Mitigation Options

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Welcometo presentation ofDirectorate General of
Health ServicesMinistry of Health Family
Welfare
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Flood ImpactonHealth Hygieneof Rural Areas
Mitigation Options

• September 2004, Dhaka

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Background
Flooded area of Bangladesh in different
year Source Bangladesh Water Development Board
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The Issues

• How flood impacts the health and hygiene
  situation in our rural areas?
• How did we handle the 2004 flood?
• Can MOHFW alone control those health and hygiene
  impacts?
• How can we improve medical care during flood,
  minimize negative impacts, and continue health
  development activities?

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Flood Impact on Health Hygiene
Movement becomes difficult

• Home goes under water

People suffer from food shortage
Flood Trap
Bathing, washing and playing in flood water cause
disease
Rural Area
Toilets become unprotected Human animal
excreta, rubbish contaminated soil mix with
water
Cooking becomes difficult
Tube wells and safe water sources are submerged
Open defecation increases
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Flood Impact on Health Hygiene
Water food-borne diseases Diarrhea, dysentery,
cholera, jaundice, typhoid, helminthiasis

• Scarcity in food supply
• monotony of uncooked food
• Malnutrition of vulnerable groups (children,
  pregnant and lactating mothers, elderly and sick
  persons)
• Lower immunity gt More infections

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Flood Impact on Health Hygiene
Over-crowding Poor Hygiene in Flood Shelters

• Many people live in small areas of flood shelters
• Sanitary condition is compromised with respect to
  cleanliness, food hygiene, toilet, safe water and
  vector control
• Water/food borne diseases, scabies and
  respiratory infections spread
• Privacy problem forces lactating mothers to delay
  breast feeding their young babies leading to
  child malnutrition

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Flood Impact on Health Hygiene
Transportation Problem

• Difficulty in food procurement, and seeking care
  in medical emergencies and for expecting mothers
  (antenatal, child birth and postnatal)
• Flood teams find difficulty to move to fields
  with logistics
• Disruption of normal health, family planning,
  nutrition and health education activities
  (center-based and domiciliary)
• Long term outcome ?Population, ?Malnutrition,
  ?Maternal mortality, ?Low birth weight babies, ?
  Stunted children

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Flood Impact on Health Hygiene

• Physical damage of health facilities
• Deployment of important personnel and staff to
  field Delay in routine decision making and
  services
• Active news media More attention of Govt. to
  field Plus Negative international image as flood
  prone country gt Decreased foreign investment
• Alert politicians and public representatives
  More attention of Govt. to field gt Pressure on
  limited manpower and resources
• Loss of crop, fish, animal poultry
  Malnutrition affecting specially vulnerable group
  (children, pregnant women, elderly, sick persons)
• Temporary loss of employment Poverty and
  malnutrition
• Soil contamination Intestinal parasites gt
  Malnutrition
• Environmental pollution Health hazards
• Loss of household assets Poverty gt Psychological
  stress

Other Impacts
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Flood Impact in Quantitative Terms
MOHFW
Flood 2004
Loss of logistics (2004) Medicines Supplies
Physical damage (2004) DGHS Tk. 32 crore
No. of deaths (Flood 2004 On 25-8-04) Disease No.
Diarrhoea 91 Pneumonia 92 Snake
bite 85 Drowning 202 Dysentery 0 Jaundice 0 Skin
disease 0 Eye disease 0 Total 475
Source DGHS, MOHFW (as of Aug 25, 2004)
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Flood Impact in Quantitative Terms
2004 Flood No. of diarrhoea cases by date
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(No Transcript)
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Flood Impact in Quantitative Terms
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Flood Impact in Quantitative Terms
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Bacterial Pattern of diarrhoea stool
samples(IEDCR, Dhaka 2004 Flood

