sensitive, can't assess drug resistance

Critical actions following CHEs

-provide a safe and health environment -provide at least 2.1k kcal/day/adult -ensure the female-headed households and unaccompanied children get food rations -provide vitamin A supplement to all children -provide additional nutritional supplementation as needed for children -control communicable diseases

Natural Disasters and Damage to Infrastructure

-roads -water sources -sewage and sanitation systems -schools -healthcare facilities

Violence against women in CHEs

-security conditions during CHEs put women at considerable risk of sexual violence -rape may be used as a weapon of war -the chaos and economic distress of conflict situations place women at risk of sexual violence and sometimes force them to trade sex for food or money ("survival sex") -data on sexual violence against women during CHEs are not good

Characteristics of Natural Disasters

-some relate to weather: droughts, hurricanes, typhoons, cyclones, and heavy rains -some caused by mvmnt of tectonic plates: tsunamis, earthquakes, volcanoes -earthquakes are the natural disaster that generally kill the most people -the number of natural disasters is increasing, affecting larger numbers of people, causing more economic losses than earlier but causing proportionately fewer deaths than before -the biggest rel. impact of natural disasters is in LMIC -the rel. impact of natural disasters on the poor is greater than on the better off because the share of the poorer people's total assets that are lost in disasters is greater than that lost by higher-income people -the poor are often the most vulnerable to losses from natural disasters because they live in places at risk from such disasters or have housing that cannot withstand such shocks -climate change could have impt impact on the number, type, and severity of natural disasters in the future -can cause significant harm to infrastructure, such as water supply, sewage systems, roads, health infrastructure itself (hospitals, health centers, clinics) -people can die direct as result of natural disaster or as an indirect result because of epidemics linked to lack of safe water or sanitation, food, or access to health services or as a result of living in camps, which pose a range of health hazards

Myanmar: Cyclone Nargis

-submerged entire towns -killed over 138k -left hundreds of thousands of survivors homeless -Rice Bowl of Myanmar (farmers, fishermen, laborers, and traders) experienced the worst destruction of infrastructure, water supplies, homes, fuel, and electricity & livelihood swept away with cyclone -Myanmar didn't have resources to adequately respond: health system weak, rural population (70%) had little/no access to basic health and sanitation services or clean water before cyclone -lacked healthcare professionals needed to deliver critical healthcare services -1/4 ppl lived below poverty line -already suffered from high burden of communicable disease, including malaria and TB -gov't was repressive, nontransparent, and limiting of political freedom -in aftermath, need for emergency relief efforts was exacerbated by poor health and living conditions -short-term needs included emergency health care for cyclone-related injuries: basic necessities for survival, such as food, shelter, water, and sanitation services; and provision of mental health services -in longer term, reconstruction of infrastructure for health, shelter, food, and transportation -gov't forced many relief workers to give aid directly to them -abuses against healthcare workers and cyclone survivors, including land confiscation and forced relocation of succors -delay in int'l response may have contributed to high rate of early mortality -mishandling of aid and strict gov't control of relief efforts prevented aid form reaching many survivors for more than a year after the cyclone

Health burden of tsunamis

-take most victims immediately by drowning -cause relatively few injuries, compared to number of deaths

TB Diagnosis—GeneXpert

-tests for rifampicin (drug) resistance -imperfect/genotypic assessment is worse than phenotypic assessment (broth culture) -rifampicin resistance is essentially a proxy for MDR-TB -skilled labor not necessary -sensitivity better than traditional smear microscopy and worse than broth culture (2 test=62% sensitivity in HIV+ patients) -requires disposable cartridges ($17-120 each) w/ short shelf-lives -requires annual machine servicing by technicians

Rwandan Genocide—Genocide & Rape as a Tool of War

-the RPF fought back against the Hutu extremists -Hutus came to believe that the solution to their problems was to eliminate all Tutsis -between 250k and 500k women were raped

Rwandan Genocide—Aftermath

-the US and other international players claimed to be taken by surprise by the genocide, but they had been warned of impending violence months earlier -the international community refused to step in to stop the killings; an ill-equipped UN force was eventually sent, but did little -RPF gained control of the country by July 1994 -Hutus feared reprisal killings and many left Rwanda

Health Effects of Complex Humanitarian Emergencies

-the burden of illness, disability, and death related to complex humanitarian emergencies is large and probably underestimated, given the difficulties of collecting such data -between 320k and 420k ppl are killed each year as a direct result of these CHEs -illness, disability, and death come about as an indirect result of these emergencies (malnutrition, the lack of safe water and sanitation, shortages of food, and breakdowns in health services) -illness, disability, and death are exacerbated by the crowded and difficult circumstances in which people have to live when they are displaced -the burden of deaths related to wars is also hard to estimate -child mortality rates early in the CHE are two to three times the rates of adults but they slowly decline to those of the rest of the pop -data on deaths by gender are limited

attack rate

-the cumulative incidence of infection in a group observed over a period of time during an epidemic -the extent to which diseases might spread in a refugee depends partly on the attack rate

undernutrition

-the outcome of insufficient food intake (hunger) and repeated infectious diseases -the three most commonly used indexes for child undernutrition are height-for-age, weight-for-age, and weight-for-height -for adults, underweight is measured by BMI less than 18.5

Why are overweight and obesity especially important?

