Flood Impact on Health & Hygiene of Rural Areas : Mitigation Options

1. Welcometo presentation ofDirectorate General of Health ServicesMinistry of Health & Family Welfare Directorate General of Health Services,Ministry of Health & Family Welfare

2. Flood ImpactonHealth & Hygieneof Rural Areas :Mitigation Options September 2004, Dhaka Directorate General of Health Services,Ministry of Health & Family Welfare

3. Flooded area of Bangladesh in different year Source: Bangladesh Water Development Board 2004 • Flood hits Bangladesh almost every year or every few years • Only the area or intensity differs • The people in area, where flood hits, suffer the same pain • The relief and medical operation teams in the affected area play the same role • In 1998, flood control room at DGHS office needed to work from June to December : a full half year leaving aside many important regular activities • Can a country like Bangladesh afford such burden every year? Background Flooded area of Bangladesh in different year Source: Bangladesh Water Development Board Directorate General of Health Services,Ministry of Health & Family Welfare

4. 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? Directorate General of Health Services,Ministry of Health & Family Welfare

5. Flood Impact on Health & Hygiene Movement becomes difficult People suffer from food shortage Flood Trap Home goes under water 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 Directorate General of Health Services,Ministry of Health & Family Welfare

6. Flood-borne Morbidities • Water & Food-borne diseases • Respiratory infections • Skin diseases • Eye infections • Drowning • Snake bites • Accidents • Malnutrition 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 > More infections Directorate General of Health Services,Ministry of Health & Family Welfare

7. 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 Directorate General of Health Services,Ministry of Health & Family Welfare

8. 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 Directorate General of Health Services,Ministry of Health & Family Welfare

9. 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 PlusNegative international image as flood prone country> Decreased foreign investment • Alert politicians and public representatives: More attention of Govt. to field > 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> Malnutrition • Environmental pollution: Health hazards • Loss of household assets: Poverty > Psychological stress Other Impacts Directorate General of Health Services,Ministry of Health & Family Welfare

10. Flood Impact in Quantitative Terms MOHFW Flood 2004 Physical damage (2004) DGHS: ~Tk. 32 crore Loss of logistics (2004) Medicines & Supplies 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) Directorate General of Health Services,Ministry of Health & Family Welfare

11. Flood Impact in Quantitative Terms… 2004 Flood : No. of diarrhoea cases by date Directorate General of Health Services,Ministry of Health & Family Welfare

12. Directorate General of Health Services,Ministry of Health & Family Welfare

13. Flood Impact in Quantitative Terms… Directorate General of Health Services,Ministry of Health & Family Welfare

14. Flood Impact in Quantitative Terms… Directorate General of Health Services,Ministry of Health & Family Welfare

15. 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 Directorate General of Health Services,Ministry of Health & Family Welfare

16. Year 2004 data are as of Aug 25, 2004 Flood Impact in Quantitative Terms… Directorate General of Health Services,Ministry of Health & Family Welfare

17. Flood Impact in Quantitative Terms… Flood 2004 Medical supplies directly from DGHS Transport Grants >Tk. 10 million Directorate General of Health Services,Ministry of Health & Family Welfare

18. Time given by Hon’ble Minister, MOHFW: 11d/22d (50% days) (Jul 23–Aug 15, 2004) Time given by Hon’ble State Minister, MOHFW: Significant Time given by Secretary, MOHFW: Significant Time given by Director General (Health): Full time supervision Deployment of senior officials: 54 DGHS:36 MOHFW: 18 No. of medical teams: 4,353 (~13,059 persons) Indirect Flood Impact Flood 2004 Directorate General of Health Services,Ministry of Health & Family Welfare

19. 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/seminars: Many Postponement of examinations in medical institutions: all in this period Directorate General of Health Services,Ministry of Health & Family Welfare

20. Monsoon moths: Jun-Oct; Non-monsoon months: Nov-May Diarrhoea load caused by flood? Observations Directorate General of Health Services,Ministry of Health & Family Welfare

21. Flood 2004 One of the best Flood Medical Care Managements Government Initiatives … 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 > Quick supply • DG (health) closely monitored all activities Directorate General of Health Services,Ministry of Health & Family Welfare

22. 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 Directorate General of Health Services,Ministry of Health & Family Welfare

23. Government Initiatives … Flood 2004 Approach to Management • 4,353 medical teams and 36+18=54 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 Directorate General of Health Services,Ministry of Health & Family Welfare

24. Government Initiatives … Flood 2004 Approach to Management • Comprehensive and improved reports were sent to PM’s 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-day’s salary to PM’s Relief Fund • News media were kept updated Directorate General of Health Services,Ministry of Health & Family Welfare

25. Donor & Private Initiatives Flood 2004 UNICEF WHO UNFPA BMA medical teams UN Flood Appeal Directorate General of Health Services,Ministry of Health & Family Welfare

26. 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 Directorate General of Health Services,Ministry of Health & Family Welfare

27. 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 Directorate General of Health Services,Ministry of Health & Family Welfare

28. Observation& Recommendation Directorate General of Health Services,Ministry of Health & Family Welfare

29. 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 Directorate General of Health Services,Ministry of Health & Family Welfare

30. 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 don’t 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 Directorate General of Health Services,Ministry of Health & Family Welfare

31. 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 don’t have digital phones • Phone ceiling is low for residence of DGHS to CS and UH&FPO • Most district and upazila health offices don’t have fax, computer, email and photocopier, etc. Directorate General of Health Services,Ministry of Health & Family Welfare

32. 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 don’t have umbrella, rain coat, gum boot, life jacket and BCC materials • Health facilities suffer from frequent interruption in supply of electricity - These don’t have generator / IPS • Inadequate buffer stock of medicines for disaster management in some districts Directorate General of Health Services,Ministry of Health & Family Welfare

33. Recommendation Coordination • Improve inter-sectoral coordination between different departments (viz. with customs) Observation • Weak inter-sectoral coordination (viz. with customs) Directorate General of Health Services,Ministry of Health & Family Welfare

34. 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) Directorate General of Health Services,Ministry of Health & Family Welfare

35. Recommendation Responding Proportionately Orientation • Conduct orientation programme for journalists and people’s representatives Stakeholder involvement • Involve community people, journalists and people’s representatives in flood planning process Observation • Active news media • Alert politicians and public representatives Directorate General of Health Services,Ministry of Health & Family Welfare

36. 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 Directorate General of Health Services,Ministry of Health & Family Welfare

37. We Need Albert Einstein Imagination is more important than knowledge ! Combating Flood Safely Appropriate Plan Safe housing Safe water Safe environment Safe and adequate food Beyond MOHFW • 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 Directorate General of Health Services,Ministry of Health & Family Welfare

38. If we don’t care for River Management Directorate General of Health Services,Ministry of Health & Family Welfare

39. Thank you Directorate General of Health Services,Ministry of Health & Family Welfare