Disaster Public Health and Older People 2019015250, 2019980621, 9780815356660, 9780815356677, 9781351127622

Table of contents :
Cover
Half Title
Series Information
Title Page
Copyright Page
Dedication
Table of contents
List of Illustrations
List of Boxes
List of Contributors
Foreword
Foreword
Acknowledgements
1 Introduction
Conclusion
References
2 Principles and theories: health and public health
Definition of health and public health
Principles of public health approaches
Health determinants
Measuring health
Demography and epidemiology
Epidemiology
Life course approach
Pathway of care
Development and health risk transition
Three domains of public health
Disease prevention
Hierarchy of prevention
Health protection
Five key spheres of health protection
Epidemiologic triangle
Communicable diseases and infection control
Non-communicable diseases control
Health promotion
Prevention paradox
Risk behaviours, health risks and high-risk groups
Health communication
Approaches and strategies in health promotion
Policy implication
Health systems
Universal health coverage (UHC)
Levels of care
Medical ethics
Conclusion
References
3 Principles and theories: ageing population
Older age
Geographic distribution of older people
Older people’s health
Health determinants of older people
Physical decline
Key physiological changes with ageing
Sensory decline
Cognitive decline
Sexuality
Independence
Economic aspect: Older age poverty
Common health problems
Disabilities
Elder abuse
Prevention
Global policy development for older people
Healthy ageing
Resilience: Age-friendly cities framework
United Nations guiding principles for older people
Conclusion
References
4 Principles and theories : disaster
Disaster
Hazard versus disaster
Classification of hazards and disasters and their impact on public health
Natural hazards and disasters
Climate change and hazards
Human-induced hazards and disasters
Technological disasters
Complex emergencies
Refugees and internally displaced persons
Global trends for disasters
Causes of global trends of disasters
Disaster risk
Disaster risk formula
Emergency threshold
Disaster cycle
Disaster response cycle
Disaster management
Myths of disaster
Disaster epidemiology
General public health impact of disasters
Overwhelming local response capacity with unexpected mortality and morbidity
Impact on disaster survivors and bystanders
Destruction of health services
Adverse impact on environment
Adverse psychological and social behaviours
Long-term consequence of disasters
Economic consequence of disasters
General public health response in disasters
Securing basic requirements for health
Determining the current and likely health threats
Identification and provision of resources to implement the first two principles
Mental health
Mental health response
Critical incident stress debriefing
Psychological first aid
Social health
Humanitarian principles
The Humanitarian Charter
The right to life with dignity
Distinction between combatants and non-combatants
Principle of non-refoulement
Sphere
Health Emergency Disaster Risk Management (Health-EDRM)
Conclusion
References
5 Contributions of older people to disaster mitigation, preparedness, response and recovery
Contribution of older people in a society
Economic contributions
Leadership, knowledge transfer and partnerships
Community development
Caregiver
The disaster context
Preparedness and mitigation
Response
Recovery and rehabilitation
Conflict resolution
Conclusion
References
6 Health impact of disasters on older people
General health impact of disasters on older people
Older people and disasters: Health risks and vulnerabilities
Poorer health conditions
Economic marginalisation
Social marginalisation: isolation
Inaccessible information
Limited legal awareness
Gender perspective
Health risks
Geophysical disasters
Earthquakes and tsunamis
Volcanic eruptions
Biological disasters: epidemics, outbreaks, pandemics and endemics
Communicable diseases following a disaster
Climate-related natural disasters and human health
Extreme temperature events
Communicable diseases: Vector-borne and food/water-borne diseases
Communicable diseases tend to more significantly affect people of extremes of age. While children have suboptimal...
Vector-borne diseases
Food-/water-borne diseases
Non-communicable diseases: Impact of air quality on respiratory and cardiovascular health
Floods
Hurricanes/cyclones/typhoons and tornadoes
Drought and famine
Physical injuries
Mental health
Fires
Manmade disasters/terrorism
Conflicts and wars
Gender-based violence
Conclusion
References
7 Post-disaster response and recovery to meet health needs of older people: I
Challenges in a disaster context
Overall basic needs
Mobility and evacuation
Environmental risks
Underlying health risks
Geriatric trauma
Protection
Principle of post-disaster response: Basic requirements for health
Water supply, sanitation and hygiene promotion (WASH)
For older people
Food and nutrition
For older people
Shelter and clothing
For older people
Health services
For older people
Information
For older people
Global standards for relief
Conclusion
References
8 Post-disaster response and recovery to meet health needs of older people: II
Emergency preparedness
Identification of vulnerability
Exclusion
Access to services and resources
Emergency health and medical care service
Geriatric care in triage
Suboptimal health systems in disasters
Protection
Tracing
Caregivers with appropriate skill training and network for older people
Informal care
Recovery and rehabilitation
Livelihood support
Relocation
Capacity at the individual, organisational and community levels
Building partnership
Conclusion
References
9 Healthy ageing, disaster mitigation and disaster risk reduction : individual, programmatic and global policy levels
Disaster risk reduction and older people
Health Emergency and Disaster Risk Management (Health-EDRM)
Approaches in Health-EDRM and its relevance to the older population
Individual level
Household level
Community level
Evacuation plan
Healthcare facilities
Programme level
Risk communication
Early warning system (EWS)
Technology, eHealth and social media for older people
Global policies
Disaster risk reduction in health
Barrier-free humanitarian services
Conclusion
References
10 Challenges and gaps in disaster public health and issues around supporting older people
Disaster preparedness and mitigation
Older people with chronic diseases
Socially vulnerable older people
Risk communication for older people
Rescue and relief
Needs assessment tool limitations
Rescue and relief issues
Building up healthcare system resilience and integrating health needs of older people into mainstream...
Other health-related emergency supporting needs
Protection of older people
Recovery and rehabilitation
Policy and research gaps
Conclusion
References
11 Conclusion
Index

Citation preview

DISASTER PUBLIC HEALTH AND OLDER PEOPLE

Disaster Public Health and Older People introduces professionals, students and fieldworkers to the science and art of promoting health and well-​being among older people in the context of humanitarian emergencies, with a particular focus on low-​and middle-​income country settings. Older people face specific vulnerabilities in physical, mental and social well-​ being during disasters. They are likely to experience socio-​economic marginalisation, isolation, inaccessible information and a lack of relevant post-emergency support services. Meanwhile, although older people can also significantly contribute to disaster preparedness, response and recovery, their capacities are often under-​utilised. Drawing on a range of global case studies, this book provides readers with a theoretical underpinning, while suggesting actions at the individual, community and national levels to reduce the health risks to older people posed by the increasing frequency and intensity of disaster, in particular those resulting from natural hazards. Topics covered range from the health impact of disasters on older people and response to their post-​disaster health needs, to disaster preparedness, disease prevention, healthy ageing, global policy developments and the contributions of older people in disaster contexts. This book draws on lessons learnt from previous disasters and targets students and professionals working in disaster medicine, disaster public health, humanitarian studies, gerontology and geriatrics. Emily Ying Yang Chan serves as Professor and Head of the Division of Global Health and Humanitarian Medicine, Professor (by Courtesy) of the Accident and Emergency Unit, and Assistant Dean of the Faculty of Medicine at The Chinese University of Hong Kong (CUHK). She also serves as Director of the Collaborating Centre for Oxford University and CUHK for Medical and Humanitarian Response (CCOUC). She concurrently holds academic appointments as Visiting Professor (Public Health Medicine) of Nuffield Department of Medicine, University of Oxford and Fellow of FXB Center, Harvard University, and is Co-​ Chair of WHO Thematic Platform for Health Emergency and Disaster Risk Management Research Network. She is author/​editor of numerous book titles and articles, including Public Health Humanitarian Responses to Natural Disasters (Routledge, 2017), Building Bottom-up Health and Disaster Risk Reduction Programme (2018) and Climate Change and Urban Health (Routledge, 2019).

Routledge Humanitarian Studies Series Series editors: Alex de Waal, Dorothea Hilhorst, Annette Jansen and Mihir Bhatt Editorial Board: Dennis Dijkzeul, Wendy Fenton, Kirsten Johnson, Julia Streets, Peter Walker

The Routledge Humanitarian Studies series in collaboration with the International Humanitarian Studies Association (IHSA) takes a comprehensive approach to the growing field of expertise that is humanitarian studies. This field is concerned with humanitarian crises caused by natural disaster, conflict or political instability and deals with the study of how humanitarian crises evolve, how they affect people and their institutions and societies, and the responses they trigger. We invite book proposals that address, among other topics, questions of aid delivery, institutional aspects of service provision, the dynamics of rebel wars, state building after war, the international architecture of peacekeeping, the ways in which ordinary people continue to make a living throughout crises, and the effect of crises on gender relations. This interdisciplinary series draws on and is relevant to a range of disciplines, including development studies, international relations, international law, anthropology, peace and conflict studies, public health and migration studies. Anti-genocide Activists and the Responsibility to Protect Edited by Annette Jansen Disaster Management in Australia Government Coordination in a Time of Crisis George Carayannopoulos Production of Disaster and Recovery in Post-​Earthquake Haiti Disaster Industrial Complex Juliana Svistova and Loretta Pyles International Humanitarian NGOs and State Relations Principles, Politics, and Identity Andrew J. Cunningham Crisis Management Beyond the Humanitarian-​Development Nexus Edited by Atsushi Hanatani, Oscar A. Gómez and Chigumi Kawaguchi Urban Poverty in the Wake of Environmental Disaster Rehabilitation, Resilience and Typhoon Haiyan (Yolanda) Edited by Maria Ela Atienza, Pauline Eadie and May Tan-​Mullins Disaster Public Health and Older People Emily Ying Yang  Chan

DISASTER PUBLIC HEALTH AND OLDER PEOPLE

Emily Ying Yang Chan

First published 2020 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 52 Vanderbilt Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2020 Emily Ying Yang Chan The right of Emily Ying Yang Chan to be identified as author of this work has been asserted by her in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing-​in-​Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-​in-​Publication Data Names: Chan, Emily Ying Yang, author. Title: Disaster public health and older people / Emily Ying Yang Chan. Description: Abingdon, Oxon; New York, NY: Routledge, 2020. | Includes bibliographical references and index. Identifiers: LCCN 2019015250 (print) | LCCN 2019980621 (ebook) | ISBN 9780815356660 (hardback) | ISBN 9780815356677 (paperback) | ISBN 9781351127622 (ebook) Subjects: LCSH: Disaster medicine. | Disaster relief. | Older disaster victims – Services for. | Older people – Health and hygiene. | Elderly poor – Services for. Classification: LCC RA645.5.C424 2020 (print) | LCC RA645.5 (ebook) | DDC 363.34/80846–dc23 LC record available at https://lccn.loc.gov/2019015250 LC ebook record available at https://lccn.loc.gov/2019980621 ISBN: 978-​0-​8153-​5666-​0  (hbk) ISBN: 978-​0-​8153-​5667-​7  (pbk) ISBN: 978-​1-​351-​12762-​2  (ebk) Typeset in Bembo by Newgen Publishing UK

This book is dedicated to my 101-​year-​old grandma, Madam Yat Fung Hui Chan. After thriving for a century, she remains an absolute believer in the resilience of the human spirit.

CONTENTS

List of illustrations  List of boxes  List of contributors  Foreword by Professor Sir James Mirrlees  Foreword by Professor Jean Woo  Acknowledgements 

ix xi xiii xvii xix xxi

1 Introduction 

1

2 Principles and theories: Health and public health 

6

3 Principles and theories: Ageing population 

34

4 Principles and theories: Disaster 

70

5 Contributions of older people to disaster mitigation, preparedness, response and recovery 

109

6 Health impact of disasters on older people 

123

7 Post-​disaster response and recovery to meet health needs of older people: I 

155

8 Post-​disaster response and recovery to meet health needs of older people: II 

180

viii Contents

9 Healthy ageing, disaster mitigation and disaster risk reduction: Individual, programmatic and global policy levels 

192

10 Challenges and gaps in disaster public health and issues around supporting older people 

213

11 Conclusion 

225

Index 

227

ILLUSTRATIONS

Figures 2.1 The Dahlgren-​Whitehead Rainbow Model of health determinants  2.2 Consequences of health outcomes  2.3 Three levels of care in a healthcare system  3.1 Global ageing trend (1950–​2050)  3.2 Global ageing trend: Rural vs. urban (1950–​2050)  3.3 Physical capacity decline of ageing  3.4 Healthy ageing components  4.1 Natural disaster classification  4.2 Technological disaster classification  4.3 Refugees and internally displaced persons (IDPs)  4.4 Human and economic impacts of disasters 2005–​2014  4.5 Global disaster trends –​natural disasters  4.6 Risk formula  4.7 The IAEA’s scale for classifying a nuclear incident  4.8 Psychosocial approach to addressing mental health needs  4.9 Cluster approach: 11 Clusters and their corresponding leading agencies  4.10 How the prevention of potential cholera outbreak in population displacement might be conceptualised in Health Emergency and Disaster Risk Management  5.1 Global and geographic comparison of active working older population (>65 years old)  9.1 Suggested items to include in the general household disaster preparedness bag 

7 10 29 36 37 39 56 73 74 77 79 80 82 83 95 102 103 111 199

x Illustrations

9.2 Specific items for older people in disaster preparedness bag  10.1 Preferred channels for weather information acquisition 

200 216

Tables 2 .1 2.2 2.3 2.4 2.5 3.1 3.2 4.1 4.2 4.3 4.4

Methods to measure health  Examples of key epidemiological indicators  Classification of prevention  Five categories of health protection  Principles of medical ethics  Age-​related physiological changes and special nutritional concerns  Age-​friendly domains and their associations with public health  Risk factors for technological disasters  Overview of public health consequences of various disasters  Humanitarian principles  Examples of selected key standards for supporting basic requirements of health post disaster  5.1 Older people as the main caregivers at the household  7 .1 Burden of chronic diseases in some disaster-​prone countries 

9 10 17 19 30 46 58 75 92 97 100 115 166

BOXES

Case boxes 1.1 Examples of older people disproportionately affected in disasters and emergencies  2.1 WHO conceptual framework to understand health systems  3.1 Oral health in older people  3.2 Preventing dementia in an ageing society  3.3 Health disparities among LGBT older people  3.4 Special nutritional concerns of older people  3.5 Evidence of the impact of air quality on the health of older people  3.6 Vulnerability and comorbidities of older people  3.7 Trauma screening for older injured patients  3.8 Global policies for older people in emergencies  3.9 Healthy ageing community with integration of Health Emergency and Disaster Risk Management (Health-EDRM)  3.10 Community canteen for older people  4.1 The 2011 Fukushima nuclear accident  4.2 The Rohingya crisis  4.3 The 2010 Haiti earthquake  5.1 Poverty alleviation in rural china  5.2 Income generating activities in Battambang, Cambodia  5.3 How older people might be organised to provide healthcare for their fellow older community members in Cambodia, Philippines, China and Vietnam  5.4 Child-​friendly space: An intergenerational approach  5.5 Cyclone Eline, Mozambique in 2000  5.6 Older people’s engagement in emergency relief response  5.7 The cases of Mozambique and Lebanon 

3 27 42 44 45 46 49 50 52 55 58 64 76 78 93 112 112 116 117 117 119 120

xii Boxes

6.1 Weather information acquisition channels: The potential of the smartphone  127 6.2 The forgotten health needs of older people after the 2005 Pakistani Kashmir earthquake  131 6.3 Delay in medical consultation for breast cancer symptoms after a disaster  132 6.4 Examples of infectious disease disasters  134 6.5 Temperature and urban heath: The case of older people in Hong Kong  140 6.6 Elderly refugees from Rakhine State, Myanmar  149 7.1 Post-disaster chronic disease care in Asia  166 7.2 The insufficient emphasis on end-​of-​life care for chronically ill older adults in disaster situations  172 7.3 Risk perception in urban contexts  173 7.4 Sphere: A protective umbrella for older people in disasters  175 8.1 Protection of older people in humanitarian crisis: Older citizen monitoring  186 8.2 Strengthening the public health capacity to respond to Myanmar’s ageing concern  190 9.1 Well-​being of older people after a disaster: The issue of shelter  201 10.1 Why older people’s needs are forgotten by healthcare providers in post-​earthquake relief  217 10.2 Interventions for health, emergency and disaster risk reduction  222

Knowledge boxes 1 .1 2.1 2.2 2.3 3.1 4.1 4.2 5.1 6.1 6.2 7.1 7 .2 7.3 7.4 7.5 8.1 9.1 9 .2 9.3

Who are the older people?  Hierarchy of prevention in the context of disaster  Transmission routes of communicable diseases  Five principles for health promotion practice  United Nations Principles for Older Persons (1991)  Fragile states  The Sphere standards  Older people in community development: Older people’s association  Common communicable diseases following disasters  Epidemics, outbreaks, pandemics and endemics  Rethinking body mass index and nutritional assessment of older people  Psychological first aid  Home-​based care  Palliative care  Age-​appropriate disaster warning and communication systems  Categories of vulnerable older people  Mainstreaming older people’s considerations in development and disaster policy-​making  WHO safe hospital initiatives  Barrier-​free humanitarian services 

2 18 21 23 62 76 99 113 136 137 161 168 169 170 174 181 195 204 209

CONTRIBUTORS

Author Emily Ying Yang Chan, MBBS (HKU), BS (Johns Hopkins), SM PIH (Harvard),

MD (CUHK), DFM (HKCFP), FFPH, FHKAM (Community Medicine), FHKCCM, serves as Professor and Head of Division of Global Health and Humanitarian Medicine, Professor (by Courtesy) of Accident and Emergency Unit, Associate Director of JC School of Public Health and Primary Care, and Assistant Dean (Global Engagement) of Faculty of Medicine at The Chinese University of Hong Kong; Director, the Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response (CCOUC), the Centre for Global Health (CGH) and the Centre of Excellence (ICoE-​CCOUC), Integrated Research on Disaster Risk (IRDR); Co-​Chairperson,WHO Thematic Platform for Health Emergency and Disaster Risk Management Research Network; Member, Asia Science Technology and Academia Advisory Group (ASTAAG); Visiting Professor, Oxford University Nuffield Department of Medicine; and Fellow, FXB Center, Harvard University. Her research interests include disaster and humanitarian medicine, climate change and health, global and planetary health, human health security and Health Emergency and Disaster Risk Management (Health-​ EDRM), remote rural health, implementation and translational science, ethnic minority health, injury and violence epidemiology, and primary care. Awarded the 2007 Nobuo Maeda International Research Award of the American Public Health Association and recognised with the National Geographic Chinese Explorer Award (2016), the University Grants Committee Teaching Award of Hong Kong (2017) as well as the National Teaching Achievement Award (Higher Education) of China (2018), Professor Chan has published more than 200 international peer-​reviewed academic, technical and conference articles and eight academic books. She also has  extensive experience as a frontline emergency relief practitioner since the mid-​1990s spanning 30 countries.

xiv Contributors

Case contributors Cheuk-​pong Chiu, BSc (PolyU), MPH (HKU), obtained his Master of Public

Health with concentration of infectious diseases from The University of Hong Kong. He has practised orthopaedic and emergency nursing for four years. He joined Médecins Sans Frontières, an international medical humanitarian organisation, in 2013 and completed various humanitarian missions in Pakistan, Liberia, Yemen and Bangladesh. Currently, he is a clinical staff and academic tutor of the Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response (CCOUC), coaching university students in field-​based training and teaching at The Chinese University of Hong Kong. Roger Yat-​nork Chung, BA, MHS, PhD, is an Assistant Professor at the JC School

of Public Health and Primary Care of The Chinese University of Hong Kong. He is also the Vice President of Hong Kong Life and Death Studies Association, a social enterprise integrating professional knowledge and ideas from a wide range of young professionals in innovating life and death education and end-​of-​life care in Hong Kong. He conceptualises the health and healthcare issues of the population using the lens of public health ethics and justice, and utilises epidemiological and demographic methods in the areas of health equity as well as ageing-​related issues on multimorbidity and long-​term/​end-​of-​life care to inform health services, system and policy. Colin A. Graham, MBChB, MPH, MD, FRCPEd, FRCSEd, FRCSGlasg,

FIMCRCSEd, FCCP, FCEM, FHKCEM, FHKAM (Emergency Medicine), is a Professor in Emergency Medicine at the Chinese University of Hong Kong. He has broad research interests within emergency medicine and has published widely. He is one of the authors of the Oxford Handbook of Emergency Medicine, a popular book for emergency department staff, and has been Editor-​in-​Chief of the European Journal of Emergency Medicine since 2009. He concurrently serves on the Executive Committee and Council of the European Society for Emergency Medicine. Kevin K. C. Hung, MBChB, MRCSEd, MPH, EMDM, FHKCEM, FHKAM(EM),

FRCEM, is an Assistant Professor in Emergency Medicine at The Chinese University of Hong Kong. Dr Hung is an emergency medicine specialist and has obtained master’s graduate training in public health and disaster medicine. He was the founding Director of Hong Kong Jockey Club Disaster Preparedness and Response Institute (HKJCDPRI). Dr Hung, an academic member of CCOUC, is also a Hong Kong Red Cross volunteer and has served as a field delegate after the Sichuan, China earthquake and typhoon Haiyan in the Philippines. Vincent C. T. Mok, MD (CUHK), FRCP (Edinburgh), FHKAM (Med), FHKCP,

MRCP, MBBS, is Endowed Mok Hing Yiu Professor of Medicine, Assistant Dean (Students Affairs, Admissions) and Head of Division of Neurology at the Faculty of Medicine,The Chinese University of Hong Kong. He also serves as the Director in

Contributors  xv

Therese Pei Fong Chow Research Centre for Prevention of Dementia as well as the Margaret K. L. Cheung Research Centre for Management of Parkinsonism. On the international level, he serves as the Advisory Council Member of the Alzheimer’s Association International Society to Advance Alzheimer’s Research and Treatment, Chair of the Local Organizing Committee of the 9th International Meeting of the International Society of Vascular Behavioural and Cognitive Disorders, as well as Honorary Treasurer of the Asian Society Against Dementia. Carol Ka-po Wong, BSSc (CUHK), MIPA (HKU), MPH (CUHK), is the Head

of Training and Development at CCOUC with an interest in older people care in disaster settings. She has years of project management experience in NGOs in Asia, with a focus on slum health, and disaster risk reduction and response. Martin Chi-sang Wong, BMedSc (Hons), MSc (Hons), MBChB, MD (CUHK),

MPH, MBA, FRACGP, FRSPH, FHKCFP, FHKAM (Fam Med), DCH (Ire), FESC, FACC, FAcadTM, FFPH, FHKAN (Hons), FRCP (Edin), is a Professor and Associate Director (General Affairs) of the JC School of Public Health and Care at The Chinese University of Hong Kong. He is a specialist family physician with an interest in cancer screening and prevention of non-​communicable diseases (NCDs). He is currently Co-​Chair of the NCD Stream of the Association of Pacific Rim Universities and Co-​Chairman of the Grant Review Board, Health and Medical Research Fund of the Hong Kong Government. He was appointed by the Peking Union Medical College as an Adjunct Professor in 2019. May Pui-​shan Yeung, MBChB (CUHK), MSc Public Health (Edin), LLB, DCH

(Sydney), FHKCCM, FHKAM (Community Medicine), FFPH, DrPH (Lond), is an Assistant Professor at the JC School of Public Health and Primary Care, The Chinese University of Hong Kong (CUHK), and an academic member of the Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response (CCOUC). She is a public health medicine specialist and has obtained her Doctor of Public Health (DrPH) at the London School of Hygiene and Tropical Medicine. She holds fellowships of the UK Faculty of Public Health and Hong Kong College of Community Medicine. She joined various public health volunteer services including the Ebola mission in Liberia in 2014 and the population movement of Rakhine in 2018. Tony Ka-chun Yung, PhD (CUHK), obtained his master’s degree in Nutrition

and Dietetics from the University of Sydney, registered as Accredited Practicing Dietitian in Australia and holds a doctorate in public health from The Chinese University of Hong Kong. He is also a Sports Dietitian and Accredited Nutritionist. He is currently senior lecturer in CCOUC responsible for teaching and research related to nutrition aspects of public health. His research interests include nutrition epidemiology, diet behaviours of vulnerable populations, and setting approach in health promotion.

xvi Contributors

Benny C. Y. Zee, PhD (Pittsburgh), is Assistant Dean (Research) for the Faculty of

Medicine and also Professor and Head of the Division of Biostatistics and Director of the Centre for Clinical Research and Biostatistics in the JC School of Public Health and Primary Care, Chinese University of Hong Kong (CUHK). He is Director of Clinical Trials and Biostatistics Lab in the CU Shenzhen Research Institute (SZRI) and serves as an Executive Committee member in the Centre for Entrepreneurship and holds honorary appointments in the Department of Clinical Oncology and the Department of Statistics of CUHK. He is also the Chairman of the Joint CUHK-​ NTEC Clinical Research Ethics Committee since 2006. Professor Zee obtained his PhD in Biostatistics from the University of Pittsburgh, USA in 1987. He then joined the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) as Senior Biostatistician, and was faculty member in the Department of Community Health and Epidemiology and the Department of Mathematics and Statistics of Queen’s University Canada from 1987 to 2001. He remains as Adjunct Professor with Queen’s University after he joined CUHK and is actively promoting international academic activities and collaborations.

FOREWORD Professor Sir James Mirrlees†

Welfare economics of healthcare and uncertainty has long been a very thought-​ provoking topic in modern economics. Professor Emily Ying Yang Chan’s book Disaster Public Health and Older People is an attempt to conceptualise the health and medical needs of older people during the ever-​increasing risks of disasters in the twenty-first century. Uncertainty associated with disasters is a reason for investing more effort, not less, in their mitigation, particularly for the resource deficient older people in the rural areas of developing countries. Professor Chan’s book is also a fine example of multi-​disciplinarity, which is an important catalyst for ­creative solutions. The publication of this book is a timely response to the issue of population ageing and the increasing frequency and severity of climate change-​related natural disasters. Together these can have dire consequences for the vulnerable older population and society as a whole. It is usually costlier to respond to a disaster than prepare for all eventualities and so reduce the social and economic consequences. It is equally important to understand the important contribution of senior citizens to disaster response and post-​crisis rehabilitation. They are a heterogeneous demographic group, whose members vary in their capacities, needs and vulnerabilities. They can play a valuable role as informal caregivers, income generators, community leaders and knowledge transfer agents in crisis settings. Their roles as “household resources managers” are often neglected and their knowledge and institutional memories, which are valuable in times of extreme events and crisis, are often forgotten. In her book, Professor Chan has noted the positive contributions that senior citizens can make to prepare for, respond to and support recovery from disasters. I enjoy spending time in discussion with people outside my own field of economics sharing thoughts on problems we are examining from different approaches   Deceased 29 August 2018

†

xviii Foreword

and perspectives. During my decade as Master of Morningside College, Chinese University of Hong Kong, I have had the pleasure of many discussions with Professor Chan on her research and work. The result is this important book focusing on the global problem of increasing natural disasters and ageing population. It is a book with relevance for today. Professor Sir James Mirrlees, FRSE FBA Nobel Laureate in Economic Sciences Master of Morningside College and Distinguished Professor-​at-​Large, The Chinese University of Hong Kong Emeritus Professor of Political Economy, The University of Cambridge 2018

FOREWORD Professor Jean Woo

Population ageing is an increasingly pressing public health issue in the twenty-​first century. It is estimated that more than 2 billion people will be aged 60 or above globally by 2050. This complicates the equally escalating global issue of more frequent and severe natural disasters, which has long been the interest and concern of this book’s author and her team. The health needs of older people have been relatively neglected during the decades of my academic and clinical career in gerontology and geriatrics. This relatively neglected aspect of population ageing offers both opportunities and challenges to individuals and society. Professor Emily Chan, my long-​time colleague at the Faculty of Medicine of The Chinese University of Hong Kong (CUHK), and her team at the Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response (CCOUC) see the importance of looking into the intersection between these two subject areas and have devoted much effort to explore the possibility of cross-​disciplinary research and community programmes. I still remember our excitement when she and her team brought up this issue for discussion in various seminars and conferences of CUHK Jockey Club Institute of Ageing. Professor Chan’s effort culminates in the publication of this book on disaster public health and older people, which outlines the diverse health needs as well as positive contributions of older people in preparing for and responding to disasters, reminding us that we are all partners in managing our own well-​being. Through this timely work, readers can have more in-​depth understanding of a crucial aspect of the multi-​faceted impact of ageing population to society. It highlights various personal and environmental determinants of health affecting ageing well of older people against a backdrop of increasingly frequent natural disasters, and explores how to enhance the well-​being of older people in emergencies with complex and pressing health needs. At the same time, their contributions may form part of the

xx Foreword

solution. I believe that this work would stimulate more research in this urgent but relatively neglected area. This will eventually help promote an age-​friendly and age-​resilient world to improve the quality of life for older people and their families in all scenarios to include natural disasters such as flooding and landslides, as well as other emergencies such as fire and major accidents, which is a common vision for all of us. I congratulate Professor Chan for her venture into this unchartered field of enquiry. I am sure readers will also appreciate the fascinating insights in her book on this very important global issue of disaster and older people as much as I do. Professor Jean Woo, MD, FRCP, FRACP Emeritus Professor of Medicine Henry G Leong Research Professor of Gerontology and Geriatrics, Director, CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong 2018

ACKNOWLEDGEMENTS

This work originates from more than two decades of frontline medical humanitarian work and research projects related to Health Emergency and Disaster Risk Management (Health-​EDRM) at the Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response (CCOUC) in China and Asia, where I have witnessed and gained insights into the health and disaster preparedness needs of older people and the opportunities missed to address them. Upon successful publication of the book Public Health Humanitarian Responses to Natural Disasters in 2017, it was Ms Helena Hurd of Routledge who encouraged me to continue my academic writing effort in exploring the public health implications of disaster and humanitarian crisis for the older population, which resulted in this publication. The author gratefully acknowledges the assistance of Mr Chi-shing Wong of CCOUC, for his effort and great friendship in supporting the whole tedious and challenging process of manuscript preparation, as well as the patience and professional facilitation from Ms Helena Hurd, Mr Matthew Shobbrook, their colleagues and supporting team at Routledge. I also wish to express my sincere appreciation to the generous support, trust, and encouragement from the two universities, specifically, to their former and incumbent Vice-​Chancellors, Professor Andrew Hamilton, Professor Louise Richardson, Professor Joseph Sung, and Professor Rocky S. Tuan; the former and incumbent Deans of CUHK Faculty of Medicine, Professor Tai-​fai Fok and Professor Francis Ka-​leung Chan; the former and incumbent Directors of JCSPHPC, Professor Sian M. Griffiths and Professor Eng-​kiong Yeoh; the former and Interim Head of Department, Oxford University Nuffield Department of Medicine (NDM), Professor Jeremy Farrar and Professor Chris Conlon, and last but not least, Mr Darren Nash, Associate Head of NDM. My special acknowledgement also goes to the late Professor Sir James Mirrlees, Lady Patricia Mirrlees, Professor Jean Woo, Professor Samuel Yeung-​shan Wong,

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xxii Acknowledgements

Professor Roger Yat-​nork Chung, Professor William B. Goggins III, Professor Colin A. Graham, Professor Kevin K. C. Hung, Professor Jean H. Kim, Professor Jennifer Leaning, Professor Vincent C. T. Mok, Professor Virginia Murray, Professor Rajib Shaw, Professor Adrian Wong, Professor Martin C. S. Wong, Professor Justin C. Y. Wu, Professor May Pui-​shan Yeung, Professor Benny C.Y. Zee, Ms Gloria Kwong-​ wei Chan, Ms Carol Sin-​yee Chiu, Mr Cheuk-​pong Chiu, Ms Janet Yiu-​wai Chow, Ms Sharon Chow, Ms Janice Ying-​en Ho, Mr Keith Yun-​chau Hon, Mr Zhe Huang, Ms Heidi Hung, Ms Christine Pui-​yan Ko, Dr Holly Ching-​yu Lam, Mr Kelvin Wai-​kit Ling, Mr Kevin Sida Liu, Mr Eugene Siu-​kai Lo, Ms Asta Yi-​tao Man, Ms Rosanna Tse-​ying So, Dr Greta Chun-​huen Tam, Ms Sophine Nok-​sze Tsang, Ms Carol Ka-​po Wong, Dr Tony Ka-chun Yung, all students helpers at CCOUC and Division of Global Health and Humanitarian Medicine at JCSPHPC, Professor Chok-​wan Chan, Mr and Mrs Robert and Irene Che-​yun Lee Yau, family, Professor and Mrs NK and Olivia Leung, and all friends who have assisted in the publication of this book for their encouragement, inspiration, support, assistance, and friendship. As always, special thanks must go to my husband Mr Eric S. K.Yau and our children, Ellie and Ernest.