-the prevalence has been increasing in almost all countries -they are closely linked to a number of communicable diseases (heart disease, stroke, and diabetes) -prevention of the problems assoc. with overweight/obesity is complex and involves strategies in a variety of sectors and across individual, local, nutritional, and global spheres -treating these problems can be extremely costly

crude mortality rate

-the proportion go people who die from a population at risk over a specified period of time -for addressing CHEs, generally expressed perf 10k population, per day -one of the significant indicators of the health impact of a complex humanitarian emergency

iodine deficiency disorders (IDDs)

-the spectrum of IDDs includes goiter (growth on thyroid), hypothyroidism, impaired mental function, stillbirths, abortions, congenital anomalies, and neurological cretinism

Role of Radio in Rwandan Genocide

-the whereabouts of Tutsi targets were publicized via radio -Tutsis were dehumanized and demeaned -the genocide was portrayed as a slave uprising, given the history of how Hutus had been treated -During a 100-day period, 800k Tutsis and moderate Hutus are killed, called the quickest killing spree the world has ever seen

Data on nutrition

-there are many gaps in data on nutrition -it is difficult to find a single consistent data set that treats issues from low birthweight to micronutrient deficiencies to overweight and obesity, organized by World Bank region -some critical data on nutrition aren't broken down into consistent age groups -existing data on nutrition are often shown using different regions

vitamin A deficiency

-tissue concentrations of vitamin A low enough to have adverse health consequences such as increased morbidity and mortality, poor reproductive health, and slowed growth and development, even if there is no clinical deficiency

Health Effects of CHEs

-trauma -malnutrition (protein energy malnutrition and micronutrient deficiencies) -lack of water, sanitation, and hygiene infrastructure -food shortages -lack of health services -conflict-related deaths -violence against women (e.g. survival sex, rape) -mental health problems, such as PTSD (this is a debated issue)

TB-Diagnosis

-two standard methods: sputum spear microscopy & broth culture -variety of other specialized tests and assays provide food info, but require specialized equipment and skills

Latent TB

-typically, in high-endeminicity countries, most people w/ latent TB aren't treated -children <5 who live with people with active pulmonary TB should be treated -people with HIV should be treated -example countries: South Africa ~80%, India ~40% -in low-endemicity countries, a variety of additional risk groups are also treated (e.g. individuals experiencing homelessness, ppl w/ diabetes)

Critical Actions followings CHEs-control communicable diseases

-vaccinate all children (6 months to 15 yrs) against measles -provide vitamin A sups to all children under 5 -set up disease surveillance systems -manage diseases such as diarrhea and malaria in children -provide good health education -promote good hygiene practices with children and adults -ensure that trauma and injuries are adequately addressed -provide care for pregnant women -NCDs are often lower priority at the beginning of a CHE, but some need to be addressed immediately (e.x. psychiatric problems)

malnutrition

-various forms of poor nutrition -underweight or stunting and overweight, as well as micronutrient deficiencies are forms

Health burden of natural disasters

-very few data available on the morbidity and disability assoc. with natural disasters -in storms and flooding, most fatalities occur from drowning and few deaths result form trauma or wind-blown objects -flood-related events generally leads increase in diarrheal disease, respiratory infections, and skin diseases -most problems that relate to natural disasters, are relatively short lived, except for a drought-related famine -epidemics usually don't spring up as result of natural disasters, except in drought-related famine and when health systems are completely destroyed for long periods of time -few data on the distribution by age and sex of morbidity, disability, and death related to natural disasters -being very old, very young, or very sick makes one more vulnerable to disasters in which one has to flee for survival -women face considerable risks in the aftermath of natural disasters if housing had been harmed and ppl are living in camps

Take Home Messages about TB

-we don't have good diagnosis options yet (cheap, provide perfect information) -diagnosis is critically important -appropriate treatment is critically important -poverty is a major underlying factor -drug resistance is a major challenge -overlap with the HIV epidemic is a major challenge

External assistance to address health effects of natural disasters

external assistance will have to: -include all of the external partners -be based on a cooperative relationship among partners -have partners working in ways that are complementary to each other -be evidence-based and transparent -involve the affected communities