In this issue> Cuts will cost £1bn extra in the long term> Brian McCloskey on polonium and the Olympics > How art rescued Debs Taylor from medicationThe magazine of the

UK Faculty of Public Healthwww.fph.org.uk

September 2015

Recipes for disaster Coping with emergencies

UP FRONT

SEPTEMBER 2015 3

FROM THE PRESIDENT

Welcome

News in brief

Nigeria reaches polio milestoneNigeria has been removed from the list ofpolio-endemic countries. It follows Nigeriagoing more than a year without a case ofwild – naturally occurring – polio. Threeyears without cases are required before acountry can be declared polio-free. Thedecision means there are now just twoendemic countries – Pakistan andAfghanistan.

Children’s health postcode lotterySome local authorities in England are notdoing enough to prevent ill health inchildren under five, a report by theNational Children’s Bureau said. It foundwide variations in levels of obesity andtooth decay, even in areas of similardeprivation. 51% of five-year-olds inLeicester had tooth decay compared with9.5% in West Sussex.

‘Tax sugary drinks by 20%’An extra 20% tax on sugary drinks shouldbe introduced to tackle the obesity crisis, theBritish Medical Association said. It estimatedthat poor diets were causing around 70,000premature deaths each year. The body calledfor the extra money raised to be used tosubsidise fresh fruit and vegetables.

MMR vaccination rates falterThe proportion of two-year-old children inEngland having the MMR vaccine hasfallen. In 2014-15, 92.3% of children hadthe jab to protect them from measles,mumps and rubella. The Health and SocialCare Information Centre said the figurewas 92.7% in the previous year. Someparts of the country had less than 80% ofchildren immunised.

Hand-washing lessons to cut drugresistanceSchoolchildren should be taught how towash their hands to tackle the threat ofdrug-resistant bacteria, according to draftNational Institute for Clinical Excellence(NICE) guidelines for England. Teachersshould also provide lessons on whenantibiotic drugs are unnecessary, said NICE.

‘Paid-to-poo’ fights open defecationA scheme in Ahmedabad, India, is aimingto instil better toilet habits in children bypaying them one rupee to use public loos.In India, nearly half of the populationrelieve themselves in the open, many evenwhen public facilities are available.Hundreds of thousands of children dieevery year because of diseases transmittedthrough human waste.

HE three pillars of public healthare health protection, healthimprovement and population

health and social care. The first of theserepresents the very foundations of publichealth especially with its environmentalfocus on the external threats to healthwhether they be biological, physical orchemical. The work of the Faculty ofPublic Health over the past 30 years hasreinstated a focus on this vital area andthe succession of public healthemergencies during this time hasreinforced the need for the relevantcompetences to be acquired by all thosewho claim to be fully formed publichealth generalists.

In this issue of Public Health Today weoffer a strong menu that touches onmany aspects of public healthemergencies. It is a rich and stimulatingset of contributions. It is conventional tocategorise such emergencies as ‘bigbang’, ‘rising tide’ or ‘slow burn’ andaspects of all these are to be found inthis issue. A sound knowledge-base,preparedness and experience areessential if we are to play our part as fullpartners when called upon to rise to thechallenge. I speak as a generalist withthe benefit of having been involved withmore public health emergencies than Icould ever have imagined when I set outon my career over 40 years ago. Wehave all had to acquaint ourselves withthe plethora of new infectious disease inrecent times, but, in addition, I havefound myself in the middle of a range ofsituations, including the Hillsboroughdisaster, two IRA bombs, the death ofChinese cocklers in Morecambe Bay, thethird largest Legionella outbreak inBarrow, a rail crash, fatal school buscrash, several major flooding incidentsand a mass shooting. I was deployed toMacedonia with colleagues during theKosovo emergency and played aperipheral role in the recent Ebola crisis.Specialist colleagues, some of whomhave written here, can claim much moreextensive experience than myself. Mypoint is that we need to be readywhether as generalist or specialist andone message I would give to thoseembarking on a career in public health isseek out opportunities for experience.Senior colleagues I would encourage toinvolve registrars and junior colleagues in

incidents that come your way. There areinvaluable experiences to be had andeach in its own way is unique.

Whether we are talking about aheatwave, a flood, an earthquake or anoutbreak of an exotic disease, some ofthe skills needed are generic. The abilityto learn quickly and think on your feet,partnership and team-working and aknowledge of the limitations of yourown skills are but a few worth thinkingabout. Nor is our focus restricted to theimmediate, blue-light phase of anemergency. Public health has a greatdeal to offer in the recovery period andin building resilience against futureincidents. Colleagues’ current work inthe latest phase of the Ebola emergencyillustrates as much. Humanitarian workmay be short-, middle- or long-term. Forthose interested in developing theircareers in this direction there areincreasing opportunities to acquire thenecessary expertise. Courses are availableat Manchester University, the LiverpoolSchool of Tropical Medicine and theLondon School of Hygiene and TropicalMedicine among others, and the Societyof Apothecaries also offers aqualification. For those interested inmaking themselves available for regulardeployment in humanitarian situations,the Department of Health now supportsa register maintained by UK-Med underProfessor Tony Redmond at ManchesterUniversity.

This area of public health is verychallenging but also very rewarding. I would like to thank the contributors tothis issue of Public Health Today forsharing their experiences with us.

John Ashton

Up Front 3

Interview with Brian McCloskey 4

Special feature: Disasters and emergencies 6

Get our act together 6

It’s getting hotter and hotter and there is only one solution 7

More disasters will mean more mental trauma 8

Debate: Is the humanitarian community fit for purpose? 8

Burning questions 9

After the earthquake prepare for epidemics 10

Giving power back to affected populations 10

Cast away 11

Build capacity now 12

MERS: A reminder that we need to be vigilant 12

Combating war with primary prevention 13

Everyone gets to benefit from global response 13

Bring water to people, not people to water 14

Books and publications 15

Endnotes 16

Noticeboard 19

The Final Word 20

Cover image: Flooding in Toll Bar nearDoncaster, June 2007

Contents

Public Health TodayThe magazine of the UK Faculty of Public Healthwww.fph.org.ukSeptember 2015

T

Is EU keepingits promise toprotect health?

ARTICLES about the risks posed by theTransatlantic Trade and InvestmentPartnership (TTIP) agreement co-authored bythe Faculty of Public Health (FPH) have beenpublished in the Journal of Public Healthand European Journal of Public Health.

In Warning: TTIP could be hazardous toyour health (http://bit.ly/1Jsw9GJ), weidentify how the numerous risks presentedwill seriously undermine the policies FPHhas called for in its recent manifesto(http://bit.ly/1wDfDv0).

In The Europe we want – a TransatlanticHealth and Wellbeing Partnership(http://bit.ly/1U9nrlu), we ask whether theEuropean Commission is abiding by its

own legal commitment to protect health inall its policies and activities.

In July, the International HealthCoordination Centre and Public HealthWales facilitated an event, UnderstandingTTIP and Europe. Read more athttp://bit.ly/1N27rBa and watch a talk byFPH’s Senior Policy Officer, Mark Weiss, athttp://bit.ly/1JpcGEV

Mark Weiss

Cuts will cost£1bn extra inthe long-term

THE Faculty of Public Health (FPH) hasmade unequivocal responses to both theDepartment of Health’s (DH’s) proposal, aspart of wider government action on thedeficit, to reduce by £200m the ring-fenced public health grant in the financialyear 2015-16 (http://bit.ly/1UbECTG) andthe Treasury’s Spending Review 2015(http://bit.ly/1IaMsUQ).

FPH has called for the proposed cuts tobe reversed, for the ring-fence to remain inplace and for no further cuts to be madein future years. The cuts will increaseinequalities in health, worsen populationhealth outcomes and increase pressure onour overburdened NHS. It is both a falsedistinction and a false economy to considerNHS and public health funding as separate– and it is contrary to NHS England’s FiveYear Forward View.

FPH did not address the questionsoutlined within the consultation on how toapportion the proposed cuts, on thegrounds that they will:n worsen significantly the health andwellbeing of local populationsn increase inequalities across the life course,including within hard-to-reach groupsn make harder the provision of population

healthcare advicen compromise the delegated healthprotection and health improvementfunctions.And will consequently:n increase the burden of preventable non-communicable disease and pressure on theNHS (which already spends 70% of itsbudget managing long-term conditions)n contradict the key premise of the

consultation in that it will increase theoverall deficit and generate at least £1billion additional costs in health andsocial care.

Read FPH’s response to the DH’sconsultation at http://bit.ly/1hulx0H andSpending Review Representation athttp://bit.ly/1KCs2dB.