1 INTRODUCTION

The global population is ageing at an unprecedented speed.The number of persons aged 60 and above in the world is projected to grow by 56%, from 901 million in 2015 to more than 1.4 billion in 2030. Rapid urbanisation, climate change, population migration, poverty and increasing frequency of disasters have changed disease patterns and the well-​being of older people worldwide (HAI, 2012a, 2012b; WHO, 2008, 2017). Specifically, changing demographic patterns and the increasing frequency of disasters will exert a disproportionate impact on the oldest and the poorest populations globally (see Case Box 1.1). Addressing the needs of the ageing population is thus considered to be among the most important public health challenges in the twenty-​first century. While there are a number of international legal and policy frameworks to facilitate discussion and ensure protection of older people, their well-​being is threatened by rapidly changing circumstances of living arrangements and socio-​economic and technological advancements with which relevant programmes and policies may not yet have caught up to include older people in their development (WHO, 2015) (see also Knowledge Box 1.1). In the coming decades, the ageing population, increasingly frequent extreme events associated with climate changes, enhanced global health security threats associated with human movement and trade across national boundaries, environmental degradation and related urbanisation, and socio-​economic disparities associated with development will all continue to contribute to the human health risks in disasters and humanitarian crises (UNDP, 2004). Tackling potential human risks and impact with multidisciplinary efforts in disaster risks reduction (DRR) has been advocated around the world in an attempt to reduce disaster risk and population vulnerabilities in crisis (United Nations Office for Disaster Risk Reduction [UNDRR], 2018). Meanwhile, among all age and demographic subgroups who might benefit from DRR attempts, the older population has always been regarded as a major at-​risk group. When compared with their younger counterparts, older

2 Introduction

KNOWLEDGE BOX 1.1  WHO ARE THE OLDER PEOPLE? Globally, there is no agreed definition of “older people”. Definitions vary across and within countries as well as cultural contexts. They might be based on chronological age, physical attributes (e.g. hair colour, such as grey/​white hair, may be associated with ageing), biological relationship (e.g. “grandparents” may refer to individuals who, due to early marriage, might have already had grandchildren in their late thirties), or social position. The United Nations proposes old age to be defined as those aged 60 years or above, while some non-​ governmental agencies working in more traditional or challenging contexts might adopt a cut-​off point at 45 years old (Chan, 2017; HAI 2012a, 2012b; WHO, 2017).

people face specific vulnerability in physical, mental and social well-​being during and after emergencies. With a narrower margin of good health, as well as likely to be heavily relied on social and support networks, a sudden breakdown of the physical and social environment will force older people to face more substantial challenges in terms of access to healthcare and essential survival supporting services like water, food, latrines and shelter, as well as information (WHO, PHE, & partners, 2017). In addition, published scientific literature has indicated that older people are more likely to encounter socio-​economic marginalisation, isolation, inaccessible information and lack of relevant post-​emergency support services. Specific health and social determinants may independently or synergistically affect older persons during an emergency situation. Physical and mental health status, oral health and dentition, underlying functional status and disability, nutritional and lifestyle habits, family and social capital, economic resources and gender are all relevant factors that may affect the survival and health outcome of an older person in crisis (WHO, 2017) (see Case Box 1.1). Despite the intrinsic challenges associated with physiological status of the older population, it is important to point out that the older population is a diverse demographic group. Advanced age is not necessarily translated into vulnerability. Although problems associated with old age (such as physical decline and economic constraints) may expose older people to increased risks in emergency and disaster situations (WHO, 2017), their experience and resourcefulness may significantly contribute to disaster preparedness, response and recovery in crises (WHO, 2008; HAI, 2012b). Unfortunately, their capacities and potential to contribute are often under-​recognised and under-​utilised. Disaster Public Health and Older People is a topic-​specific reference textbook for professionals, students and fieldworkers who are interested in examining how health and well-​being of the older population might be affected in the context of increasing frequency and intensity of disaster and humanitarian emergencies in the twenty-​first

Introduction  3

CASE BOX 1.1  EXAMPLES OF OLDER PEOPLE DISPROPORTIONATELY AFFECTED IN DISASTERS AND EMERGENCIES Due to their physical and potential socio-​economic vulnerabilities, older people across the world are reported to be disproportionately affected by disasters. The following are some notable examples post millennium: • Heatwave in France (2003): Around 70% of the 14,800 deaths were older people aged above 75. • Mega tsunami in Aceh of Indonesia (2004): Age-​specific death rates for those aged 60–​69 and those aged 70 and above were 22.6% and 28.1% respectively. • Hurricane Katrina in Louisiana of the United States (2005): More than 70% of the 1,330 deaths were aged above 60, among whom almost half were above 77. • Triple disaster of earthquake, tsunami and nuclear incident in East Japan (2011): About 65% of the 19,000 deaths were aged above 60 and 24% were aged above 70. • Super Typhoon Haiyan (or Typhoon Yolanda) in the Philippines (2013): Almost 40% of the 6,300 deaths were aged above 60. • Double earthquakes in Nepal (2015): Around 29% of the 9,000 deaths were aged above 60. Sources: Brunkard, Namulanda, & Ratard (2008); HAI (2013, 2016); Hutton (2008); Nakahara & Ichikawa (2013).

century. Through the application of relevant public health theories and principles, readers will take a deep dive into exploring the public health impact and the health needs of older people at the forefront of disasters and crises. Insights in the challenges and opportunities to mitigate and reduce disaster risk and to mount up better response for older people will be examined.This book also aims at making lessons learnt from previous disasters available and comprehensible to students and practitioners of disaster medicine, disaster public health, humanitarian studies, gerontology and geriatrics, with a particular focus on low-​and middle-​income country settings. This book attempts to provide an overview of relevant topics, ranging from preparedness to health impact and needs, response and post-​ disaster rehabilitation among the interface of disaster public health and older people. It is composed of three parts. Part I includes four chapters that describe the common principles and theories related to the theme of this book. Chapter 1 provides an overview of the book’s structure and discussion. Chapter 2 highlights key principles in public health (including the emerging paradigm of Health Emergency and Disaster Risk

4 Introduction

Management [Health-​EDRM]) that are relevant to the understanding of how health risks and well-​being of a population might be conceptualised. Chapter 3 reviews the current status, well-​being and common health problems of older people in the twenty-​first century. Chapter 4 describes theories and concepts of disaster that may be useful for practitioners in health and related disciplines in examining, analysing and describing the challenges and problems faced by older people in emergency contexts. Part II of the book includes four chapters that examine issues among disaster, public health and older people. Chapter 5 begins with exploring older people’s contributions before, during and after emergencies and crises, which are often forgotten and under-​utilised. Chapter 6 delineates the specific health impacts on older people of various common disaster categories. Chapters 7 and 8 discuss key health, medical needs and specific response concerns that may help maximise survival and well-​being of older people in crisis. Part III consists of three chapters and discusses global policy and programme development regarding how older people might be supported in emergencies and crises. Chapter 9 examines how “healthy ageing”, “disaster mitigation” and “disaster risk reduction” initiatives might be developed at individual, community and policy levels. Chapter 10 offers a discussion of the challenges, as well as opportunities, in addressing needs and gaps for older people in times of crisis. Chapter 11 concludes the main theme of this book.

Conclusion In the twenty-​first century, progress in socio-​economic development and technological advancement have allowed people to extend their longevity beyond that of their historical predecessors. Global population ageing has made older people an increasingly significant demographic subgroup worldwide. Regardless of a country’s socio-​economic development status, national policies and government agendas will inevitably need to increase government and societal involvement in addressing relevant needs, capitalising on skills and resources of the older population. The needs, strengths, capacities and vulnerabilities of older people require attention and support to maximise their potential and well-​being and minimise their risks and suffering. In emergency and disaster contexts, the ability to identify the most vulnerable and marginalised and the poorest among the affected as well as the most experienced, well-​ connected and resourceful among the impacted older people are of similar importance. This book aims to offer a public health perspective to examine determinants of older people’s health outcomes and to share principles and approaches such as health emergency and disaster risk management (as embodied in the framework of Health-​ EDRM) to protect, empower and maximise the response capacity of the older population, and thereby the ways to build intrinsic resilience in our society.

References Brunkard, J., Namulanda, G., & Ratard, R. (2008). Hurricane Katrina deaths, Louisiana, 2005. Disaster Medicine and Public Health Preparedness, 2(4), 215–​ 223. doi: 10.1097/​ DMP.0b013e31818aaf55

Introduction  5

Chan, E.Y.Y. (2017). Public health humanitarian responses to natural disasters. London: Routledge. HelpAge International (HAI). (2012a). Health interventions for older people in emergencies. Retrieved from https://​reliefweb.int/​sites/​reliefweb.int/​files/​resources/​Health-​ Interventions.pdf HelpAge International (HAI). (2012b). Older people in emergencies: Identifying and reducing risks. Retrieved from www.helpage.org/​silo/​files/​older-​people-​in-​emergencies-​-​identifying-​ and-​reducing-​r isks.pdf HelpAge International (HAI). (2013). Older persons disproportionately affected by Typhoon Haiyan. Retrieved from www.helpage.org/​newsroom/​latest-​news/​older-​people-​disproportionately​affected-​by-​typhoon-​haiyan/​?keywords=Typhoon+Haiyan HelpAge International (HAI). (2016). Rising from the rubble: Nepal earthquake one year on. Retrieved from www.helpage.org/​newsroom/​latest-​news/​r ising-​from-​the-​rubble-​nepal-​earthquake​one-​year-​on/​ Hutton, D. (2008). Older people in emergencies: Considerations for action and policy development. World Health Organization. Retrieved from https://​apps.who.int/​iris/​bitstream/​handle/​ 10665/​43817/​9789241547390_​eng.pdf?sequence=1&isAllowed=y Nakahara, S., & Ichikawa, M. (2013). Mortality in the 2011 tsunami in Japan. Journal of Epidemiology, 23(1),  70–​73. United Nations Development Programme (UNDP). (2004). A global report: reducing disaster risk: A challenge for development. Retrieved from www.preventionweb.net/​files/​1096_​ rdrenglish.pdf United Nations Office for Disaster Risk Reduction (UNDRR). (2018). UNISDR annual report. Retrieved from www.unisdr.org/​files/​58158_​unisdr2017annualreport.pdf World Health Organization (WHO). (2008). Older persons in emergencies:An active ageing perspective. Retrieved from https://​apps.who.int/​iris/​bitstream/​handle/​10665/​43909/​9789241563642_​ eng.pdf;jsessionid=F8136B9473DB2B5C461A1668298B22DE?sequence=1 World Health Organization (WHO). (2015). World report on ageing and health. Retrieved from https://​apps.who.int/​iris/​bitstream/​handle/​10665/​186463/​9789240694811_​ eng.pdf?sequence=1 World Health Organization (WHO). (2017). Older persons in emergencies. Retrieved from www.who.int/​ageing/​projects/​emergencies/​en/​ World Health Organization, Public Health England, & partners. (2017). Health emergency and disaster risk management: Overview (Health Emergency and Disaster Risk Management Fact Sheets). Retrieved from www.who.int/​hac/​techguidance/​preparedness/​who-​ factsheet-​overview-​december2017.pdf

2 PRINCIPLES AND THEORIES Health and public health

Public health is an academic discipline which concerns health and well-​being at a population level. In this chapter, key concepts in health and public health will be introduced and discussed.They will form the building blocks for understanding how health and well-​being of older people as a population subgroup might be affected by context and situations (e.g. emergencies and disasters).These principles will also help formulate strategies, programmes and policies that may improve older people’s well-​ being, and will prevent and protect them and the community from adverse health outcomes of determinants of health and from catastrophic events such as disasters.

Definition of health and public health The World Health Organization (WHO, 1946) defines health as “a state of complete physical, social and mental well-​being, and not merely the absence of disease or infirmity”. Public health is a multidisciplinary subject that integrates various disciplines and practices not only to support health on an individual level, but also to protect and improve a community’s health as a whole. It concerns patterns, determinants, impact and outcomes that might influence health and well-​being of individuals and the population. As a multidisciplinary field in medicine, it utilises epidemiology, clinical trials, biostatistics, laws and ethics to protect health, improve health, and secure the provision of health services. Concepts of public health practices may be grouped into three main domains, namely health protection, health improvement and health services (Griffiths, Jewell, & Donnelly, 2005).

Principles of public health approaches In public health, health determinants describe clusters of causes, risk factors and outcome modifiers as public health emphasises prevention and adopts the

Principles and theories: Public health  7

life-​course approach in strategy and policy planning. It aims to balance between population-​wide and individual-​based approaches to set health priority and narrow health disparity. It advocates the importance of evidence-​based decision making and improves health with settings and system approaches.

Health determinants Among the existing theories that attempt to explain the factors affecting health, Dahlgren and Whitehead’s Determinants of Health is one of the most commonly referenced conceptual frameworks (Dahlgren & Whitehead, 1991).Their “Rainbow Diagram” illustrates how health may be a result of the interactions of multiple factors and determinants (see Figure 2.1). Factors in the innermost layer are non-​ modifiable and intrinsic biological personal traits like age, gender and genes. The subsequent layers are determinants that may be modifiable theoretically.The second layer comprises individual lifestyle and behavioural factors, e.g. diet, physical exercise and sleeping patterns. Individual habits might be modified by education, information, skills and knowledge that can alter health risk and health outcomes. The third layer consists of social determinants that are associated with social and living contexts. Examples might include social network/​social capital, work, occupation, income, marital status and education status. The fourth layer highlights the influence of community and environmental factors (such as living and work environments, and access and availability of health facilities) that may change health

FIGURE 2.1  The

Dahlgren-​Whitehead Rainbow Model of health determinants

Source: Adapted from Dahlgren and Whitehead (1991).

8  Principles and theories: Public health

risks and outcomes. The outermost layer is the most macroscopic. These macro-​ determinants range from global, economy, culture and religion, to earth ecological and environmental conditions. Due to their interconnected nature, the synergetic impact of health determinants, their risk factors and specific solutions should be considered simultaneously upon exploring a health issue.

Measuring health Health might be measured in terms of outcomes, frequency, subgroups and condition severity. Although health is typically measured by a summary measure (e.g. mortality rate, life-​expectancy at birth), in recent years the development of health measurement has enabled the combination of mortality and morbidity under the umbrella of “summary measures of population health” (SMPH). These SMPH measures have enabled the measurement of quantity as well as quality of health (such as health expectancies and health gaps). Table 2.1 outlines some examples of each method to measure health. Health outcomes are health impacts of a condition, an event or an intervention. Measuring health outcomes provides an opportunity to understand the extent to which an individual’s health may be affected, how population may be burdened and the priority needs for developing appropriate health-​protective policies and interventions. It might offer baseline measures for subsequent evaluation of an implemented health intervention or policy. Health outcomes are usually presented as quantifiable epidemiological health indicators, e.g. mortality rate, morbidity rate and incidence rate. However, not all health outcome have existing agreed quantifiable measurements. Table 2.2 lists examples of key epidemiological indicators. The iceberg diagram in Figure 2.2 describes the relationship between the incidence and severity of health impacts/​outcomes of an event, such as air pollution or a heatwave. When a condition or a health-​affecting event occurs, people might experience symptoms, discomfort and subtle effects (i.e. the lowest, first level of the iceberg in Figure 2.2). Self-​management and obtaining over-​the-​counter medicines to get over the discomfort are usually the first attempts to manage health by an individual (the second level). A smaller portion of affected people may seek primary medical help (the third level). Among those who might need more significant help or support in ill health due to their serious conditions, some may require more intensive care and hospitalisation (the fourth level). The most severe health impact is death (the fifth level), but the number of people affected at this level is the smallest when compared with the previous four levels.

Demography and epidemiology Age structure and disease patterns can be tracked and studied though demography and epidemiology. Demography is the study of population structure that

Principles and theories: Public health  9 TABLE 2.1  Methods to measure health

Health measures

Description

Examples

Health outcomes

Physical/​Mental/​Social

Assessment based on population subgroups

Health impacts of an incident possibly varying between specific population subgroups (e.g. children, pregnant women, older people, people with chronic diseases) Quantifying health outcomes in rates, ratios, etc.

-​  Mortality/​Morbidity -​  Economic implications, e.g. unemployment -​  Age specific mortality and morbidity -​  Gender specific mortality and morbidity -​  Diseases specific mortality and morbidity

Frequency

Disease severity

-​ Describing the disease impact on individual health outcomes -​  Differentiating personal experiences in health -​  People with early stage of diabetes having a different quality of life when compared with people with severe diabetes with dialysis

-​  Incidence -​  Prevalence -​  Case fatality rate -​  Standardised (adjusted) death rates -​  Infant mortality rate (IMR), maternal mortality ratio (MMR) -​  Potential Years of Life Loss (PYLL) Health gap measures: -​  Disability-​Adjusted Life Years (DALYs) Health expectancy measures: -​  Health-​Adjusted Life Expectancy (HALE) -​  Disability-​Free Life Expectancy (DFLE)

Source: Chan (2017).

may be affected by changes in births, deaths and migration. It helps describe the size, characteristics and future trend predictions in a human group or population. Epidemiology is the study of disease distribution in a population and risk factors determining this disease distribution and progression. Epidemiology is a vital tool of public health practice and uses statistical methods to measure disease occurrence and make comparisons between population groups in order to help us understand how health conditions are distributed among a population and risk factors or causes associated with those conditions. Demographic and epidemiological profile will provide important information for anticipating current and future public health threats as well as evidence for implementing interventions for disease prevention and health promotion. Over the past century, age structures and disease patterns have changed significantly worldwide. These changes have altered population dynamics and health needs accordingly.

10  Principles and theories: Public health TABLE 2.2  Examples of key epidemiological indicators

Indicators Mortality

Morbidity

Examples Mortality rate

Excess mortality rate Incidence rate Prevalence rate

-​ Number of deaths occurring in a population at risk in a specific time period, e.g. deaths per 10,000 persons per day/​deaths per 1,000 persons per year -​ Infant mortality rate, i.e. probability of dying between birth and age 1 per 1,000 live births -​ Age specific mortality rate -​ Case fatality rate Mortality rate above the non-​crisis mortality rate in a specific population, indicating mortality attributable to the crisis event Number of new cases divided by the total over a given period, e.g. the incidence of measles among children in camp A The proportion of a population with a particular condition e.g. the prevalence of HIV/​AIDS in a population

Source: Sphere (2011).

FIGURE 2.2   Consequences

of health outcomes

Source: Chan (2017).

Epidemiology Epidemiology describes the time, place and person associated with the occurrence of the disease. In principle, diseases might be categorised into two main subgroups, namely, communicable and non-​ communicable diseases. Communicable

Principles and theories: Public health  11

diseases, also known as infectious diseases, have long been the major causes for morbidity and mortality in human history. Communicable disease refers to: “illness due to the transmission of specific infectious agent (or its toxic products) from an infected person, animal… to a susceptible host, either directly or indirectly” (Guest, Ricciardi, Kawachi, & Lang, 2013, p. 166). As the diseases might be transmitted in the environment among persons/​animals, their occurrence may be affected by behavioural, social, environmental and biological determinants of a susceptible community. In the twenty-​first century, suboptimal hygiene in environment and behavioural patterns in many developing contexts have made communicable diseases the largest public health threats for preventable child and adolescent mortality. Social and environmental changes that resulted from urbanised lifestyle, deforestation and increased living density may influence infectious diseases burden at the global level. Antibiotics misuse has created new emerging communicable diseases, such as multidrug-​resistant TB and vancomycin-​resistant Staphylococcus aureus that have affected developed and developing contexts alike. Increased international movements of people and expansion of international trade have also increased communicable disease risk in developed communities. Non-​communicable diseases (NCDs) are diseases that do not pass between living beings or humans and hence are not communicable in nature. Although NCDs can be both acute and chronic, many are chronic in nature. There are a range of NCDs, but they share some common characteristics. An NCD i) does not transmit between persons; ii) tends to progress slowly and may lead to chronic or permanent illness; iii) may be influenced by multiple risk factors; iv) may cause restrictions to physical and mental functions and daily activities; v) might require continuous and/​or permanent life-​sustaining medical treatments, such as daily medication or kidney dialysis; vi) requires a range of health services and support, such as prevention, treatment, rehabilitation and palliative care; vii) may cause acute complications, such as brain haemorrhage from uncontrolled high blood pressure; and viii) increases household health expenditure due to continuous medical costs. NCDs account for 71% (41 million) of total global deaths annually. Common chronic NCDs include cardiovascular diseases (e.g. coronary heart disease, hypertension and stroke), cancers, chronic respiratory diseases (e.g. chronic obstructed pulmonary disease), diabetes mellitus, mental health disorders, injuries, renal diseases and chronic neurologic disorders (e.g. Alzheimer’s, dementias and epilepsy), etc. Moreover, over 80% of all NCD deaths are caused by one of four NCDs: cardiovascular diseases (17.9 million), cancers (9.0 million), respiratory diseases (3.9 million) and diabetes (1.6 million). More than 75% of NCD deaths (32 million) occurred in low-​and middle-​income countries (WHO, 2018, June 1). In many developing countries, both communicable and non-​communicable diseases constitute the double burden of healthcare needs. Mental disorders are prevalent worldwide, and more than 10% of the global burden of disease, measured in disability-​adjusted life years (DALY), is attributed to mental disorders. Mental health problems are mostly non-​communicable in nature. Globally, reports indicate that more and more people are reported to be

12  Principles and theories: Public health

affected by adverse mental health outcomes and there is a general increase in demand for public health interventions to address mental health needs. However, unlike other NCDs such as cardiovascular diseases or diabetes, there are many barriers to address mental health problems and needs. Physical invisibility, lack of technical expertise, prejudice and stigma on people with mental illness have often masked the impact of mental health problems and their impacts are often underestimated and neglected. Common mental disorders are depression, anxiety disorders, bipolar affective disorder, schizophrenia and other psychoses, dementia, and intellectual disabilities and developmental disorders including autism. According to WHO (2017), the two most globally prevalent mental disorders are depressive disorders and anxiety disorders. In 2015, over 300 million people globally were estimated to suffer from depression – 4.4% of the world’s population (prevalence rates peak in older adulthood: over 7.5% among females aged 55–​74 years old, and above 5.5% among males of the same age group) – and there was a similar prevalence of anxiety disorders. Moreover, some individuals may be suffering from both conditions simultaneously (i.e. comorbidity). In 2015, depression was the largest contributor to global disability (7.5% of all years lived with disability, YLD) and suicide deaths (close to 800,000 per year). The numbers of people affected by mental illness are expected to increase in the coming decades. This will impose significant social and economic consequences on society, due to treatment costs and lost productivity. For example, depression alone cost approximately US$800 billion in lost economic output in 2010. Therefore, the need for good understanding of mental health issues and provision of effective public health strategies for preventing mental disorders is rising. Injury typically refers to the physical damage that results in a human body when an individual is suddenly subjected to energy in amounts that exceed the threshold of physiological tolerance or suffers from a lack of one or more vital elements (for example, oxygen). The energy may be mechanical, thermal, chemical or radiant. Although injuries may cause death, a larger proportion of people who suffer from injury survive and have to live in temporary or permanent disabilities. Injuries are commonly classified based on intentionality and might be divided into intentional (e.g. suicide, homicide, assault and self-​harm) and unintentional (e.g. traffic accidents, drowning and falls) injuries.Violence associated with intentional injury might be further classified into individual-​directed violence (e.g. suicide, homicide and assault), or collective violence (e.g. war). Violence can result in a large number of injury, death, psychological harm, mal-​development or deprivation. Evidence suggests that some children and adolescents are more vulnerable to certain types of injuries. For example, overall injuries tend to be more prevalent among males; poisoning, drowning, burns and maltreatment by caregivers affect primarily small children, while road traffic accidents, interpersonal violence and sports injuries tend to affect older children and adolescents; household falls are more likely among older people. Understanding the nature of diseases, injuries and their associated risk factors is crucial for public health decision making and

Principles and theories: Public health  13

planning. Monitoring national and global disease burden and injury trend will help prioritise the most needed interventions for the target population under limited financial resources.

Life course approach WHO has proposed two main perspectives of how experiences in the life course might contribute to well-​being and health outcomes. The first model assumes there are critical periods in one’s life and certain exposure and behavioural traits during the specific period might exert long-lasting or life-long impacts on one’s health and well-​being. An example of such influences is detrimental exposure in the intrauterine foetal period which might be the origin, and lead to the development, of diseases in later life. The second model describes the impact of risk accumulation. It suggests factors that might increase disease risks which accumulate gradually over the life course. The accumulative impact or damage will increase with exposure intensity and duration in biological systems throughout the lifespan. Regardless of the models, the concept recognises that health is influenced by contextual and dynamic experience early in life and thereby argues for health and social policies which enrich maternal and child health and yield benefit throughout life. “Life-​course health development” (LCHD) has underlined health policies and system developments (Halfon, Larson, Lu, Tullis, & Russ, 2014) as well as ageing health outcomes (Dannefer & Daub, 2009). In principle, health risk across the life cycle might be categorised into four main subgroups based on the relevant life stages, namely, i) infancy and children (age 0–​14); ii) adolescents and young adults (age 15–24); iii) the “prime of life” (age 25–​64); and iv) the older years (age 65 till death) (Jenkins, 2003). Reproductive period of women (typically defined as age 15–49) is also another important stage of life with specific health risks associated with the physiological functions of a female. Maternal and child health (MCH) involves a wide variation of mortality and morbidity which might be attributed to avoidable health risks. With global efforts in vaccination, improvement of ante-​natal and post-​natal care, policy foci such as Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs), health risks, particularly those affecting the younger extreme of age, shift from predominantly communicable diseases to non-​communicable diseases (e.g. injury, behaviour-​and lifestyle-​related problems such as obesity). For young adults, behaviour-​ related health risks—​ like substance abuse (e.g. tobacco and alcohol), unsafe sex behaviours (e.g. teenage pregnancy), sexually transmitted diseases (STD), and injury and violence—​remain important risks. Health risks for the prime of age are related to genetics, predisposition, lifestyle and environmental context. With the increase of life expectancy where more individuals live much longer than before and with the general demographic ageing, the understanding of health risks and their transition associated with old age are still evolving. In addition to the various health risks associated with physiological deterioration, risks are also associated with dependency (support/​assistance available for disabilities, e.g. vision/​hearing impairments which

14  Principles and theories: Public health

are accompanied with ageing) and environmental and living contexts (e.g. whether the community is age-​friendly). An example of this evolving understanding may be the discussion of “disability-​free life expectancy” (Crimmins, Hayward, Hagedorn, Saito, & Brouard, 2009; Seeman, Merkins, Crimmins, & Karlamangla, 2010). These evolving health risks for older people will be further discussed in the next chapter.

Pathway of care Pathway of care conceptualises how health needs could be addressed over the course of an individual experiencing a health condition. For any health condition, tackling health risks might be conducted at various phases of the pathway. Activities/​ interventions that target health protection or health promotion may keep an individual free from diseases. If the individual is found to have a condition, the disease experience may be affected by the accuracy and timeliness of diagnosis, treatment and rehabilitation and, finally, palliative care if the individual is in the terminal stage of a disease. Public health approach emphasises prevention along the pathway of care and demonstrates how comprehensive healthcare services might be possible even under limited resources. Management of medical conditions may be possible by low-​cost services ranging from disease prevention, health protection, health promotion, diagnosis, treatment, rehabilitation (a form of tertiary prevention as explained later) to palliative care. Health groups with limited technical capacity and resources may consider technical knowledge transfer and community capacity training of local staff. Community partnerships and collaborations may promote local ownership and technical transfer, which are essential for service sustainability. For chronic non-​communicable disease treatment, agencies may consider: i) providing health education that can equip NCD patients with knowledge regarding how to reduce potential disease complications; ii) identifying access to relevant services and clinical management support; iii) facilitating referrals via proper clinical record keeping; and iv) coordinating with stakeholders in other areas (e.g. food-​and nutrition-​based assistance groups) to provide nutritionally appropriate diets for an NCD-​affected population (e.g. a low-​salt, low-​sugar diet) to minimise avoidable disease complications. Under very limited resources, health groups can still well document the key disease burdens in population to locate the health gaps that need to be addressed.

Development and health risk transition As defined by WHO (2009), health risk can be understood as factors which might raise the probability of adverse health outcomes. These risks might lead to poor outcomes in physical, mental and social well-​being of an individual or a community. These health risks also change with age (as physiological changes occur throughout the life course) as well as environmental and circumstantial living contexts through time.

Principles and theories: Public health  15

Major shifts in health risks are associated with socio-​economic developments. For instance, traditional health risks might be associated with suboptimal hygiene and nutrition status, which might expose individuals and community to unsafe water, infections and nutritional deficiencies. As a result of industrialisation, economic and social development, as well as urbanisation, health risks might shift to those associated with lifestyle, economic disparities, occupational hazards and access to healthcare and services. WHO proposed that changing of health risks might be attributed to public health interventions (e.g. vaccination), improved infrastructure (e.g. water and sanitation and electricity), scientific advancement, improvement of medical care and population ageing (WHO, 2009; McCracken & Phillips, 2017). With the diversity of population structures and socio-​economic development stages across the global communities, health risks should be examined as a combination of health risks in the context of interest.

Three domains of public health Public health consists of three major domains, namely health protection, health improvement and health services. Health protection includes the prevention and control of infectious diseases, monitoring environmental factors that potentially threaten public health (such as the quality of the air, drinking water and food) and responding to chemical and technological emergencies (such as bioterrorism or radiation disaster; Chan, forthcoming). Examples of public health protection activity include occupational health monitoring, vaccination, air quality monitoring, rodent and pest control and management of hygiene in restaurants. Health improvement refers to activities that encourage and enable the general public to adopt healthy lifestyles and reduce health inequalities. It usually requires multi-​sectoral collaboration (in the fields of housing and education, as well as working environment and family/​community networks) in policy implementation, health improvement activities and health education that empowers individuals to choose their lifestyles wisely. Examples include promoting a balanced diet, health education, sex education, as well as smoking cessation campaigns. Health services focus on health service-​related policies and service delivery management, the advocacy of evidence-​based medicine and the espousal of service management and resources allocation that promote effective clinical practices.

