CASE BOX 1.2 SCHOOL- IN- A- BOX BY UNICEF

Public health has been defi ned as “the science and art of preventing dis-ease, prolonging life and promoting health through organised efforts of society”

(Acheson, 1988, p. 1; World Health Organization [WHO], 2004, p. 32). Unlike clinical medicine , where physicians and allied health professionals focus on treat-ing diseases and managtreat-ing the health of individuals, public health professionals focus on optimising the health of populations . The fi eld of public health comprises evidence- based methods, decision- making and the application of theories in society.

Effective public health practice is a multidisciplinary effort to make health a prior-ity for all by understanding the determinants of health, addressing health disparities, identifying disease risk factors and implementing preventive strategies.

In the context of disaster preparedness, response and management, the defi nition of health implies the importance of addressing all three fundamental components of health: the physical, social and mental well- being of a population. Although health and medical disaster response programmes tend to focus heavily on safeguard-ing physical health (e.g. injury management, communicable disease control, food access), an effective health response should consider the mental and social health aspects as well as activities which lead to health improvements instead of focusing only on physical dimensions (see Case Box 1.2).

Scope of the fi eld of public health:

three domains of public health

Public health is a multidisciplinary fi eld in medicine that utilises epidemiology, clini-cal trials, biostatistics, laws and ethics to protect health, improve health and secure the provision of health services. The various components of public health prac-tice can be grouped into three widely accepted domains of public health: health protection , health improvement and health services (Griffi ths, Jewell, & Don-nelly, 2005). The three domains of public health illustrate the multidisciplinary nature of this fi eld and its potential applications in the development of evidence- based medical and humanitarian response in disasters.

CASE BOX 1.2 SCHOOL- IN- A- BOX BY UNICEF

Psychosocial interventions in the post- impact phase of disasters and crises are useful for creating a supportive environment and restoring a sense of normalcy for the affected people. For example, for the child population, being able to return to school is very important for their psychosocial health. In the 1990s, the United Nations Children’s Fund (UNICEF) developed the “School- in- a- Box”

programme for children in disaster- affected situations. It is literally a box con-taining supplies and basic materials that can be used to support the teaching of 40 students for approximately three months; temporary classrooms can be set up within 72 hours after a disaster. Further information can be found in this video: http://www.unicef.org/supply/kits_flash/schoolinabox.

Figure 1.1 shows the anatomy of public health. The three domains include health protection, health improvement and health services, with global health encompass-ing, and some common tools supportencompass-ing, all the domains.

Health protection involves the prevention, control and response to outbreak of infectious diseases, the regulation of occupational hazards, the monitoring of environ-mental health hazards, such as air, water and food quality, and response to chemical or technological emergencies (e.g. bioterrorism and radiation disasters). Health improvement involves actions to improve outcomes and health determinants and to reduce health inequalities in a population. This area of work combines different sectors (e.g. housing and education) to ensure that policies and health promotion and education activities at the population level will empower and support individuals to make informed lifestyle choices. Health service and management focuses on the policies and delivery of health services. It promotes evidence- based clinical practices, governance and resource allocation. Of note, the three domains of public health are not mutually exclusive to each other; these subjects overlap and are often interdepen-dent. These domains are commonly applied in general public health practice.

Epidemiology, biostatistics, clinical trials, and law and ethics are overlapping pub-lic health skill sets that serve as foundation tools for pubpub-lic health practice. They provide common technical approaches to support the knowledge- based domains, as illustrated at the centre of the Venn diagram ( Figure 1.1 ). Epidemiology is the

FIGURE 1.1 Three domains of public health

branch of medicine studying the distribution and determinants of health- related states. Biostatistics is the application of statistical techniques to research related to the health fi eld. Clinical trials are a specifi c type of clinical research that conducts comparisons between treatments/intervention options and serves three major pur-poses: confi rming the safety of treatment, identifying side effects and comparing the effect of a new treatment with the existing standard procedure. This type of research produces evidence- based interventions in disaster response. Law and eth-ics provide frameworks for decision making. Specifi cally, public health law is the study of the legal power and hence the duties of the state in providing conditions where people remain healthy. Ethics provides a guiding principle for deciding what is right and wrong. In health care, it is also related to how professionals behave, based on professional bodies’ defi nition of what is right, fair and just when serving the general community (Griffi ths, Jewell, & Donnelly, 2005).

In public health- and medical- related disaster studies, epidemiology and bio-statistics can provide the technical tools to assess and evaluate the impact and outcomes of disasters. Health policy and service analysis can support service emer-gency preparedness and training planning, and disaster response management.

Health protection actions, such as outbreak and infection control, environmental health assessment and protection, and psychological fi rst aid to support the mental health of responders and affected community, are important activities to protect the community from the secondary impact of a disaster. Health promotion, nutri-tional programmes, health risk communication, resource mobilisation and technical capacity building (e.g. human resources development and disaster response team building) might not only support a disaster- affected community but also improve its underlying resilience in its health systems and technical capacity and, ultimately, safeguard the health and well- being of the community.

Measuring health

There are four major ways to measure health. Firstly, it can be measured by conse-quences , such as mortality, morbidity, economic implications and so forth. Secondly, it can be assessed by targeting population subgroups . The health impact of an incident toward children, women, older people or those with chronic diseases may vary within the same context. Health outcomes may thus be categorised according to the specifi c characteristics and needs of each of these subgroups. Thirdly, health might be measured by frequency . Incidence, prevalence, mortality rates and ratios are examples of metrics by which one can quantify health outcomes. Last but not least, disease severity might differentiates a person’s experiences in health. For example, someone who has early asymptomatic stage of diabetes mellitus might experience a different quality of life when compared with someone who has a severe diabetic condition which requires dialysis or diabetic foot- related amputation.

In a disaster, the actual health impact may be diffi cult to quantify. Available infor-mation (e.g. mortality data and hospitalisation inforinfor-mation) might allow only a partial overview of the actual health implication of a situation. Figure 1.2 shows that unless

specifi c effort is dedicated to examine the overall real impact of an incident or disaster, most reports provide only a specifi c and partial perspective toward the true impact.

In order to build responsible and evidence- based disaster preparedness and response programmes, it is important to choose the relevant and appropriate met-rics to quantify health impacts, assess needs, plan programmes, track intervention programmes and evaluate the effectiveness of activities in a post- disaster context.

Disaster epidemiology

Epidemiology is the study of how disease/health outcome is distributed in popula-tions and the factors that infl uence or determine this distribution. The underlying principle of this technical discipline assumes adverse health outcomes do not occur randomly within a population but follow a predictable pattern. Thus, although a population might be exposed to health risks or environmental hazards, not every-one will be affected equally by disasters or suffer from their adverse impact to the same extent. For example, if someone lives in a well- engineered, earthquake- resistant concrete building, the risk of this individual being injured by the building collapsing during an earthquake is likely to be lower than for those who live in makeshift shelters built of lumber and bricks.

Epidemiologic methodologies applied to the disaster context are useful to measure and describe the adverse effects of disasters on human populations. Through epidemi-ological analysis, risk factors may be identifi ed to explain why certain people are more prone to the negative health impact of disasters and protective measures may be devel-oped to protect people before a disaster strikes. Publications about the public health impact of disasters using epidemiological methodologies were signifi cant because their focus was on fi nding ways to prevent and mitigate the impact of future disasters. The development of the Interagency Emergency Health Kit 2011 is an example of applying research to maximise the effectiveness of medical and relief efforts (see Case Box 1.3 ).

FIGURE 1.2 An iceberg of health outcomes

CASE BOX 1.3 HOW DOES DISASTER EPIDEMIOLOGY