FPH is working closely with its partnersin calling on the DH and Treasury toreverse the proposed £200m cuts. If youare aware of any likely impacts from thecuts, please tell us in confidence, byemailing lizskinner@fph.org.uk

Mark WeissSenior Policy OfficerFaculty of Public Health

It is a false distinctionand a false economyto consider NHS andpublic health fundingas separate‘

‘

had made quite a substantial difference to people’s attitudes todisability was a good moment.

Our preparations over seven years worked. Not a lot happenedduring the Games, but when things did happen, such as rumoursabout measles or food poisoning, the surveillance systems that we had in place meant that those rumours could be tackled very quickly.

I have a photograph of one of the rowing races in London 2012,when the British crew were expecting to win. They came secondand they were so completely worn out that when the BBC wasinterviewing them, Steve Redgrave had to lift them out of theboat. I think it’s 0.02 seconds between them and the Goldmedallists. Eight years of work comes down to 0.02 seconds. If theathletes are doing that much to prepare for the Games, then therest of the people involved need a similar commitment to makesure it works.

Which have been some of the more challenging times?I was in Bosnia during the civil war, and the job was mainly around

trying to identify the health needs of the population and how theinternational community could provide them. It was important tokeep in touch with reality and family, which was difficult in thedays before mobile phones.

We had to think about how to create a better health system forpeople after the war and keep the focus on the longer-term. Oneof the earliest pieces of advice I got in my public health career was:everything takes a long time to happen, and by the time ithappens, someone else is taking the credit for it!

The other serious challenge over the past 12 months has beenEbola. It was probably the most complex public health event I’vebeen involved in. We had to focus on a strategy that would get usthrough it and resist the temptation to change the strategy everytime there was a blip in the epidemiology. The range of peopleinvolved in the response made focusing on a single strategy achallenge, but, if we had started responding to every blip, wewould have ended up getting lost. A combination of factors madeEbola more scary than it should have been.

Is there anything that keeps you awake at night?We need to learn to do things differently to manage the risk of thenext emerging diseases, perhaps something like MERS. We’ve saidso many times that we need to learn the lessons, but globally wehaven’t. The idea that the next infectious disease will be on top ofus before we’ve learnt those lessons does keep me a little bitawake at night.

How do you relax?I took up rowing after I moved to England. It’s a relaxing thing tobe out on the river on a sunny Saturday morning. A bit of exerciseand some good food and wine is my public health balance.

Interview by Liz Skinner

SEPTEMBER 2015 5

INTERVIEW

4 PUBLIC HEALTH TODAY

INTERVIEW

Brian McCloskey is Director of Global Health at Public HealthEngland. He was involved in the Health Protection Agency’sresponse to the 2005 London bombings, the Buncefield OilDepot fire in 2005, the 2007 floods and pandemic flu in2009. He tells Public Health Today what it takes to handlehigh-profile health protection situations

Preparation and communication are crucial

Olympic-sized achievementMiscommunication isprobably one of themost common reasonswhy incident responsesgo wrong – or areperceived to‘

‘ GOOD MOMENT: London 2012 Olympic Park showing the Olympic Stadium

What was it that first interested you about publichealth?I was training to be a consultant in cardiology. I took a couple ofyears out to do my research degree and decided I’d enjoyed theepidemiology more than the cardiology, because it was moreintellectually challenging.

I was doing outpatient appointments in cardiology and wouldsee the same people come back every month with their angina –mostly still overweight, smoking and with high cholesterol. I thought: “There must be a better way of solving this problem.”Public health seemed to be it.

What kind of qualities do public health people need inhigh-profile health protection situations?You need to be logical and analytical. You need to go into ameeting with a clear view about what is possible and acceptableand what is not, and the limits to what you can compromise on.You need to be fairly flexible, and good communication skills areone of the essential requirements, both in terms of working yourway through complicated meetings, but also explaining it all to thepublic afterwards. Miscommunication or failure to communicatewell is probably one of the most common reasons why incidentresponses go wrong – or are perceived to.

What do you think is the most high-profile healthprotection situation you have had to face?In pure health protection terms, one of the most challenging wasthe Litvinenko poisoning with polonium. That was the first timethat we systematically applied epidemiology skills from infectiousdiseases to a radiation hazard and realised that a lot of the sameprinciples, expertise and training worked. That was a complex andhigh-profile, politically-charged event. Explaining difficult conceptsabout radiation, which I had only learned an hour before, to

politicians was a challenging time.

What advice would you give to public healthspecialists about how to communicate in a politicalenvironment?Remember that the politicians were elected to run the country andyou weren’t. They are coming at the problem with a differentperspective. While we would like all of our decisions to be madeon the basis of science and evidence, the reality is that politicianshave, quite legitimately, other factors to consider. We have to fightfor the science to the very end, but science is not the only thingthat will influence a decision.

If you had a magic wand, what would you do to makeit easier for public health specialists to improvehealth? Get rid of tobacco companies. Not just because of the healthimpact of tobacco, but also because the way in which the tobaccoindustry works has gradually influenced other companies whomight be doing things that are not particularly good for health.

Secondly, give public health more money. Given the currentclimate, we understand that’s difficult. At a time when we areseriously looking to reduce health inequalities, there are plenty ofopportunities to do that, but you can’t do it without funding.

Which have been the high points in your career so far?The obvious one is getting my CBE from Princess Anne. The otheris that I was invited to the opening ceremony of the ParalympicGames, and sitting in that stadium and seeing – for the first timeever – a completely full stadium for the Paralympic Games, not justthe Olympic Games, brought home just how good the LondonOrganising Committee had been. Watching the amount ofcommunity engagement for the Paralympics and realising that it

ONE of the worst heatwaves India had everexperienced struck the country in May thisyear. While heatwaves are a feature ofmany summers, the 2015 event wassignificant because of the rapid rise inrecorded deaths totalling approximately2,500 and reported to be the highest tollsince 1979. The temperatures increased tolevels as high as 48 degrees Celsius insome places. Roads melted and hospitalswere inundated with patients sufferingfrom dehydration and heatstroke.

The heatwave occurred in India's dryseason which generally lasts from Marchuntil June when the monsoons areexpected to bring rain and relief from thesearing heat. This year, however, themonsoon arrived late and the rainfall wassparser than usual, contributing not only tothe heatwave but also to fears that thecountry was facing its first drought inseveral years. The government struggled tominimise the health impacts. Relief effortsincluded ensuring that drinking water andoral rehydration salts were freely availablein public places and raising awareness ofthe need to wear hats and light-colouredcotton clothes and to avoid being outdoorsduring the hottest time of day. But what is the future likely to bring both to Indiaand the world, as climate changeprogresses, global mean temperaturescontinue to rise and heatwaves becomemore intense and frequent?

Few health impacts result directly fromheatstroke, but rather it contributes toincreasing mortality and morbidity due toother causes such as cardiovascular andrespiratory disease. The elderly areparticularly vulnerable, a risk likely to bemagnified as the population ages in manyparts of the world. Governmentexhortations to remain indoors aremeaningless for outdoor workers, thegroup at greatest risk, as they face a starkchoice between a livelihood or protectionfrom the blistering heat. Genderinequalities are especially amplified amongoutdoor workers. Women make up themajority of agricultural workers globallyand in construction work in India wherethey do the most physically exhaustingjobs. Animal health too, may becompromised. During the 2015 heatwave,three million chickens perished in oneIndian state within a fortnight, causing

the price of eggs and chicken to soar.Perhaps the most ominous impact onpublic health is related to the increasingrisks of water scarcity, crop failure andreduced food security, not only in countries heavily reliant on rain-fedagriculture but worldwide. Furthermore,heat stress has already reduced globallabour capacity to 90 per cent and, in theworst-case climate scenario, may drop toas low as 40 per cent.

Air-conditioned tractors may improve thelot of the American farmer, but suchadaptations are out of reach in manycountries. And everywhere, the poor facethe worst risks. Life-threatening poweroutages and the consequent rise indemand for energy are reported even indeveloped countries during heatwaves,highlighting that technology is unlikely tooffer long-term solutions. Similarly, policiesto improve occupational standards toprotect workforce health may offer short-term benefit to some workforces. There is increasing realisation that the onlysustainable solution is to reduce globalwarming. Let us hope that our leaders can agree a deal to achieve this at the upcoming climate summit in Paris in November.

Mala Rao OBEProfessor & Senior Clinical FellowDepartment of Primary Care and PublicHealthImperial College London

SPECIAL FEATURE: DISASTERS & EMERGENCIES

SEPTEMBER 2015 76 PUBLIC HEALTH TODAY

SPECIAL FEATURE: DISASTERS & EMERGENCIES

A LITTLE boy lies face-down on a Turkishbeach, washed up, drowned. Theunforgettable image of three-year-old SyrianAylan Kurdi shone the global spotlight on ahumanitarian crisis that had been unfoldingfor months. Aylan was just one of thousandsdrowning or dying in an attempt to escapefrom mayhem. But his image helped tosting reluctant governments into action.