Disease prevention Health protection and health promotion are the two major strategies to achieve disease prevention. Health protection strategies focus on removing negative harms by slowing down disease progress and reducing the impacts of established diseases with a wide range of prevention strategies. Health promotion strategies, in contrast, focus on encouraging healthy behaviours to improve well-​being and to reduce the risk of developing diseases.

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Hierarchy of prevention “Prevention is better than cure” is one of the most widely known principles in public health. The hierarchy of prevention, the disease prevention framework proposed by Leavell and Clark (1958), classifies disease prevention into three broad levels: primary, secondary and tertiary prevention. Primary prevention activities typically target at-​risk populations, aiming to prevent the occurrence of a disease through health protection and health improvement strategies. Health protection strategies include vaccination programmes and enforcing regulations, legislations and policies. Health improvement strategies encompass various population-​based health promotion activities, such as health education to promote physical exercises and healthy diets. Secondary prevention generally targets high-​r isk population groups and aims to slow down or stop existing disease progression and development of disability with prompt interventions, such as early screening, diagnosis and treatments. Tertiary prevention strategies target those who have already been affected by a disease and aim to cure the disease or to reduce the risk of disability with therapeutic and rehabilitative measures. Services in this category include treatment, rehabilitation and palliative care. In addition to the three prevention levels, primordial or pre-​ primary prevention also becomes important for health prevention practices, particularly in environmental health protection. Primordial prevention activities focus on reducing health threats and risks in general. Examples include environmental control measures to improve air quality and reduce potential environmental hazards, such as biological or chemical hazards (Davidson, 2013). Table 2.3 summarises the four levels of disease prevention. The application of these prevention concepts in establishing disaster mitigation strategies, response programmes and post-​disaster recovery policies may enhance individual survival and protect communities from adverse health outcomes in natural disasters (see Knowledge Box 2.1).

Health protection Health protection is a core domain in public health, which aims at “[protecting] individuals, groups and populations through expert advice and effective elaboration to identify, prevent and mitigate the impacts of infectious disease, and environmental, chemical and radiological threats” (Ghebrehewet, Stewart, & Rufus, 2016, p. 3). By removing any potential negative health hazards and risks, health protection strives to prevent diseases and protect the health of individuals, local communities and the wider population. To achieve this goal, health protection actions and strategies employ a wide range of public health activities, such as direct actions with individuals or communities, implementing legislation, or other control measures (Taylor and Guest, 2013). Examples include epidemiological investigations to identify health hazards through risk assessments and provisions of clinical services, such as screening or immunisation. Many health protection activities are preventive by nature as they are in place to address the unpredictable nature of some health issues. To establish and maintain

Principles and theories: Public health  17 TABLE 2.3  Classification of prevention

Level of prevention

Primordial prevention

Primary prevention

Avoiding Detecting existing development diseases at an of “preventable” early stage diseases to retard progression and inhibit symptom development Target General At-​r isk Early stage population population asymptomatic Example • Health • Health • Health strategies improvement protection protection -​ Health -​ Legislation -​ Early education & policy screening • Health -​ Vaccination -​ Early protection intervention -​ Vector -​ Air quality control control • Health -​ Water improvement quality -​ Health control education Responsible • Public  health • Public health • Public health sectors • Primary • Primary • Primary healthcare healthcare healthcare • Other • Other sectors, e.g. sectors, e.g. education, education, housing housing Disease progression  Goals

Reducing health risks & threats

Secondary prevention

Tertiary prevention Reducing complications or disability arising from an already established disease

Symptomatic • Therapeutic treatment -​ Pharmaceutical treatment • Rehabilitative measures

• Hospitals • Specialist services

Source: Adapted from Davidson (2013).

readily available local services, health protection efforts are frequently deployed by government agencies, such as Public Health England (PHE, United Kingdom), Environmental Protection Agency (EPA, United States) and Chinese Center for Disease Control and Prevention (China CDC, People’s Republic of China). These agencies plan, develop, implement and maintain health protection interventions. Comprehensive health protection systems share several important characteristics, such as good surveillance mechanisms, strong multi-​agency partnerships, clear and robust epidemiology, supportive science and research institutions (e.g. microbiology, toxicology, environmental sciences and radiation science), clear communication strategies and learning and development.

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KNOWLEDGE BOX 2.1  HIERARCHY OF PREVENTION IN THE CONTEXT OF DISASTER In the context of disaster, prevention effort might be implemented even under limited resources. Primary prevention proactively addresses the potential health risk associated with disasters before their onset. For example, in flood-​prone areas, heavy rainfall might leave behind stagnant water to provide breeding grounds for mosquitoes and increase the risk for vector-​borne diseases such as malaria, dengue fever and West Nile fever (World Health Organization Regional Office for the Eastern Mediterranean [WHO-​EMRO], 2005). Primary prevention activities include promoting infrastructure and building designs that prevent the accumulation of stagnant water, as well as enhancing community awareness of vector-​borne disease risks. Design and building codes for disaster-​resistant safe hospitals are other examples of primary prevention to minimise the health impact of disaster (World Health Organization Regional Office for the Western Mediterranean [WHO-​WPRO], 2010; World Health Organization [WHO], United Kingdom Health Protection Agency [HPA], & partners, 2011). Secondary prevention strategies are usually employed post disaster to prevent a disaster’s potential health impacts. For instance, the post-​disaster health needs of people with underlying chronic disease conditions (e.g. drug and specific food requirements) should be taken care of to avoid medical complications arising from lack of management of these conditions, which could increase the burden of health services. Take the potential release of radioactive materials to the environment in a nuclear power plant accident as another example. Due to the concerns over thyroid cancer associated with radioactive contamination of food and water, WHO has developed guidelines for iodine prophylaxis post nuclear power plant accidents and recommended the distribution of iodine tablets to the affected population to reduce the potential harm (WHO, 1999). In a disaster context, tertiary prevention aims to minimise the health impact and damage to health post disaster. The targets of tertiary prevention are those who have already sustained the impact of a disaster. For example, after an earthquake, patients suffering from orthopaedic trauma require surgical operations. While rapid operations could save lives, early post-​operational physiotherapies can maximise the functional recovery potential of patients like amputees.

Principles and theories: Public health  19

Meanwhile, as not all diseases can be eliminated or prevented by health protection strategies alone, health promotion strategies often play a complementary role to reduce certain health risks. For example, to eliminate the risk of communicable disease outbreak, a health protection strategy may include various primordial and primary prevention strategies, such as hand-​washing, immunisation, provision of clean water and wearing facemasks. However, it would be more effective if complementary health promotion strategies for improving hygiene techniques, e.g. health education in proper hand-​washing practice, were also implemented at the same time.

Five key spheres of health protection Health protection approaches could be divided into five categories: i) communicable disease control; ii) emergency management; iii) environmental and food safety management; iv) climate change; and v) related global initiatives and policies. These five categories are important for disease prevention (Chan, forthcoming; Commonwealth Secretariat, 2017). Table 2.4 provides a brief overview for each category.

Epidemiologic triangle Infectious diseases are communicable diseases caused by pathogens and spread via vectors. These pathogens, including bacteria, virus, fungi and parasites, replicate

TABLE 2.4  Five categories of health protection

Description Environmental public health

Communicable disease control Emergency & disaster management Climate change

Health protection related global policies

• Ensuring the safety and quality of environment, e.g. food, water, air • Example activities: Identification and characterisation of hazards and health risks, and provision of response at local, regional, national and global levels • Preventing the transmission of communicable diseases • Example activities: Preparation, prevention, investigation and control at local, regional, national and global levels • Managing emergencies and other environmental issues that can threaten health • Example activities: Preparation, prevention, investigation and control at local, regional, national and global levels • Adaptation, mitigation, response and recovery at local, regional, national and global levels • Example activities: Reducing CO2 emissions • Global cooperation in communicable disease control and response -​ Example: International Health Regulations (IHR)

Sources: Adapted from Chan (2017) and Ghebrehewet, Stewart, & Rufus (2016).

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inside a host’s body and can cause disease by releasing toxins. They damage normal cells, interrupt their functioning and can be fatal in severe cases. From the public health perspective, an understanding of the three essential components of infectious disease spread is a vital first step in the effective management of different infectious diseases.These three components are agents, hosts and environment, which form the “epidemiologic triangle”. Effective disease prevention and control can be achieved if the connection between any two components is disrupted. Epidemiologic triangle is an important conceptual framework for the analysis and planning of public health policies to address disease control approaches. When there is a risk of an epidemic that warrants control, different infection prevention and control strategies should be introduced in line with the three components that affect disease pattern, available resources and the potential intervention’s impact on society.

Communicable diseases and infection control There are three basic principles in infection control: i) boosting the immune system of the host by such means as vaccination and consumption of preventive medicine; ii) removing the source of infection by sterilisation, clearing of pathogen breeding grounds, as well as isolation and treatment of patients; and iii) blocking the transmission route by, for instance, maintaining good personal, environmental and food hygiene (see Knowledge Box 2.2).The following four examples show how different methods and foci can be used to deal with different principles in infection control. Influenza is transmitted by droplets. It can be controlled by vaccination, good personal and environmental hygiene, good indoor air ventilation and frequent handwashing. Tuberculosis is an airborne transmitted disease. When the patients cough, sneeze and speak, they release the germs into the air. People, particularly immune-​compromised people, may get infected by inhalation. To control the spread of tuberculosis, BCG vaccination, rapid treatment, good personal and environmental hygiene, and good indoor air ventilation are commonly employed measures. Malaria is an example of vector-​borne transmitted disease. Its transmission requires mosquitoes. Control of malaria can be achieved by elimination of the breeding grounds of mosquitoes and spraying pesticides. Personal preventive measures include wearing pale, long-​sleeved tops and long trousers, using insect repellent and mosquito nets and taking prophylactic medicine before going to areas where malaria is prevalent. Human immunodeficiency virus (HIV) is spread by blood and body fluids.The main transmission routes include sexual contacts, the sharing of needles and mother-​to-​child vertical transmission. Quitting drugs and having safe sex (e.g. using condoms), which are based on the principle of blocking the transmission routes, can control the spread of HIV.

Non-​communicable diseases control Rapidly evolving personal habits and living conditions under the global economy and social development, coupled with changing disease pattern and population

Principles and theories: Public health  21

KNOWLEDGE BOX 2.2  TRANSMISSION ROUTES OF COMMUNICABLE DISEASES The transmission routes can be broadly divided into seven categories: 1. Contact transmission: This refers to the direct contact with patients or their body fluids or indirect contact with contaminated objects. Examples of contact transmitted diseases include scabies, head lice, hand-​foot-​and-​ mouth disease and acute infectious conjunctivitis. 2. Droplet transmission: Victims release pathogen-​containing droplets into the air when they cough, sneeze or speak. Disease examples include influenza, common cold and severe acute respiratory syndrome (SARS). 3. Airborne transmission: Patients spread the pathogens when they cough and sneeze. The pathogens can stay in the air for some time and enter human bodies via the respiratory tracts. Tuberculosis is an example of airborne transmitted disease. 4. Vector transmission: Vector refers to tiny organisms such as mosquitoes, house dust mites and ticks. They can transfer the pathogens from an infected person to another person. Disease examples are dengue fever, malaria and Japanese encephalitis. 5. Blood-​borne and body fluid transmission: Pathogens can be spread from an infected person to others via blood and body fluids. Disease examples include hepatitis B, hepatitis C and acquired immunodeficiency syndrome (AIDS). 6. Food-​ borne transmission: It refers to the transmission of disease via ingestion of contaminated food. Examples of relevant diseases are food poisoning, cholera and shigellosis. 7. Congenital transmission: Also known as vertical transmission, a disease arising from this kind of transmission is spread from an infected mother to her foetus. Acquired immunodeficiency syndrome (AIDS) is an example.

ageing around the world, have significantly increased non-​communicable diseases (NCDs) prevalence in both developed and developing countries in the twenty-​ first century. NCDs are medical conditions that do not spread person to person and can be grouped into two main types based on their temporality–​–​chronic and acute NCDs (refer also to earlier section of this chapter on NCDs). Acute NCDs are conditions such as stroke, myocardial infarction, injuries/​accidents and overdose of drugs and alcohol. Chronic diseases are those with a long course of disease and may exert a long-​term effect on health. The four key common NCDs in the twenty-​first century are cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. Mental health issues, which present a huge threat to global health, are also a kind of chronic NCD.The burden of mental health issues varies considerably

22  Principles and theories: Public health

among countries, with a prevalence rate ranging between 4% and 26%. As the most common cause of self-​harm and suicide, mental health problems are also associated with an increased risk for cardiovascular diseases and diabetes. Moreover, patients of other NCDs have a higher risk of developing mental problems. Globally, approximately 36 million people lose their lives to NCDs or their related complications annually. NCDs account for 43% of the global health burden, with 80% of these deaths taking place in countries of low and middle income.They are the main cause of death in all regions except Africa. It is predicted that in 2020, NCDs will be responsible for 60% of the global health burden and 73% of deaths. An individual’s likelihood of developing NCDs varies with many determinants. Among them, personal lifestyle choices are found to be closely associated with the development of NCDs. Lifestyle risk factors include smoking, lack of exercise, alcohol abuse and unhealthy diet. These unhealthy lifestyles could trigger physiological changes to increase the risk of developing NCDs. For example, having a diet high in salt, sugar and fat may lead to the development of three “hyper diseases” (hypertension, hyperglycaemia and hyperlipidaemia), which increase the risk of obesity, cardio-​vascular diseases and diabetes. Nevertheless, since these NCDs tend to take a long time to develop and the direct relationship between lifestyle and these diseases (e.g. smoking and lung cancer, alcoholism and liver cancer) are not conspicuous, the awareness and active management of these diseases remain low. Another notable example is mental health. The development of psychological distress and other mental health problems is associated with various social, physiological and environmental factors. Stressful work and unhealthy habits could also directly affect people’s mental health. Control of NCDs thus requires multidisciplinary approaches to ensure risk factors and disease development and management are managed (refer to the next section on health promotion).

Health promotion While health protection and health promotion are complementary, their disease prevention approaches are different. Health protection focuses on premorbid and primary disease prevention and aims to remove negative health influences through monitoring and screening, while health promotion focuses on enhancing health through strengthening personal resilience and supportive environment as well as enabling individuals and communities to take responsibility for their health. It is challenging to influence the health-​related behaviours of those with shallow knowledge about their own health. Many health promotion theories and models have been developed to conceptualise human behaviour to support the planning of health intervention projects. However, the choice of theories and models depends on the objectives of the intervention and the target audience. Hence, it is always important to evaluate local contexts at the very early stage. The Ottawa Charter for Health Promotion, as an outcome of the First International Conference on Health Promotion held in 1986 in Ottawa, Canada, defined health promotion as: “the ­process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behavior towards a wide range of social and

Principles and theories: Public health  23

KNOWLEDGE BOX 2.3  FIVE PRINCIPLES FOR HEALTH PROMOTION PRACTICE Health promotion encompasses a wide range of social and environmental interventions to improve and protect health and well-​being by addressing the root causes of ill health. Developing a successful health promotion programme requires collaborative efforts from all sectors of society, such as the government, health service institutions, non-​governmental organisations and the media. WHO proposes five essential principles for health promotion practices and strategies: i)   Formulating healthy public policies: Health promotion puts health on the agenda of policy-​makers in various sectors and directs them to be conscious of the health impact of their decisions and to accept their responsibilities for health, with related health promotion policies like legislation, fiscal measures, taxation and organisational change. ii)   Creating a supportive environment: This involves the creation of a society which upholds the principle of taking care of each other, communities and the environment. iii)   Strengthening community actions: Better health can be achieved through concrete and effective community actions in priority setting, as well as planning and implementing strategies, which mobilise existing human and material resources in the community to enhance self-​help and social support, as well as to develop flexible systems for encouraging public participation in health issues. iv)   Developing personal skills: By providing information, health education and life skills enhancement, people can be empowered to take control over their own health and personal and social environments and to make informed choices to achieve better health. v)   Reorienting health services: To support the needs of individuals and communities for a healthier life, the health service sector should steer toward a health promotion direction beyond its responsibilities for providing clinical services.

environmental interventions” (WHO, 1986). See Knowledge Box 2.3 on the five principles for health promotion practice. There are diverse views regarding whether health should be considered as an individual or collective responsibility in society. Approaches based on individual responsibilities focus on activities or initiatives which enable informed choice (i.e. information sharing), deregulation (i.e. relying on individuals to make their own choices) or decision making (e.g. choice of healthcare services). In contrast, health approaches emphasising collective responsibilities encourage legislation, regulation, population-​wide measures and the like. Regardless of the approaches, determinants of health will be examined to identify the most relevant components to be addressed.

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Prevention paradox A common paradox for health practitioners designing population-​based health promotion initiatives is targeting people with the greatest risk of a disease/​condition or lowering the risk across the whole population. Rose (1981) argues that universal-​ based programmes aiming to address the risk of the overall population will have the greatest overall impact in a community. However, he also highlights the paradox that while such a universal preventive measure can bring large benefit to the community, it offers few benefits to participating individuals. The implication of such concern suggests that targeted approaches may be more attractive, because the prevention paradox can lead to lost credibility of health promotion activities which have little benefits to the more visible/​high risk groups (Hunt & Emslie, 2001).

Risk behaviours, health risks and high-​risk groups Risk behaviours are actions that can potentially harm individual health or the health of others. Health risks associated with an individual may be categorised into three main subgroups: pure harms (e.g. smoking), mixed risks which hold both harms and benefits (e.g. pattern of food consumption) and harms to oneself and second or third parties (e.g. drunk driving and unprotected sexual intercourse). Based on the understanding that risk behaviours can be controlled, health promotion activities aim to improve individual health by enhancing the understanding of the risks associated with certain behaviours to allow individuals to decide whether to take actions to avoid these risks. There are different types of activities which might bring health risk to an individual. It is nevertheless important to differentiate the type of health risks such as pure harm, mixed risk with harms and benefits, or harm which also affects second parties or others before engaging in health promotion. Health risk interventions might be implemented at different levels. It might be done at the public level, targeted to patients, through professional oriented services to earmarked policy that address issues at the national and community levels.Typically, at the policy level these include approaches such as bans and restrictions of availability, usage, sales, advertisement and information, and fiscal measures like taxation and subsidies. In addition, an appropriate environment (e.g. smoking bans) can be created.

Health communication Effective health communication is essential to success in health promotion. Careful considerations should be made for the core message, how it is said and the media/​ medium to be used for the health promotion efforts. McGuire (1989) highlights the five inputs (source, message, channel, receiver and destination) which are important to craft the behavioural changing messages in health. Specifically, the type of message might include verbal, non-​verbal, horizontal (good behaviours that might simultaneously improve a few aspects of well-​being, e.g. handwashing might

Principles and theories: Public health  25

reduce diarrhoea, food hygiene, etc.) and vertical (for a specific health problem). More related discussion can be found in Chapters 4 and 5. Successful community requirements include: Be seen/​heard, attract attention, be understood, be accepted and change behaviour.

Approaches and strategies in health promotion Health promotion programmes might address health issues at various levels. Typical programmes might involve: Change of policy to shift culture or behaviour, distribution/​redistribution of resources (incentives, or removal of barriers that obstruct good health-​promoting behaviour), and community development, which includes health. Implementation success might depend on values, motivation, skills of the relevant staff, guidance available and time commitment of the project. Health promotion approaches may adopt different strategies and can be broadly categorised into seven subgroups, namely health education strategies, health communication strategies, health policy/​enforcement strategies, environmental change strategies, health-​related community service strategies, community mobilisation strategies and others (McKenzie, Neiger, & Thackeray, 2009). As these strategies are often complementary to each other, a health promotion programme may employ multiple strategies to achieve its goals.

Policy implication Globalisation of trade, urbanisation, increased global travel, global environmental change and climate change are rapidly influencing diverse aspects of our lives, and many challenges that affect determinants of health go beyond national borders. Health promotion approaches have been used as an important tool to promote health and prevent illness and diseases at the global level. A wide range of international policies, programmes and agreements has been arranged by governmental and non-​ governmental organisations around the world, such as the Alma Ata Declaration in 1978 and Sustainable Development Goals in 2015. The healthy settings movement is a settings-​based approach to health promotion, which aims to maximise disease prevention based on a “whole system” approach. The settings approach originates from the Ottawa Charter for Health Promotion, focusing on community participation, partnership, empowerment and equity.

Health systems The objectives of a health system are to improve health in society, respond to the needs of society in terms of healthcare, ensure that healthcare does not become a huge financial burden to patients, and increase the efficacy of services (see Case Box 2.1: WHO conceptual framework to understand health systems). It is necessary to understand the scope of the health system in order to identify opportunity and

26  Principles and theories: Public health

mobilise its resources to address health needs. WHO defines a health system as “all units, individuals and behaviour that aim to improve, resume and maintain the health of the population” (WHO, n.d., 2000). There are six main components in a health system. Leadership and governance concerns the oversight, coalition, regulation and policy of a country’s or a region’s health system. Healthcare financing structure concerns the appropriate collection, allocation and utilisation of resources as well as risk management which are all important to a well-​functioning health system. Health workforce describes people working within the healthcare system to fulfil the healthcare needs of the community. Medical product and technology includes medical products, vaccines, medical technologies, and safety protocols and guidelines that ensure quality, effective and safe medical. Information and research refers to the exchange and management of information, as well as the application of new findings in medical science, that can improve people’s health. A smoothly run health system should be able to disseminate reliably and effectively any timely information and results of scientific research relevant to determinants of health, health impacts and health systems, thus enhancing health in the community. Health service delivery is the mechanism for which appropriate and comprehensive healthcare services, ranging from primary care and specialist treatment to recovery, are being delivered in a community.The ultimate target of a health system is to achieve full coverage of healthcare and medical services and enhance the health of the entire population. According to the definition of WHO, a health system includes “all the activities whose primary purpose is to promote, restore or maintain health” and comprises “all the organizations, institutions and resources that are devoted to producing health actions. A health action is defined as any effort, whether in personal healthcare, public health services or through intersectoral initiatives, whose primary purpose is to improve health” (WHO, 2000, pp. xi, 5). A healthcare system is the organisation of people, institutions and resources that deliver healthcare services to meet the health needs of target populations. The World Health Report 2000 (WHO, 2000) defined three fundamental health system goals and responsibilities: to improve the health and health equity, to respond to people’s expectations and to provide financial protection against the costs of ill-​health. Hence, health systems have a responsibility to improve people’s health, protect them against the financial cost of illness and treat them with dignity.

Universal health coverage (UHC) Globally, due to inaccessibility, unavailability, lack of ability to pay (unaffordable), or poor quality, more than one billion people in the world have no access to health services they need. People may also fall into poverty due to catastrophic out-​of-​ pocket payment for health services. Building a good health system that offers available, affordable and accessible health services for everyone when and where they need them is key to protecting population health. Universal health coverage (UHC) is based on the WHO constitution of 1946 and the recognition of health as a fundamental human right on the Health for All agenda set by the Alma Ata

Principles and theories: Public health  27

CASE BOX 2.1  WHO CONCEPTUAL FRAMEWORK TO UNDERSTAND HEALTH SYSTEMS Building Block 1: Health services Health services should be effective, safe, quality personal and non-​personal health interventions, and be provided to those that need them, when and where needed, with minimum waste of resources.

Building Block 2: Health workforce A well-​performing health workforce is one that is responsive, fair and efficient to achieve the best health outcomes possible.

Building Block 3: Health information system A well-​functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status.

Building Block 4: Medical products, vaccines and technologies There should be equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-​effectiveness.

Building Block 5: Financing system A good health financing system raises adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for them.

Building Block 6: Leadership and governance Leadership and governance involve ensuring strategic policy frameworks exist and are combined with effective oversight, coalition-​ building, regulation, attention to system design and accountability. Source: WHO (2007).

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Declaration in 1978. In recent years, UHC is included in all the health-​related Sustainable Development Goals. Although UHC is defined and understood differently by different people and countries, WHO defined its goal as ensuring that “all people obtain the health services they need without suffering financial hardship when paying for them” (WHO, 2014, December). It aims to ensure financing and organisational arrangements covering the entire population to access the services that address the most important causes of disease and protect people from financial risks. Thus, when a person needs healthcare, he/​she can receive essential services at affordable or no cost at the point of service delivery. UHC embodies three essential dimensions: i) population coverage means equity in access to health services, and refers to a situation in which everyone gets the services they need, not only those who can pay for them; ii) service availability and quality refers to the quality of health services, which should be good enough to improve the health of those receiving services; iii) financial protection means people should be protected against financial risk and the cost of services does not put people at risk of financial harm. The three dimensions of UHC can be described in the UHC cube. These three dimensions can guide how universal coverage can be achieved. Increasing the financial protection to the population is a common approach to reduce out-​ of-​pocket health expenditure. In addition, structuring organisational and financial mechanisms can increase the proportion of financially protected population. Another way is by widening the range of subsidised services, so that the services for which one has to pay out of pocket (and hence face financial risks) can be minimised.

Levels of care A good health system can offer appropriate and comprehensive healthcare services, ranging from primary care and specialist treatment to recovery. The ultimate aims of any health systems are to achieve full coverage of healthcare and medical services and to enhance the health of the entire population in the society. This could be achieved by responding to the healthcare needs of society and increasing the service efficacy while ensuring that healthcare does not cause financial catastrophe in households. Health services include all service provision along the pathway of care, e.g. dealing with the diagnosis and treatment of disease, or the promotion, maintenance and restoration of health. Service provision requires inputs such as money, staff, equipment and drugs, and good service delivery also concerns quality, access, safety and coverage. Effective and equitable service provision is possible when all the six building blocks are combined to allow the delivery of health interventions. As illustrated in Figure 2.3, the healthcare system is traditionally divided into three levels of health service provision. Primary healthcare (PHC), which comprises the main health and medical services in most developing countries, typically serves as the entry point of the health system and aims to provide basic packages of preventive and curative health service to the population. It might include health and

Principles and theories: Public health  29

FIGURE 2.3  Three

levels of care in a healthcare system

Source: Adapted from Chan (2017).

nutrition education, health maintaining habits (e.g. boiling water before drinking, washing hands after using the latrine, etc.), disease prevention (immunization, elimination of stagnant water for vector-​borne disease prevention), diagnosis and treatment of common diseases (injury, diarrhoea). Primary care providers may be doctors such as general practitioners, nurse practitioners or physician assistants. Secondary healthcare is usually provided in facilities (can be outpatient or inpatient such as in hospital) which offer specialist medical care (e.g. surgery), more elaborate and complex services (laboratory diagnosis) and treatment. Tertiary level care is usually produced in a specific context and comprises highly specialised care on referral from primary and secondary healthcare for advanced medical investigation and treatment, such as certain types of advanced surgeries. In many developing country contexts, these services are very limited and often only available in national level hospitals. People-​centred and integrated health services are essential for reaching universal health coverage. People-​centred care focuses on the health needs and expectations of people and communities and people in their communities may be involved in shaping health policy and health services. Integrated health services incorporate the management and delivery of quality and safe health services so

30  Principles and theories: Public health TABLE 2.5  Principles of medical ethics

Principle

Concepts

Description

Autonomy

Human rights Dignity Freedom Do no harm

The right of an individual to decide whether to participate or not

Non-​maleficence Beneficence Justice

Do good Equity Fairness

Obligation to cause no harm to participants, whether physical or psychological Acting in the best interests of the population Public health specialists should always act in a just way, ensuring fair distribution of benefits and risks

Source: Adapted from Lewis, Sheringham, Bernal, & Crayford (2015, p. 54).

that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care services, through the different levels and sites of care within the health system, and according to their needs throughout the life course. Improving access, coverage and quality of services involves many interrelated elements, such as service planning, improving evidence-​based practices, clinical effectiveness, good governance and fair resource allocation (Griffiths et al., 2005; Frumkin, Hess, Luber, Malilay, & McGeehin, 2008). The important aspect when evaluating health services is assessing the quality of healthcare. Quality of care refers to “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Lohr & Schroeder, 1990).

Medical ethics Ethics underlie decision-​making in medicine, public health and healthcare organisation. With resource constraints, there are bound to be population subgroups that are disadvantaged in the process of making choices for health and medical services. It is thus important to understand the principles of medical ethics to understand how decisions were made in health and medical systems.There are four principles of medical ethics, namely autonomy, non-​maleficence, beneficence and justice. In principle, before decisions on clinical care, health and medical resource allocations are made, the four principles should be applied and used for evaluating how the affected individuals/ groups might be affected by the decision. Table 2.5 lists the four common medical ethics frequently applied in decision making in health and clinical care.

Conclusion This chapter provides an overview of core public health theories and principles to understand and analyse human health patterns and medical needs in modern

Principles and theories: Public health  31

societies. Although health challenges evolve with the demographic and epidemiological patterns of the population in different periods of time, basic public health concepts and approaches have proven to be useful and are effective tools to analysis, plan, implement, monitor and evaluate attempts to address health needs and support the vulnerable in a community. The next chapter will discuss how health and well-​ being might be affected by age and the ageing process.

References Chan, E. Y. Y. (forthcoming). Essentials for health protection: Four key components. Oxford: Oxford University Press. Chan, E. Y. Y. (2017). Public health humanitarian responses to natural disasters. London: Routledge. Commonwealth Secretariat. (2017). Health protection policy toolkit: Health as essential component of global security. Retrieved from www.thecommonwealth-​healthhub.net/​wp-​content/​ uploads/​2017/​05/​HPToolkitwordversionEd2-​CHMM-​2017.pdf Crimmins, E. M., Hayward, M. D., Hagedorn, A., Saito,Y., & Brouard, N. (2009). Change in disability-​free life expectancy for Americans 70 years old and older. Demography, 46(3), 627–​646. Dahlgren, G., & Whitehead, M. (1991). Policies and strategies to promote social equity in health (Working Paper). Stockholm, Sweden: Institute for Further Studies. Retrieved from www.iffs.se/​media/​1326/​20080109110739filmZ8UVQv2wQFShMRF6cuT.pdf Dannefer, D., & Daub, A. (2009). Extending the interrogation: Life span, life course, and the constitution of human aging. Advances in Life Course Research, 14(1–​2),  15–​27. Davidson, W. (2013). Principles of prevention: The four stages theory of prevention. Retrieved from www.academia.edu/​10916848/​Principles_​of_​Prevention_​The_​Four_​Stages_​Theory_ ​ of_​Prevention_​PDF_​File?auto=download Frumkin, H., Hess, J., Luber, G., Malilay, J., & McGeehin, M. (2008). Climate change: The public health response. American Journal of Public Health, 98(3). Retrieved from www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2253589/​pdf/​0980435.pdf Ghebrehewet, S., Stewart, A. G., & Rufus, I. (2016). What is health protection? In S. Ghebrehewet, A. G. Stewart, D. Baxter, P. Shears, D. Conrad, & M. Kliner (Eds.), Health protection: Principles and practice. Oxford: Oxford University Press. Retrieved from http://​ oxfordmedicine.com/v​ iew/1​ 0.1093/m ​ ed/9​ 780198745471.001.0001/​med-​9780198745471​chapter-​1 Griffiths, S., Jewell, T., & Donnelly, P. (2005). Public health in practice: The three domains of public health. Public health, 119(10), 907–​913. Guest, C., Ricciardi, W., Kawachi, I., & Lang, I. (Eds.). Oxford handbook of public health practice (3rd ed.). Oxford: Oxford University Press. Halfon, N., Larson, K., Lu, M., Tullis, E., & Russ, S. (2014). Lifecourse health development: Past, present and future. Maternal and Child Health Journal, 18(2), 344–​365. Hunt, K., & Emslie, C. (2001). Commentary: The prevention paradox in lay epidemiology-​ Rose revisited. International Journal of Epidemiology, 30, 442–​446. Jenkins, C. D. (2003). Building better health: A handbook of behavioral change (Scientific and Technical Publication No. 590). Washington, DC: Pan American Health Organization. Leavell, H. R., & Clark, E. G. (1958). Preventive medicine for the doctor in his community: An epidemiologic approach (2nd ed.). New York: McGraw-​Hill. Lewis, G., Sheringham, J., Bernal, J. L., & Crayford, T. (2015). Mastering public health: A postgraduate guide to examinations and revalidation (2nd ed.). Boca Raton, FL: CRC Press.

