The Role of Public Health Within the United Nations Post-2015 Framework for Disaster Risk Reduction

Health systems can be defined as the structured and interrelated work of all agencies contributing to health within a country and includes efforts to influence determinants of health as well as more direct health improving activities (WHO 2007). The WHO describes six building blocks or “levers” that are related in a dynamic interdependent manner: (1) Service delivery; (2) Health workers; (3) Health information; (4) Medical products, technology, and vaccines; (5) Health finance; and (6) Governance and leadership.

Disaster management is a global issue and countries are being encouraged to improve their disaster preparedness, along with a growing international commitment to strengthen health systems. The World Health Organization’s 64th World Health Assembly in May 2011 adopted a resolution on strengthening national health emergency and disaster management capacities and resilience of health systems (World Health Assembly 2011). Lessons identified from disasters have not been effectively collated and essential experience is considered to have been forgotten. Bayntun (2012) emphasized that a holistic health system approach to disaster management has not been established in practice or evaluated in the core literature. Analysis of the disaster management literature identified how a strengthened health system can promote resilience and an efficient recovery in the face of disasters (Bayntun et al. 2012).

The WHO Regional Office for Europe has adopted health system strengthening as an approach to support emergency preparedness and enhancement of crisis management capacities of member states and this approach supports and complements the organization’s toolkit (WHO Europe 2012a; WHO Europe 2012b). In response to international requests, this practical, action-oriented toolkit was developed and refined (during the course of pilot assessments carried out between 2007 and 2010) in a series of expert consultations. Countries can use the WHO toolkit and its specific guidance on writing assessment reports to assess their disaster management capacities and identify priorities for strengthening their health systems.

A report using the WHO toolkit to evaluate England’s health system arrangements to deal with crises, risk prevention, and mitigation initiatives was submitted in January 2012 by the Health Protection Agency (now known as Public Health England) to WHO Regional Office for Europe and the UK Department of Health. The findings concluded that the National Health Service (NHS) in England is largely integrated in regard to disaster management and identified that the structured response system which involves multisectoral collaboration and coordination is beneficial (WHO Europe 2011).

Power outages are an example of a health systems specific issue. Extreme events (flooding, strong winds and so on) threaten critical infrastructure including power supplies. Electricity was recognized by the UK Department of Health as the “most vital of all infrastructure services” because “without it most other services will not function” (UK Department of Health 2007). Many interlinked systems in the modern world depend on a reliable power supply to function effectively, and the health sector is no exception. But the impact of power outages on health is poorly understood. Klinger et al. (2014) found that power outages impact health at many levels within diverse settings, including the difficulties of accessing health care, maintaining frontline services, and addressing the challenges of community health care such as the provision of electrically generated home oxygen supplies. A survey conducted in Japan, for example, found that 65 % of disaster base hospitals (that is, hospitals responsible for supporting other hospitals during a disaster) considered electricity to be the most vital lifeline for the functioning of their hospitals; 60 % of these hospitals indicated that key services such as emergency surgery and dialysis would have to be stopped if generator power was unavailable. Key equipment related to services such as laboratories, imaging, and sterilization would also stop if generators failed (Klinger Klinger et al. 2014). Most hospitals have generator backup for only eight hours. During longer-term power outages hospitals can be faced with limited fuel and difficulties in sourcing fuel for generators. This is a particular issue if transportation and communication services are disrupted as well. The survey also found that the current evidence and knowledge base is poor (Klinger Klinger et al. 2014).

With scientific consensus predicting an increase in the frequency and magnitude of extreme events due to climate change, the gaps in knowledge need to be addressed in order to mitigate impacts of disasters in global health systems.

In the Intergovernmental Panel on Climate Change (IPCC) Special Report on Managing the Risks of Extreme Events and Disasters to Advance Climate Change Adaptation, the balance between reducing risk and other disaster risk management strategies is influenced by a range of factors, including the financial and technical capacities of stakeholders, the robustness of the risk assessment information, and cultural elements involving risk tolerance (IPCC 2012). Therefore risk assessment is a key tool, particularly to inform public health risks.

Recognizing that most countries continue to have difficulties integrating risk reduction into public investment planning, urban development, spatial planning and management, and social protection, the European Commission (EC) has promoted the use of risk assessment and analysis. An EC report stated that data derived from past losses are useful for the implementation of disaster risk reduction strategies in Europe (from local to national scales) and to help understand wider disaster loss trends at the global level (De Groeve et al. 2013). The report emphasized that risk modelling is a valuable tool for improving risk assessment and forecast methods, but loss datasets are needed for calibrating and validating model results, in particular to infer vulnerabilities.

By building on the available national risk assessments, the EC has prepared the first cross-sectoral overview of risks in the EU, taking into account (where possible and relevant) the future impact of climate change and the need for climate adaptation. Following a consistent approach, multi-hazard national risk assessments are to be produced by Member States by the end of 2015 and followed up by an assessment of national risk management capabilities and improved risk management planning (European Commission 2014a). The EC reported that of the 32 countries participating in the Mechanism for Civil Protection, 18 contributed to the review through their national risk assessments (NRAs) (European Commission 2014b). Of these, nine Member States provided information on their national assessment criteria and scenario-building. The EC concluded that more systematic and complete information on the assessment criteria and on the risk scenarios assessed may help the Commission carry out an informed and coherent analysis of risks addressed in NRAs (European Commission 2014b).