Flashback 15 months, and it was picturesof corpses lying shunned in the streets andvillages of Sierra Leone that seized theworld’s attention. The Ebola epidemic inWest Africa had been running out ofcontrol for months. Despite the mountingconcern of non-governmental organisationson the ground and many experts, includingthe co-discoverer of the Ebola virusProfessor Peter Piot, the internationalcommunity was agonisingly slow to

respond. Denial was rife at all levels. Itwasn’t until August 2014, a full fivemonths after the first cases, that the WorldHealth Organization belatedly declared theoutbreak an international public healthemergency, and the full-responsemachinery at last swung into action.

Every major emergency or disaster teachesus lessons, from Haiti to New Orleans, fromFukushima to Nepal, or closer to home, from

Buncefield to the 7/7 London bombings.One persistent failing seems to run throughthem all to a greater or lesser degree. Lackof coordination. The effectiveness of everyresponse stands or falls on how well itsmany elements are orchestrated. Humanresources, supplies, expertise, intelligence,logistics, infrastructure, liaison, negotiation– all have to be brought into play in theright place at the right time in the rightquantity and working in the right direction.And it requires a clarity of purpose and

fleetness of foot that the internationalcommunity continues to lack.

Not surprisingly it’s also a commonthread that emerges in the articles we’vegathered for you in this edition of PublicHealth Today. We’ve tried to look atdisasters and emergencies from a variety ofpublic health angles. So we’ve got pieceson topics ranging from the prevention ofpublic health crises in war zones torebuilding the health and wellbeing ofMediterranean migrants, and from copingwith the aftermath of the earthquakes inNepal to restoring public health capacity inSierra Leone. Plus we have thought pieceson the importance of cultural sensitivity inhumanitarian responses and the hiddenpsychological burden borne by thoseworking in disaster relief on the ground.

The public health role in emergencypreparedness, resilience and response iscrucial. But we have an even greater role in helping to build or rebuild healthsystems in countries where the set-up isinadequate and coordination lacking. Wemay not be able to stop wars or preventearthquakes, but our skills can certainlyhelp reduce the toll of many anotherdrowned boy on the beach.

Alan Maryon-DavisEditor-in-Chief

Get our act togetherThe message that consistently emerges from emergencies is that coordination is the key to effective response, says Alan Maryon-Davis

The effectiveness ofevery response standsor falls on how wellits many elementsare orchestrated‘

‘

It’s getting hotter andhotter and there isonly one solution

More disasterswill mean moremental trauma

LAST year, I asked a director of publichealth (DPH) about the provision ofpsychological trauma support services forpeople in the event of a major emergencyin her area and was so shocked by herresponse. She replied, somewhat curtly,that she did not know: it was neither herresponsibility nor her budget. I postedabout it on the Faculty of Public Healthblog. I was told I obviously hadn’t read theHealth and Social Care Act, 2012.“Confusion reigns as to who does what”on emergency preparedness and healthprotection, as one person put it, inresponse to my blog.

Since then Public Health England hashelped develop the National FloodEmergency Framework for England, astrategic reference point for all thoseinvolved in flood planning and response. It acknowledges that the mental healthimpact as well as other health effects ofliving through flooding of a home or a loss of livelihood can have a profoundeffect on a person’s wellbeing. In responseto the challenge of assessing, monitoringand protecting against the long-termhealth impacts of flooding it has produceda protocol for establishing a health registerafter a flood. It emphasises the role publichealth has to play in major incidentpreparedness, planning, response and recovery.

The role of local authorities, via theirDPH, is to provide leadership for the publichealth system within their area. In theevent of flooding events, the role of publichealth includes actively contributing tomulti-agency humanitarian assistanceworking groups and longer-term recoverystrategies, working closely with thosedirectly affected in ensuring access topsychological and other support services.

Public health must address the psycho-social needs of people before,during and after any disaster. There will always be human consequences and measurable health effects from any potentially devastating, large-scale life-and-death experience. With expertsanticipating more rather than fewerdisasters in future, being clear about therole of public health professionals is moreimportant than ever.

Anne EyreDirectorTrauma Training

LESSONS: The fire at Buncefield oil depot, Hertfordshire, December 2005

SPECIAL FEATURE: DISASTERS & EMERGENCIES

SEPTEMBER 2015 9

SPECIAL FEATURE: DISASTERS & EMERGENCIES

8 PUBLIC HEALTH TODAY

MOST people do not consider the fireservice to be a health provider, yet we arecontributing to a healthier community andworking with the same cohort of people aspublic health specialists.

West Midlands Fire Service (WMFS)incorporates into its wide-ranging work theso-called Marmot Principles – the six keypolicies for reducing health inequalitiesrecommended by Michael Marmot in his2008 report Fair Society Health Lives. Webelieve this has made the West Midlands asafer place, particularly for vulnerableresidents and communities. At aconference hosted by WMFS at itsheadquarters in Birmingham, Sir Michaelpraised the brigade for “clearlyrecognising” the links between people’srisk from fire and the conditions in whichthey lived, and endorsed the work ofWMFS in tackling health inequalities.

Our first step towards this endorsementwas beginning to understand what wascreating fires and why people were gettinghurt. We knew fires were created byfactors such as careless disposal, arson orthe inappropriate use of electricalappliances. We wanted to target ourresources to deliver ‘upstream firefighting’,and we focused on three basic themes:behaviour, environment and support.

When we started to consider how toprevent fires, we developed a home safety

check. The behaviours and issues we wereidentifying – such as mental health issues,drug dependency and type-2 diabetes –are all part of social inequalities. Some ofthe measures we use to prevent slips, tripsand falls when someone needs to get outof a building quickly can also reduce healthinequalities. Replacing an elderly person’sworn-out slippers helps them escape theirhome in the event of fire and also reducesthe possibility of them falling in their

home, breaking a femur and needinghospital treatment.

We realised that the best way to preventpeople dying in fires was to look for thecauses of health inequality and tacklethem. For example, if you are male, aged25 to 45, living alone in certain areas andunemployed for more than a year, you aremore likely to have a fire in your home.

As a prevention service, we have tounderstand the cross-overs and become anextension of the wider workforce that

supports public health. We have workedwith Coventry University to map out theselinks. The next step will be to work with abig enough cohort of people to producethe scientific proof that backs up ourexperience.

My advice to public health specialistswould be to work with their fire servicecolleagues and gain an understanding ofhow they can support each other. Healthprofessionals have the data and theintelligence. The fire service has a group ofprofessionals who are respected andwelcomed into the community. Yet, untilthese conversations take place, it can bedifficult for public health professionals tosee beyond the firefighting kit and seehow our work can bring about widerhealth benefits.

We have worked with public healthprofessionals to help tackle child obesity bydevising a programme conveying both firesafety and health messages to children inYear Six over a sustained period; this wasdesigned to empower them to makedecisions for themselves. We are not socialworkers; we are a practical health supportin the community that increases people’slivability in their homes.

Steve Vincent Area CommanderWest Midlands Fire Service

Burning questionsThe best way to prevent fires is to tackle inequalities, and this places the fire service at the heart of public health, says Steve Vincent

Some of the measureswe use to preventslips, trips and fallscan also reducehealth inequalities‘

‘

Humanitarianwork – thehuman costTHERE is a hidden cost of humanitarianoperations. Crises and disasters clearlyhave an impact on psychosocialwellbeing and mental health of theexposed population, but studies haveshown that humanitarian workers andorganisations are also affected.Research by the Antares Foundationand the United Nations’ Office for theCoordination of Humanitarian Affairs(OCHA) has found alarming levels ofanxiety, depression and burnout amonghumanitarian workers. Behind thestatistics, we find stories of chronichealth problems, alcohol abuse,relationship breakdown and years ofhidden suffering within thehumanitarian workforce.

Organisations and employees tend toview stressors, such as insecureemployment status, security risks andvariable funding, as an inevitable aspectof the work. However, the impact of

this stress is often underestimated.Persistent and inevitable stress can leadto a high turnover of staff, healthproblems, loss of productivity and a lackof empathy towards affectedpopulations, family and co-workers.

However, research has also shownthat organisational support, delivered bypositive supervisory relationships andteam cohesion, can help to diffuse thelong-term negative outcomes of stress.Within the OCHA report, there was a

clear correlation between organisationalsupport and staff wellbeing. Manyrespondents specifically identifiedorganisational support as a factor whichcould mitigate their stress levels. Factorssuch as psychological support, positiveorganisational culture, clear leadership,recognition and reward of effort,workload management, physical safetyand work-life balance all help to

promote long-term staff wellbeing. There is a need for programmes and a

culture that supports humanitarian staff.This means ensuring that policies areimplemented through comprehensiveand holistic actions that include the oftenneglected ‘heroes’ – locally recruitedstaff. Such investment in staff welfare canimprove productivity and reduce burnout,making organisations far more effective.