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Lohr, K. N., & Schroeder, S. A. (1990). A strategy for quality assurance in Medicare. New England Journal of Medicine, 322, 707–​712. doi: 10.1056/​NEJM199003083221031 McCracken, K., & Phillips, D. R. (2017). Global health: An introduction to current and future trends (2nd ed.). London: Routledge. McGuire, W. J. ( 1989 ). Theoretical foundations of campaigns . In E. R. Rice & C. K. Atkin (Eds.), Public communications campaigns (2nd ed., pp. 43–65). Newbury Park, CA: Sage. McKenzie, J. F., Neiger, B. L., & Thackeray, R. (2009). Planning, implementing, and evaluating health promotion programs: A primer (5th ed.). San Francisco: Pearson Benjamin Cummings. Rose, G. (1981). Strategy of prevention: Lessons from cardiovascular disease. British Medical Journal, 282, 1847–​1851. Seeman, T. E., Merkins, S. S., Crimmins, E. M., & Karlamangla, A. S. (2010). Disability trends among older Americans: National Health and Nutritional Examination surveys, 1988–​ 1994 and 1999–​2004. American Journal of Public Health, 100(1), 100–​107. Sphere. (2011). Humanitarian charter and minimum standards in humanitarian response (3rd ed.). Geneva: Author. Retrieved from www.spherehandbook.org/​en/​the-​humanitarian​charter/​ Taylor, R., & Guest, C. (2013). Environmental health risks. In Oxford handbook of public health practice (3rd ed.). Oxford: Oxford University Press. WHO. (n.d.). Health systems strengthening glossary [online]. Retrieved from https://www. who.int/healthsystems/hss_glossary/en/index5.html World Health Organization (WHO). (1946). Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York 19–​22 June 1976; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. World Health Organization (WHO). (1986). The Ottawa Charter for Health Promotion. First International Conference on Health Promotion, Ottawa, 21 November 1986. Retrieved from www.who.int/​healthpromotion/​conferences/​previous/​ottawa/​en/​index1.html World Health Organization (WHO). (1999). Guidelines for iodine prophylaxis following nuclear accidents: Update 1999. Retrieved from www.who.int/​ionizing_​radiation/​pub_​meet/​ Iodine_​Prophylaxis_​guide.pdf World Health Organization (WHO). (2000). The world health report 2000: Health systems: Improving performance. Geneva:World Health Organization. Retrieved from www.who.int/​ whr/​2000/​en/​ World Health Organization (WHO). (2007). Everybody’s business: Strengthening health systems to improve health outcomes: WHO framework for action. Retrieved from www.who.int/​ healthsystems/​strategy/​everybodys_​business.pdf?ua=1 World Health Organization (WHO). (2009). Global health risks: Mortality and burden of disease attributable to selected major risks. Geneva: Author. World Health Organization (WHO). (2014, December). What is universal health coverage? Retrieved from www.who.int/​features/​qa/​universal_​health_​coverage/​en/​ World Health Organization (WHO). (2017). Depression and other common mental disorders: Global health estimates. Geneva: Author. Retrieved from http://​apps.who.int/​iris/​ bitstream/​handle/​10665/​254610/​WHO-​MSD-​MER-​2017.2-​eng.pdf?sequence=1 World Health Organization (WHO). (2018, June 1). Noncommunicable diseases (Fact Sheet). Retrieved from www.who.int/​en/​news-​room/​fact-​sheets/​detail/​noncommunicable​diseases World Health Organization (WHO), United Kingdom Health Protection Agency (HPA), & partners. (2011). Safe hospitals: Prepared for emergencies and disasters (Disaster Risk

Principles and theories: Public health  33

Management for Health Fact Sheet). Retrieved from www.who.int/​hac/​events/​drm_​ fact_​sheet_​safe_​hospitals.pdf World Health Organization Regional Office for the Eastern Mediterranean (WHO-​ EMRO). (2005). Vector-​borne diseases:Addressing a re-​emerging public health problem (Technical Report). Retrieved from http://​apps.who.int/​iris/​bitstream/​10665/​122334/​1/​EM_​ RC52_​3_​en.pdf?ua=1 World Health Organization Regional Office for the Western Mediterranean (WHO-​ WPRO). (2010). Safe hospitals in emergencies and disasters: Structural, non-​structural and functional indicators. Retrieved from www.wpro.who.int/​emergencies_​disasters/​documents/​ SafeHospitalsinEmergenciesandDisastersweboptimized.pdf

3 PRINCIPLES AND THEORIES Ageing population

In the twenty-​first century, with the fertility rate declining and longer life expectancy worldwide, population ageing is a global phenomenon. Between 2015 and 2050, the percentage of the world’s population aged 60 and above will double, from 12% to 22%, or from 900 million to 2 billion in absolute terms (WHO, 2018, February 8). The pace of population ageing is much faster than it was in the twentieth century, and by 2020 the number of people aged 60 years and older will outnumber children younger than 5 years (WHO, 2018, February 8). While there is a major increase in longevity and potential for a greater contribution from the older population when compared with previous generations, the added years of life do not necessarily translate into better health (WHO, 2015c). Globally, most health and social systems have already been experiencing challenges posed by this demographic shift. In 2050, 80% of older people will be living in low-​and middle-​ income countries. This chapter examines various issues which affect the health and well-​being of the older population.

Older age The ageing process is a biological reality. The United Nations (UN) defines an older person as someone over 60 years of age, with those over 80 years old termed as “oldest-​olds” (WHO, 2015c). Yet, the definition of older persons varies across regions, and is affected by factors like culture and life expectancy. Community norms might contribute to the socially constructed meanings of “old age”. Chronological time appears to be the common definition adopted in developed countries and the retirement age, 60–​65, is usually associated with “old age”. Meanwhile, chronological time has limited importance in the meaning of old age in many developing contexts. In contrast to the chronological milestones that mark life stages in the developed world, old age in many developing countries is seen to begin at the point

Principles and theories: Ageing population  35

when active contribution is no longer possible (Gorman, 1999). Clinically, physical and sensory decline may define old age. As age classification varies between countries and over time, if the socio-​economic definition is also applied, the transition in livelihood may become the basis for the definition of old age, which occurs between the ages of 45 and 55 years for women and between the ages of 55 and 75 years for men (Thane, 1978).

Geographic distribution of older people With rapid changes in socio-​economic context and infrastructure, the pace of population ageing around the world has shortened dramatically throughout the past century. While France had almost 150 years to change the population proportion of older people from 10% to 20%, countries such as Brazil, China and India have only about 20 years to make the same adaptation (WHO, 2018, February 8). While this shift in distribution of a country’s population towards older age –​known as population ageing –​started in high-​income countries (for example, 30% of the population in Japan are over 60 years old), the most significant change is expected to occur in low-​and middle-​income countries. By the middle of the century, many countries (e.g. Chile, China, Iran and Russia) will reach a proportion of older people similar to that of Japan (see Figure 3.1). The Caribbean region was found to be the fastest ageing population in developing world, and people aged over 60 will increase from 11.1% in 2005 to 24.6% in 2050 (Pan American Health Organization, 2012). As for the oldest-​olds, the number will increase from 125 million in 2015 to 434 million in 2050, with 120 million living in China alone (WHO, 2018, February 8). The Asia-​Pacific region is at the forefront of global population ageing, with north-​east Asia being the fastest growing sub-​region in the world (United Nations Population Fund & HelpAge International, 2012). While ageing is the global trend in urban demographic characteristics, the greying of the population is particularly apparent in rural communities compared with the urban context (see Figure 3.2). In addition to demographic transition in rural contexts, the lower standard of living and social and economic pressure will attract reverse migration of urban older people back to rural communities. Increase in life expectancy might not mean that the years gained in older age are supported by good health. In high-​income countries, research indicates that quality of life is uncertain in these extra years (Crimmins & Beltrán-​Sánchez, 2011), when disease and disability may affect the quality of life (Lin, Beck, Finch, Hummer, & Master, 2012; Stewart, Cutler, & Rosen, 2013). The extra years might simply be a matter of prolonging the end stage of life through medical treatment rather than improving well-​being overall. Trends and outcomes of well-​being in older people with disabilities appear to vary according to the individual’s socio-economic and environmental context (Zheng, Chen, Song, Liu, Yan, Du, et al., 2011; Olshansky, Antonucci, Berkman, Binstock, Boersch-​ Supan, Cacioppo, et al, 2012; WHO, 2015c). In low-​and middle-​income countries, with the exception of China, there

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Least developed countries (60+) Less developed regions (60+) More developed regions (60+) Least developed countries (80+) Less developed regions (80+) More developed regions (80+)

1950

1955

FIGURE 3.1   Global

1960

1965

1970

1975

ageing trend (1950–​2050)

Sources: United Nations (2017a, 2017b).

1980

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Principles and theories: Ageing population  37

1980

1985

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Year

FIGURE 3.2   Global

ageing trend: Rural vs. urban (1950–​2050)

Source: United Nations (2014).

is limited published data (WHO, 2015c). In China, a comparison of the same population in 1986 and 2006 show a significant decrease in old-​age-​related limitations in vision, hearing, intellect and speech, while increase was observed in both physical and mental limitations.

Older people’s health Longer life expectancies bring opportunities, not only for older people and their families, but also for societies as a whole. Additional years provide the chance to pursue new activities and careers to enable older people to contribute in many ways to their families and communities. Yet the extent of these opportunities and contributions depends heavily on the health and well-​being of the older person. If people can experience these extra years of life in good health and live in a supportive environment, their ability to do these things will be similar to the opportunity available to a younger person. Yet, if these added years are dominated by

38  Principles and theories: Ageing population

declines in physical and mental capacity, the implications for older people and for society are more negative. Although rates of severe disability seem to have declined in high-​income countries over the past 30 years, there has been no significant change in mild to moderate disability over the same period. However, evidence seems to suggest that older people today are experiencing their later years in better health than their parents (WHO, 2018, February 8).

Health determinants of older people Diversity of health outcomes in older age is not random. A significant contributor to the diversity is the cumulative impact of these health inequities across the life course (WHO, 2018, February 8). Public health policy must aim to reduce, rather than reinforce, these inequities. Health is determined by a number of factors (see Chapter 2 for the discussion of “Determinants of Health”) and these factors may influence the ageing process from early life. Although there are genetic variations in health outcomes, health in older age is an accumulated result of physical, behavioural and social environment exposure in the early life. The environment that a person is born into and lives in as a child, as well as personal characteristics, have long-​term effects on how that person ages. Environments also have an important influence on the development and maintenance of healthy behaviours. Maintaining healthy behaviours throughout life, particularly having a balanced diet, engaging in regular physical activities and refraining from tobacco and alcohol use, all contribute to reducing the risk of non-​communicable diseases as well as improving physical and mental capacity. Strength training in middle age maintains muscle mass and good nutrition can help preserve cognitive function, delay care dependency and reverse frailty. Although it is difficult to generalise the characteristics of the older population subgroup as they might be represented by a diverse group of individuals who might present with a variety of physical and mental capacities, supportive environments enable people to do what is important to them despite losses in physical capacity. Safe, age-​friendly and accessible public buildings, transport and environments are examples of supportive environments that enrich the lives and participation of older people.

Physical decline Physical capacity decline that accompanies ageing has important implications for well-​being and health outcomes. Changes in physiological, sensory and cognitive capacity with ageing lead to progressive loss of adaptability and self-​care capacity. Lifelong accumulation of molecular and cellular damage results in generalised deterioration and impairment of many body functions as one ages.With constraints of physiological functions, psychosocial evolution with socio-​economic status (e.g. retirement) would also change the environmental reality of an aged individual. Figure 3.3 shows the decline of physiological capacity which might be associated with ageing.

Principles and theories: Ageing population  39

FIGURE 3.3   Physical

capacity decline of ageing

Source: Adapted from WHO (2015a, p. 31).

Physiologically, health generally deteriorates with age. A 70-​year-​old may enjoy extremely good health and functioning while other 70-​year-​olds can be frail and require significant help from others. In general, better food and nutrition, improved public health and access to healthcare have increased longevity and delayed decline in older age. If aged individuals manage to maintain health, a longer life span means older people can pursue new interests and activities, enjoy time with their families, build new relationships and maintain the old ones, as well as contribute to society through prolonged working life or philanthropy engagements. Nevertheless, with the increase in life expectancy, managing and supporting older people with suboptimal health may become a public challenge for an ageing population.

Key physiological changes with ageing Numerous physiological changes are associated with ageing. Overall, tissue elasticity and muscle strength decrease. The muscle and skin no longer bend and stretch as easily as during youth. Muscle and bone masses decrease with age and research has indicated that bone elasticity decreases by 66% and its compressive strength deteriorates by 25% throughout lifetime (Raviraj, 2012). The capacity of healing damage and wound also decreases with age. With these intrinsic changes, it is thus more challenging for older people to withstand physiological stress and recover from injury and trauma. Cardiovascular system: Cardiac performance and output deteriorate with the decreases of myocytes with the ageing process. There is also a decrease in arterial compliances which might affect blood pressure (systolic and gradually also diastolic

40  Principles and theories: Ageing population

dysfunction) and some people may develop congestive heart failure. With ageing, although diminished cardiac function can support resting state of older people, with stress or trauma, the lack of cardiac reserve will become problematic and potentially pathological which might affect the well-​being of the older individual.The hardening of coronary arteries associated with ageing will predispose older people to high blood pressure. In trauma, with the need of myocardial oxygen consumption in stress and trauma, coronary artery disease (due to atherosclerosis) might be fatal to the older individual if the shock induces physiological stress that might be beyond the body’s ability to perfuse the heart to address the trauma physiological state (Crispell, 2003). Respiratory system: With ageing, there is a decrease in chest wall and lung compliance, and decreased number of alveoli and capillaries in the lungs (Chen & Kuo, 1989).When compared with the younger age, an older individual experiences a state of hypoxia with the physiological changes that decrease efficiency of gas exchange. If compounded with muscular functional decrease, the lung function might reduce up to 50% when compared with his/​her youth. In a traumatic state, the injury, fluid administration and accompanied chest infection might further burden the tenuous lung and create dependency on the use of a ventilator. The ciliary function might also impair with ageing and thus render older people more likely to be affected by nosocomial infection (e.g. pneumonia). Neurological system: Cerebral atrophy, the shrinking of the brain associated with ageing, predisposes older people to more severe brain injury in trauma as the brain is smaller and more mobile within the skull which can lead to haematoma development. Poor healing capacity in brain injury is an important risk factor associated with older people’s mortality. Dementia is a common condition for older people and its prevalence increases substantially with age. It leads to the limitation of self-​ care as the condition progresses and is likely to increase clinical complications for older patients (e.g. aspiration and fall injury) (see Case Box 3.2). Gastrointestinal system: Ageing is associated with slower peristalsis and diminishes in nutrition absorption due to gastric and enteric mucosa atrophies. In addition, with ageing, dental integrity and well-​being tends to be compromised (see Case Box 3.1). These physiological changes predispose the alteration of nutritional state in an older individual (see Case Boxes 3.4 and 3.10). The reduction of blood flow also leads to poor hepatic metabolic state of an older person and less efficient elimination of metabolic toxic in the body. With the various medications that an older person is likely to consume to maintain health, close monitoring of liver function is necessary to avoid adverse unintended impact of drug interaction. Musculoskeletal system: After peaking in adulthood, muscle and bone mass and strength of an individual decrease with age (Cruz-​Jentoft, Baeyens, Bauer, Boirie, Cederholm, Landi, et al., 2010; WHO, 2015c). Although the age of maximum strength, usually measured by “hand grip”, varies with early life exposure, nutrition and genetic factors, females tend to have weaker muscle strength than males. Moreover, “hand grip” is also used as a measure of muscle function and appears to be strong predictor of mortality (Rantanen, Volpato, Ferrucci, Heikkinen, Fried,

Principles and theories: Ageing population  41

& Guralnik, 2003; WHO, 2015c). Bones and joints are also affected by ageing. Bone density is found to reduce with ageing, with particular significance in post-​ menopausal women. Risks of bone fracture will significantly increase with osteoporosis. If an older individual with osteoporosis suffers from injury (e.g. hip fracture) that results in broken bones, there might be serious implications for disability and subsequently reduced of quality of life. Globally, the median age-​standardised rates of osteoporosis-related fractures vary geographically but with the highest rate observed in North America and Europe (Cauley, Polimeni, Bhat, Wang, Wald, & Setsompop, 2014). For joints, articular cartilage degenerates with age. Joint cartilage might soften and erode with repeated mechanical damage and joint fluid decrease, which render the joint more rigid and fragile (Novelli, Costa, & Souza, 2012). Osteoarthritis is a common joint-​related disorder that is associated with age. Gait speed –​time required to walk a specific distance –​is a common proxy indicator to reflect age-​related declines in musculoskeletal function and movement (Studenski, Perera, Patel, Rosano, Faulkner, Inzitari, et al., 2011). Research has indicated it as a significant predictor for future outcomes of health in an old individual. Immune system and skin: With ageing and immune-​senescence, the body’s ability to respond to new infection decreases (Lang, Govind, & Aspinall, 2013; Castelo-​ Branco & Soveral, 2014).Vaccination effectiveness tends to decrease as T cell activity in the body declines with age (Lang & Aspinall, 2012; Lang, Mendes, Socquet, Assir, Govind, & Aspinall, 2012; MacAulay, Akbar, & Henson, 2013). The skin’s ability to serve as a barrier also decreases with age-​related changes (White-​Chu & Reddy, 2011). Loss of collagen, elastin fibres in dermis, progressive vascular atrophies and accumulative environmental insults (e.g. sun exposure) could make an older individual more susceptible to skin tears, pressure ulcers, dermatitis and neoplastic diseases (Farage, Miller, Berardesca, & Maibach, 2009; Patel & Yosipovitch, 2010). Renal system: Efficiency of kidney functions and the ability of the body to keep fluid balance and metabolise drugs (for underlying health problems) are hampered with physiological decline. In addition to fluid retention, the impact of medication and their side effects (as well as potential interaction) need to be closely monitored.

Sensory decline Sensory deterioration such as impaired hearing and vision are natural physiological processes which accompany old age. These sensory decline conditions also affect self-​care and independence of older people. Globally, it is estimated that 180 million people aged older than 65 have some form of hearing loss (Gates & Mills, 2005; Olusanya, Neumann, & Saunders, 2014; WHO, 2015c). Presbycusis, age related hearing lost, is usually bilateral and at the higher frequency ranges. Although many factors (environmental exposure of noise, genetic predisposition, etc.) might be associated with presbycusis, cochlear ageing is the most likely reason for the problem. Not only would this condition affect normal speech and conversation, untreated presbycusis and hearing impairment might also render older people vulnerable to environmental risks (e.g. injury due to failing to hear warning), loss of

42  Principles and theories: Ageing population

CASE BOX 3.1  ORAL HEALTH IN OLDER PEOPLE Poor oral health has important implications for well-​ being regardless of age. The discomfort, pain, the implications for eating, communicating and socialising (due to bad breath) and the potential health effects of untreated dental infection can be grave. In most cases, teeth loss is associated with dental caries and injury. For older people, it might also be associated with poor oral hygiene, dental caries, suboptimal nutrition, chronic diseases, osteoporosis, periodontal diseases, long-​term excessive use of tobacco and alcohol, as well as oral cancer. Reports indicate health problems associated with the mouth and teeth might range from 29% in high-​income countries to 42% in low-​income countries (Petersen, Kandelman, Arpin, & Ogawa, 2010). Disadvantaged older people may suffer from more risks of having poor oral health. Undesirable social determinants which pre-​dispose disadvantaged groups to poorer dental health and inequitable access to dental care might vary with health systems and service development and cause adverse dental outcomes. Source: WHO (2015c).

autonomy, depression, cognitive decline and social isolation (i.e. decrease of social participation) (Ryan, Giles, Bartolucci, & Henwood, 1986; Parham, McKinnon, Eibling, & Gates, 2011; WHO, 2015c). Vision is another significant sensory decline that older people might experience with ageing. Presbyopia, cataract and age-​related macular degeneration are common eye conditions associated with ageing. Presbyopia is the blurring of near vision which results from the decrease in focusing ability of the eyes.The condition is commonly experienced by middle age globally. Cataracts are the increasing opacity of the crystalline lens and the intensity of opacification increases with ageing. Clinically, genetic predisposition and environmental exposures could affect the age of onset, rate of progression and level of visual damage. Fortunately, there are simple interventions available to revert the condition. Age related-​macular degeneration is the leading cause of blindness in upper-​middle to high-​income countries. As a result of ageing, macular degeneration causes retinal damage and might cause rapid severe vision impairment/​blindness. Visual impairment limits mobility (person and driving), affects social interaction and participation, creates barriers to information access and increases risk to injury.With limited visual simulation, there might also be a decline of cognitive function.

Cognitive decline Overall cognitive development and function varies among people and appears to be associated with socio-​economic status, years of education, lifestyles, underling chronic diseases and use of medication (Park & Gutchess, 2000; WHO, 2015c).

Principles and theories: Ageing population  43

With its various function modalities (learning memory, information processing speed, multi-​tasking capacities, concentration, etc.) deteriorating in different speeds, cognitive function presents in a heterogeneous manner in older people. Although many of these functions deteriorate with age, language capacities, once acquired, appear to remain quite constant in life. Mental training (Baltes, Freund, & Li, 2005), physical activities (Muscari, Giannoni, Pierpaoli, Berzigotti, Maietta, Foschi, et al., 2010) and experience-​related competence are found to help partially mitigate the cognitive decline, such as dementia (see Case Box 3.2).

Sexuality Sexuality in older people might be affected by physiological, psychosocial and socio-​environmental changes of ageing in both genders (Ni Lochlainn & Kenny, 2013). Vascular diseases (resulting in erectile dysfunction), medication and treatment (e.g. mastectomy of a woman with breast cancer) might all impact on sexual function. As reported in literature, although most studies appear to focus on problems and vulnerability of sexual function in older age, physical intimacy and sexuality remains an important issue in older age in both genders (Nicolosi, Laumann, Glasser, Moreira, Paik, & Gingell, 2004; Lusti-​Narasimha & Beard, 2013). Studies point out that 73% of those aged 57–​64, 53% of those aged 65–​74, and 26% of those aged 75–​84 years old remain sexually active (Lindau, Schumm, Laumann, Levinson, O’Muircheartaigh, & Waite, 2007) (see also Case Box 3.3).

Independence Frailty is the progressive age-​related decline in physiological state, which leads to lower reserve in intrinsic capacity and vulnerability to care dependence and comorbidity in older age. Studies indicate frailty is more commonly found in women, people with low socio-​economic status and in low/​middle income countries. Urinary incontinence is one of the most common impairments in older age and women are more likely to be affected. It is a strong predictor of the need of care. Not only does this affect quality of care for the older person, it also affects how an older person might engage socially and becomes a burden of the caregiver. Course of frailty varies widely across individuals and is often found to be reversible. For instance, increasing physical activities appears to be effective in reversing frailty.

Economic aspect: Older age poverty Beyond biological changes, ageing is also associated with other life transitions such as death of friends and partners, retirement and relocation to age-​appropriate context (e.g. old-​age homes). In developing a public-​health response to ageing, not only are approaches needed to ameliorate the losses associated with older age, but also interventions that may reinforce recovery, adaptation and psychosocial growth.

44  Principles and theories: Ageing population

CASE BOX 3.2  PREVENTING DEMENTIA IN AN AGEING SOCIETY Vincent C. T. Mok and Benny C. Y. Zee The burden of dementia is expected to increase with an ageing society. Dementia prevalence increases from around 10% among >65 years old to around 20% for those >80 years old. With increasing life expectancy, and assuming no effective preventive measures could be implemented in the coming decades, it is estimated that dementia sufferers will triple from 45.6 million in 2015 to 131.5 million in 2050. Much of this increase is expected to occur in low-​income countries. Designing strategies that can prevent dementia in the coming decades is of paramount importance. Recent evidence derived from clinical and preclinical studies has consistently shown that vascular factors (e.g. midlife hypertension, diabetes) and cerebrovascular diseases, namely acute stroke and cerebral small vessel disease (SVD), contribute significantly not only to vascular or poststroke dementia, but also to the development of Alzheimer’s disease (AD). Vascular dementia, AD and mixed AD and vascular dementia account for almost 90% of dementia cases. The CU-​STRIDE (Chinese University of Hong Kong –​STroke Registry Investigating cognitive DEcline) study, which is to date the largest single centre cohort study (n=1013) investigating cognitive decline poststroke, has shown that dementia incidence is 10 times higher than that of stroke-​free subjects, and that chronic cerebral SVD (manifested as lacunes and white matter hyperintensity on neuroimaging) predicts dementia development in both the short and long term poststroke (Mok et al., 2017). The CU-​STRIDE further showed that even a transient ischemic attack is able to trigger dementia onset in subjects harbouring amyloid plaques (the pathological hallmark of AD), who otherwise may remain asymptomatic if the cerebrovascular event has not happened. Overall, converging evidence demonstrates that control of vascular factors and prevention of stroke and/​or cerebral SVD will contribute to the prevention of dementia. Indeed, a few recent epidemiological studies showed that dementia incidence (in particular vascular dementia) has declined in Western countries and this was partially attributed to better control/​treatment of vascular diseases and better education (i.e. better cognitive reserve) in the recent cohorts compared with older cohorts. To control vascular diseases or prevent stroke or cerebral SVD among groups with less exposure to health information (low-​income and low-​education-​level) is extremely challenging, because vascular diseases (e.g. hypertension) and early pathological changes of brain arteries are asymptomatic. Hence, motivation to change lifestyle, to have regular body checks or to remain compliant to prescribed medications is low. The Chinese University of Hong Kong (CUHK)

Principles and theories: Ageing population  45

JC School of Public Health and Primary Care, in partnership with the Division of Neurology, has developed an automatic, artificial intelligence powered retinal imaging analysis method that can screen out subjects who may have subclinical pathological changes in brain arteries (Zee et al., 2016). This method is quick (few minutes), accessible (portable retinal camera), non-​invasive and can provide objective evidence to subjects that their brain arteries are already damaged (i.e. at-​risk for cerebral SVD, stroke or dementia). Its effectiveness in detecting undiagnosed vascular diseases (e.g. hypertension) and subclinical cerebrovascular diseases and its impact of how it may change the lifestyle of the subjects are being evaluated. It is hoped that such endeavours will accelerate the progression towards the goal of ageing without dementia. Sources: Zee, Lee, Li, Mok, Kong, Chiang, et al. (2016); Mok, Lam, Wong, Ko, Markus, and Wong (2017).

CASE BOX 3.3  HEALTH DISPARITIES AMONG LGBT OLDER PEOPLE Carol Ka-​po Wong Health disparities exist in all old-​age groups, and LGBT older persons are no exception. There is accumulating evidence of health disparities, including poor physical health and psychological distress in the ageing LGBT population. According to a survey conducted by LGBT Foundation in 2015, half of the older LGB respondents responded that their sexuality has a negative impact on getting older (Walding, 2015). Older LGB people have endured discrimination and isolation from family and community, while at the same time, they struggle to renegotiate their identities within the wider LGBT community. LGB older people reported a higher risk of disability, poor mental health, smoking and excessive drinking than did heterosexuals. Lesbians and bisexual women had a higher risk of cardiovascular disease and obesity, and gay and bisexual men had a higher risk of poor physical health and living alone than did heterosexuals. Lesbians reported a higher rate of excessive drinking than did bisexual women; bisexual men reported a higher rate of diabetes and a lower rate of being tested for HIV than did gay men (Fredriksen-​Goldsen et al., 2013). Sources: Fredriksen-​Goldsen, Kim, Barkan, Muraco, & Hoy-​Ellis (2013); Walding (2015); Eichler (2017); Grossberg & Grossberg (2017).

46  Principles and theories: Ageing population

CASE BOX 3.4  SPECIAL NUTRITIONAL CONCERNS OF OLDER PEOPLE Tony Ka-​chun Yung Changes in body and organ function occur throughout the life cycle. In the absence of disease, the general physical function is retained by older people. However, there is an overall decline of reserve capacity during ageing. The number of active cells, as well as the size and function of most organs, diminishes. For example, by the age of 70, the renal function of a normal person will reduce to 60% of his/​her 30-​year-old level, while maximum O2 uptake, as an indicator of the respiratory system’s function, is likely to reduce to 40%. Some of these physiological changes may require nutritional attention in order to counter-​balance the adverse effect both to the physical health and to the general well-​being of older people. Table 3.1 lists the major ones. TABLE 3.1  Age-​related physiological changes and special nutritional concerns

Age-​related physiological changes

Special nutritional concerns

Body composition Older people are likely to experience a As the amount of body fat is a strong linear decline pattern in muscle mass at risk factor of many NCDs, dietary approximately 2–​3% per decade. At the same fat intake of older people should time, percentage of body fat increases. keep at a low level constantly. Basal metabolic rate (BMR) There is a gradual but accelerating Encouragement of performing physical decrease in BMR after the age of 30. exercise is needed to avoid massive A decreased dietary intake usually starts decrease in muscle mass and thus during early ageing. BMR. The amount of overall food intake should be controlled to prevent significant weight change. Taste and smell Hypogeusia (diminished sense of taste) and The amount of sodium is usually hyposmia (diminished sense of smell) high in strong-tasting food. Given are common with advancing age. This its empirical association with may lead to inadequate food intake and hypertension, older people are to compromised nutrition status. Also, encouraged to use alternative older people tend to choose strongerseasoning to minimise the associated tasting food to stimulate their palate. negative effect. Oral cavity Loss of teeth and periodontal disease are Texture of food is highly essential to highly common. Xerostomia (decreased ensure older people’s normal dietary salivary flow) is also prevalent among intake. In some extreme cases, puree older people causing food sticking to diet is prescribed to assist them in the tongue and difficulty swallowing. swallowing. Artificial saliva is also being used to facilitate swallowing.

Principles and theories: Ageing population  47 TABLE 3.1  (Cont.)

Age-​related physiological changes Colon The decreased mobility of the colon causes constipation, an extremely common gastrointestinal problem among older people.

Skeleton Bone density decreases with age after reaching 30. Osteoporosis widely exists among ageing population. This is particularly serious among females after menopause. Kidney The net loss of nephrons causes the decreased ability to concentrate or dilute urine. It takes a longer time to excrete a large amount of, for example, dietary sodium after a meal high in salt.

Special nutritional concerns The poor fitting dentures among older people discourages the intake of chewy vegetables and fruits, which may further reduce the colon’s mobility. They are thus encouraged to have sufficient amount of fluid in order to keep the bowel moving. Sufficient dairy products are particularly important to ageing population. However, unless for the reason of special medial needs, low fat dairy should be the only choice to reduce overall fat intake. The variation of dietary minerals (e.g. sodium) intake should be kept minimal to avoid sudden change in plasma concentration of these minerals.