• Division No. of samples E. coli Vibrio cholerae
  01 Salmonella typhi
• Dhaka 34 33 0 1
• Sylhet 20 20 0 0
• Chittagong 4 4 0 0
• Rajshahi 29 26 2 1
• Barisal 4 3 0 1
• Total 91 (100.0) 86 (94.5) 2 (2.2) 3 (3.3)

• Sensitivity
• No bacteria were found sensitive to tetracycline,
  ampicillin, erythromycin and cotrimoxazole
• Nalidixic acid and cefalexin were also less
  sensitive
• Ceftriaxone, pefloxacin and ciprofloxacin worked
  well to kill the bacteria

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Flood Impact in Quantitative Terms
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Flood Impact in Quantitative Terms
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Flood Impact in Quantitative Terms
Flood 2004
Medical supplies directly from DGHS
Transport Grants gtTk. 10 million
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Indirect Flood Impact
Flood 2004
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Indirect Flood Impact
Flood 2004
EPI service loss BCG 41,544 doses Measles
41,544 doses DPT 1,24,632 doses OPV 1,24,632
doses Hepatitis B (25 dist 5 City Corps) 4,800
doses TT 2,18,064 doses EPI out-reach
sessions (not held) 10,384 Nos.

• Family planning service loss
• Mother child care
• Ante-natal, natal post-natal care
• Sterilization camps
• Clinic based services (IUD, Injection, Norplant)
• Home visits

• NNP service loss
• Programme Upazila affected 70
• Community Nutrition Centre (CNC) did not
  function 3,802
• Nutrition gardens damaged 88,369
• Nursery damaged 985
• 1-day old chick died 62,355
• Chicken died 51,807

Postponement of health FP training/workshop/sem
inars Many
Postponement of examinations in medical
institutions all in this period
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Observations
Diarrhoea load caused by flood?
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Government Initiatives
Flood 2004 One of the best Flood Medical Care
Managements

• Approach to Management
• DGHS opened 24-h Disaster Monitoring Cell
• Control Room at DGHS National Monitoring System
  were strengthened
• CMSD kept open for 24h
• A 24h Drug Sub-Depot established at EPI
  directorate under direct supervision of Director
  of Primary Health Care, DGHS gt Quick supply
• DG (health) closely monitored all activities

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Government Initiatives

• Approach to Management
• Quick decision Switching from water purifying
  tablets to solutions
• Extra production of ORS IV fluid at IPH in 5
  NORPs in different districts under DGHS by
  increasing daily shifts from 1 to 3 and also by
  EDCL
• Outside sale of all the productions from IPH,
  NORPs EDCL was cancelled and reserved for use
  by DGHS
• DGHS provided allocation of extra fund for boat
  transportation to all districts
• Good coordination collaboration between MPs,
  administration and health managers at district
  and upazila levels

Flood 2004
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Government Initiatives
Flood 2004

• Approach to Management
• 4,353 medical teams and 361854 senior health
  officials deployed to work in fields
• Lists of medical team members were given to local
  MPs and local administration for close monitoring
  supervision
• All types of leaves, workshops, seminars, both in
  home abroad were cancelled

MOHFW DGHS managed the entire medical care
service without taking assistance from armed
forces unlike in previous floods
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Government Initiatives
Flood 2004

• Approach to Management
• Comprehensive and improved reports were sent to
  PMs Monitoring Cell, MOHFW, and Disaster
  Monitoring Cell at MOFDM on daily basis
• Key health education messages were disseminated
  in flood camps and flood affected areas
• All of MOHFW staffs donated 1-days salary to
  PMs Relief Fund
• News media were kept updated

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Donor Private Initiatives
Flood 2004

• UNICEF
• WHO
• UNFPA
• BMA medical teams

UN Flood Appeal
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Policies and Regulations
Flood 2004

• Strengths
• Standing Order of MOHFW for disaster management
• Standing Guidelines of MOHFW for Emergency
  Preparedness and Response
• Weakness
• GOB MOHFW Orders and Guidelines need more
  adherence