Within many organisations, there is awidespread macho culture that preventsthose who are most in need of helpfrom seeking support. Humanitarianorganisations have a responsibility topromote a positive work environmentand staff wellness. However, this canonly be achieved with long-terminvestment in preventive practices and acultural shift at all levels of anorganisation. The stigma againstseeking support must be addressed,beginning with management andleadership placing health and wellbeingas a priority on their agenda.

Jorge Sierralta Clinical Psychologist UN Office for the Coordination ofHumanitarian Affairs

DEBATE: Is the humanitarian community fit for purpose? Karl Blanchet criticises the Ebolaresponse, while Jorge Sierralta is concerned about aid workers’ mental wellbeing

A crisis ofhumanitariangovernanceTHE Ebola outbreak has revealed theweaknesses of the internationalhumanitarian system to respond quicklyand efficiently to a regional public healthoutbreak. It took the World HealthOrganization (WHO) too long to declare itan international health emergency. BySeptember 2014 there were 1,800fatalities confirmed but still no clear signon the ground of a structured andcoherent international response. A handfulof international non-governmentalorganisations (NGOs) had not waited forthe United Nations (UN) to be operational(eg. Medecins Sans Frontieres, InternationalMedical Corps). But the major internationaldonors had no clear strategy in place atthe moment of the WHO declaration.

Following institutional tensions amongUN agencies, the Coordination ClusterSystem usually put in place during relief

interventions was not chosen. WHOdecided to take the lead and in September2014 put in place the UN Mission for EbolaEmergency Response (UNMEER). Thestrategy was focused on casemanagement, case finding, contact tracing,safe and dignified burials and socialmobilisation. All other humanitarianmatters such as education, access to foodand water, protection of civilians and

security were outside their scope of work.As a result, many NGOs, and morespecifically the ones with no medicalmandate, did not feel recognised aslegitimate operational actors and decidednot to sit down at the table of UNMEER.

All other sectors of the health systemwere neglected. No comprehensive packageof care was delivered to respond to theother needs of the population, such as

malaria, measles, malnutrition, HIV/Aids orobstetrics, although most patients in Ebolatreatment centres systematically receivedmalaria prophylaxis. In Guinea-Conakry itwas estimated that 74,000 malaria cases didnot get access to anti–malaria treatmentduring the outbreak, which suggests thatfatalities attributed to malaria might havebeen higher than the number of deathsrelated to Ebola. Based on the Ministry ofHealth and Sanitation’s recent FacilityImprovement Team (FIT) assessment, thepressure of Ebola on the healthcare systemled to the closure of health facilities and adrop in those that were able to provideemergency obstetric and neonatal care.

This regional crisis must help us reshapeour humanitarian system to better respondto major public health outbreaks, not onlyto avoid governance issues but also torevisit the content of our interventions.

Karl BlanchetCo-founderPublic Health in Humanitarian CrisesGroupLondon School of Hygiene & TropicalMedicine

All other sectors ofthe health systemwere neglected‘

‘The impact of thisstress is oftenunderestimated‘

‘

ON 25 April 2015 Nepal suffered acalamitous earthquake (7.8 on the Richterscale). As though this were not enough, on12 May a strong aftershock (7.2 inintensity) hit the same area. The combineddestruction led to the deaths of around9,000 people and displaced thousandsmore, many of whom are still living intemporary shelters.

Many infectious diseases are endemic inNepal, including enteric fever andrickettsial illnesses such as murine typhus,hepatitis E and cholera. Post earthquake,with deteriorating hygiene and sanitationespecially in the temporary shelters, thereis a high risk of outbreaks of such diseases,perhaps even epidemics, in the ensuingmonsoon months. Preparation is vital.

The government of Nepal says it is doingits best to provide clean water andsanitation to keep these diseases at bay.But it may be important to go one stepbeyond these usual measures. A case couldbe made for stockpiling vaccines effectiveagainst typhoid, hepatitis E and cholera.

A large trial reported in the Lancet inJuly 2015 about the effectiveness ofcholera vaccine in Bangladesh found thatbehavioural interventions to improve waterquality and personal hygiene afforded littleadditional protection beyond that providedby the vaccine. This was a disappointingfinding but clearly shows the importance ofvaccination against cholera. Because typhoidfever and hepatitis E, like cholera, aretransmitted by the fecal-oral route, it maybe important to keep this finding in mind.

Clearly, proper sanitation and hygieneare very important in the prevention of

diseases spread by fecal-oral transmission –but it may be necessary to deploy vaccines,at least in the short term, to deal withthese life-threatening illnesses.

Little known to people outside theresearch community in Nepal, murinetyphus is transmitted by rat fleas and is thesecond most common cause ofundifferentiated febrile illness in this partof the world. Since no vaccination isavailable, pest control and improvingsanitation are clearly key in preventing thisdebilitating and potentially fatal disease.

The Nepali Ministry of Health andPopulation, in collaboration with manynon-governmental organisations, is tryingto provide proper sanitation and cleanwater in the temporary shelters and camps,but prevention of these illnesses is adaunting task during the monsoon rains ofthe summer months.

Buddha Basnyat DirectorOxford University Clinical ResearchUnit – NepalPatan HospitalKathmandu

SPECIAL FEATURE: DISASTERS & EMERGENCIES

SEPTEMBER 2015 11

SPECIAL FEATURE: DISASTERS & EMERGENCIES

10 PUBLIC HEALTH TODAY

After the earthquake,prepare for epidemics

MEDIA coverage of overcrowded boats inwhich migrants risk everything to cross theMediterranean has graphically illustratedthe horror of a journey that has alreadyclaimed the lives of more than 1,500people this year. These perilous voyages are likely to kill more than 2,500 children in 2015.

What we hear less of, and what isprobably harder for many ordinary peopleto really comprehend, are the back storiesof those individuals forced into the handsof ruthless traffickers as they head for anuncertain future. Maintaining a focus onthe drivers of migration is essential tounderstand and respond effectively.

On 14 May this year, the Faculty of PublicHealth (FPH), the Royal College of Paediatricsand the British Association of Child andAdolescent Health wrote to the Timesoffering the expertise of their membershipsto help address the complex determinants ofthe tragic and often fatal flow of migrants.

The Times letter drew attention to thestigma often placed on migrants in apolitical context in which we regularly seeimages of UK borders apparently undersiege. At a safe distance from the harshreality of the refugee camps of Greece andItaly, we can perhaps be forgiven forstruggling to reconcile the images ofdehydrated people rescued from the seawith images of gangs of fit young migrants

climbing into lorries in search of economicsecurity. These contrasting images ofmigrants and a media-fuelled fear ofeconomic migration in a context ofausterity are the real threat to publichealth, threatening our solidarity withvulnerable and traumatised people. Wemust guard against prejudice underminingour sense of common humanity anddiminishing our care. The public’s health isbuilt upon a foundation of community,

and eroding the solidarity at the heart ofcommunity is a threat to public health.

So what is it that the membership of FPHcan offer? The FPH Global Health Strategy,launched in June at the FPH annualconference in Gateshead, identified fourkey functions of our international work: n Advocacyn Standardsn Our workforcen Knowledge, evidence and research.It is these resources we need to draw upon

to support action. The UK has a long tradition of accepting

and integrating people from othercountries. Past international crises have ledto other waves of migration which,although often challenging, have beenmanaged. Documenting the evidence ofhow systems have coped and using thisknowledge to highlight the system’sresilience is necessary to reduce the fearand stigma generated by the current crisis.

Direct contact with people in need canhelp overcome the sense of difference thatunderpins ‘us’ and ‘them’ attitudes. Whendirectly confronted by a humanitarian crisis,our inclination is to help. The public healthcommunity (our membership and workforce)can help bridge the distance between ‘us’and ‘them’ by using personal stories to focusin on individual lives and help strengthenthat sense of common humanity.

It will be through our collection ofevidence on successful integration of pastwaves of migration and through ourmembership reaching out to tell the storiesof the current wave of migrants that webecome effective advocates for addressingand responding to the tragedy unfolding inthe Mediterranean.

Neil SquiresChairFPH International Committee

We must guardagainst prejudiceundermining oursense of commonhumanity‘

‘

Giving powerback to affectedpopulations

THE power balance between the affectedpopulation (often in developing countriesand nearly always in areas of deprivation)and the organisations who fly in to helpout in their hour of need (predominantlybased and funded in developed countries)is particularly pertinent in public healthdisasters. When survival depends onexternal help, would any of us say thanks,but no thanks? However, the argumentbecomes more nuanced if, for the requisiteresources to be effective, culturally specificvalues and practices need to be suspended.