Source: Berry (1992).

With global success in family planning programmes, families are smaller in size, and the traditional family structure (of large young population supporting a smaller older population) has diminished in supporting older people and providing old age security. If old age is dominated by poor health, an ageing population could bring significant consequences to the individuals, families and societies, especially on the capacity and sustainability of the systems and institutions that aim to protect and preserve people’s well-​being, e.g. pension systems, social securities and healthcare systems (WHO, 2015c). In addition, global age dependency rates increase with decreased fertility and increase of life expectancy. Older people with no dependants, family or social networks are more likely to experience social exclusion and suffer from a breakdown of their social support networks because they may be separated from their families, peers, or caregivers. Enabling “healthy ageing” is therefore the key approach to tackling the issue of ageing population. While a person’s health is affected by genetic make-​up, people’s opportunity to experience healthy ageing also depends on a range of environmental (physical and social) and behavioural factors, e.g. family support, neighbourhood and community network, socio-​economic status, public policies (WHO, 2015c).

48  Principles and theories: Ageing population

Common health problems In addition to health issues associated with physiological changes mentioned earlier in this chapter, older age is characterised by the emergence of several complex health states that tend to occur only later in life and that do not fall into discrete disease categories (WHO, 2018, February 8). Commonly called geriatric syndromes, they are often the consequence of multiple underlying factors and include frailty, urinary incontinence, falls, delirium and pressure ulcers. Geriatric syndromes appear to be better predictors of death than the presence or number of specific diseases. Yet, except for countries with geriatric medicine as a specialty, geriatric issues are often overlooked in traditionally structured health services and in epidemiological research. Minor health complications may cause non-​life-​threatening conditions for the young, but these may easily become major catastrophic health problems for older people. For example, inadequate thermal protection while sleeping may lead to health risk among older people who tend to be more vulnerable to heat and cold and have suboptimal immune systems. With ageing, people’s financial capacity and mobility decrease, resulting in difficulties in accessing health services, queuing up for food, or engaging in self-​care. In addition, old age can lead to decreases in sight, hearing and muscle strength. The loss of hearing makes it difficult for them to hear emergency warning messages. Suboptimal dental health (e.g. lack of teeth) might lead to difficulties in digesting/​consuming food and subsequently poor nutritional status (see Table 3.1). Older people might also suffer more joint pain, especially in the hips, knees and back. In developed countries, it is estimated that 40% of those aged 65 or above suffer from chronic diseases and disabilities that limit their daily activities. Chronic diseases such as hypertension, diabetes mellitus and respiratory diseases are common among older people (see also Case Box 3.5). The impact of chronic diseases may worsen if older people lose their routine medications and are unable to seek health and medical help. Specifically, older people often suffer from multiple morbidities as they age. The cause of death might be associated with a number of diseases as they conjointly deteriorate the well-​being and ultimately cost the survival of older people. In addition to non-​communicable diseases such as cardiovascular diseases, cerebrovascular conditions (stroke) and cancers that are reported to be the main causes of mortality, it should be pointed out that fall incidents have been found to be the most common cause of injuries and avoidable cost of hospitalisation for the geriatric population. Falls might result in minor injury as well as major fatal consequences (head trauma) (see also Case Box 3.7). In addition, cognitive impairments (such as dementia) and deterioration may have psychosocial implications for ageing. The prevalence of dementia has been reported to double for every five years lived beyond 65 years old. Approaches to provide long-​term care and offer protection and clinical support for palliative and end-​of-​life care are all important considerations for healthcare systems, regardless of developed or developing context, globally.

CASE BOX 3.5  EVIDENCE OF THE IMPACT OF AIR QUALITY ON THE HEALTH OF OLDER PEOPLE When compared with their younger counterparts, older people are more sensitive and more likely to be affected by their living environment and context. More scientific evidence has established the link between air quality and adverse health outcomes of the older population. The following three studies were published with a large population sample in China and examined how air pollutants (e.g. particulate matter [PM]) might be associated with poor health outcomes. Li et al. (2019) conducted a time-​stratified case-​crossover study to examine the association between air pollution and ST-​elevation myocardial infarction (STEMI). Findings indicated slightly larger associations of STEMI hospitalisation with PM among patients who were older than 65, females, non-​smokers, and those with comorbidities (hypertension, diabetes or hyperlipidaemia). The associations were generally robust to adjustment of criteria gaseous pollutants except for carbon monoxide. A study conducted by Song et al. (2019) examined the short-​term effects of air pollutants on daily respiratory mortality. Using generalised additive Poisson models adjusted for meteorology and population dynamics, the analysis included 16,931 non-​accidental respiratory deaths (except lung cancer and tuberculosis) among older adults (>65 years old) in Jinan, China, from 2011 to 2017. Outdoor air pollution was found to be significantly related to mortality of all respiratory diseases especially from chronic airway disease. Sex, age, temperature, humidity, pressure and wind speed might modify the short-​ term effects of outdoor air pollution on mortality in Jinan. Compared with the other pollutants, O3 exhibited a stronger effect on respiratory deaths among older people. The effects of air pollutants had lag effects and harvesting effects, and the effects estimates usually reached a peak at lag 1 or 2 day. The effects of air pollutants were usually greater among females and varied by respiratory disease subgroups. Specifically, patients of chronic airway diseases, from which older people were more likely to suffer, were more susceptible to air pollution. The study of Yang et al. (2018) examined the association between exposure to fine particles (PM2.5) and the prevalence of diabetes among Chinese older people. A total of 11,504 adults aged ≥ 50 years old in China were surveyed and the annual concentrations of ambient PM2.5 were estimated using a satellite-​ based model of aerosol optical depth information. With a generalised mixed effects model to examine the association between PM2.5 and the prevalence of diabetes, the analysis indicated a statistically significant association between exposure to PM2.5 and diabetes. The adjusted odds ratio was 1.27 (95% confidence interval [CI], 1.12, 1.43) for each 10 μg/​m3 increment in ambient PM2.5. The research team estimated that 22.02% (95% CI: 8.59%, 43.29%) of the diabetes cases could be ascribed to ambient PM2.5. The findings suggested that PM2.5 exposures appeared to be associated with an increase in diabetes risks among the Chinese older people.

50  Principles and theories: Ageing population

Multi-​morbidities combined with socio-​economic constraints further expose older people to health risks and create needs and resource priorities that might be different from those of younger age groups (see Case Box 3.6). Besides, despite the vulnerabilities and physiological (e.g. pregnancy) and social challenges experienced throughout the life course, females tend to have a longer life expectancy regardless of their geographic location.

CASE BOX 3.6  VULNERABILITY AND COMORBIDITIES OF OLDER PEOPLE Martin Chi-sang Wong The prevalence among Hong Kong residents of at least one chronic condition increases markedly once the individuals reach 45 years old. From the Census and Statistical Department of the Hong Kong government, the risk of individuals aged 45–​64 years having multiple medical diseases is six times higher than for those aged 14–​25 years (Census and Statistics Department, 2013), and 18 times higher among those who are aged 65 years or older (Our Hong Kong Foundation, 2016). Older people are at higher risk of “geriatric giants”, including immobility, instability, incontinence and impaired intellect or memory. Inevitably, older patients with multiple comorbidities require higher levels of healthcare service, incur much more substantial healthcare costs, demand more complex healthcare interventions, and are closely linked to poorer health outcomes –​including poorer disease control, significantly lower quality of life, and increased mortality rates (Wong et al., 2014). Added to this are more frequent incidence of polypharmacy, experience of more medication side effects or drug–​drug interactions, poorer compliance to multiple medications, and increased frailty that impairs their self-​care ability. Frail older people are unable to perform some of the activities that are essential to living independently, due to debilitating conditions that induce physical challenges to their activities of daily living. The comorbidities not only impair their bodily functions, but also adversely influence their psychosocial health, especially for individuals with relatively poor social support. Therefore, it is not surprising for older people to encounter frailty as part of an ageing process –​including exhaustion, muscle weakness, unintentional weight loss, slowed walking speed and physical inactivity. Hence, older people represent a group of populations who are disproportionately vulnerable to natural hazards and disasters. It has been suggested that healthcare policies and services (Our Hong Kong Foundation, 2016) should be targeted to vulnerable older people to reduce prevalence of lifestyle-​related chronic diseases; implement earlier detection of chronic diseases to allow more optimal chronic disease management; and enhance the physical and social infrastructures for better functioning of the older population with poor health. Sources: Census and Statistics Department (2013); Wong, Wang, Cheung, Tong, Sek, Cheung, et al. (2014); Our Hong Kong Foundation (2016).

Principles and theories: Ageing population  51

Disabilities Globally, more than 80% of the disabled population resides in developing contexts, and the prevalence of disability will dramatically increase in countries that might be experiencing the pressure of increased numbers of aged people. As estimated by reports, sub-​Saharan Africa, India and China will experience the highest incidence increases among older people by 2050 (Elwan, 1999; Harwood, Sayer, & Hirschfeld, 2004). Disabilities are often associated with old age and physical limitations may affect access to health services and emergency aid. According to the estimation of the Pan American Health Organization (2012), 20–​30% of the population over age 60 were estimated to suffer one or more disabilities (physical, mental or sensory related), while the prevalence of disability increases to 50% for those over 80. In another estimation, based on data from 59 countries, the World Health Organization found that for those aged 65–​74 the prevalence of disability ranged from near 30% in high-​income countries to over 40% in low-​income countries, while for those aged over 75 the range was from over 40% in the former and 60% in the latter (WHO, n.d.b; WHO & World Bank, 2011, p. 35).

Elder abuse Elder abuse is defined as a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, that causes harm or distress to an older person. It is an important public health issue that tends to be under-​reported and may lead to serious physical injuries and long-​term psychological consequences. Violence associated with abuse may include physical, sexual, psychological and emotional abuse; financial and material abuse; abandonment and neglect; and serious loss of dignity and respect. It is a violation of human rights and the consequences of elder abuse can be especially serious. Minor injuries in older people may cause serious and permanent damage, or even death. A 13-​year follow-​up study found that victims of elder abuse are twice as likely to die prematurely than people who are not victims of elder abuse (Lachs, Williams, O’Brien, Pillemer, & Charlson, 1998). Elder abuse is predicted to increase, particularly in countries experiencing rapidly ageing populations but with limited resources to address related needs. It is predicted that by the year 2050, the global population of people aged 60 years and older will more than double, from 900 million in 2015 to about 2 billion, with the vast majority of older people living in low-​and middle-​income countries. A study estimated that 15.7% of people aged 60 years and older were subject to some form of abuse over the previous year (Yon, Mikton, Gassoumis, & Wilber, 2017). If the proportion of elder abuse victims remains constant, the number of victims will increase rapidly due to population ageing, growing to 320 million victims by 2050 (WHO, 2018, February 8). Around 1 in 6 people who are 60 years and older experience some form of abuse in community settings annually. Rates of elder abuse are high in institutions such

52  Principles and theories: Ageing population

CASE BOX 3.7  TRAUMA SCREENING FOR OLDER INJURED PATIENTS Kevin K. C. Hung and Colin A. Graham The management of older trauma patients is challenging even for experienced clinicians. Older trauma patients have a significantly higher mortality rate despite receiving care in tertiary trauma centres (Demetriades et al., 2002; Hung et al., 2019). Various factors contribute to the higher mortality rate, including poor physiological reserve, the presence of comorbidities, increased bleeding risk from anticoagulation, and increased fracture risk due to osteoporosis. Furthermore, low energy trauma, particularly low falls (fall from height 60 years old). Their income might constitute additional household economic sources and older people might continue to serve as the focal point of family network and resources distribution. In contexts such as urban enclaves or poor neighbourhoods in developed settings or developing locations where no official social and security support systems might be available, remaining in the workforce is a survival necessity for older people. Older people’s income contribution might remain the main household income sources. In rural, resource-​ deficient communities, working older people may be the only household income generators (in agriculture-based communities), labour force and the main care providers for the young, dependants and sick family members. Poor older people might be self-​employed or work in the informal economy of long working hours, irregular pay, and lack of occupation protection. Traditional healing and crafts might also facilitate income generation activities. Overall, in modern societies, older people often engage as an informal labour force to support the family in the role of caregivers and as main housekeeping managers when the adult working population are forced to leave home to chase after job opportunities. They serve as guardians and educators for junior household and community members. If older people can be organised systematically, their capacity to enhance resources and knowledge to the community can be maximised. Figure 5.1 presents the comparison of the global active working population of aged 65 or above. Case Boxes 5.1 and 5.2 describe how older people might be organised and maximise their contribution in developing contexts.

Leadership, knowledge transfer and partnerships Older people hold leadership, respect and decision-​making positions within their communities and households. In a traditional context such as tribal or religious communities, seniority confers respect and power and is often associated with influence and the power to determine resource allocation, choices and quality of well-​being. Older people’s social network, experience and credibility can facilitate conflict resolution and community development. Skills in midwifery, handicrafts and farming might maximise informal resources and knowledge. Thus, if mobilised effectively, older people are the core community partners in community development. Their resources (time, skills and knowledge) and social network may facilitate and organise community improvement projects. Targeted partnership and mentorship programmes might enable and empower older people to play important roles in mentoring and coaching of the younger generation.

newgenrtpdf

Labour force participation rate, 65 year olds or older (2016 or latest available) 45 40

% in same age group

35 30 25 20 15 10

0

ESP BEL SVK HRV FRA LUX GRC SVN MLT MKD ITA HUN BGR POL AUT CZE ZAF DEU NLD CYP LTU LVA ROU DNK HK IRL GBR FIN PRT TUR RUS CHE AUS CRI CAN SWE BRA NOR USA NAM ISR JPN NZL CHL EST MEX COL KOR IDN ISL

5

FIGURE 5.1   Global

and geographic comparison of active working older population (>65 years old)

Sources: Hong Kong Census and Statistics Department (2018); Organization for Economic Co-​operation and Development (2017).

112  Contributions of older people

CASE BOX 5.1  POVERTY ALLEVIATION IN RURAL CHINA Older people’s associations (OPAs) in China have proven to be an effective platform in supporting older people to engage in economic activities through revolving loan funds and training such as agriculture and animal husbandry. Examples of the livelihood activities in China from 12 OPAs in 2009 included distribution of loans to a total of 3,682 older men and women. Such efforts were reported to lead to an average increase in participant household income of 23% in a little over two years. The loan repayment rate was 99% and around 65% of participants reported having used the profits to purchase a wider variety of food to improve nutrition status. Source: HelpAge International (2009).

CASE BOX 5.2  INCOME GENERATING ACTIVITIES IN BATTAMBANG, CAMBODIA Small start-​ up grants and vocational training supported by agencies such as HelpAge International have helped some of the poorest older people in Cambodia participate in income generating activities. OPA members have been trained in new skills suited to their physical capacity, such as raising livestock or establishing food stalls and small shops. Additional business skills training has helped participants quadruple their profits since the project start up. Source: HelpAge International (2009).

Community development With lifelong insights and working experiences, older people might play active roles in community development. Older people’s associations (OPAs) are innovative community-​based organisations that are formed by older people. The objectives and aims of these agencies are frequently targeted towards improving the living conditions of fellow older people and the overall development of their communities (HelpAge International 2009, 2014). OPAs mobilise the resources and skills of older people, provide effective social support, facilitate activities and deliver services. Successful OPAs often support sustainability and knowledge transfer. Related activities are often based on leadership and contribution of knowledge, experience and organisation skills of the respected older members of the community.Younger community members and wider stakeholders also have a vested interest in the success of the OPAs as not only do these OPAs benefit the community as a whole, but young people also see themselves as future members of the associations. Knowledge Box 5.1 discusses the activities and nature of older people’s associations.

Contributions of older people  113

KNOWLEDGE BOX 5.1  OLDER PEOPLE IN COMMUNITY DEVELOPMENT: OLDER PEOPLE’S ASSOCIATIONS Older people’s associations (OPAs) are innovative community-​ based organisations of older people, aiming at improving the living conditions for older people and developing their communities (HelpAge International, 2009). There are a number of activities that these OPAs might organise to support their fellow older citizens (HelpAge International, 2009). Building livelihood security: Older people tend to be affected by poverty more than other age groups. Despite their own poverty and vulnerability, older people might play important roles in alleviating family and community poverty. OPAs can help older people access micro-​credit, livelihood grant schemes, and job training, which lead to income generating activities to support themselves and their families. ii) Improving healthcare: Healthy older persons are important resources for their families, their communities and the economy. Maintenance of good nutrition, adequate exercise and proper mental stimulation may delay the onset and lessen the impact of chronic diseases. Yet, lack of access to basic medical care and maintenance of well-​being are fundamental health risks faced by many older people. OPAs might organise medical check-​ ups, promote healthy living strategies and provide health education for older people. These agencies would also facilitate better care arrangement for older people through facilitating home visits arrangement, shortening waiting time in clinics providing training on home and community care to take care of lonely older people and those with mobility issues. Some services might target isolation and loneliness reduction. iii) Promoting participation in community life: OPAs might create social support networks that facilitate community development activities. They might utilise skills and experiences of older people to organise specific activities in their communities. OPAs empower older women, who are the majority of the OPA members, to form mutual support and friendship networks, which would improve emotional well-​being and facilitate social support groups to support families and communities facing problems as well as organise celebrations and religious ceremonies. Support groups are usually arranged locally to avoid the senior members needing to travel long distances when members are sick, experiencing financial hardship or in emergencies. i v) Knowledge and skill transfer: Older people are encouraged to mentor and transfer skills to assist younger people in areas such as agriculture, health, and water and sanitation. Such efforts can create positive profile of older people within communities and strengthen intergenerational bonds. i)

114  Contributions of older people

Participation of older women: Some OPAs have specific gender mandate and encourage participation of older women. For example, in the region of Rajasthan, India, where a significant history of child marriage, purdah, feudalism, and female infanticide results in oppressive social conditions for women, the village older people’s associations (VOPAs) have formed female self-​help groups (SHGs). So far, the successes of these SHGs include the management of saving schemes, encouraging women to put themselves forward to leadership roles, increasing school enrolment of girls, and sterilisation for birth control. vi) Promoting participatory governance: OPAs may help raise the awareness of the rights and entitlements of older people and improve their access to existing services. Linking up with government service providers enables OPA members to recognise that government departments are resources for them to utilise. This builds confidence among older people and articulation in expressing their specific needs. v ii) Older citizens monitoring (OCM): This involves watching the government delivery of policy commitments and sensitising implementers and policy-​ makers to influence and improve the implementation of policy for the well-​being of vulnerable older people. Successes of the OPAs include increases in the number of older people accessing old age allowances and increased access to free (or reduced cost) health services for older people. v iii) Supporting disaster response: Natural and man-​made disasters, such as heat-​waves, floods, droughts and earthquakes, are causing increasing human suffering, great loss of life and financial loss each year. OPAs supported by HelpAge International and partners adopt disaster risk reduction (DRR) activities such as disaster preparation, early warning systems, and relief and rehabilitation. Older people are seen as respected sources of knowledge in their communities, providing information on traditional coping mechanisms and/​or their experiences of previous disasters, which is invaluable as part of preparedness planning. v)

Caregiver Although older people are unlikely to be physically as robust as their younger counterparts, they are likely to have the experience and patience to provide child care and care for other dependants (e.g. the sick or the disabled) at home.Their roles as “caregivers” and “household resources managers”, housekeepers and guardians are often downplayed or neglected. Older people often serve as the main health and medical caregivers when spouses and partners require long-​term care, or disabled family members are grounded at home. In emergencies and disasters, older people are also likely to be core supporters in disaster-​affected communities rather than

Contributions of older people  115 TABLE 5.1  Older people as the main caregivers at the household

Country (year)

Caregiver aged above 65 (%)

US (2015)* Canada (2012) UK (2000) UK (2007)

34 12 16 >15

* Average age of caregivers: 49.2; percentage of care recipients aged above 75: 47%; average age of care recipients: 69.4; percentage of spousal caregivers: 62.3% Sources: Beesley (2006); National Alliance for Caregiving & AARP Public Policy Institute (2015); Sinha (2013).

mere service users or assistance receivers. Older women, especially, might serve as the main caregivers for their grandchildren if the parenting generation are working as migrant workers or have died in conflict or from HIV/​AIDS. With their life experiences, older people are also more likely to have better emergency and disaster coping knowledge and strategies. With their institutional memories, they are valuable in times of extreme events to preserve cultural heritage and transmit to the younger generation. Overall, supporting older people can thus translate to the support of the disaster-​affected community. Their experiences in construction, cooking and farming are useful transient skills to bridge the emergency needs during disasters and crisis. In disaster-​ affected rural communities where the extremes of age tend to be the main residents, as the younger working population might frequently have left the community as migrant workers, older people might be the core members of the reconstructing and rebuilding workforce. Although there is a general lack of data globally, Table 5.1 shows the caregiver role in various communities. Case Boxes 5.3, 5.4 and 5.5 discuss how services might be organised for older people and how older people might contribute to intergeneration care in communities.

The disaster context Older people are as likely to be emergency service and assistance providers as being support receivers (HelpAge International, 2000). Although they are frequently viewed as a vulnerable subgroup, their experience and knowledge of how to survive in crisis and emergencies should not be overlooked. Older people can play a critical role, from disaster preparedness to response and recovery. They can be an important focal point for education, communication and leadership in their households.

Preparedness and mitigation Older people possess the knowledge, wisdom and experience of previous disasters, and their “sense of history” is valuable to the community (Chan, Hung, & Chan,

116  Contributions of older people

CASE BOX 5.3  HOW OLDER PEOPLE MIGHT BE ORGANISED TO PROVIDE HEALTHCARE FOR THEIR FELLOW OLDER COMMUNITY MEMBERS IN CAMBODIA, PHILIPPINES, CHINA AND VIETNAM Fully trained volunteers from 15 OPAs in Cambodia provide homecare services for 111 frail and poor older people, and assistance to access primary healthcare services. Similarly, in the Philippines 80 OPAs have coordinated volunteer-​based homecare services for more than 600 older people (HelpAge International,  2009). Following OPA health and nutrition activities and training in rural China, 40% of participants showed better nutritional habits, 80% reported that they had adopted healthy habits (changed diet, exercised more, disposed of waste properly, or drinking), and 10% reported they had quit smoking (HelpAge International, 2009). In Vietnam, older people shouldered most of the growing health burden of HIV infection. Empathy clubs were established for older people affected by HIV and AIDS to develop practical initiatives to address specific health and social needs. These included promoting homecare, raising community awareness and training on HIV prevention, promoting health check-​ups and self-​care, visiting sick members and providing livelihood activities such as microcredit loans and training. Sixty-​seven clubs were currently in operation in four provinces, and their work had resulted in a reduction of the stigma associated with HIV and AIDS and of discrimination within communities, as well as increasing access to treatment and support for affected family members. Source: HelpAge International (2009).

2017). Knowledge of local hazards and potential conflicts in their community can facilitate mitigation strategy. Their lifetime experience and knowledge might formulate the core coping strategy and support sustainable disaster risk reduction and mitigation strategy in the local context. For disaster resilience building, older people can share and provide useful information and knowledge related to the potential magnitude, hazard mapping and resilience capacity building for important disaster events that the young population might have never experienced due to their age and experience. Older people often have good knowledge and experiences of local climate variabilities, patterns and predictability (HelpAge International, 2014). Literature has indicated that local wisdom, as shared by older people, might include important life-​saving skills and knowledge to guide practical actions in extreme events. For example, a report on the Japanese earthquake and tsunami of 2011 highlighted that the experience and community insights gained from previous tsunami incidents appeared to be the most useful guide to disaster response actions (HelpAge International, 2013).

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CASE BOX 5.4  CHILD-​FRIENDLY SPACE: AN INTERGENERATIONAL APPROACH The contribution of older people in crisis should not be underestimated. For example, older people’s committees in Bangladesh actively disseminated early warning messages to older people and their families. The warning system also served as communication channel to notify people when and where to receive relief goods after the 2007 Cyclone Sidr. In addition, child-​friendly spaces (CFSs) have been widely organised in emergencies to help and protect children since the CFS initiative was launched by UNICEF in Albania in 1999. Safe spaces, child-​centred spaces and emergency spaces for children were used by different agencies to address the psychosocial needs of vulnerable children and provide them with long-​term support through activities like storytelling, playing and learning. Together with HelpAge in Pakistan, UNICEF and its partners agreed to adopt an intergenerational approach in CFSs and encouraged older people to participate and support the process. Older people were invited to contribute to a CFS for half an hour once a week. This turned out to be a great success. Some older people even turned up at the CFS every day to tell stories, organise activities, and help site maintenance. Sources: Ager and Metzler (2012); Chan (2017); Day, Pirie, and Roys (2007); UNICEF (2011).

CASE BOX 5.5  CYCLONE ELINE, MOZAMBIQUE IN 2000 Flooding after Cyclone Eline in Mozambique in 2000 led to 700 deaths and 500,000 displaced. HelpAge International mobilised retired people to carry out home visits to identify issues experienced by older people and to monitor the delivery of food, blankets and clothing after the disaster. The programme also raised community awareness of older people’s participation in the community rebuilding process. The programme report indicated that older people were represented in village decision making bodies and were actively integrated in the reconstruction process. Older people were an integrated and essential part of planning and implementation of recovery activities (e.g. access to agricultural seeds, animal distribution, and credit of income generation activities) (Hutton, 2008).

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Response With an enabling environment, older people may serve many roles in disaster response. They may support themselves, care for children and families, assist other older people, and participate in disaster planning and relief. For example, older women might care for their injured spouses, grandchildren and the orphaned, engage in income-​generating activities, produce food and cook meals, rebuild shelter, consolidate non-​food relief items, and help educate the young when the education system might have collapsed due to the crisis. In resource-​deficient settings, older people’s community knowledge may assist in relief targeting, planning and distribution. A cross-​culture study found that there is a strong sense of independence among older people who have experienced disasters, and they regard themselves as extremely important stakeholders to be consulted on the disaster response (Duggan, Deeny, Spelman, & Vitale, 2010). A study in Sri Lanka after the 2004 Indian Ocean Tsunami found that older people were frustrated more by the lack of work and engagement than their perceived vulnerabilities (WHO, 2015). In addition, older people might help mobilise their own demographic group by organising home visits and support vulnerability assessments. They can help deliver resources, support shelter reconstruction, organise service and engage in temporary relief care store management, etc. In disaster-​prone communities, older people might also serve as community resources for coping strategies, traditional skills and local knowledge. This emphasis on respect and enabling independence is very much in line with the human security concept that encourages the consideration of the needs of the most vulnerable groups such as older people. Empowerment strategies enable the affected people to act on their own behalf and on the behalf of others (Futamura, Hobson, & Turner, 2011). When mounting up disaster response, the perspectives of older people should always be included to ensure service effectiveness. For example, older adults are often less willing to accept mental health services (Aldrich & Benson, 2008).The form of response sometimes means more than physical supplies but also the dignity and social well-​being of the older people. After the Haiti earthquake in 2010, some displaced older people living in camps served as “focal points” of the affected older population for identifying the most vulnerable among the older population, collecting data related to older people’s health needs, and delivering aid to those with minimal mobility. In Bolivia, there are regular associations of older people called the “White Brigades”, which assist in registering older people, get involved in emergency planning, participate in drills, and identify the older people’s needs during an emergency (Guzman, 2012). Not only are some older people able to cope with disasters, but they may be able to support vulnerability mapping, participate in relief distribution, and provide post-​ disaster service. With inclusion of older people in disaster planning and programming, misconceptions and unfounded assumptions about their needs and capacities may be minimised. With better allocation of resources and support, physical and psychological health of older people can be improved by allowing them to be self-​sufficient, autonomous and independent. Case Box 5.6 introduces how older people might contribute to flood relief operations.

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CASE BOX 5.6  OLDER PEOPLE’S ENGAGEMENT IN EMERGENCY RELIEF RESPONSE 2006 Flood Relief in Rajasthan, India Rajasthan, the drought-​impacted state in India, suffered severe floods in the monsoon months of 2006: 5,809 villages in ten districts of the state were affected; thousands of people lost their homes and all belongings; 75,000 animals were killed and 75% of food crops were washed away. In communities with Village Older People’s Associations (VOPAs), these associations played vital roles in the relief response. They took initiatives of organising community kitchens utilising village level funds, to provide food support for up to 2,250 people for four days.

2004 Indian Ocean Tsunami, Aceh, Indonesia An estimated 14,000 people over the age of 60 died when the tsunami hit Sri Lanka, India, Thailand and Indonesia in 2004. Around 93,000 older people were displaced and many older people lost their relatives, homes and possessions. Other older people became main caregivers of grandchildren orphaned by the disaster. HelpAge International and its partners provided food, drinking water, shelter and medicines helping over 20,000 older people. In addition, older people’s associations (OPAs) were instrumental in rehabilitation activities such as rebuilding livelihoods. Cash grants were distributed by self-​managed OPAs to over 2,000 of the poorest older people in Aceh, enabling them to regain a steady income to provide for their families’ basic needs. Source: HelpAge International (2009).

Recovery and rehabilitation In disasters and emergency contexts, the older population share their wide range of (indigenous) knowledge and experience in post-​disaster coping strategies, preparedness, recovery and reconstruction. Skills in shelter construction, farming and education are important knowledge assets which may be transferred by older people to the younger generation. Older people also play a key role in post-​recovery context. An estimation in 2007 suggested that more than half of the children in the north of Uganda were cared for by their grandparents, and up to 60% of orphans in sub-​Saharan Africa live in grandparent-​headed households (Chan, 2017). Case Box 5.7 suggests how older people might contribute to recovery and rehabilitation.

Conflict resolution In conflict contexts, older people might provide education and training opportunities to the younger members. They may, as a community memory vault, facilitate

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CASE BOX 5.7  THE CASES OF MOZAMBIQUE AND LEBANON Older people are regarded as valuable social capital in times of crisis. In 2000, during the post-​ flooding period in Mozambique, older people supported the recovery of their own demographic group by carrying out home visits, supporting distribution of food, blankets and clothing to the immobile older people, implementing the distribution of agricultural tools, seeds and animals, and facilitating in a number of income-​generation activities (Hutton, 2008). During the 2006 conflict in Lebanon, older people also offered social support for families and communities, and made contributions across areas of care, coping strategies, counselling and rehabilitation (WHO, 2015).

the sense of history to support the preservation of the cultural and social identity of the displaced population. Their knowledge of traditional medicine, farming, construction, survival skills and food production are all valuable for living in suboptimal, unconventional camp contexts. Their leadership and community positions might also help restore certain levels of leadership and management structure and may help the maintenance of community justice in the absence of law and order. Their experiences, social position and status will support older people to play important roles in conflict resolution in the fragile context of unstable law and order. Older people might serve as institutional memory to support reconciliation. Their social network and skills might facilitate community rebuilding, micro-​ conflict resolution, community reconciliation and peace initiatives. In protracted conflicts and war settings, constant population movement might hamper education opportunities for children and young adults. Older people might bridge the gap by ensuring opportunities for children to access education and acquire skills that enable livelihood in the absence of formal schooling and vocational training.

Conclusion Older people are important assets and resources for societies. Not only have they contributed throughout their early and prime life to society, in times of crisis and adversity older people’s presence and wisdom can support and motivate courage in adversity. Older people may help preserve and transmit cultural heritage, maintain care and health service at the community and informal levels, and support family and community conflict resolution. Frequently, they also are actively involved in disaster responses by contributing to income generation, disaster coping strategies, reconstruction and recovery in crises. Unfortunately, their significance is often under-​recognised and proper recognition of how the older population have been supporting disaster-​and conflict-​affected communities is long overdue.