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Status of Institutional Capacity
Flood 2004
National Public Health Institutions (viz. IEDCR,
NIPSOM, IPHN, IPH) do not have adequate
funding for flood outbreak investigations and
research
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Observation Recommendation
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Recommendation
Observation

• Manpower strength
• Fill up vacancies at rural centers
• Fund and Authority
• Provide adequate fund and authority to district
  and upazila health managers for emergency
  purchase, repair or rental
• Provide adequate fund to National Public Health
  Institutions for flood outbreak investigations
  and research

• Vacancy (doctors and other staff) at rural
  centres
• District and upazila health managers do not have
  fund or authority for emergency purchase, repair
  or rental
• National Public Health Institutions do not have
  fund for flood outbreak investigations and
  research

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Recommendation

• Better Transportation
• Ensure jeeps for all Civil Surgeons and Upazila
  Health Managers
• Raise fuel ceiling for field managers
• Provide motor bikes, bicycles, speed boats, river
  ambulances, country boats, floating hospital,
  etc. for field service

Observation

• Many Civil Surgeons dont have vehicles
• Fuel ceiling for field managers is very low (200
  L/month)
• No UHFPO has vehicle
• Motor bikes, bicycles, speed boats, river
  ambulances, country boats, etc. for field service
  are not available

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Recommendation

• Information Communication
• Provide digital phones to all Upazila Health
  Complexes
• Withdraw residence phone ceiling for CS, Div. Dir
  (health), like DCs and Div. Commissioners
• Withdraw residence phone ceiling for DG (Health)
• Provide fax, computer, email and photocopier,
  etc. to all district and upazila health offices
• Provide mobile phone for field service

Observation

• Many Upazila Health Complexes dont have digital
  phones
• Phone ceiling is low for residence of DGHS to CS
  and UHFPO
• Most district and upazila health offices dont
  have fax, computer, email and photocopier, etc.

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Recommendation

• Logistic Support
• Provide umbrella, rain coat, gum boot, life
  jacket and BCC materials to field staff
• Provide generator/IPS to cope with power supply
  problem
• Maintain adequate buffer stock of medicines and
  supplies in all districts

Observation

• Field staff dont have umbrella, rain coat, gum
  boot, life jacket and BCC materials
• Health facilities suffer from frequent
  interruption in supply of electricity - These
  dont have generator / IPS
• Inadequate buffer stock of medicines for disaster
  management in some districts

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Recommendation

• Coordination
• Improve inter-sectoral coordination between
  different departments (viz. with customs)

Observation

• Weak inter-sectoral coordination (viz. with
  customs)

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Recommendation

• Training Drills
• Provide EPR training to health personnel and
  staff
• Hold regular drills

Observation

• Inadequacy of trained health manpower on
  Emergency Preparedness Response (EPR)

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Recommendation
Responding Proportionately

• Orientation
• Conduct orientation programme for journalists and
  peoples representatives
• Stakeholder involvement
• Involve community people, journalists and
  peoples representatives in flood planning process

Observation

• Active news media
• Alert politicians and public representatives

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• 5 crucial factors
• in flood impact managements
• Keeping people above water level
• Preventing water contamination
• Maintaining hygiene sanitation
• Supply of adequate food
• Health care education

Ministry of Health Family Welfare looks after
only the last factor
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Beyond MOHFW
We Need
Combating Flood Safely Appropriate Plan Safe
housing Safe water Safe environment Safe and
adequate food

• Integrated local flood contingency plan
  prioritizing flood prone zones
• Appropriate river and water reservoir management
  programme
• Clustered community with housing at high levels
• Innovative and safe latrines
• Innovative source for all time safe water
• Standard guidelines for food supply during and
  after flood
• Standard guidelines for flood shelter setup and
  operation
• Strong and sustained health education campaigns
• Better inter-sectoral collaboration

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If we dont care for River Management
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Thank you