Long-term development work hasevolved because time taken to work slowly,alongside people (particularly leaders andinfluencers in a community) often bringsthe greatest benefits for a community.There is mutual learning and respect forboth development worker and community,and the population claims knowledge astheir own to best serve their needs.

Is this possible in a disaster where everysecond is of the essence? Perhaps not tothe extent of a 15-year developmentproject, but it is necessary to adapt thisapproach to ensure that communities feelinvolved in the response. This can beundertaken through couching theintervention in culturally understandableways, using collaborative approaches andallowing the community to take ownershipof the intervention process wheneverpossible. These approaches are nowadopted with far more frequency aslessons have been learned from majordisaster-relief operations, including thetsunami in south-east Asia in 2004 andHurricane Katrina in New Orleans in 2005.These approaches also allow developmentto continue in a community long after therelief teams have moved to the nextheadline disaster.

It is always worth bearing in mind thatthe clash between cultural values andeffective interventions (ie. saved lives) doesnot and will not always default in favour ofsaving lives. This is perhaps one of themost difficult issues in public health ethics– your own perspective on the right thingto do does not always correspond withother people’s reality. For this reason,public health ethics must continue to bedebated in all areas of the profession.

Rebecca CooperPublic Health ConsultantSolutions4Health

A case could bemade for stockpilingvaccines effectiveagainst typhoid,hepatitis E andcholera‘

‘STRANDED: Migrants on the island of Kos, Greece

Cast awayWe must understand what drives migration in order to respond to it effectively,otherwise we risk undermining our solidarity with the vulnerable, says Neil Squires

Cast awayWe must understand what drives migration in order to respond to it effectively,otherwise we risk undermining our solidarity with the vulnerable, says Neil Squires

Combating warwith primaryprevention

A BILLION children live in areas affected byarmed conflict and will consequentlyexperience a range of preventable healthoutcomes including psychological trauma,malnutrition, forced displacement, disease,physical injury and death. However, publichealth professionals often feel that thediplomatic and political determinants ofmodern warfare are not within their remitto address. On the contrary, we wouldargue that a robust public health approachto this grievous international health andhuman rights issue is urgently needed.

Both authors have spent time working inarmed-conflict zones trying to amelioratethe malnutrition, lack of medical care andpsychological distress they generate, aswell as treating the injuries that thoseconflicts directly cause. Although neither ofus thought of it in precisely these terms atthe time, we might now classify thoseactivities as secondary and tertiaryprevention strategies for the negativehealth impacts of war. It seems to us thatthe real challenge is to promote greaterpublic health engagement with the primaryprevention of armed conflict.

International laws governing the rules ofwar are the product of many self-interestedcompromises and are ultimately only asgood as their enforcement – a test ofcredibility which the internationalcommunity is currently failing, mostnotably in Syria. We are keen to be involvedin forming a special interest group of theFaculty of Public Health (FPH) to explorethe positive contribution that public healthprofessionals can make to this issue.

See the FPH blog at betterhealthforall.orgfor a full version of this article.

Bayad Abdalrahman and DanielFlecknoeSpecialty Registrars in Public HealthDerby Hospitals NHS Foundation Trust

HUMAN trials of a new vaccine againstEbola infection have been exceptionallysuccessful, in what is widely seen as abreakthrough both in control of this deadlydisease, and in rapid vaccine developmentand inter-agency collaboration. This hasbeen one of the few highlights in a globalresponse that otherwise lacked therequired urgency in its early stages andsuffered a damaging lack of insight andcoordination. While an Ebola vaccine willplay an important role in the prevention ofthe disease, we must not forget thecontexts in which people first contractedEbola, and how it rapidly spread to severalWest African countries. Public education,vigilance and a shift in traditional culturalpractice are needed to protect people’shealth in the long run.

The UK government responded to theEbola crisis by supporting disease-controlefforts in the affected region, screening atmajor ports of entry to the UK andensuring local services were preparedshould suspected cases arise. Public healthprofessionals have provided support,technical expertise and local and nationalleadership in each of these areas. However,the UK’s early efforts did not have thenecessary urgency or importance.The firstUK-funded treatment facility opened inNovember 2014, when weekly cases werealready in the hundreds. Should the public

health community in the UK have played agreater role in ensuring a timely andeffective response? Certainly, they shouldbe in a better position than most toidentify and communicate the threat posedby situations such as the Ebola outbreakand to make the case for early interventionon humanitarian, health protection andeconomic grounds.

Questions are being asked at all levelsabout what can be done to prevent

future outbreaks like this. Much has been written about the need for adedicated international emergencyresponse unit and the need to encouragecountries to declare outbreaks and seekhelp, but public health leaders muststrengthen their calls for morefundamental action. There needs to beurgent, coordinated activity by theinternational community to improve andsupport the health systems of the countriesmost likely to suffer widespread outbreaksof diseases like Ebola. Before the Ebolaoutbreak, Sierra Leone had only 120

doctors, including only one virologist, whothen became an early victim of the disease.The health system was ill-prepared to dealwith a small outbreak of highly infectiousdisease, yet was faced with thousands ofcases in a period of only a few months.Without an immediate and long-termcommitment to change this, we cannotfully address the risk of another Ebola. The recent vaccine development hasdemonstrated that, with a strong,coordinated international effort, changesthat usually take years can be broughtabout much more quickly. This approachmust be taken to build the capacity ofpublic health and health services in thecountries most at risk.

Public Health Africa, an FPH specialinterest group, aims to support thebuilding of public health capacity withinAfrican nations. The tragedy of Ebola hascreated a platform for Public Health Africato make the case that global health is thebusiness of all public health professionals.We urge our colleagues across the publichealth system to do the same and toadvocate for the change required toprevent – rather than belatedly cure –the next big outbreak.

Aliko Ahmed, Victor Joseph,Matthew NeilsonPublic Health Africa

SPECIAL FEATURE: DISASTERS & EMERGENCIES

SEPTEMBER 2015 1312 PUBLIC HEALTH TODAY

SPECIAL FEATURE: DISASTERS & EMERGENCIES

Public education,vigilance and a shiftin traditional culturalpractice are needed‘

‘ONCE again the world has had a wake-upcall about the risks of emerging infectionsand the need for a transparent globalresponse. On 28 July 2015 the PrimeMinister of South Korea declared the end ofthe outbreak of Middle Eastern RespiratorySyndrome (MERS). The preceding monthshad been an anxious time.

MERS is caused by a coronavirus, a typefrom the family that includes SARS as wellas the common cold. Much remainsunknown about the disease and how itmay behave in the future.The first cases ofMERS emerged in 2012 in the Middle Eastand the first confirmed death in SaudiArabia that year. Researchers believe itsorigins are animal-to-man transmission fromdromedary camels. It does not pass easilybetween humans and in most cases therehas been close contact between affectedindividuals. Globally the total number ofreported cases from 26 countries as of 7July 2015 stands at 1,368 with 487 deaths.

The MERS outbreak in South Korea startedin May when a patient returned from visitingthe Middle East with respiratory symptoms.He visited four hospitals; 186 patients wereinfected and 36 died. Questions about thespeed of response became a matter ofglobal concern, leading to the PrimeMinister’s apology on 28 July. Since MERSis probably spread by droplets, goodprevention and control of infection practiceand appropriate standard isolation facilitiesin hospital would be expected to control itsspread. There is no vaccine, but reportsfrom Hong Kong suggest that there areuseful drugs on the horizon.

MERS can be difficult to diagnose andneeds to be in the differential diagnosis ofpatients presenting with respiratorysymptoms, including fever, cough, sorethroat and muscle pain, particularly if there

is a history of travel. Once suspected,isolation to prevent spread is essential ashospitals present a high-risk environment,not only because of close contact, but alsobecause immunocompromised and elderlypatients are at higher risk. Contact tracingof suspected cases is critical, as isinformation for the public on good handhygiene and general health. This isparticularly important for people who haveclose proximity to animals.

The need for system-wide control ofinfection was a lesson learned from theSARS epidemic in 2003. SARS was morehighly infective and spread more rapidlythan MERS, but both viruses impacted notonly on hospital systems but on thesocioeconomic environment. As the diseasebegan to spread in Korea, 209 schoolswere closed as a precautionary measure. InHong Kong, when a South Korean manwho transited in Hong Kong en route toChina fell ill with MERS, other passengerssitting within two rows of him on the flightto Hong Kong were quarantined at a holidaycamp for two weeks. This action remindedthe community of the importance of airtravel as a vector of spread and of theneed for airport information and controls.

As in Hong Kong post-SARS, the impactof the coronavirus outbreak has contributedto falling GDP in South Korea and the needto rebuild confidence in health protectionsystems. For now, the threat of MERS inSouth Korea has abated, but recent eventsunderline the need for good surveillanceand communication and the importance ofthe World Health Organization in a globallycoordinated response.