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References Ager, A., & Metzler, J. (2012). Child friendly spaces: A structured review of the current evidence-​ base. Retrieved from www.wvi.org/​sites/​default/​files/​CFS%20Literature%Reveiw%20 final%20Aug%202012.pdf Aldrich, N., & Benson, W. F. (2008). Disaster preparedness and the chronic disease needs of vulnerable older adults. Preventing Chronic Disease, 5(1), A27. Beesley, L. (2006). Informal care in England. Wanless Social Care Review. Retrieved from www.kingsfund.org.uk/​sites/​default/​files/​Securing_​Good_​Care_​background_​paper_​6_​.pdf Chan, E.Y.Y. (2017). Public health humanitarian responses to natural disasters. London: Routledge. Chan, E.Y.Y., Hung, H., & Chan, G. K.W. (2017). Policy implications for managing older people in disaster (Policy Brief). Retrieved from www.ccouc.ox.ac.uk/​_​asset/​file/​policy-​brief-​4.pdf Day, W., Pirie, A., & Roys, C. (2007). Strong and fragile: Learning from older people in emergencies. Retrieved from www.helpage.org/​download/​4c754e9356cc6 Duggan, S., Deeny, P., Spelman, R., & Vitale, C.T. (2010). Perceptions of older people on disaster response and preparedness. International Journal of Older People Nursing, 5(1),  71–​76. Futamura, M., Hobson, C., & Turner, N. (2011). Natural disasters and human security. Retrieved from https://​unu.edu/​publications/​articles/​natural-​disasters-​and-​human-​security.html Guzman, J. M. (2012). Ageing in the twenty-​first century: A celebration and a challenge. New York and London: United Nations Population Fund (UNFPA) and HelpAge International. Retrieved from www.researchgate.net/​publication/​314205132_​Ageing_​in_​the_​ Twenty-​First_​Century_​A_​Celebration_​and_​A_​Challenge HelpAge International. (2000). Older people in disasters and humanitarian crises: Guidelines for best practice. Retrieved from www.helpage.org/​silo/​files/​older-​people-​in-​disasters-​and-​ humanitairan-​crises-​guidelines-​for-​best-​practice.pdf HelpAge International. (2009). Older people in community development: The role of older people’s associations (OPAs) in enhancing local development. Retrieved from www.helpage.org/​silo/​ files/​older-​people-​in-​community-​development-​the-​role-​of-​older-​peoples-​associations-​ opas-​in-​enhancing-​local-​development.pdf HelpAge International. (2013). Displacement and older people: The case of the Great East Japan earthquake and tsunami of 2011. Retrieved from https://​reliefweb.int/​report/​japan/​ displacement-​and-​older-​people-​case-​g reat-​east-​japan-​earthquake-​and-​tsunami-​2011 HelpAge International. (2014). Disaster resilience in an ageing world: How to make policies and programmes inclusive of older people. Retrieved from www.unisdr.org/​2014/​iddr/​ documents/​DisasterResilienceAgeingWorld.pdf Hong Kong Census and Statistics Department. (2018). Labour force characteristics. Retrieved from www.censtatd.gov.hk/​hkstat/​sub/​gender/​labour_​force/​ Hutton, D. (2008). Older people in emergencies: Considerations for action and policy development. Retrieved from https://​apps.who.int/​iris/​bitstream/​handle/​10665/​43817/​ 9789241547390_​eng.pdf?sequence=1&isAllowed=y National Alliance for Caregiving & AARP Public Policy Institute. (2015). Caregiving in the U.S.: 2015 report. Retrieved from www.aarp.org/​content/​dam/​aarp/​ppi/​2015/​ caregiving-​in-​the-​united-​states-​2015-​report-​revised.pdf Organization for Economic Co-​operation and Development. (2017). Labour force participation rate. Retrieved from https://​data.oecd.org/​emp/​labour-​force-​participation-​rate.htm Sinha, M. (2013). Portrait of caregivers, 2012. Statistics Canada. Retrieved from https://​ www150.statcan.gc.ca/​n1/​en/​pub/​89-​652-​x/​89-​652-x​ 2013001-e​ ng.pdf?st=8pSLo4DE United Nations Children’s Fund (UNICEF). (2011). Guidelines for child friendly spaces in emergencies. Retrieved from www.unicef.org/​protection/​Child_​Friendly_​Spaces_​Guidelines_​ for_​Field_​Testing.pdf

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United Nations Department of Economic and Social Affairs (UNDESA). (2007). Population ageing 2007. Geneva: United Nations. Retrieved from www.un.org/​en/​development/​ desa/​population/​publications/​pdf/​ageing/​WorldPopulationAgeingReport2007.pdf World Health Organization. (2015). World report on ageing and health. Retrieved from https://​ apps.who.int/​iris/​bitstream/​handle/​10665/​186463/​9789240694811_​eng.pdf?sequence=1 World Health Organization Regional Office for Europe. (2008). Healthy ageing profiles. Retrieved from www.euro.who.int/​_​_​data/​assets/​pdf_​file/​0011/​98399/​E91887.pdf?ua=1

6 HEALTH IMPACT OF DISASTERS ON OLDER PEOPLE

Disasters affect people of all ages.Yet, the extremes of age are often disproportionately affected in times of crisis. The realities and impact of disaster on older people are not always visible. The severity of the impact of disasters and emergencies on older people depends on specific characteristics of affected individuals, environment (exposure), hazards (subtype and its severity of impact), and the disaster preparedness/​management in the affected community. This chapter will provide an overview of the general health impact of various common disasters. Health impact of climate change-​related disasters such as tropical cyclone/​hurricane/​typhoon, floods, drought and famine as well as extreme temperature events such as heatwaves and cold waves will also be examined.

General health impact of disasters on older people Ageing is a lifetime ongoing process. Coupled with the impact of gender, disability, poverty and discrimination, which might all vary across an individual’s life-​span, vulnerability, health risks and outcomes associated with an older age person in a disaster context might vary widely. However, the impact of disasters on the older age group is frequently embedded in the data and statistics which describe the general outcomes of adult population. Unless specific efforts or age-​specific analysis are done, older people might suffer from unintended exclusion from disaster response (lack of concern for their vulnerabilities, their physical access to services, their health needs, etc.). In recent years, data have indicated that older people, as a demographic subgroup, are disproportionately affected by disasters. More than half of the deaths consistently occurred among people over 60 years of age in five main disasters arising

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from natural hazards (Allaire, 2013). In developed contexts with more developed natural disaster response and health systems, older people are at higher risk when compared with the younger population. For instance, during the 2003 heatwave in France, reports indicated that among the 14,800 deaths, 70% were people over 75 years old (Hutton, 2008). During Hurricane Katrina in the United States, in 2005, over 70% who died were 60 years old or above (Jonkman, Maakant, Boyd, & Levitan, 2009). Over 60% of those killed in the 2011 Japan earthquake were aged over 60 (United Nations Population Fund & HelpAge International, 2012). Effective management of the ageing population and enhancing their resilience and preparedness will have implications for disaster risk reduction strategy and community preparedness. The lack of support for older people in emergencies was cited as one of the major concerns raised in World Health Organization consultation with older people around the world (WHO, 2015a). Older people’s chance of survival could be negatively affected by disasters due to injuries, limited access to medical care, mental and psychological issues, lack of management plan for chronic conditions, inaccessibility to social support, susceptibility to communicable diseases and worsening of existing medical conditions (WHO, 2015a). At the same time, the potential contributions of older people during disaster management should be recognised. Due to the physiological changes and various barriers (e.g. the inability to access technology), special needs assessment protocol, guidelines and programmes might need to be developed to effectively understand and address the needs of older people post disaster (WHO, PHE, & partners, 2017).

Older people and disasters: Health risks and vulnerabilities In disasters, survival depends on hazard, exposure and underlying vulnerabilities. Although advancing age is not directly associated with vulnerabilities, challenges associated with old age such as deteriorating physical ability and tolerance, poorer immune and nutritional status, functional limitations and decrease in sensory awareness often increase vulnerability of an individual. Coupled with limited mobility and economic capacities in older age, the ability to recover after a major crisis might be constrained.

Poorer health conditions Physical and mental changes associated with ageing predispose older people to poor health and suboptimal energy levels. Disabilities are often associated with old age and affect access to health services and emergency aid. Of the global population over 60, 20–30% are estimated to suffer one or more disabilities (physical, mental or sensory related) (WHO, 2015a). By 80 years old, the prevalence of disability will increase to 50%. In disaster, older people often sustain more injuries than other age groups as they have intrinsic physical limitations. Suboptimal musculoskeletal functions also affect an older individual’s ability to evacuate without support. Older people with degenerated joints and pain suffer reduced mobility.

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Sensory deterioration in eyesight and hearing, issues with dental health and mental deficiencies (such as loss of memories and dementia) are all conditions that reduce the possibility of self-​care and management. With a vulnerable state of health, older people succumb more easily to simple health problems and injury. Minor conditions can easily escalate to become significant or even catastrophic for older persons during a disaster. The weak immune systems of older persons mean they are more susceptible to diseases, including dehydration, hypothermia and hyperthermia (WHO, 2015a), and have poorer wound healing. Hypothermia, immobility due to loss of eyeglasses and walking sticks and the lack of assistive devices (e.g. wheelchairs) in relief settings will also affect self-​ care possibilities of older people. Older people are more susceptible to communicable disease risk and worsening of their underlying health conditions. As it was reported during the cholera outbreaks in Haiti, adults aged 60–​79 were four times more likely to die than younger counterparts. For those older than 80 years, the odds of dying increased to 11 times more likely. In Zimbabwe, older people were reported to be twice as likely to experience severe dehydration (Kwok, Fritsch, Raza, & Newport, 2012). Disruption of health services can affect access to medication and treatment for ongoing underlying health needs of patients with chronic diseases such as hypertension, diabetes mellitus and respiratory diseases. A study of the 2005 Kashmir earthquake found that “the greatest gap in health services at all sites was that non-​ communicable disease management was inadequate” (Chan & Griffiths, 2009). Even with no direct injuries associated with the disaster event, for older people with prolonged unmanaged NCDs, disruption of treatment (e.g. dialysis for patients with chronic renal failure) and disease-​managing drug supply might increase morbidity risks or even be fatal. In general, older people are more vulnerable to the (in)stability of infrastructure support. In particular, electricity, water and sanitation supply are important dimensions to maintaining the health and well-​being of the elderly. For older people with impaired mobilisation who live in high-​rise buildings (and need to rely on elevators and medical equipment with electricity), the stability of basic life-​ sustaining machines and access to basic supplies during blackout/​crisis might affect self-​care and survival.

Economic marginalisation Poverty among older people is common in developing countries. Even in cities like Hong Kong, a well-​developed city, reports showed a persistently high poverty rate of older people aged 65 or above: 30.1% in 2015 (Hong Kong SAR Government, 2016). Population groups that lack recurrent employment earnings include elderly persons aged 65 or above, elderly households and households with elderly head. For working older persons, their median monthly income from main employment was $8,500, about 77% of the average of the whole working population (Census and Statistics Department, Hong Kong SAR Government, 2013). Poverty status is

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also closely associated with many health outcomes in older people who suffer from poor chronic long-​term illness management. With poorer health conditions, older people are less able to cope with the impact of disasters. The lack of economic and social alternatives, and lack of property rights and personal documentation would further marginalise older people post disaster. In a post-​disaster context, older people are also more likely to be unemployed despite their capacity. Older people expressed frustration of their inability to obtain work and improve the economic situation of their household after the 2004 Indian Ocean Tsunami (Duggan, Deeny, Spelman, & Vitale, 2010).

Social marginalisation: isolation Traditionally, care for the young, older and sick relies on intergenerational support. However, intergenerational dependencies are increasingly eroded in many parts of the world due to urbanisation, migration and economic instability (Hutton, 2008). As a result, older persons are often left behind without traditional family support when the younger generation migrate, and older people are often the victims of neglect, violence and abuse (United Nations Population Fund & HelpAge International, 2012). During a disaster, older persons may suffer from a breakdown of their social support networks when they are separated from their families, peers or caregivers, and this causes social isolation and exclusion. Dependency, discrimination and isolation increase vulnerability and decrease access to services. Immobility in the older population might restrict the ability of older people to gain access to food, water, sanitation, medicine and health services after disasters. Search and rescue might also be hampered if no up-​to-​date information is available to understand the location of isolated people or older people as population data do not reflect the geographic distribution of older people who might be living in enclaves or isolation. Exclusion might be experienced across all age groups for communities affected systematically by a resource deficient context. However, older women are frequently more vulnerable than older men, as females have a propensity to live longer, and older women in many conflict-​affected communities have not engaged in active war fighting and thus often outnumber men in demographic composition in these communities. With discrimination toward and exclusion of women in access to services and legal rights in many developing contexts, older women also tend to confront more survival challenges compared with both younger women and men after emergency and crisis.

Inaccessible information Early warning and public health information are crucial for empowering older people to protect themselves from the negative consequences of disasters. Yet, disaster education materials, warning information and methods might not be presented in the format and channel which older people might understand or have access to

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CASE BOX 6.1  WEATHER INFORMATION ACQUISITION CHANNELS: THE POTENTIAL OF THE SMARTPHONE Over 30% of the older people aged 65 or above in Hong Kong were reported to have no schooling or only pre-​primary education (Census and Statistics Department, Hong Kong SAR Government, 2013). Their ability to understand and respond to warning, disaster advice or information is thus affected by a range of factors, including their underlying literacy, language use, access to information and how messages might be delivered. A study conducted in Hong Kong among elderly residents in a nursing home found that over 80% of the interviewees (aged from 65 to 82) had no or little knowledge about severe acute respiratory syndrome (SARS) despite access to TV, radio and visitors (Tse, Pun, & Benzie, 2003). A recent local study on weather information acquisition behaviour during cold waves in 2016 revealed that although smartphone was the most preferred channel for accessing information, old age was significantly associated with less smartphone applications use and preference. The population-​based telephone survey was conducted in Hong Kong with 1,017 respondents at the beginning of 2016, immediately after the strongest cold wave since the 1950s. The study aimed to examine the patterns and socio-​ demographic predictors of weather information acquisition in Hong Kong and to understand health impact and health service implications of cold waves in a subtropical city. Results indicated that television (50.1%) and smartphone app (32%) were the most popular channels for seeking weather information in the extreme temperature event. Older age and lower education level were significantly associated with less smartphone apps use and preference. With the global discussions in information technology and smart city development, the study results indicate that there may be age and sociodemographic differentiation of information acquisition patterns. Demographic profile of warning system users should be considered carefully to avoid unintentional discrimination of information access against the older age groups.

(see Case Box 6.1 for details). Inaccessibility of information often severely hampers older people’s benefits from rescue efforts and potential for self-​help, as well as access to resources. In addition, due to social marginalisation, older people might not have access to relevant information/​procedures to claim their post-​disaster service entitlement.

Limited legal awareness Although the right to health is firmly enshrined in a number of international instruments, including the Universal Declaration of Human Rights, the Constitution

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of the World Health Organization, and the International Covenant on Economic, Social and Cultural Rights, older people in general may lack the awareness of their rights. In disasters, older people are frequently neglected in policies, implementation or monitoring. Core disaster life-​saving decisions related to older people such as evacuation and advanced medical directives are not communicated before, during or after the disasters. The lack of discussion or mechanism of disaster planning for older people poses challenges to rescue/​medical workers during rescue actions.The limited legal awareness also adds further vulnerability to an older individual who may be incapacitated or living alone.

Gender perspective In crisis, even if the affected older age groups survive and incur no or limited physical injuries, the geographic displacement and the destruction of traditional social structure would render older people vulnerable. Although both men and women are systematically challenged and disempowered by poverty, lack of possession of assets, identity and documents, older women face more significant risk and challenges during the crisis. Gender disparities existing between the sexes remain throughout life. Special attention must be paid to the needs of older women, which is particularly important in more conservative cultures. Women are often excluded from decision-​making and resource allocation, and older widows are often among the most marginalised (HelpAge International, 2000). When compared with their male counterparts, older females are also more likely to be living in poverty and have limited economic opportunities.Women’s access to education and their inability to join the formal economic sector often create barriers and exclude them from decision-​making and resources, especially in rural communities and urban areas in traditional economic contexts. Women are more likely to take up the role of caregiver of the household, but have less marketable skills and retirement compensation to support livelihood at old age. After disaster or crisis, older women are also more likely than men to be the long-​term caregivers of children or affected family members. In addition, religious and social restrictions on speech, movement and public exposure also increase women’s vulnerabilities in emergencies. Culture and dress codes in certain communities might restrict mobility and severely affect survival possibility during disasters like earthquakes and flooding. Older women frequently enjoy only suboptimal health, living in a context that is more traditional and conservative and observing stricter religious and cultural observance. Communal sharing facilities in camp settings, if not designed with proper consideration (gender separation in latrines and sleeping areas), might expose disaster-​affected women to access barriers or violence. Among various sociodemographic female subgroups, older widowed women are regarded as the most marginalised subgroup. These females might be less likely to re-​marry after their spouse passed away. In times of disaster, the capacity of widowed women to fend for themselves and recover from the financial impact is often very limited. Post-​crisis displacement from traditional social structure and

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social capital would render older women extremely vulnerable. Their status might also hamper their access to resources (e.g. if the relief delivery system requires a male head of household for registration). In developed contexts, women are more likely to experience economic marginalisation. In the United States, women’s earning as a percentage of men’s in the age group of 65 or above was 75.3% in the first quarter of 2018 (United States Bureau of Labor Statistics, 2018). In Asian developed countries, labour force participation rates among older women aged 65 or above were 13.4%, 13.7% and 23.0% in Japan, Singapore and South Korea respectively, while those for men in the same age group were around double at 28.7%, 32.4% and 41.6% (United States Census Bureau, 2016). In Hong Kong during the same period, labour force participation rate among older women (3%) was only a third of men (11.5%), with a lower median monthly income for those who are working (HK$6,940 for women and HK$9,000 for men). In terms of social and familial support, older women were much more likely than their male peers to live alone globally (United Nations, 2017), while the rate of older women living alone (14.7%) in Hong Kong was almost 50% higher than that for older men (10.4%) in 2012. A huge difference in education level put older women in Hong Kong in a weak position to comprehend and act on disaster-​related information: 44.2% of older women have no schooling or pre-​primary level only, while that for older men is 17.4% (Census and Statistics Department, Hong Kong SAR Government, 2013). Mainstreaming of gender perspectives in disaster management has been gaining attention and momentum in global policies, as higher death tolls are recorded among women and girls due to various reasons. For example, women are less willing to seek temporary shelters that lack privacy and protection (International Federation of Red Cross and Red Crescent Societies, 2010), and staying with male strangers could have negative implications for women in certain cultures. Living arrangements in a mixed-​gender environment also means women are vulnerable to different kinds of abuse, such as rape and other forms of violence. As for health impacts, women are particularly vulnerable to various health impacts of disasters and, because of their longevity, a large proportion of older women, when compared with men, may experience negative health outcomes.

Health risks Older people are more likely to sustain health risks and injuries in disasters than other age groups because of functional limitations of poor balance, muscle weakness and exhaustion, poorer immune response and physiological recovery potential as well as higher rates of underlying chronic conditions (AARP, 2006). In disaster-​prone countries such as China and India, chronic disease rates and the number of disabled older people in the community are high. The capacity to evacuate, survive, respond and recover from catastrophic events might be limited in such contexts, which could affect physical and economic well-​being of older persons.

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Geophysical disasters Earthquakes and tsunamis Earthquakes and tsunamis are geophysical events which may receive global attention for their dire consequences. Magnitude, location and timing of occurrence are all important determinants of the extent of their health impact (Chan, 2017). Collapse of buildings and infrastructure, falling debris and entrapment cause direct trauma, crush injuries and fractures to victims. Cuts and bruises are the most common reasons for patient admissions to the hospital during the first week. Other associated health risks include entrapment induced hypoxia (lack of oxygen), hypothermia (especially during winter) and electrocution. Debris and dust from collapsed infrastructure may trigger acute respiratory distress. Tsunamis are the result of earthquakes or volcanic eruptions under the sea. Volcanic tsunamis are usually of greater magnitude than tsunamis caused by seismic events. Most deaths are due to drowning and people living close to the sea line and lowland areas are the most endangered. Moreover, the number of dead may outnumber the injured in tsunamis. Asia, as a region, has been reported to have the highest human impact of these events. Although people across all ages who live in the affected communities experience the impact of these disasters, in developed contexts such as the United States, older people (aged >50) are often reported as one of the age subgroups with the highest risks of mortality and morbidity (Greenburg, 2014). The senior population has been reported to have the highest death rate among all age groups, and being trapped and injured in collapsed buildings/​structures was the most common cause of mortality for the 1994 Northridge earthquake in the United States (Peek-​ Asa, Kraus, Bourque,Vimalachandra,Yu, & Abrams, 1998). Search and rescue are the key immediate responses to earthquakes. Medical services are needed to manage the casualties, with a high volume of injuries and fractures expected in the first few weeks after an earthquake. Orthopaedic surgeons and anaesthesiologists are vital. Nephrologists or physicians specialising in renal care are also essential in the initial phase of disaster relief as patients with crush injuries may develop acute kidney failure. In Haiti, after the earthquake in January 2010, kidney failure became one of the most urgent medical concerns (Portilla, Shaffer, Okusa, Mehrotra, Molitoris, Bunchman, & Ibrahim, 2010) (see also Case Box 4.3). Collapse of buildings, falling debris and entrapment produce a high number of injuries and deaths. The most successful rescues are carried out by the immediate action of nearby survivors, when the chance of survival is the highest. Earthquakes place a huge burden on general service delivery not only through incurring large amounts of injuries but also by destroying infrastructure, transportation and communication systems. Secondary disasters such as fire and contamination are common after geophysical disasters. However, disease outbreak is uncommon as water sources are usually not contaminated and unburied bodies do not normally cause

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CASE BOX 6.2  THE FORGOTTEN HEALTH NEEDS OF OLDER PEOPLE AFTER THE 2005 PAKISTANI KASHMIR EARTHQUAKE On 8 October 2005, an earthquake measuring 7.6 on the Richter scale hit the Pakistan-​administered part of Kashmir causing more than 79,000 deaths in Pakistan alone. Of Pakistan’s population of 158 million at that time, 3.7% were over 65 years of age. In February 2006, four months after the disaster, a study about the health needs and health outcomes of the older people was conducted in both rural and urban areas of the Neelum Valley of Pakistani Kashmir. The study observed that older people have different health needs from their younger counterparts. The most common diseases presented by the older population in clinical settings included upper respiratory tract infection, pneumonia, arthralgia, backache and skin infections (such as scabies). Increased age disparities in access to chronic medical condition management were also observed and 25%–​38% of the respondents to the study reported at least one such unmanaged condition. Geographic inaccessibility was found to be a main barrier for older people to obtain health services, particularly for those residing in remote rural areas. Clinic utilisation rate of older people was lower for remote mountainous clinics than for clinics in internally displaced person (IDP) camps near cities. A gender difference in health service utilisation was also observed among the older disaster victims. In remote rural areas, although men were the most likely users of health services, they had limited or no access to psychological health services since most mental health programmes targeted women and children. This study suggests that relief agencies should be more sensitive towards the health needs of the older population. Targeted needs assessments with gender sensitivity are needed at the immediate post-​disaster phase to identify the specific needs of older people. With the prevalence of chronic non-​ communicable diseases (NCDs) among the older population, formulating a long-​term NCD management strategy among the older population in the post-​disaster phase is also necessary to address the current medical response gap in relief work. Sources: Chan (2017); Chan & Griffiths (2009).

the spread of infectious diseases. Despite this low risk of disease spread, speedy and proper burial of the deceased could be beneficial to the mental well-​being of their family members (see also Case Boxes 6.2 and 6.3). In addition, since earthquakes bring huge destruction and damage to buildings, provision and management of the homeless population is also a crucial response need.

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CASE BOX 6.3  DELAY IN MEDICAL CONSULTATION FOR BREAST CANCER SYMPTOMS AFTER A DISASTER May Pui-​shan Yeung After the 2011 earthquake, tsunami and nuclear incident in Fukushima, Japan, medical consultation delays among breast cancer patients were reported (Ozaki et al., 2017). The delay in patients attending to their breast symptoms was unlikely due to poor knowledge or awareness, because such delay was found when compared with the same population before the disaster. The devastating impact of mass disasters has long-​lasting effects on the healthcare system, social support and psychological distress. These factors would have contributed to a delay in seeking medical help, which can lead to late-​stage diagnosis and contribute to poor prognosis. In many countries, breast cancer incidence increases with age; and the median age of diagnosis is late 50s and early 60s. The elderly population who were evacuated and displaced in the 2011 triple disaster was prone to social isolation, thus loss of social networks and support. Evidence showed a two-​fold increased risk of breast cancer mortality in women who were socially isolated compared with those who were socially integrated (Kroenke, Kubzansky, Schernhammer, Holmes, & Kawachi, 2006). Social support has lessened the risk of patient delay in medical attendance in disaster settings (Twombly, 2005). Support and caregiving from close relatives, friends or adult children are particularly important and associated with cancer survival (Kroenke et al., 2006).

Volcanic eruptions A volcanic eruption is the geological process by which underground magma or gases are transported from the core of the Earth to the surface. This can be accompanied by tremors on the ground and interactions of magma and water below the Earth’s surface. Depending on the composition of the magma, eruptions can be explosive or effusive, resulting in diverse combinations of rock falls, ash falls, lava streams, pyroclastic flows, and emission of gases (CRED, 2009). Volcanic eruptions can lead to disasters because many volcanic areas in the world are also densely populated urban areas such as Tokyo, Mexico City, Jakarta and Manila. In 1990, nearly one tenth of the world’s population lived within 100 kilometres of an active volcano. With two to four fatal volcanic eruptions happening annually since the eighteenth century, more than 270,000 volcano-​ related fatalities have been recorded. It occurs most commonly along the Ring of Fire in the Pacific Rim. Volcanic eruptions can also affect populations that live hundreds of kilometres away via the airborne dispersion of gases and ashes (Ciottone, Anderson, Auf Der Heide, Darling, Jacoby, Noji, & Suner, 2006; Hansell, Horwell, & Oppenheimer, 2006).

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The activity level of a volcano, such as the frequency of harmful gas emission and volcanic mudflows between eruptions, is a key indicator for the future volcanic eruptions and the current impact of the volcano on neighbouring communities. High population density and long-​term exposure to the hazard mean that a good early warning system and evacuation plans are vital to mitigating the impact of volcanic eruptions. There are currently no standardised tools to estimate the population risk of being exposed to volcanic activities. However, the Smithsonian Global Volcanism Program (GVP) provides a way to assess the hazard risk of a volcano by scoring eruption characteristics, such as the type of lava flow, maximum output capacity, eruption history and volume of surrounding glaciers and snow caps. Various countries typically also classify a volcano as of “high”, “medium” or “low” risk based on its eruption history, number of people affected and potential economic losses. Although volcanic eruptions are uncommon disasters, they have resulted in the highest mortality rates among all types of natural disasters. Pyroclastic flows cause high numbers of deaths, fatal injuries and severe burns. Pyroclastic flow is a mass of hot volcanic ash, lava fragments and gases that erupts from a volcano, moving rapidly down the slope at more than 300 kilometres per hour and reaching a temperature as high as 600°C to 900°C (Jay, 2006; Hogan & Bearden, 2007). The fragmentary material emitted from a pyroclastic flow is called tephra, while ashes are tephra fragments less than 2 mm in diameter (Hansell et al., 2006). Ashfall can damage buildings and contaminate water sources. Heavy ashfall can even cloud the sky, leaving people in complete darkness during day time. The free silica and high iron content of ash irritate the upper and lower respiratory tracts, eyes and skin. High levels of airborne ash can result in a two-​to threefold increase in hospital admissions and a three-​to fivefold increase in emergency room visits for respiratory-​related illnesses (Baxter, Ing, Falk, & Plikaytis, 1983). Lapilli are tephra fragments between 2 and 64 mm in size, while lava bombs or blocks are those bigger than 64 mm in diameter (Jay, 2006); the ejection of the latter can thus cause severe head injuries, burns and blunt trauma. Volcanic gases, such as sulphur dioxide, carbon dioxide and hydrogen fluoride, also impose severe health risk. Sulphur dioxide and hydrogen fluoride can be irritating to respiratory airways, eyes and skin, while the latter can produce fluorosis when ingested by animals to cause death. Inhaling carbon dioxide with a concentration above 20% can cause unconsciousness and asphyxiation (Baxter, 1990). Key health issues to be considered when responding to health needs after volcanic eruptions include care for burns, injuries, inhalation and respiratory trauma due to exposure to ash and toxic gases. Health risks include mucosal irritation of the eyes and burn injuries to the skin and respiratory tract from volcanic ashfall, pyroclastic flows and mudflows. Toxic gases emitted may also cause suffocation and respiratory illnesses. Indirect health impacts from the loss of homes and relocation are likely to cause more serious adverse outcomes than direct injuries resulting from falling rocks and burns. Volcanic eruptions may damage infrastructure, agricultural land and property causing economic loss. To protect the population against

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the adverse impacts, surveillance systems to detect volcanic movements and early warning systems are regarded as most effective.

Biological disasters: epidemics, outbreaks, pandemics and endemics Communicable diseases may trigger epidemic and pandemic-​prone diseases, such as cholera, meningitis, influenza, SARS, viral haemorrhagic fevers (e.g. Ebola) and Zika virus disease, and result in high mortality and morbidity. An infectious disease disaster refers to “events that involve a biological agent/​disease and that result in mass casualties, such as a bioterrorism attack, a pandemic, or an outbreak of an emerging infectious disease” (Rebmann, 2014, pp. 120–​121). They can threaten human health and security, leading to national, regional and global wide disaster. Therefore, it requires well-​ planned emergency management in preparedness, mitigation, response and recovery to prevent and control the spread of infectious diseases (see Case Box 6.4).

Communicable diseases following a disaster Disasters, either natural or man-​made, may alter various elements that affect disease epidemiology and patterns. Environmental change caused by a heavy rain may create more favourable environmental conditions for pathogens and vectors and subsequently change the pattern of infectious disease transmission, distribution and community susceptibility (Watson, Gayer, & Connolly, 2007).Although there is a tendency to overestimate a risk of infectious diseases following a disaster, if not managed properly various factors within the post-​disaster context will increase the potential risk to

CASE BOX 6.4  EXAMPLES OF INFECTIOUS DISEASE DISASTERS The 2014 Ebola virus disease outbreak in West Africa is an example of an infectious disease disaster which resulted in more than 11,000 deaths across multiple countries. The Zika virus disease is another recent infectious disease disaster. Zika infection during pregnancy is linked to a rare birth defect of the brain known as microcephaly. The first case was identified in Brazil in May 2015 and there were an estimated 440,000 to 1,300,000 Zika cases in Brazil in 2015 alone. There have been 4,783 suspected cases of microcephaly, most of them in the north east of Brazil associated with 76 deaths. These outbreaks raised awareness of the global burden of infectious disease and highlighted the importance of well-​prepared public health systems. Source: Centers for Disease Control and Prevention (2017).