The UK’s National Risk Register of Civil Emergencies aims to understand disaster risks and determine their relative significance in terms of potential impact, and provides the starting point for emergency planning. Key to ensuring useful planning information is the understanding that it is not the risks themselves that people have to deal with when things go wrong, but their consequences. In an increasingly complex and interdependent society, emergencies can have increasingly multifaceted and wide ranging effects. The Register identifies both direct and indirect consequences, many of which are common to several risks, and provides information on how to prepare for them. The UK National Risk Register of Civil Emergencies has been published since 2008. In the July 2013 edition the Register provides an updated government assessment of the likelihood and potential impact of a range of different civil emergency risks (including naturally and accidentally occurring hazards and malicious threats) that may directly affect the UK over the next five years. The Register also provides information on how the UK government and local responders such as emergency services need to prepare for these emergencies (UK Government Cabinet Office 2013). For the public health community in the UK, pandemic influenza remains the most significant civil emergency risk.

An additional area of policy and research importance in DRR, including risk assessment, is the role of inclusion and combating inequality, specifically how to ensure that vulnerable groups are given full consideration as risk is unevenly distributed. This converges with a growing interest in the global public health sector into the inequalities in the distribution of health and disease and the role of socioeconomic factors and other dimensions of inequality including age, disability, and gender through the societal factors that affect health (WHO 2008). For example, disasters can have systematically unequal impacts by gender before, during, and after a disaster event. The role of gender in a particular society often means separate or varying levels of access to health care services, social support systems, and in some cases, access to aid relief (WHO 2002). The gender mix of the affected community can also impact the types of services those working within the health system will be required to provide. In poorer countries, for example, pre- and post-natal care can be challenging even without the added strains of a disaster. Lack of basic facilities that may have been destroyed or damaged make the delivery of a child under these circumstances even more precarious and put mothers and children at high risk (Nour 2011). The WHO has developed several documents relating to the role of gender in the aftermath of disasters (WHO 2005a) and highlighted that recognition of the potential gendered issues that may be encountered during disasters will assist with the swift and effective implementation of health services in response and recovery (WHO 2005c).

Because disasters and other emergencies often result in significant impacts on people’s health, WHO/UNISDR and the Health Protection Agency (HPA)—Public Health England (PHE) since 2013—developed a series of Disaster Risk Management for Health Fact Sheets (WHO et al. 2012).

Every new threat reveals the challenges for managing health risks and the effects of emergencies and disasters. Deaths, injuries, diseases, disabilities, psychosocial problems, and other health impacts can be avoided or reduced by disaster risk management measures involving the health and other sectors. These advocacy materials of the Disaster Risk Management for Health Fact Sheets were written as an introduction for health workers engaged in disaster risk management and for multisectoral partners to consider how to integrate health into their disaster risk management strategies. An overview places disaster risk management in the context of multisectoral action and focuses on the generic elements of disaster risk management, including potential hazards, vulnerabilities of a population, and capacities across the health system. Each fact sheet identifies key points for consideration within a number of essential health domains. Because all health domains are interlinked each fact sheet should be considered as part of the entire set and in conjunction with the overview and a summary of definitions in the natural hazards fact sheet.

Within a short, easy to read document (two sides of a single page) the fact sheets address the key points including why the hazard is important, the health risks, and the risk management considerations, and provide key references and suggested further reading. The fact sheets address the following topics: chemical safety; child health; climate risk management; communicable diseases; mass casualty management; mass fatalities/dead bodies; mass gatherings; mental health; non-communicable disease; nutrition; people with disabilities and older people; radiation emergencies; safe hospitals prepared for emergencies and disasters; sexual and reproductive health; and water, sanitation, and health. For the public health community these fact sheets have provided useful teaching resources.

People with life threatening and chronic diseases, due to their particular needs, must be included in the design of policies and plans to manage their risks before, during, and after disasters, including giving them access to life saving services. By definition, people with chronic diseases have ongoing medical needs that can easily be disrupted in a disaster situation. While further evidence is required in this area, a recent systematic review (Ochi et al. 2014) revealed that a considerable number of patients lose their medication during evacuation, many lose essential medical aids such as insulin pens, and many do not even have a record of their prescriptions with them when evacuated. Understanding the impact of medication loss may lead to raising awareness and better preparation among patients and health care professionals. Those with chronic diseases could have worse outcomes and many risk dying when their medication is not available. More research is needed on the impact of disasters on people with chronic care needs, including those with physical or mental disabilities, although mental health is receiving growing attention as a key element of recovery. For the public health community, how to share the learning from the recent systematic review to inform evidence-based policies is of concern.

The need to enhance recovery schemes by including the provision of psychosocial support and mental health services is also part of the current draft of the post-2015 agreement. Rapid and extensive changes occur in people’s lives and the worlds in which they live when they are exposed to extreme events and disasters. These can cause great stress to people, families, and communities because of their inherent effects, such as causing short-term fear of death and other mental health disorders (Williams and Drury 2011). People’s abilities to rebuild, recover, and adapt following a disaster are determined by their physical, psychological, and social characteristics, as well as the characteristics of, and support they receive from, their families and the communities in which they live (Ochi et al. 2014). Primary stressors inherent in many disasters can include injuries sustained or watching someone die. The literature recognizes the distress that primary stressors cause and their association with mental disorders. Secondary stressors such as lack of financial assistance, the grueling process of submitting an insurance claim, parents’ worries about their children, and continued lack of infrastructure can manifest their effects shortly after a disaster and persist for extended periods of time. The roles of secondary stressors in affecting people’s longer-term mental health should not be overlooked (Williams and Drury 2011).

The UK Department of Health in England (DH) (UK Department of Health 2009), the North Atlantic Treaty Organization (NATO), and the Euro-Atlantic Partnership Council (EAPC) (NATO and EAPC 2009) clearly differentiate between distress and mental disorders following a disaster. The threshold between what might be considered a common or anticipated response of distress, and what is indicative of a person developing a mental disorder, are difficult to define and the pathways are complex. Further research is needed to enhance our knowledge and to improve outcomes.