Siân GriffithsEmeritus ProfessorChinese University of Hong Kong

MERS: a reminder thatwe need to be vigilant

ILL-PREPARED: Small village near Makeni, Sierra Leone

Build capacity nowUrgent action is needed to improve the health systems of countries likely to suffer outbreaks of diseases such as Ebola, says Public Health Africa

Build capacity nowUrgent action is needed to improve the health systems of countries likely to suffer outbreaks of diseases such as Ebola, says Public Health Africa

BOOKS & PUBLICATIONS

SEPTEMBER 2015 15

When opiumwas the opiumof the peopleHOW did opiates, once regarded as kind ofwonder drugs, become an internationalscourge and a multi-billion-pound criminalindustry? And conversely, why is alcohol,once the target of the massively populargrass-roots temperance movement, now asembedded in our culture as ever?

These are questions that are answered byVirginia Berridge’s fascinating history of thepublic and private attitudes to these drugsand others. She takes us step by stepthrough the scientific research, internationalconventions, parliamentary reports, mediastories and cultural shifts which havebrought us to this point – a point at which,after 200 years of public panic, drug warsand burgeoning subcultures, there exists asimilar kind of ‘normalisation’ of drug useto that which existed right at thebeginning of the period.

However, if you are looking for anopinionated voice on one side or other ofthe legalisation argument, you will not findit here. Professor Berridge, Director of theCentre for History in Public Health at theLondon School of Hygiene and Tropical

Medicine, is refreshingly unpolemical in hertreatment of the subject, casting ameticulous and dispassionate eye over thefacts. What she is more interested in doingis seeing patterns and movements over thecourse of the many decades she examines.The point is to read the book and drawyour own conclusions.

Berridge is also keen to debunk some ofthe myths and over-simplifications of thedrugs debate when it tries to use history tosupport its arguments. The often stated‘fact’ that Queen Victoria used cannabis(one repeated in this magazine’s review ofDavid Nutt’s book Drugs Without the HotAir) has, it turns out, little foundation intruth. (Instead, judging by Berridge’sstartling depiction of opium use in everystratum of 19th Century society to treatalmost every ailment in existence, it wouldseem much more likely that Her Majestywas a regular user of the latter drug.) And,when it comes to the mantra that alcoholprohibition did not work in 1920s America,having discussed the problems ofenforcement and the rise in organisedcrime, she demonstrates that, all in all,Americans drank less and alcohol-relateddisease fell.

Berridge identifies several key influences,such as trade, tax receipts, technology,war, xenophobia and gender politics,which have shaped the history of drugs

policy far more than medical research.Policy-makers, who are often overconcerned with short-term trends, mightdo well to read this book and take freshlessons from history.

Richard Allen

The big threatto HIV/AIDSprevention ALMOST 30 years have passed since aleaflet dropped onto the doormats of everyhousehold in the country. It explained thefacts about a new virus – how it was spread,how serious a threat it was and how it couldbe avoided. With neither a vaccine nor acure on the horizon, its bleak message –“Don’t die of ignorance” – offered thepublic a vital means of protecting themselvesand preventing its spread: information.

In the intervening years, much scientificand medical progress has been made inunderstanding Human ImmunodeficiencyVirus (HIV) and Acquired ImmunodeficiencySyndrome (AIDS). Standard AntiretroviralTherapy (ART) is now very effective,enabling people with HIV to live long andhealthy lives. Yet today UNAIDS estimatesthat half of the 35 million people livingwith HIV are undiagnosed.

Norman Fowler was Secretary of Statefor Health and Social Security in theThatcher government and architect of thatfirst national HIV/AIDS public awarenesscampaign. He offers a unique and

dispassionate insight into the internalmachinations of the government as itconfronted the emergent epidemic – andof some of the most important issuesfacing nations today.

Ten areas requiring focus are identified: n Investment in preventionn Public education to increase testingn Sex and relationship educationn Offering ART to all people with HIVn Development of a vaccinen Confronting the corruptionn Ending criminalisation of sex workn Global drug harm-reduction policiesn A new dialogue with faith leadersn Political leadership.

However, it is during Fowler’s travelsacross four continents, that an 11th factoris identified. It creates an optimalenvironment within which HIV can thriveand through which efforts to address thecritical areas identified are failing: prejudice.The rights of minority groups, in particularLesbian, Gay, Bisexual and Transgender(LGBT) people, are, in many countries,comparable to the position “of being blackunder apartheid in South Africa, or being aJew living under the Nazis in Germany”.

The solutions are complex, but, as astarting point, Fowler calls for aninternational convention to protect therights of those most at risk: not only LGBT

people, but also drug users, sex workersand, more generally, women. We knowwhat works. We understand the evidence-base. AIDS: Don’t Die of Prejudice offers acompassionate and urgent call to fight thebiggest threat to HIV/AIDS prevention.

Mark Weiss

AIDS: Don’t Die of PrejudiceNorman Fowler

Published by BitebackISBN 9781849547048RRP: £14.99

Demons: Our changingattitudes to alcohol, tobaccoand drugsVirginia Berridge

Published by Oxford University PressISBN 9780199604982RRP: £16.99

Everyone getsto benefit fromglobal response

IN NOVEMBER 2013, Typhoon Yolanda,otherwise known as Haiyan, causedwidespread destruction to the Philippinesresulting in an estimated 6,300 deaths and28,689 injuries. It was the deadliestPhilippine typhoon recorded in modernhistory. An international humanitarianresponse was swiftly mobilised.

Experienced Public Health England (PHE)field epidemiologists, microbiologists andinfectious disease surveillance and controlexperts were deployed as part of the WorldHealth Organization (WHO) country teamto assist in the emergency response. Twoexperts arrived in the WHO country officewithin 48 hours of the disaster. The PHEteam worked within the WHO structure tosupport the Philippines Department ofHealth under the WHO responseframework. They were involved withdrafting the immediate response plans andpublic health priorities leading to a phasedrecovery plan. They worked closely withthe health cluster, the co-ordinatingmechanism for disaster response, led theWHO response team, developed infectiousdisease outbreak control plans, identifiedrehabilitation priorities for health facilitiesand developed a wide range of publichealth development strategies. They alsohad skills in environmental health anddead-body management which wererequired during the response.

Key to the success of this work, as in anyresponse, was the strong workingrelationships between PHE and thePhilippines Department of Health, existing

WHO country office staff and numerouslocal, national and international non-governmental organisations.

Given the scale of the disaster, the teamremained in-country with WHO to continuesupporting recovery. They focused onlogistical support, team leadership, publichealth recovery and rehabilitation planning.PHE experts in disaster risk reductioncontinue to support the development ofpolicies, such as the United Nations’ Sendai

Framework for Disaster Risk Reduction 2015-2030, to help countries prepare for disasters.

On their return from assisting the publichealth response to international disasters,the overwhelming majority of PHE staffdescribe their experience as positive. Firstand foremost is the opportunity to helpreduce avoidable mortality, morbidity anddisability. But many find they also gainprofessionally and personally.

And it’s not just individuals who benefitfrom a response. Public healthorganisations are becoming increasinglyaware of the value that internationalassistance can bring. New networks oftenlead to ongoing partnerships andsuccessful international collaborations.Individuals return with transferable skillshaving seen first-hand how organisationssuch as WHO operate during anemergency. They also benefit from

exposure to infectious-disease threats nolonger common in the UK, building theircapacity to respond to risks emerging froman increasingly interconnected world.

The broad training received by publichealth specialists in the UK is consideredinvaluable in preparing them for theflexibility, adaptability and knowledgerequired for the early phase of a disasterresponse. Sudden onset and oftenunexpected challenges can mean that those deployed need to quickly turn theirhand to any aspect of public health. PHErecognises this and aims to complementthe existing knowledge base of staff byensuring that each person deployed hasadequate technical and practical pre-deployment training.

Globally, there are a significant numberof emergencies with public healthimplications. The need for the internationalcommunity to work together to developrapid and effective responses is clear, andPHE is committed to playing its part.

Katie CarmichaelInternational Emergency PreparednessCoordinatorPublic Health England

14 PUBLIC HEALTH TODAY

SPECIAL FEATURE: DISASTERS & EMERGENCIES

Bring water topeople, notpeople to water

OXFAM is well known for providing cleanwater in emergencies, and this is vital forpreventing a range of waterborne andhygiene-related diseases. For decades, ourtechnical experts have been designing andadapting equipment for use in difficultconditions across the world, from hugetanks holding 90,000 litres of water toportable filtration devices for individuals.