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communicable diseases in affected populations. The risk of communicable outbreaks following a disaster may be increased in certain vulnerable population groups, e.g. children and pregnant women. Outbreak potential is likely to be higher in displaced populations due to their compromised living conditions, such as inadequate access to clean water, overcrowded shelters and compromised hygiene access.The following are some factors that influence impact and health outcomes in a disease outbreak. • • • • • • • •

S​ ize and characteristics of population displacement, e.g. overcrowded shelters ​Availability of healthcare services and disease control programmes ​Amount and availability of safe water and sanitation facilities ​Availability of life line supplies, e.g. electricity and logistics ​Presence of well-​coordinated and monitored disaster response ​Vaccination coverage of vaccine-​preventable diseases, e.g. measles ​Underlying health and nutritional status of affected population ​The state and environmental context of the disaster-​affected site

A number of communicable diseases might escalate into major disease outbreaks if not proactively controlled and managed in a timely manner (see Knowledge Box 6.1). Defining a disease distribution as epidemic, endemic or pandemic is useful to help health professionals and policy-​makers to set priorities for controlling illness at local, national and global levels (see Knowledge Box 6.2). Although global data show that infectious diseases are in an overall downward global trend, people in older age and with chronic diseases tend to accumulate more mortality and morbidity associated with infectious disease incidents. Underlying health problems, multiple-​ morbidities, sub-​ immune status and overall limited health resilience would render the older age group more vulnerable to outbreaks. Although researchers have reported that the risk to older people did not significantly increase in major epidemics and pandemics (Cox & Subbarao, 2000), impact of specific outbreaks on population subgroups should be noted. For example, in the H3N2 pandemic (1968–​69), people aged 65 or above constituted 80% of excess mortality (Simonsen, Clarke, & Schonberger, 1998), while studies of H1N1 hospitalisation (Glezen & Simonsen, 2006) and the impact of SARS showed that younger age group (0–​9) were more severely affected than the older population.Vaccination programmes that target older people also tend not to be as effective as those for the younger population (Chowell, Miller, & Viboud, 2008). In recent years, HIV/​AIDS, the re-​emergence of tuberculosis, influenza, Ebola and Zika are all examples of infectious disease risks which transcend national boundaries and further render older people at risk.

Climate-​related natural disasters and human health Climate change is one of the main global environmental changes (GEC) that affect global communities in the twenty-​first century. Climate change refers to “a change of climate which is attributed directly or indirectly to human activity that

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KNOWLEDGE BOX 6.1  COMMON COMMUNICABLE DISEASES FOLLOWING DISASTERS Diarrhoeal diseases: These are commonly caused by consuming contaminated water or food and lack of proper hygiene practice. Power outage may also indirectly increase diarrhoeal risk by disrupting lifeline infrastructure, such as water and sanitation facilities and refrigeration systems. Measles: Measles outbreaks may be related to suboptimal immunisation coverage, nutritional status and compromised living conditions (such as overcrowding) among displaced populations. Acute respiratory infections (ARIs): ARIs are common among displaced populations particularly in children 85 years old) were found to be 3.92 times more likely to die when compared with the reference group (45–​54 years old). Displacement has a major impact on health status decline of the older population. Research studies conducted after the 2005 Hurricane Katrina in the United States showed that the increase in morbidity rate of the survivors aged 65 or above was nearly four times that of the national sample of older people who were not affected by the disaster (HelpAge International, 2012, p. 29). Support might be needed for caregivers and responders to facilitate management of older people’s medical conditions. Relief supply (e.g. diet and medication needs) and allied medical care might also be addressed specifically for older populations.

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Drought and famine Most natural disasters might be acute and last for a short period of time, ranging from a few minutes to a few weeks. However, impacts of droughts, famines and extreme temperature events might take a long period of time to manifest or their impact may last for prolonged periods. Droughts are climatological events that can last from a couple of weeks to several years, and famines are a subtype of disaster that slowly affect a large population over months and years.They have a devastating impact on the health and livelihood of people. Drought is usually a preceding factor of famine but not every drought results in a famine. A drought is a climatological natural disaster defined as a regional water supply deficiency for an extended period of time due to persisting below-​average precipitation. It may affect inland navigation and hydropower plants, lead to a shortage of drinking water and cause famine as a result of losses in agricultural production (CRED, 2009). The global trend of drought is altered by climate change. The Intergovernmental Panel on Climate Change (IPCC) has identified regions (southern Europe and West Africa) that may experience longer and more intense droughts while some regions (central North America and north-​western Australia) may have less frequent and less intense droughts as a result of global climate change. A famine is an extreme form of food crisis. A food crisis is a “combination of drought, rising food prices, poverty, natural disasters, conflicts, disease, and complex emergencies” (World Vision Hong Kong, n.d.). When food crises continue and reach certain measures of mortality, malnutrition and hunger, they can develop into a famine. According to the United Nations (2011), a location is defined as being affected by famine when “at least 20% of households in an area face extreme food shortages with a limited ability to cope; acute malnutrition rates exceed 30%, and the death rate exceeds two persons per day per 10,000 persons”. It involves a regional failure of food production or supply sufficient to cause a marked increase in disease and mortality due to a severe lack of nutrition and necessitates emergency intervention, usually at an international level (Cox, 1981). Famines can result from natural disasters. However, because many underlying causes of famines are related to food distribution, management of food prices and regulation of other economic activities, they are now considered as man-​made disasters. In addition, famines are often accompanied by an economic and social collapse of the community. Traditionally, famine is believed to be associated with the decline in food supplies: “A sudden, sharp reduction in food supply in any particular geographic locale has usually resulted in widespread hunger and famine” (Brown & Eckholm, 1974). This decline usually arises from one or more of the following events: climate events, pestilence (i.e. an infectious epidemic disease that is virulent and devastating), wars, overpopulation and economic mismanagement. However, Amartya Sen (1981) proposed a new theory of famines, which focuses on each person’s entitlement to commodity bundles, including food, and views starvation as a failure

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to be entitled to a bundle with enough food. Therefore, famine is considered not simply as a product of climate events or natural disasters but also related to the decline in both income and employment opportunities. Major contributing factors are a lack of financial access to commodities, as well as to social, political and human rights. In the past, food crises usually affected rural food producers first. However, the rise in food prices, a key feature of modern times, now puts the urban poor more at risk (World Vision Hong Kong, n.d.). Another important factor of famine is the decrease in food security, which consists of three components: food availability, food access and food use. As food security continues to decrease, actions taken to sustain survival become less reversible: people start to sell household possessions and productive tools and thereby lose their capacity to generate income for exchange of food and other necessities in the future. This generates a vicious cycle of deteriorating food insecurity. When a period of unusual dryness and rainfall deficit occurs before the harvest season, causing a drought, it can have a more devastating health impact than if it happens after the harvest season, often in the form of famine as the failure in harvest leads to a reduction of food availability. However, a drought is usually predictable; therefore, it is important to develop and disseminate an early warning so that people can prepare for and store food before the drought happens. Poor irrigation systems and water supply infrastructure also play an important role in increasing the health impact of rainfall deficit. One of the significant health impact of drought is the lack of clean water as related diarrhoeal diseases cause more than 760,000 annual deaths for children under five years old globally, while malnutrition as a result of food crisis kills 3.1 million people annually (WHO, 2015b). The increased frequency of droughts in the future in some regions may intensify this health risk. Many risk factors influence drought vulnerability: demographic pressure on the environment, inappropriate land use, food insecurity, the socio-​economic status of the population, economic systems strictly dependent on agriculture, poor infrastructure (e.g. inadequate irrigation, water supply and sanitation), the poor health status of the population prior to the disaster, the season/​timing of drought occurrences, the absence of early warning systems, population displacement and other concurrent socio-​economic and political situations (e.g. economic crises, political instability and armed conflicts). In addition to water, the impact of a drought is dependent upon the context and underlying population vulnerability, such as the underlying water-​use practices, infrastructure and socio-​ economic environment (Stanke, Kerac, Prudhomme, Medlock, & Murray, 2013). Acquiring sufficient nutritional intake becomes the biggest challenge in droughts and famines because these disasters often involve decreases in the quantity and quality of the food available. Droughts can cause health impacts via a variety of pathways. One of the major health risks of drought is malnutrition.The resulting food production/​distribution disruption of drought can lead to reduced food intake and various nutrient deficiencies among the population. Specifically, people can encounter protein-​energy

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malnutrition and morbidities related to micronutrient deficiencies, such as iron-​deficiency anaemia, scurvy due to vitamin C deficiency and vitamin A deficiencies (which in turn increases the risk of developing measles). Undernutrition is a major cause of morbidity and mortality, particularly among children and pregnant women. Lack of clean drinking water and sanitation as a result of drought, compounded by the effects of malnutrition and displacement, can contribute to a higher population vulnerability to communicable diseases, such as cholera, typhoid fever, diarrhoea, acute respiratory infections and measles. Water stress also changes the dynamics of vector-​borne diseases. The disruption and reduction of local health service delivery due to the lack of water supplies or healthcare worker emigration can compromise the health of a community. Loss of buying power and lack of health facilities also limit people’s access to health services to increase overall morbidity and mortality (Stanke et al., 2013). The health impact of drought is also compounded by its economic, environmental and social impacts. Firstly, the reduction of crop production decreases farmers’ incomes, and the reduced food availability causes an increase in food market prices. Secondly, droughts might trigger insect infestations, increase plant diseases, worsen air quality and aggravate soil erosion and landscape degradation. While the natural ecosystems can usually rebound after short-​term droughts, the impact of long-​term droughts requires a lengthy recovery period. Lastly, water utilisation rights are often disputed in a drought, which can cause conflict among users. Moreover, the emigration of people from a drought-​stricken area increases the demand for water in the receiving area and threatens water security in these host communities, possibly leading to complex emergencies, such as conflicts and civil wars. Young children, women and older people are the most at-​risk groups in drought and famine situations. Famine relief organisations must consider not only victims’ dietary needs and food preferences, but also both the physical and economic access to food of the vulnerable populations. Relief organisations must also pay attention to micronutrient deficiency in long-​term feeding camps and food aid. In summary, droughts are slow-​onset disasters characterised by an extended period of unusual dryness, while famines are an extreme form of food production or food supply failure. Droughts and famines result in poor health outcomes, such as vector-​borne diseases, communicable diseases, malnutrition, vitamin and micronutrient deficiencies, and metabolic syndrome.

Physical injuries Physical injuries are often associated with climate-​related disasters or extreme weather events, e.g. drowning; injuries sustained from walking or driving through flood water; being injured by collapsed or damaged buildings; being crushed, cut or struck during storms; traffic accidents resulting from poor road conditions and landslides. In urban cities, major incidents with multiple casualties are likely to occur when extreme events happen in densely populated areas (e.g. a landslide causing high casualties to

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people residing near to slopes) as well as at-​r isk locations vulnerable to the secondary impacts of climate change (e.g. flooding after heavy rainfall or fire after a heatwave) and to damage of underground lifeline infrastructure (e.g. water and sewage, gas-​ pipes, electricity and telecommunication lines). With a sedentary lifestyle, older people are more vulnerable and likely to sustain injury. To protect the community from the expected increases of extreme weather events in the coming decades, better understanding of injury patterns, relevant contingency plans and health response surge capacity, as well as community resilience building towards emergency health impacts, will be necessary to minimise physical harms caused by climate change.

Mental health Extreme weather conditions and weather-​related disasters, e.g. flooding and storms, easily put extra stress on those who are suffering from mental illness and bring about new cases of anxiety, disaster-​related psychiatric trauma, depression and aggression, which have both short-​term and long-​term impact (Smith et al., 2014, p. 732). To address mental health needs associated with climate change-​related incidents, urgent research evidence is needed to understand how various aspects of climate change might directly and indirectly affect mental well-​being.

Fires Fires are a common injury and disaster risk across the world. In developed contexts such as the United States, Barillo and Goode (1996) showed that fire was responsible for 20 times more death than other natural disasters such as earthquakes and floods. For seniors aged over 70, fire-​related fatalities was double that of other age groups. Other fire epidemiological trend studies also show that fire mortality risks increased with age (Burdge, Katz, Edwards, & Ruberg, 1988). For wildfire incidents, studies in the United States also pointed out that older people were likely to be victims (Shusterman, Kaplan, & Canbarro, 1993) and medically affected (Sutherland, Make, Vedal, Zhang, Dutton, Murphy, & Silkoff, 2005; Analitis, Geogiadis, & Kotsouyanni, 2012; Kochi, Champ, Loomis, & Donovan, 2012). Studies indicate community responders of older age are also at risk. A study of mortality of volunteer firefighters found that those in the older age group (60+) were more likely to die of overexertion, stress and underlying medical conditions (Mangan, 1999).

Manmade disasters/​terrorism In general, as terrorism targets the general community, older age does not seem to be associated with higher risks of being affected (Greenberg, 2014). Nevertheless, the consequences of the impact (e.g. destruction of infrastructure, loss of electricity and water supply, etc.) would disproportionately affect older people, who tend to be less mobile and more reliant on public infrastructure. In addition, if their support

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and social network are disrupted due to disasters (e.g. losing contact with family members), there may be long-​term implications for the mental and social well-​ being of older individuals.

Conflicts and wars Older people are also more vulnerable in complex emergencies like armed conflicts and the ensuing challenges of becoming refugees and IDPs. During a disaster, older persons may have less capacity to leave their community. They suffer more significantly from a breakdown of their social support networks when they are separated from their families, peers or caregivers, which causes social isolation and exclusion. During the conflict in West Darfur in the late 1990s, reports indicated that 34% of the refugees aged over 50 were disabled. About 61% of those who had underlying chronic conditions had no access to the required medication or treatment (HelpAge International, 2000). In the 2006 Lebanon War, some 68% of older persons were depressed or showed probable depression. Inaccessibility to information, language and literacy barriers, social isolation and lack of gender segregation render women (including the older ones) more vulnerable to various kinds of abuse, such as rape, gender-​based violence and theft. Except for human impact associated with terrorism attacks, the relative risks of mortality and morbidity for extreme events and natural hazards were reported to be two to ten times higher for older people than their younger counterparts in developed contexts such as the United States (Greenberg, 2014). Less is known about developing contexts, where the population is relatively young and fewer data were available. Nevertheless, in these developing areas, it is expected that more severe impact would be experienced by the older people as there are fewer resources to support the vulnerable population. In addition, older people living in protracted crisis context also face extra dimensions of vulnerability and are less resilient to survive prolonged crisis. According to a HelpAge International report (2000), the cumulative and repeated physical and psychological trauma, loss of contact with families, prolonged impact of living in hiding and under siege, and being separated from resources (income, livelihood and social capital) will render extra challenges for frail older people to survive. In Rwanda, older people identified the destruction of family, the basic unit of socio-​economic power and social support, as exerting the single most devastating effect on their well-​being (see also Chan, Chiu, & Chan, 2018 and Case Box 6.6).

Gender-​based violence Data or analyses of gender-​based violence often focus on girls and women of reproductive age. Such focus might lead to the age cut-​off at 40–​45 (or up to 49) in standard situation reports. Women who might not be expected to become pregnant (e.g. older women, unmarried women) might be forgotten as their experience might not be captured or documented in the relief programmes or media reports.

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CASE BOX 6.6  ELDERLY REFUGEES FROM RAKHINE STATE, MYANMAR May Pui-​shan Yeung The refugee movement from Rakhine State in Myanmar (Burma) to Bangladesh, starting on 25 August 2017, has been the biggest in history. As of May 2018, there were estimated 720,849 arrivals from Myanmar. Children (under 18 years old) account for 55%, adults 42% and elders 60-​ years-​old or above 3% of the population (United Nations High Commissioner for Refugees, 2018). The old and sick are the most vulnerable among the refugee community. For older persons, chronic diseases and a progressive loss of function causes difficulty in adapting to the challenges and coping with disruptions. There is grave absence of information on health status and access to health­care services of elderly refugees. There is no health service for treatment and follow-​ up of chronic diseases in general. Reports indicate that older refugees attended healthcare facilities for acute presentations of late manifestations of chronic disease complications, such as acute myocardial infarction, acute retention of urine, large foot ulcers with gangrene etc. In other refugee crises, elderly refugees reported a high burden of chronic illnesses, with hypertension, diabetes mellitus and heart disease being the commonest (Strong, Varady, Chahda, Doocy, & Burnham, 2015). The past medical records of these elders were usually missing, and the patients themselves cannot recall their medical history or previous treatment details. Such patterns could arise from their receiving no diagnosis and treatment all along, or their receiving traditional treatment back in Myanmar.

Conclusion Older people are disproportionately affected in almost every serious natural hazard event.Vulnerability of older individuals might affect older people’s ability to recover from disaster impact unless specific support is given to bridge this constraint. Health threats brought about by extreme weather/​climate disasters are expected to increase in frequency and intensity globally, and their potential implications for the older population require urgent attention. The next chapter will discuss disaster response and how older people might require extra facilitation and support to obtain the basic requirements to survive in crisis.

References The 2015 Lancet Commission on Health and Climate Change. (2015). Health and climate change: policy responses to protect public health. The Lancet, 386, 1861. Allaire, A. (2013). Protection interventions for older people in emergencies. London: HelpAge International.

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Chan, E.Y.Y., Goggins, W. B.,Yue, S. K., & Lee, P.Y. (2013). Hospital admissions as a function of temperature, other weather phenomena and pollution levels in an urban setting in China. Bulletin of World Health Organization, 91(8), 576–​584. doi: 10.2471/​BLT.12.113035 Chan, E. Y. Y., & Griffiths, S. (2009). Comparison of health needs of older people between affected rural and urban areas after the 2005 Kashmir, Pakistan earthquake. Prehospital and Disaster Medicine, 24(5), 365–​371. Chiu, C. H., Schnall, A. H., Mertzlufft, C. E., Noe, R. S., Wolkin, A. F., Spears, J., et al. (2013). Mortality from a tornado outbreak, Alabama, April 27, 2011. American Journal of Public Health, 103(8), e52–​e58. Chowell, G. M. A. M., Miller, M. A., & Viboud, C. (2008). Seasonal influenza in the United States, France, and Australia: Transmission and prospects for control. Epidemiology & Infection, 136(6), 852–​864. Ciottone, G. R., Anderson, P. D., Auf Der Heide, E., Darling, R. G., Jacoby, I., Noji, E., & Suner, S. (2006). Disaster medicine (3rd ed.). Philadelphia, PA: Mosby Elsevier. Cox, G. W. (1981). The ecology of famine: An overview. In J. R. K. Robson (Ed.), Famine: Its causes, effects and management (pp. 5–​18). New York: Gordon and Breach. Cox, N. J., & Subbarao, K. (2000). Global epidemiology of influenza: Past and present. Annual Review of Medicine, 51(1), 407–​421. Crimmins, A., Balbus, J., Gamble, J. L., Beard, C. B., Bell, J. E., Dodgen, D., et al. (Eds.). (2016). The impacts of climate change on human health in the United States: A scientific assessment. US Global Change Research Program. Retrieved from https://​health2016.globalchange.gov/​ Doocy, S., Daniels, A., Murray, S., & Kirsch, T. D. (2013). The human impact of floods: A historical review of events 1980–​2009 and systematic literature review (Version 1). PLoS Currents, 5(Disasters). doi: 10.1371/​currents.dis.f4deb457904936b07c09daa98e e8171a Duggan, S., Deeny, P., Spelman, R., & Vitale, C.T. (2010). Perceptions of older people on disaster response and preparedness. International Journal of Older People Nursing, 5(1),  71–​76. Field, C. B., Barros, V., Stocker, T. F., Qin, D., Dokken, D. J., Ebi, K. L., et al. (2012). IPCC, 2012: Managing the risks of extreme events and disasters to advance climate change adaptation: A special report of Working Groups I and II of the Intergovernmental Panel on Climate Change. Cambridge: Cambridge University Press. Glezen, W. P., & Simonsen, L. (2006). Commentary: benefits of influenza vaccine in US elderly—​new studies raise questions. International Journal of Epidemiology, 35(2), 352–​353. Goggins, W. B., Chan, E. Y. Y., Ng, E., Ren, C., & Chen, L. (2012). Effect modification of the association between short-​term meteorological factors and mortality by urban heat islands in Hong Kong. PLoS ONE, 7(6). doi: 10.1371/​journal.pone.0038551 Goggins, W. B., Chan, E.Y.Y.,Yang, C.Y., Chong, M. (2013). Associations between mortality and meteorological and pollutant variables during the cool season in two Asian cities with sub-​tropical climates: Hong Kong and Taipei. Environmental Health, 12(1), 59. doi: 10.1186/​1476-​069X-​12–​59 Greenberg, M. R. (2014). Protecting seniors against environmental disasters: From hazards and vulnerability to prevention and resilience. London: Routledge. Hansell, A. L., Horwell, C. J., & Oppenheimer, C. (2006).The health hazards of volcanoes and geothermal areas. Occupational and Environmental Medicine, 63(2), 149–​156. doi: 10.1136/​ oem/​2005.022459 HelpAge International. (2000). Older people in disasters and humanitarian crises: Guidelines for best practice. London: Author. HelpAge International. (2012). The neglected generation:The impact of displacement on older people. London: HelpAge International and the Internal Displacement Monitoring Centre.

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7 POST-​DISASTER RESPONSE AND RECOVERY TO MEET HEALTH NEEDS OF OLDER PEOPLE: I

Although older people are vulnerable to disaster, their needs are often overlooked in response. Survival of older people in crisis might depend on access to the appropriate support and healthcare services as they are more susceptible to injuries, communicable diseases, worsening of existing medical conditions, and lack of access to appropriate nutritional and social support. This chapter examines the health needs of older people following disasters, and the typical response gaps in meeting those needs.

Challenges in a disaster context Overall basic needs In disasters and emergencies, injury and environmental health risks may impact on survival and well-​being. When compared with the younger population, older people might present different health needs-​ patterns in post-​ disaster contexts. Although disruption of basic and critical infrastructure such as lack of access to clean water, food, electricity, sanitation and waste management, and healthcare service would affect the whole community, regardless of their status, older people with limited intrinsic capacity to address external stressors are more likely to be living on their threshold of survival. The following discussion shows how suboptimal disaster context might affect older people’s exposure to risks and vulnerability.

Mobility and evacuation Older people, with age related musculoskeletal deterioration and associated disability, are more likely to be housebound and living in isolation. They might be difficult to locate, with limited access to information and more barriers to

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receiving warning messages. In addition, those who lost their supportive devices (e.g. spectacles, walking prostheses and hearing aid) during emergencies might have difficulty accessing and participating in relief and rescue efforts. Unless special measures are put in place to provide support for older people and to prepare them for disasters (e.g. outreach services might have to be organised to identify isolated older people, help with evacuation or ensure receive of relief materials), sensory impairments (vision and hearing) and mobility constraints might render them less likely to escape and evacuate in a timely manner. As a result, many older people might face the fate of being left behind in evacuation and rescue efforts.

Environmental risks Disruption and deterioration of basic lifeline resources supply (e.g. water and sanitation), exacerbation of underlying environmental hazards (e.g. secondary disasters such as landslide) and augmented health risks (e.g. vector-​borne diseases) often increase communicable diseases risks for a disaster-​affected community. Due to constraints in mobility and resources, older people are also less likely to reside in favourable temporary housing and camp settings in the emergency crowded living context. Suboptimal immune systems and nutritional status render older people more likely to contract common communicable diseases such as diarrhoea, pneumonia and skin infections. With a more sedentary and context-​bound lifestyle, older people are also more susceptible to malaria, dengue fever and scabies, as well as to contracting chronic communicable conditions such as tuberculosis in emergency or camp settings.

Underlying health risks As mentioned in earlier chapters, chronic non-​communicable diseases (NCDs) often accompany ageing. Published evidence shows disasters and extreme contexts would exacerbate morbidity and mortality of people with underlying NCDs. Potential consequences of poorly managed or non-​treated NCDs might be fatal. For example, untreated ischemic heart diseases might lead to higher risks of myocardial infarction, and poor management of diabetes might result in poor wound healing, renal failure, blindness, limb amputation, stroke and death. Unfortunately, unless medical and health responses are sensitive to the underlying medical needs, the likelihood of priority given to NCDs during emergency will remain low.

Geriatric trauma Aged-​related physiological changes and comorbidities have made care and management of elderly trauma patients different from the younger population subgroups. Trauma case fatality in older people can be triple that of their younger counterparts (McGwin, Melton, May, & Rue, 2000). Traumatic brain injury accounts for 80% of mortality in older people (Peters, Beyth, & Bautista, 2009; Stuke, Greiffenstein,

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Marr, & Hung, 2014). With advanced aged, an increased propensity of injury due to falls, and the potential uses of anticoagulants and antiplatelet as underlying NCD treatment, have made management of intracranial haemorrhage a major challenge. Patients of older age are also less likely to have favourable health outcomes with haemorrhagic shock, spinal cord injury, rib, hip and pelvis fractures and concurrent use of multiple medication. If no review of the type of underlying medication is done, clinical and survival prognosis for a patient might be compromised. For instance, the use of beta blockers, a typical medication used for hypertension and myocardial ischemia, might affect the outcome and prognosis for people experiencing haemorrhagic shock. Age, pre-​trauma health status, underlying medical problems and medication use, and intrinsic capacity will affect both assessment and management of injury (Stuke et al., 2014). In addition, with ageing, there come the problems of response time to emergencies, capacity for thermoregulation, injury, infection risks, diet needs and recovery time. After disasters, during evacuation, older people might exhibit reluctance to leave familiar surroundings; and this might also hamper rescue effort. Service delivery points need to be accessible and age-​friendly (in terms of terrain, opening hours, weather and transportation) to ensure older and vulnerable populations are not excluded from service access and do not experience decreased survival potential. Special arrangements (e.g. fast-​track queues and transportation which is age-​friendly) might need to be organised to ensure the most vulnerable and frail older people might not be disadvantaged if demand of relief supplies as well as security risks are high.

Protection Protection and ensuring equal access to essential services in emergency and crisis settings are of paramount importance for extremes of age. In emergencies where there may be a breakdown of security and order, protection of vulnerable people from theft, physical and sexual abuse, and legal entitlement will be necessary.Trauma, lack of physical strength, immobility and isolation bestow on older people extra vulnerabilities in terms of essential service access. Special attention should be paid to ensure older disaster-​affected individuals, even with physical function limitations such as impairment in hearing, vision, situational awareness and mobility, will not be disadvantaged in accessing medical services (e.g. health-​/​life-​maintaining drugs/​ treatment), social support (e.g. meal preparation and relief material delivery), transport, communication and information (e.g. access to media/​wifi connection).

Principle of post-​disaster response: Basic requirements for health In emergencies, public health and medical response should aim to maintain and address the five core areas of survival, health and well-​being to reduce the adverse health impact of emergency in the affected community. These core areas include

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water and sanitation, food and nutrition, shelter and non-​food items, health service and information (Bolton & Burkle, 2013; Chan, 2017). Each of these key areas has its own technical challenges, standards and key respondents and stakeholders in an emergency situation. The following section provides a description of the general principles as well as the specific consideration for older people in crisis.

Water supply, sanitation and hygiene promotion (WASH) Water is essential for human life. Inadequate or contaminated water poses threats to the health and survival of human beings. “WASH”, an acronym of water, sanitation and hygiene, is a core determinant of post-​emergency health outcomes, as well as in the normal routine of life. Equitable access to safe water and basic sanitation services, coupled with improved hygiene practices, is proven capable of reducing mortality and improving health outcomes across all age groups (UNICEF, 2006). Disasters such as earthquakes, floods and chemical spill accidents may severely disrupt regular water supply facilities. Damaged public water systems may not be able to support water distribution and maintain sufficient water supply for daily health-​maintaining activities. Inadequate water supplies, substandard sanitation, and poor hygiene practices render people more vulnerable to water-​and sanitation-​ related illnesses such as diarrhoeal diseases, measles, cholera and malaria. In emergency displaced camp situations, it was found that more than 40% of deaths were attributed to diarrhoeal diseases, with more than 80% happening among children under two years of age (Connolly, Gayer, Ryan, Salama, Spiegel, & Heymann, 2004). Most of these post-​emergency water-​related diseases are preventable. Sphere and the World Health Organization (WHO) recommend the implementation of WASH programmes to reduce faecal–​oral transmission of disease and exposure to disease-​bearing vectors arising from stagnant water sources, contaminated water, lack of water, and unwashed hands (Sphere, 2011; WHO, PHE, & partners, 2017b). Vector-​borne diseases are a common disease burden in emergency settlements. In overcrowded situations with poor hygiene, particularly in geographic areas where underlying vector risks such as mosquitoes, flies, fleas, or lice are common, the possibility of post-​disaster outbreaks of malaria, dengue fever and filariasis might be of major concerns. The provision of safe drinking water, the promotion of good hygiene practices and the reduction of environmental health risks are thus of highest priority among interventions in emergency situations (WHO, PHE, & partners, 2017b). Provision of clean water is the immediate need in the early phase of an emergency. Typically, the water resources are contaminated or the water pipe system is disrupted/​ destroyed in disasters. Water tankering or water trucking is one of the common rapid means of transporting water to the affected areas. There are various ways of treating water before it can be consumed by humans safely. Water treatment (such as filtration, boiling, chlorination and solar disinfection) and proper water storage are some of the simple methods that can be carried out at the household level. In

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addition to water quality, water quantity should be prioritised as an essential need (Chan, 2017; WHO, PHE, & partners, 2017b). Effective hygiene promotion is one of the public health tools for reducing the incidence of water-​related diseases. It covers a wide range of activities that aim to reduce health risks and disease transmission through good hygiene practices, such as hand-​washing, water boiling and proper latrine-​use. In an emergency, the provision of sanitation facilities is essential for containing excreta and human waste. A simple pit latrine structure is the simplest type of emergency latrine that can be built speedily awaiting the installation of communal toilets. If water is available, preferable sanitation facilities such as trench latrines might be constructed. While it depends on ground capacity in the emergency context, the basic principle when building these latrines is to design and place the latrines at least 15 metres away from the groundwater sources and the bottom of the latrine at least 1.5 metres above the water table (Sphere, 2011). Communal latrines should be constructed as soon as possible. Special attention should be paid to building latrines when the community has significant groups of vulnerable populations, such as older and disabled people. Modifications, such as providing a handrail, a chair and a rope fed through a pulley to the door for closing, should be considered to enable these people to use the toilet independently (Oxfam, 2007). Another important concern is protection against violence and sexual assault for latrine users, especially when the facilities might be used at night. For this purpose, there should be separate facilities for men and women, and adequate lighting should be provided (Inter-​Agency Standing Committee, 2005). Clean water should also be made available near sanitation facilities for hand hygiene use. The United Nations Children’s Fund (UNICEF) is one of the most important global actors in ensuring the provision of water, sanitation and hygiene in emergency situations.

For older people While the risks of contracting diarrhoea diseases are similar in the camp setting, older people might experience more rapid debilitation or even fatal consequences associated with dehydration if not treated in a timely manner. Age, gender analysis and cultural sensitivity should be used to identify and ensure access to water and sanitation facilities for older people. Ensuring safe and appropriate access to water and sanitation is especially important for older people who might have difficulty walking long distances for essential water collection and using sanitation facilities. Older people might also have problems in using water pumps and carrying heavy loads during the water collection process. To maximise the possibility of self-​care and self-​help, modification of hand pumps, availability of special adapted water containers (to facilitate water collection) and latrines supporting rails should be built to reduce barriers for older people to access this lifeline health facilities. In addition, to protect and respect the dignity of the affected population, latrines types should be selected according to geographic context, culture, gender

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and religious sensitivity. Adequate toilet facilities with gender separation should always be attempted (HelpAge International, 2000).