However, we know that facilities will onlybe used if they are culturally appropriate,easy for children or disabled people toaccess, and placed where people feel safe togo. Listening to communities through groupdiscussions, interviews and observation iscrucial to understanding local norms,customs and tastes. Our principle is to ‘bringwater to people rather than make people goto water’. This saves the women and girlswho usually fetch it many hours’ walkingtime, often in dangerous conditions.

Innovation has always been central toOxfam’s approach; staff are asked topropose technical solutions to hard-to-crack problems. These can then be workedup with universities or companies. In 1985,Oxfam and Surrey University collaboratedto design the Delagua water-testing kit – aportable ‘lab in a box’ allowing instanttesting of water potability in isolated ruralsettings. It is now used all over the world.

Sometimes what’s needed is a new wayof providing information. Unable to get intoSomalia during a recent cholera epidemic,Oxfam sent interactive text messages in thelocal language on cholera preventionwhich helped mobilise the community tounderstand the risks and stay healthy.

Sophie Mack SmithKnowledge Management Advisor inEmergencies Oxfam

New networks oftenlead to ongoingpartnerships andinternationalcollaborations‘

‘

Water point, South Sudan ©Kieran Doherty/Oxfam

16 PUBLIC HEALTH TODAY

ENDNOTES ENDNOTES

SEPTEMBER 2015 17

From the CEOA GREAT number of column incheshave been devoted to the refugee crisisin Europe. Sections of the media havereferred to a ‘flood’ of ‘migrants’‘swarming’ towards Europe, while thepublication on 2 September of a photoof the body of three-year-old AylanKurdi on a Turkish beach seemed to shiftpublic attitudes. The debate remainspolarised. There has been publicoutcry – mainly in favour of improvingthe UK’s response. There continues to be

significant discussion about migration,immigration, domestic and foreignpolicy and what constitutes ‘humanity’.

At the heart of it, thousands ofpeople are fleeing their countries andtaking huge risks in the hope of a safer,better life. We have heard of peoplebeing drowned, suffocated in lorries,electrocuted on rail lines, beaten bysmugglers and fatally injured afterclashes with authorities.

In the continuing absence of aconsensus for action from across theEuropean Union, refugees and individualcountries are taking matters into theirown hands. We have seen Germanybeginning to deal with the consequencesof its generous pragmatism towardsrefugees, Hungary using water cannonsand tear gas and closing its borders,and Croatia shipping people intoHungary for onward transport toAustria. Here in the UK, the PrimeMinister has announced a doubling ofthe numbers of refugees Britain willtake in over a five-year period.

Some of the world’s religious leadershave not only called on theircommunities to house people seeking

help, they have opened their ownhouses. And Europeans have marchedwith banners welcoming refugees andtaken to social media to pressurise theirpoliticians into action.

And what are the practical solutionsto this centuries-old issue? It seems tome it’s as complicated or as simple aswe want to make it. Europe has apopulation of 740 million and some ofthe wealthiest economies in the world.We should be able to do more, faster,than we have to date – both inhandling the crisis and its causes.

It’s good to see the public healthcommunity responding in partnership tothe issues with the evidence and withcompassion. The Faculty of PublicHealth and the Association of Directorsof Public Health have issued a joint callfor action (http://www.fph.org.uk/joint_adph_and_fph_press_statement),and we are inviting support from ourpartners across the public healthcommunity and from the Academy ofMedical Royal Colleges. Together wecan make a difference.

David Allen

In memoriam

Shakeel Bhatti1979 – 2014

SHAKEEL qualified from University CollegeLondon in 2003 and began training inSouthwark public health department in2006, initially as senior house officer andthen on the specialty public health trainingprogramme. He contributed significantly to the department’s output over theyears – most recently by drafting thedepartmental training policy and workingwith Transport for London on acomparative review of London versus otherEuropean cities in terms of access fordisabled people on public transport – asubject close to his heart.

As a teenager, Shakeel was a keensportsman, excelling in football, cricket,and table tennis, with a broad spectrum of interests, including debating and chess.He won a scholarship to Dulwich College.It was in his third year at medical schoolthat he developed symptoms of aneurodegenerative disease, spinocerebellarataxia, which led to his increasing andsevere disability. Many will remember the standing ovation he received at hismedical school degree ceremony, when he walked slowly, unaided, to receive his final degree, an act that defined the determination with which heapproached the challenges he faced dailyas his disease progressed.

The spinocerebellar ataxias are a groupof rare, inherited neurological disorders.Shakeel’s father died from the samecondition. However, Shakeel was affectedearlier and more severely than his father,which is characteristic of this type ofgenetic disorder. The condition remainspoorly understood and at present there isno cure.

Shakeel was an inspiration to us all in his life and work and in the dignity andfortitude with which he accepted hiscondition and the future that lay ahead of him. We remember his resolve tomaintain his independence, his dry

humour, his daily Café Nero cappuccino,his passion for football – he was a keensupporter of Tottenham Hotspur FootballClub – and his avid interest in all newtechnologies and how they might beapplied to enable him in his work andactivities of daily life.

Gillian Holdsworth

Richard (Dick) Keenlyside FFCM1944 – 2014

DICK qualified from Westminster MedicalSchool before gaining a Diploma in Tropical Medicine and Hygiene at theLondon School of Hygiene & TropicalMedicine and a Masters in Epidemiology at Harvard.

He first joined the Centers for DiseaseControl (CDC) in Atlanta in 1976, initiallyas an officer in the Epidemic IntelligenceService carrying out research on a varietyof infectious and non-infectious diseases.

Over the ensuing years he held variouspositions in and out of CDC including aspell as Associate Director for GlobalHealth in the National Center for HIV, STD, and TB prevention in 1999-2000.Prior to his retirement in 2012 he wasCountry Manager for CDC’s HIV/AIDSprogrammes in China, Russia, Ukraine,Central Asia and India.

Dick’s career in epidemiology also took in a period as a lecturer at the London School, as a consultant to the Pan-American Health Organization’sCaribbean Epidemiology Center and asState Epidemiologist to the Rhode IslandDepartment of Health. In his later years, he became closely involved in Buddhism,studying at the Drepung LoselingMonastery, a Tibetan Buddhist learningcentre affiliated to Emory University,Atlanta.

Well known for his ability to bringmindfulness, calmness, humour and joy to any situation, Dick was widely regardedas a charming, witty and endearing personwho made countless friends across the world.

Victor Hawthorne FFCM1921 – 2014

GRADUATING from Glasgow in 1951 anddeeply affected by the toll of tuberculosisin the poorer parts of that city, Victor wassoon drawn to epidemiology. After studiescomparing the burden of respiratorydisease and hypertension in the west ofScotland, he was offered a seniorlectureship at the new department ofepidemiology and preventive medicine atGlasgow in 1966.

There he pioneered the MIDSPANprospective cohort studies, including thefamous Renfrew/Paisley Study followingthe cardio-respiratory health of 15,000men and women aged 45-64. Unusually atthe time, this study involved 4,000 marriedcouples and in 1996 spawned theMIDSPAN Family Study including sons anddaughters, which continues to this day.

In 1978 Victor took up the chair inepidemiology at the University of Michigan.He was very much involved in the chronicdisease research studies that formed thebasis of the renowned TecumsehCommunity Health Project and the SevenState Hypertension Control andDemonstration Project, as well as a rangeof studies looking at the quality of localhealthcare provision.

Victor retired in 1986, although heremained active in research and practice,his last journal article appearing as recentlyas 2009.

DeceasedmembersThe following members havealso passed away:

Mohamed Ashraff FFPHMWilliam Barton MBE FFPHHastings Carson FFPHAidan Halligan FFPHThomas Plumley MFPHGeorge Ritchie MFPHPeter Roads FFPHWalter Wigfield MFPH

18 PUBLIC HEALTH TODAY

ENDNOTES NOTICEBOARD

News in brief

FPH governance reviewWe are very pleased to announce that theFaculty of Public Health (FPH) membershipapproved the proposed changes to the FPHgovernance structures in the recentmembership ballot, and we will therefore beproceeding to incorporation as a companylimited by guarantee. The Memorandum andArticles of Association and Regulations forthe new company were approved by 86.2%.The preferred choice of name was ‘Facultyof Public Health’ (53.4%). Applications arebeing prepared for submission to CompaniesHouse and the Charity Commission toregister FPH as a company limited byguarantee by 31 December 2015 ifpossible. The full results of the ballot areavailable in the FPH online members’ areaor from carolinewren@fph.org.uk

Election of FPH PresidentNominations opened on 21 September2015 for the election of a President to takeoffice at the FPH annual general meeting inJune 2016. The post is open to all FPHFellows and Honorary Fellows in good

standing. Nomination papers are availableon the FPH online members’ area or fromcarolinewren@fph.org.uk. The deadline fornominations is midday on 19 October 2015.

There will also be elections during thecourse of 2015/2016 for a Treasurer,Academic Registrar, Assistant Registrar andlocal council members. A full electionstimetable can be found in the FPH onlinemembers’ area.

FPH courses in 2015Getting the Most Out of Your ProfessionalAppraisal – London, 9 OctoberHow the appraisal system works, and howto enhance the process so that it canmaintain your practice. More informationfrom garethcooke@fph.org.ukMental Wellbeing in Population Health: AnIntroduction – London, 16-17 NovemberProvides an understanding of the principlesof mental wellbeing, the effect on theindividual and community and how toaddress these issues. More informationfrom garethcooke@fph.org.uk

PHAST courses in 2015FPH is hosting the following courses inLondon in partnership with the PublicHealth Action Support Team (PHAST). Moreinformation frommarion.deacon@phast.org.uk

Transformational Leadership Workshop –23 October 2015 Covers all the key elements oftransformational leadership for publichealth professionals working in a complex,multi-agency environment. Furtherinformation at http://tinyurl.com/obdltcrSocial Media with Confidence Workshop –30 October 2015Explores the uses, opportunities and risksof social media, offering real-timedemonstrations and hands-on experience.Describes the most popular channels,explains their uses, differences andlimitations. Further information athttp://tinyurl.com/qxujdpoCritical Appraisal: Making Sense ofResearch Evidence – 6 November 2015Develops skills in appraising research ondifferent study types and refreshesunderstanding of research methodologies.Reviews a randomised controlled trial, asystematic review and a case-control study.Further information athttp://tinyurl.com/ofg98r6

CorrectionIn Public Health Today June 2015 weincorrectly quoted Clare Gerada in the pull-out quote in the Big Interview. Thathas been corrected in the online version.Apologies.

New publichealthspecialists

Congratulations to the following onachieving public health specialtyregistration:

UK PUBLIC HEALTH REGISTER

Training and examination routeDuncan CooperHelene DennessLouise SigfridVictoria Spencer-HughesKirsten WattersGlen Wilson

Generalist portfolio routeLydie Lawrence

Defined specialist portfolio routeWilliam BeerFarrah HartFiona McGonigle

GENERAL MEDICAL COUNCIL REGISTER

Amina Aitsi-SelmiElspeth AnwarCatherine CoyleJane FowlesSrinivasa KatikireddiFatim LakhaBruce McKenzieRichard PinderCharlotte SimpsonCharlotte StevensonRhianwen StiffJanine ThoulassNicholas Young

Honorary FellowsAmanda AmosMichael BannonIlora Finlay of LlandaffTrevor HancockJanet HemmingwayDavid HeymannRonald Labonte

Fellows through distinctionKarin DentonAkram Eltom MohamedSarah HawkesMuhammad KhanHa Yun LeeAnna MillerEdward O’DwyerIkushi OnozakiRosalind Parkes-RatanshiNeil PearceJoseph PeirisJem RashbassJacqueline ReillyJohn RumunuAziz SheikhHong-Bing ShenJane SouthAlistair StoryAmmar Suliman-AbbasPeter WrightJoseph Tsk Kei Wu

FellowsMarta BusanaSin ChorBethan DaviesHelene DennessJane FowlesRachel IsbaJillian JohnstonSrinivasa KatikireddiRabia KhanBen LeamanBruce McKenzieGillian O’NeillMaha SaeedRuksana Sardar-AkramLouise SigfridSamit ShahSarah SmithJason StrelitzCelia WattKirsten Watters

Honorary MembersRhys BlakeAlex BottleRosamund BryarBen CaveCarmel ClancySarah Jane Cunningham-Burley

David DickinsonSheila DuffySimon EllisAnders FreibergPhilip InsallSally JamesAlhussein KhaledMonika KosinskaBennett LeeJohn MoxhamDanielPopeBayard RobertsEdmond RooneyCathy RothAnthony RuddCatherine SwannIan TrimbleKaren WheelerSandra WhilesPatti WhiteDavid WilkinsonWilliam C W WongGeoff Wykurz

Members through distinctionRobin IrelandChristopher LewisTom LoneyChe Chung LukHelen McAvoyAnna Pronyszyn-HughesColin SibbaldMary Tooley

MembersAmina Aitsi-SelmiDominique AllwoodBehrooz BehbodJane BrayKathryn CobainAnna DonaldsonDurka DougallGemma DunnAshley GoodfellowKaty HarkerMeetali KakadStuart KeebleAbigail KnightFatim LakhaCatherine MbemaGerardo Javier Melendez-TorresMatthew PearceSarah RayfieldDavid RobertsJudith StonebridgeAngeline Walker

Diplomate MembersBalsam AhmadShazia AhmedSuzanne Bartington

Welcome to new FPH membersWe would like to congratulate and welcome the following new members who wereadmitted to FPH between April 2015 and September 2015

SEPTEMBER 2015 19

NOTICEBOARD

Timothy Crocker-BuqueAndrew DaltonDaniel FlecknoeRebecca HamsRuth MellorEmily-Rose PhippsRobin PooleDarryl QuantzZainab ShatherPaul SouthworthMatthew TyrerEmmeline Watkins

Specialty Registrar MembersEmily Walmsley

THE FINAL WORD

‘ ’ Bed-bound and taking 21 tablets a day, Debs Taylorwas resigned to a life of debilitating mental illhealth. Then one day she picked up a paintbrush and everything changed...

HAVING had mental health issues from avery young age, it was part of my life. I was resigned to the fact that I would beon medication and have this illness forever.Even the ‘experts’ told me I would, so itmust be true, right? Wrong.

Three-and-a-half years ago I embarkedon an ‘art-for-wellbeing’ course withCreative Minds, part of the South WestYorkshire NHS Trust. I went along to ataster session, having been ridiculed about the appalling state of my drawingwhen playing picture games with mychildren. Although I was not expectingmiracles, that day was the start of themost incredible journey that I could ever imagine.

I was heavily medicated (21 tablets aday), bed bound most of the time and, asmy girls were my carers, life didn’t hold outmuch hope. After the initial taster, I begangoing regularly to the group. As mypaintings improved my mind did too. I started to reduce medication and myconfidence was growing along with mycollection of work. I started doing talks toinspire service users that they too couldhave hope of getting better. Professionalsstarted listening and started asking mequestions on how they could help peoplelike me. I felt I was contributing to life. I was making a difference to the world

of mental illness.Three-and-a-half years later, I do talks all

over the country about mental illness andhow it affects people. I have many piecesof my work adorning people’s walls. I wentto the Garden Party at Buckingham Palacelast year after someone heard my story andwas so inspired that they nominated me. Ihave had an art exhibition at Canary Wharf

in London. Not bad for someone who wasjust a statistic in a failing system.

I want people to see that mental illnesscan be improved. If I can make such ahuge difference with my life then I have nodoubt others can too. I feel like I am finallyliving life. I am finally a part of what manytake for granted. I once felt jealous of a

terminal patient in hospital; her life wascoming to an end, and mine was beingforced to carry on with this illness that wasconsuming my whole body. The obstacles Iused to see are now challenges. I willcontinue in my quest to change people’sattitudes to mental illness. I want people tosee that there are millions living with thisillness. I don’t want people to think only ofthat one person who has done somethinghorrific and presume we are all like that.

Not only did my art therapy save theNHS essential funding (Social Return OnInvestment has been done on mytreatment before and after the course), butthe impact on my family and myself hasbeen priceless. Art has changed my life.Something as simple as painting has givenme a totally different outlook. I am nolonger reliant on medication – I am nowdown to zero tablets. I have found skillsthat have equipped me to live my life. I never dreamed I would ever feel ‘normal’,let alone be an active campaigner inchanging attitudes towards mental illness.The sky has no limit.

Debs Taylor

http://www.thedebseffect.co.ukhttp://www.southwestyorkshire.nhs.uk/quality-innovation/creative-minds/

I went along to ataster session, havingbeen ridiculed aboutthe appalling state ofmy drawing whenplaying picture gameswith my children‘‘

Information

ISSN – 2043-6580

Editor in chief Alan Maryon-Davis

Managing editorsLindsey Stewart and Mag Connolly

Commissioning editorLiz Skinner

Production editorRichard Allen

2

Editorial board

Editorial boardAndy BeckinghamStella BotchwayMatthew DayDavid DickinsonRachel JohnsFrances MacGuireHelen McAuslaneSally MillershipThara RajLeonora Weil

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SubmissionsIf you have an idea for an article or specialfeature subject, please submit a 50-wordproposal and suggested authors tonews@fph.org.uk. The subject ofDecember 2015’s special feature isHealthcare Public Health. The subjects of2016’s special features will be decided inNovember 2015

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All articles are theopinion of theauthor and not thoseof the Faculty ofPublic Health as anorganisation