Food and nutrition Adequate food and nutrition are required for survival and maintenance of good health. Although the right to adequate food, as a human right, should be ensured in any circumstances (United Nations, 1948, Article 25:1), food shortages and inadequate nutritional support are often associated with emergencies and their responses. Morbidity and mortality associated with food shortages can hamper disaster recovery (WHO, 2000). Malnutrition refers to both under-​nutrition and over-​nutrition (Chan, 2017). Under-​nutrition occurs when intake or absorption of energy, protein and micronutrients is inadequate. Acute under-​nutrition can result in wasting, which is defined as having a weight-​to-​height ratio two standard deviations below the median of a reference population. It is characterised by a rapid deterioration in nutritional status over a short period of time. In infants and children, chronic under-​ nutrition due to poor maternal nutrition status, poor infant and young child feeding practices, or repeated infections can lead to stunting, characterised by achieving a height two standard deviations below the median height of people of the same age in a reference population (UNICEF, 2012). In contrast, over-​nutrition occurs when an excessive amount of nutrients is absorbed due to over consumption of food, resulting in people becoming overweight and obese. Severe acute malnutrition/​under-​nutrition is of specific concern in low-​ income countries afflicted by drought, famine, wars and conflicts, leading to both short-​and long-​term health impacts, such as growth retardation and lowered immunity due to protein-​energy malnutrition; anaemia, maternal and foetal mortality and intrauterine growth retardation resulting from iron deficiency; and night blindness as a result of vitamin A deficiency. In emergency settings, it is important to ensure that the affected population is able to access adequate and safe food (Sphere, 2011). Current literature has limited discussion and publications regarding older people’s nutrition and dietary situation in various disastrous contexts (see also Knowledge Box 7.1). The World Food Programme (WFP) and the Food and Agriculture Organization of the United Nations (FAO) are the two international agencies responsible for food assistance. WFP coordinates food supply during emergencies including natural disasters, wars and civil conflicts, and it helps communities rebuild their lives and livelihoods with food after the emergency phase. WFP is also responsible for coordinating logistics during an emergency response: improving logistics infrastructure, offering common logistics services and providing logistics information such as the United Nations Humanitarian Air Service (UNHAS) flight schedule and detailed lists of available local transport for the humanitarian community (World Food Programme, n.d.a, n.d.b). Established in 1945, FAO is a UN agency leading international efforts to fight hunger. One of its priority work areas is to increase

KNOWLEDGE BOX 7.1  RETHINKING BODY MASS INDEX AND NUTRITIONAL ASSESSMENT OF OLDER PEOPLE Tony Ka-​chun Yung Measuring the nutritional status of older people is a challenging task, not only because of their diminishing taste threshold and poorly fitting dentures which lead to a decreased food intake, but also the existence of chronic diseases (sometimes multiple) makes it difficult to interpret the collected measurements. Body mass index (BMI), referring to the individual’s weight (kg) divided by the square of height (m2), bears an important role in assessing nutritional status of older people. World Health Organization (WHO) defines the healthy (normal) BMI range as 18.5–​24.9 kg/​m2 for adults. Any BMI lower than such range would be defined as underweight, while a BMI of 25 kg/​m2 or above classifies as overweight or obese. Currently, although there is no specific guideline for practitioners in classifying BMI for older populations, there is strong evidence that the abovementioned WHO cut-​ off is not suitable for assessing nutritional status of ageing populations. A recent meta-​ analysis by Winter, MacInnis, Wattanapenpaiboon and Nowson (2014) analysed 32 cohort studies involving a total of about 200,000 subjects of age ≥65. It reveals the lowest all-​cause mortality is at BMI range of 24–​31 kg/​m2. Therefore, some agencies including Australia & New Zealand Society for Geriatric Medicine recommend the use of 24–30 kg/​m2 as the practical guideline for healthy weight range (Australian and New Zealand Society for Geriatric Medicine, 2011). In addition, measuring body weight and height could be difficult when the older person is bed-​bound. The use of knee height as a proxy to estimate body height is thus commonly practised. By measuring the length of the lower leg and substituting it into the designated equation,1 the body height can be estimated for the subsequent calculation of BMI. In recent years, some new design of electronic balance can assist measuring the weight of immobile individuals. However, these devices are usually costly and they might not be accessible in emergency and humanitarian contexts. In addition to BMI, the use of nutritional screenings could also effectively assess and identify malnourished older people. Among them, the Malnutrition Universal Screening Tool (MUST) (Elia, 2003) is an example that has been extensively used in both clinical settings and older people institutions. It calculates a score by assessing the current weight, weight change in the previous six months, and recent dietary intake. The resultant score will then be classified into low, medium or high risk of malnutrition, which provides a hint to the assessor for necessary nutrition intervention. As this is extremely easy to carry out, healthcare workers with appropriate training would be able to assess older people’s nutritional status independently. This helps relieve the workload of frontline clinicians and, most importantly, it speeds up the identification of potential malnourished older people for following up. Note Male: (2.02 x knee height (cm)) –​(0.04 x age) + 64.19. Female: (1.83 x knee height (cm)) –​(0.24 x age) + 84.88 1

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the resilience of livelihoods from disasters through reducing risks and enhancing the resilience of a country’s food and agriculture systems.When emergencies strike, FAO is responsible for ensuring disaster response plans are coordinated at different levels (Food and Agriculture Organization of the United Nations, n.d.). During the emergency phase of a disaster, rapid nutritional needs assessments are needed at the individual, family, vulnerable group and the general population levels to differentiate needs and gaps of services. As nutritional needs are different for particular groups, e.g. older people with chronic diseases might have special dietary needs and food avoidance, it is important to disaggregate data by sex and age at the minimum so that the most affected groups can be identified and the needs of vulnerable groups can be addressed appropriately. Nutritional interventions, such as general food distribution, additional micronutrients in staple food and specific interventions, may then be targeted at high risk subgroups in a disaster-​affected community (WHO, PHE, & partners, 2017a). Food and nutrition programmes as means of nutritional interventions can generally be classified into general feeding programmes and selective feeding programmes. As ensuring that basic food and nutrition is of utmost importance for basic survival in an emergency setting affecting a large population, the general feeding programme aims to provide the affected population with minimum energy, protein, fats and micronutrient requirements adequate for light physical activity. It could be implemented by on-site feeding or distribution of a dry ration. A selective feeding programme is a more targeted food programme aiming to reduce the prevalence of malnutrition and related mortality among vulnerable groups such as older people by providing them with additional energy and nutrients not provided in the general feeding programme. An example of special nutritional products commonly used at the emergency phase is ready-​to-​use food provided as a supplement to children of six to 59 months old at high risk of developing malnutrition (WHO, 2000). Moreover, the selection of appropriate nutritional interventions should follow the scientific evidence and the latest best practice (WHO, PHE, & partners, 2017a).

For older people With different physiological status, underlying health problems (non-​ communicable diseases such as diabetes and dental health problems) and nutritional requirements, risk factors towards poor nutritional status in older people should be reviewed and relief programmes should be planned accordingly. Actions that aim to address food and nutrition needs in an emergency context should consider the best way to facilitate access for older people to appropriate food and relevant nutritional support. To address physiological changes and the potential denture issues, food rations should be developed that are consumable and digestible by older patients. The food choice should also be culturally and religiously appropriate (no pork-​based food rations for a Muslim-​based community). Special supplementary feeding support should be made available for older

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people who might be undernourished or severely malnourished. Age-​friendly cooking and eating utensils should be made appropriate for the limitations of older people (e.g. smaller in size and lighter in weight, especially for those living alone) (HelpAge International, 2000). Older people’s access to food provision should be ensured to address potential underlying mobility problems. To avoid exclusion by age, special food distribution for the older age group might need to be developed (e.g. a food delivery mechanism, the facilitation of a “foster” family to support cooking for older people who might be unable to prepare a meal for themselves, and seating arrangements in feeding sites for those who have problems standing for a prolonged period of time).

Shelter and clothing In a disaster-​affected population, damage and destruction might lead to the loss of shelter and personal assets. Shelters provide physical and environmental protection to individuals and post-​disaster shelters protect disaster-​affected individuals from further adverse health impacts of environmental risks and offer personal safety, privacy and dignity. Suboptimally constructed shelters and overcrowded living environments with poor indoor air quality may contribute to poor health outcomes. The resulting acute respiratory infections, such as pneumonia and bronchitis, are common causes of non-​trauma-​related death in disaster and emergency contexts. Safe shelters and the provision of adequate clothing at the emergency phase in disaster are critical for survival and they should be constructed to minimise local environment and health risks. In hot and humid climate contexts, people might be exposed to excessive heat and humidity if adequate air ventilation is neglected. The resulting heat stress might cause dehydration or even heat stroke. In cold climates, emergency temporary shelters need to consider heat insulation to decrease the risk of respiratory diseases that can be contagious and affect the whole camp. Shelters and clothing may also serve as vector and insect barriers, which help prevent vector-​borne diseases (Checchi, Gayer, Grais, & Mills, 2007; Chan, 2017). While there are different types of shelter and approaches that could be used in an emergency context, it is essential to assess local needs, capacities and resources before planning and preparing for shelter provision. The safety and security of the potential shelter building sites, availability of human resources, institutional capacity within communities, availability of building materials and technology, as well as financial resources should be explored during the assessment phase. For areas with less destruction of houses and without major population displacement, housing repair might be the prime strategy to ensure safe sheltering. Repairing damaged houses is the cheapest and quickest way to provide adequate housing to the affected community and may also be a less traumatic approach for the affected community (Barakat, 2003). In areas where housing repair is not feasible, emergency and temporary shelters would need to be considered. Emergency and temporary shelters usually

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involve plastic sheeting, tents or emergency centres, which are designed to endure the shelter needs in the early phase after a major disaster. Plastic sheeting, a type of temporary building material made from polyethylene, is one of the most commonly used materials for emergency shelters. While this kind of shelter has the advantages of high versatility and low cost, it is intended as a short-​term solution for sheltering and its typical anticipated lifespan is less than two years. To improve the suboptimal indoor environment of makeshift camps, framing and support should be provided along with the plastic sheeting to prevent people from cutting down trees to build frames for their camps. Sheeting made from non-​renewable materials should have a proper disposal plan, and fire risk prevention should always be promoted in displaced shelter contexts when inflammable living tents are used. Emergency and humanitarian agencies might respond differently, according to local situations where shelter building or repair is needed. The specific approach adopted should be based on disaster type, geographical condition and cultural practices. Agencies can help by providing appropriate construction materials, tools and fixings, cash or vouchers, technical guidance and training, or a combination of the above (Sphere, 2011). It is important to highlight that the “sheltering process” is a continuum between short-​term humanitarian action and long-​term development. During the construction of shelters, social and education services, access to market and responsible use of natural resources should also be taken into consideration (International Federation of Red Cross and Red Crescent Societies, 2012). Under the cluster approach led by the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), the International Federation of Red Cross and Red Crescent Societies (IFRC) and the Office of the United Nations High Commissioner for Refugees (UNHCR) co-​chair the shelter cluster during disasters. The former is responsible for coordinating shelters in disaster contexts while the latter coordinates shelters for IDPs. IFRC is one of the largest international humanitarian organisations. It carries out relief operations to assist victims of disasters, combining this with development work to strengthen the capacities of its member national societies. In a natural disaster, IFRC usually leads the shelter cluster for a minimum of three months or until the end of the emergency phase (International Federation of Red Cross and Red Crescent Societies, 2012). Established in 1950, UNHCR is mandated to lead and coordinate international action to save lives, protect rights and build a better future for refugees, forcibly displaced communities and stateless people, as well as to resolve refugee problems worldwide. It leads the shelter cluster during man-​made disasters and conflicts (Office of the United Nations High Commissioner for Refugees, n.d.a, n.d.b). Non-​shelter-​and non-​food-​related items for disaster relief typically include clothes, utensils, personal hygiene materials and basic temporary devices (e.g. lamps). The appropriateness of these items provided during a disaster should be considered, specifically in terms of local culture, weather, age and gender appropriateness, to address special needs of the vulnerable population. Durability and sustainability should also be evaluated to avoid the production of waste and useless supply in the relief context.

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For older people Given the mobility, sensory, dietary and protection needs of older people, special consideration should be given to site selection, delivery mechanisms, facilities and shelter construction to ensure accessibility, relevancy, safety and protection of dignity for older people in times of crisis. “Age-​friendly” infrastructures (e.g. ramps, large information signs), lighting and age-​supportive devices (walking sticks, spectacles, hearing devices, the provision of mattresses or straw/​g rass for carpeting hard floor) might dramatically increase the self-​care and management potential of an older person. The availability of mattress and sleeping floor can help avoid joint and muscle pain, which might be debilitating for older individuals if the emergency-​ shelter context requires a prolonged stay. Age-​related non-​food items should be included for older people. In addition to clothing (cultural and gender appropriate), blankets, cooking utensils, fuel/​water collecting buckets and personal hygiene items, availability of specific health related items such as older people’s urinary napkins would be useful for older people who suffer from lower limb injuries or have no mobile capacity to walk to latrines or toilets. As older people typically have less capacity to withstand cold temperatures, extra blankets and clothes should always be distributed for the older population subgroup. Fuel and water access should be ensured for older individuals. It is also important to consider the family and social dynamics associated with the allocation of shelter or temporary accommodation for older people. Having accompanied family members is not necessarily related to being supported or cared for. Additional rations should be provided for “foster families” who are willing to support and adopt care for isolated and left-​behind older individuals in emergency settings. In addition, grouping older people to reside/​live together, regardless of gender and cultural appropriateness, might cause serious problems such as abuse, exclusion, violence and affected survival. Specifically, gender separation and protection should always be attempted in shelters (HelpAge International, 2000). If unavoidable due to constraints, permission must be sought and obtained to avoid potential sexual harassment and abuse of older women.

Health services Medical and health services in crisis situations should prioritise those who are most vulnerable and might be most likely to benefit from the care or services. In addition to ensuring access to healthcare service and social support that might maintain well-​being, secondary prevention of medical conditions and health complications from comorbidities is crucial for avoiding underlying health problems from escalating. Availability of relevant medications (e.g. those for chronic conditions) and follow-​up management to address common underlying medical needs (e.g. NCDs) should also be ensured. In urbanised settings, attempts should be made to ensure that medical records of older people are available to ensure continuity of care.

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CASE BOX 7.1  POST-​DISASTER CHRONIC DISEASE CARE IN ASIA Chronic disease management might be forgotten during emergency situations, as disaster and emergency response often tend to focus on the management of trauma and the prevention of disease outbreaks. Meanwhile, epidemiological transition of disease burden and global population ageing have shown an overwhelming burden of chronic diseases in many disaster-prone countries and patients with chronic diseases will present essential health-maintaining needs in disasters. Table 7.1 shows the burden of chronic diseases in some disaster-​prone countries. TABLE 7.1  Burden of chronic diseases in some disaster-​prone countries

Country

Total number of natural disasters 2000–​2008

Proportion of chronic disease deaths (among total deaths, %)

China India Indonesia Pakistan

235 160 133 61

79 53 61 42

Sources: Chan (2017); Chan and Sondorp (2008).

Regardless of the causes of the disasters, extreme or emergency events are likely to disrupt regular provision of health services. At the early stage of disasters, the access to and provision of life-saving healthcare service is a critical determinant for survival. With large numbers of injured people, the mass influx of injured victims combined with a shortage of health workers may cause chaos in health service provision. In addition, damage to health infrastructure and injury and death of healthcare providers may disrupt existing health services and leads to access issues for people who need regular healthcare for non-​communicable diseases to maintain health although they might not have sustained injury during the disaster. Case Box 7.1 describes the chronic diseases care needs in many disaster-​prone countries in Asia. The World Health Organization (WHO) is a specialised agency of the United Nations responsible for providing leadership on global health matters. Under the UN cluster approach, it is the leading agency in the health cluster and responsible for coordinating health needs in emergencies. Apart from WHO, the military, non-​governmental organisations (NGOs) and civil society (general community) are also involved in providing health services during emergencies. Immediately after a major disaster, military medical forces are usually the earliest medical teams to arrive in the immediate aftermath of a disaster and coordinate the re-​establishment

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of civilian services. Their access to resources and logistic capacity often facilitate a structured approach in early relief response for resource distribution, security services, search and rescue, medical interventions, building temporary camps and ensuring transportation and logistical capacity. With limited resources during and after disasters, how medical and health services are to be organised remains a subject of debate and research. Triage sorts and prioritises victims for medical attention based on the severity and prospect for survival, which ensures the orderly provision of healthcare in emergency situations. The two basic principles of triage are first, that it is not possible to do everything for everybody, due to time, material and human resource constraints; and second, that the aim is to achieve the best possible results for the greatest number of people (Checchi et al., 2007). Disasters often result in an enormous number of casualties and a massive damage to the health infrastructure. Setting up a field hospital is considered one of the strategies to handle this situation. Field hospitals are typically mobile, self-​contained, self-​sufficient healthcare facilities capable of rapid deployment and expansion or contraction to meet immediate emergency requirements for a specified period of time. According to the WHO recommendation, field hospitals should be able to provide early emergency medical care (up to 48 hours post disaster), offer follow-​up care for trauma cases, routine healthcare and emergencies (from day 3 to day 15 post disaster), and act as a temporary facility to substitute damaged installations, pending repair or reconstruction (from the second month to two years or more post disaster). Basic requirements for field hospitals include: i) being fully operational within 24 hours of the disaster; ii) being entirely self-​sufficient; and iii) offering comparable or higher standards of medical care than were available in the affected country prior to the precipitating event (Pan American Health Organization/​WHO Regional Office for the Americas, 2003). The organisation of mobile health units is another service provision strategy to provide healthcare in remote unstable situations. However, due to their complexity, mobile health units often remain a last resort to reach out to the population that has no access to the health system. They are usually considered for a short transition period before the opening or reopening of fixed health service facilities to provide both preventive and curative services. Several factors need to be assessed before setting up mobile health units, such as what possible services might be included, whether such services may respond to the priority needs, if logistical resources are available and the capacity to refer patients to permanent health or care facilities (International Committee of the Red Cross, 2006; Checchi et al., 2007). A foreign medical team is a group of health professionals and supporting staff travelling outside their countries of origin to provide healthcare to disaster-​affected populations. It can involve governmental (both civilian and military) and nongovernmental staff members (WHO, 2013). Moreover, availability of mental health services post disaster is essential for protecting and maintaining the well-​being of the affected community and such services should be made available as early as possible. While mental health services

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KNOWLEDGE BOX 7.2  PSYCHOLOGICAL FIRST AID Developed since 2000, psychological first aid (PFA) is an emergency psychological tool or approach that aims to support individuals affected by emergencies and crises (Inter-​Agency Standing Committee, 2008; Sphere, 2011). PFA intends to be a self-​resilience technique based on communication and community support to individuals in psychological distress and the intervention might be offered through individual sessions or group counselling. The key elements of PFA include the provision of practical care and support to people in distress, needs and concern assessments, helping people address basic needs, emphasising the importance of listening but not pressurising affected individuals to talk, comforting affected individuals and helping them to feel calm, helping people connect to relevant information, services and social support, as well as protecting affected people from further harm.

require professional training and systems to ensure service provision (e.g. drug treatment for acute psychological distress and essential drug treatment for dementia and depression), community non-​specialised services that emphasise strong community participation should also be developed and promoted. For instance, psychological first aid (PFA) and mobile multidisciplinary community outreach health teams (which might provide both medical and psychosocial care support) may be pre-​trained and should be in place to support the affected community (see Knowledge Box 7.2). Health education and information sessions on approaches for self-care, health maintenance, use of medication and treatment might also be helpful to support and encourage self-​care post disaster.

For older people Health service organisation and prioritisation should align with needs associated with the disaster subtypes, contexts and epidemiological patterns. Although most essential preventive and curative health services are applicable across age cohorts, ensuring service continuity, availability of drugs for chronic disease management, rehabilitation and palliative care should be in place to address survival and health needs of the disaster-​affected population that might be of older age. Targeted geriatric care (eye or dental), disability, nutritional and care management might be provided through age-​related clinics that address common medical issues associated with ageing (e.g. joint and muscle pain) to reduce the service need pressure in regular emergency clinics, which need to treat more acute medical needs and for diverse groups of patients. In addition, ageing is usually accompanied by sensory deterioration, and additional clinical services might be required to support self-​care and older people’s needs. For example, making ophthalmological services available (e.g. for common geriatric

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KNOWLEDGE BOX 7.3  HOME-​BASED  CARE Home-​based care can reach out to people who might experience logistic challenges in accessing medical and health services. The care arrangement might be particularly valuable to older people who are living alone, in isolation, who are homebound in enclaves and remote areas. Typical services for home-​based care might include medical consultations, counselling sessions, self-​care skill training (wound management) as well as health education for awareness raising. The service might also help reduce tension arising from family member/​ caregiver dependency. Monitoring of service needs and patterns can also help ensure care quality and well-​being of older people who might be forgotten and underreported in general clinic care settings.

visual problems including cataract and presbyopia, cataract operations, provision of eye assessments and corrective spectacles) in developing resource-​deficient settings not only will improve self-​care possibilities for older people in time of crisis, the services might also have a positive impact on the well-being of older people even beyond the emergency period. Dental care is another essential service that is often missed in service provision during emergency contexts. Older people with dental problems might have difficulties in consuming emergency food supplies. This might hamper nutrition support despite the availability of food rations (especially in areas experiencing food crisis and famine). In terms of service organisations, home-​based care and palliative care might constitute important healthcare needs of older people after an emergency or crisis (see Knowledge Boxes 7.3 and 7.4 and Case Box 7.2). For older people who have underlying physical disabilities before the disaster event, vulnerability assessment to evaluate mobility support is crucial to enable disabled older people to access care. Age-​friendly, barrier-​free service, care referral systems, mobile clinics, properly trained clinical and supporting staff and appropriate resources are all necessary to ensure older people obtain their support during emergencies. Coordination is necessary to ensure implementation and monitoring. In addition to acute (trauma) and chronic (non-​communicable diseases) service needs, psychosocial and palliative care services should be integrated in the context if ever possible. Health rehabilitating service and allied medical support (e.g. provision of assistive devices) should be organised with the aim to minimise capacity loss and promote self-​care and independence. In addition, gender equality awareness in access to services and information might be limited. Studies have shown well-​ meant gender sensitive (e.g. female-​only psychosocial health service post disaster) services might also unintentionally lead to a situation of reversed discrimination of gender access (i.e. males having no access) (Chan & Griffiths, 2009; Chan, 2017). Due to the limited self-​care and recovery potential of older individuals who might be injured during emergency and disaster, the capacities and mobilisation of

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KNOWLEDGE BOX 7.4  PALLIATIVE CARE As defined by WHO, palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-​ threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual (WHO, 2018). It aims to provide relief from pain and other distressing symptoms; to affirm life and regard dying as a normal process; neither to hasten nor postpone death; to integrate the psychological and spiritual aspects of patient care; to offer a support system to help patients live as actively as possible until death; to offer a support system to help the family cope during the patient’s illness and in their own bereavement; to use a team approach to address the needs of patients and their families, including bereavement counselling, if indicated; to enhance quality of life, and perhaps also positively influence the course of illness. It is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications. Palliative care is a process of aggressive symptom management, supported decision-​making and optimal end-​of-​life care, and it has traditionally been strongly associated with oncology care and end-​stage management of chronic diseases. But palliative care and services also constitute significant clinical service needs in a context with mass casualties and severe resources constraints. Proper end-​ of-​ life support not only relieves suffering but also protects an individual’s right to die with dignity. Older people, with their limited intrinsic physical capacity, are more likely to require such service and support (Gibson, 2014). Nevertheless, palliative care is often neglected or ignored in emergency and crisis contexts even though palliative medical care might be the only care option for patients with limited survival possibility in the extremely resource-​ deficient context. The technical knowledge and capacity required to provide competent palliative care are suboptimal. Relevant drugs for palliative care use might be unavailable in the essential drug lists (e.g. opioid analgesics) in emergency contexts. In addition, the capacity to engage in symptom control, provision of nursing care of dying patients, family support, psychosocial and spiritual care should not be underestimated. However, there remain major gaps in awareness of respecting the dignity of dying patients, which should always be observed regardless of the available resources (Knaul, Farmer, Krakauer, De Lima, Bhadelia, Jiang Kwete, et al., 2017) (see also Chapter 10).

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informal caregivers in disaster and emergency contexts matter to health outcomes and well-​being of older individuals after disasters. Nevertheless, limited literature has been published for understanding how the profile of caregivers and their services and support might influence the health outcomes and survival of disaster-​affected older people (refer to Chapters 8 and 10 for relevant discussions). Moreover, to address older people who might have been residing in nursing homes or institutions prior to the disaster, special support might be necessary to provide for these institutions (psychiatric units) to maximise normality of related service for their residents. For older people with dementia, knowledge and regular up-​to-​date training of emergency health carers is necessary to ensure staff will recognise symptoms and understand how to manage patients. During an emergency, especially when institutional facilities might be affected, volunteer networks should be organised to care for “orphaned” or single older individuals who have no family/​network. In addition, psychosocial programmes should involve or target older persons. Raising awareness of the impact of grief, loss of home and livelihood, bereavement, trauma and fear of dying in a foreign land is essential. The destruction and breakdown of social and cultural structure in crisis may cause disorientation, distress, anxiety and depression in older population. Sensitivity towards gender in obtaining mental or psychosocial support should also be taken into account to avoid reverse discrimination against older men in access to services (Chan & Griffiths, 2009).

Information Access to information is one of the basic human needs and tools for self-​care and self-​help in emergency response. In the modern world, however, information is often neglected and underestimated in relief and response planning. For instance, if there is a tsunami following an earthquake, lack of a warning announcement may hamper the evacuation and self-​help of the affected population. Disaster risk literacy and awareness may enhance community and individual awareness of health risks and capacity to respond and protect themselves. In addition to the disaster-​ affected people, information is also essential for humanitarian relief coordination and disaster response management. Disease monitoring and surveillance is vital in public health protection and can ensure efficiency in resource allocation. In recent years, more research literature has highlighted the gaps in community knowledge, emergency warning, disaster risk perception, disaster literacy, as well as individual-​ and household-​level preparedness (see Case Box 7.3).

For older people Information is vital for older people to plan and respond in an emergency. Nevertheless, literacy and sensory limitations of older people may imply the lack of capacity of processing general information provided by the government and agencies, which assume literacy, language and sensory competency of the information users.Thus, when planning for risk communication in emergency contexts, the

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CASE BOX 7.2  THE INSUFFICIENT EMPHASIS ON END-​OF-​LIFE CARE FOR CHRONICALLY ILL OLDER ADULTS IN DISASTER SITUATIONS Roger Yat-​nork Chung There is a general trend of declining mortality risk associated with disasters, largely credited to the life-​saving efforts of improved preparedness such as early warning systems and evacuation and response strategies (UNISDR, 2012). However, a disproportionate number of deaths during disasters are of older adults. As such, the benefits brought about by the disaster preparedness efforts should be extended toward the older adults for greater equity. In addition to mortality reduction, the care for older adults who are approaching the end stage of their lives when disaster strikes should also be emphasised. In fact, insufficient emphasis has been placed on palliative and end-​of-​life care during disaster situations, due to the fact that most of the attention will be paid to acute and emergency care. Palliative and end-​of-​life care has only been highlighted in recent years as an integral component of disaster preparedness –​the first guide on providing palliative care in mass casualty events was published in 2001 by the Agency for Healthcare Research and Policy (Phillips & Knebel, 2001); the importance of end-​of-​life care for long-​term residents in nursing home settings during disasters was highlighted by Frahm, Brown and Gibson (2011); and a book chapter advocating for the integration of palliative and end-​of-​life care within emergency preparedness and disaster response for seniors was published in 2014 as a guide for healthcare professionals (Gibson, 2014). Despite these recognitions of the importance of end-​of-​life care in the context of disaster, it has still been largely unaddressed in the Sendai Framework for Disaster Risk Reduction under the United Nations International Strategy for Disaster Reduction (UNDRR, 2015), the most high-​profile and encompassing international accord to date on disaster risk reduction. Moreover, it has been made increasingly clear by the shortfalls of some recent disasters in terms of secondary surge capacity to meet the increasing chronic healthcare demand following the acute phase of the disasters (Runkle, Brock-Martin, Karmaus, & Svendsen, 2012) that further progress needs to be made in terms of chronic disease management during disaster. In moving forward to a more comprehensive disaster preparedness that encompasses end-​of-​life care for chronically ill older adults, it is important to note that, although end-​of-​life care concerns mainly the last phase of life for the dying patients, any guidelines and/​or protocols of end-​of-​life care in the context of disaster should not only focus on the last phase but should be an integral part of a long-​term, continued care for the chronically ill patients.

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CASE BOX 7.3  RISK PERCEPTION IN URBAN CONTEXTS With its high population density, Hong Kong, a subtropical city in southern China, is susceptible to large-​scale natural disasters and health crises such as typhoons, fires and infectious disease outbreaks. Nevertheless, the vast majority of Hong Kong residents did not perceive the city as disaster-​susceptible and thus household preparedness was suboptimal. Although Hong Kong has frequent typhoon risks, the general public perception of the likelihood of a disaster was low and individuals and household preparedness towards typhoon disasters remained low. Even though more than three quarters believed that basic first-​ aid training was necessary to improve individual disaster preparedness, only one quarter had participated in such training. Besides, when compared with households with no older people, those with older people were found more likely to be prepared with relevant household supplies in case of emergency needs (Chan, Yue, Lee, & Wang, 2016).

literacy of the older population and their access to the message should always be considered.The sensory limitations of older people, particularly those who are alone in a disaster-​prone context, should be supported with targeted information delivery and network (e.g. a buddy system). Regular risk reminders and updates should be provided to older people, via channels and methods which they would normally use. Traditionally, visual depictions and pictures with simple text are often preferred to text-​only materials for older people to cater for the limited literacy skills or underlying visual impairment in older age. Design and presentation of disaster preparedness promotion materials should also obtain feedback from users (especially in older population who might have a different education and/or cultural background from the general population of the targeted community) for appropriateness and relevancy. Moreover, limited access to well-​designed communication content and channels might affect access to warning and life-​saving materials. Print materials, public service announcements and web-​based media have a lot of potential to support older people in disasters, but it is crucial to understand that the accessibility of the warning and life-​saving materials might be hampered by lack of knowledge and access to information technology devices (e.g., phone, computers and internet). A recent study in urban contexts in Asia showed that older people (especially the young olds) had indicated significant preference of switching to accessing disaster information using mobile/​internet information sources, but they also faced a major gap of information access capacity (Chan, Huang, Mark, & Guo, 2017). To ensure health systems can function in emergency contexts, attempts should be made to ensure medical records of older people are made available to allow emergency access to care information (e.g. underlying medical, drug and allergy records) for treatment planning (e.g. surgery) and continuity of care (see Knowledge Box 7.5).

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KNOWLEDGE BOX 7.5  AGE-​APPROPRIATE DISASTER WARNING AND COMMUNICATION SYSTEMS Older people with functional impairment (hearing, sight) might not be able to respond to a typical warning. With an assumption of the increasing use of social media, the sensitivity of computer literacy of the older population should be taken into account in warning systems. Disaster literacy has been a challenge for disaster preparedness efforts for seniors (Brown & Haun, 2014). Published scientific literature showed literacy might affect the ability of people to read, understand, and react to information that might allow them to make good decisions; and this may result in poor health outcomes such as hospitalisation, costs and self-​care management. For older people, poor health literacy might have potential implications on capacity to maintain basic well-​ being in a disaster context. In addition, there is currently a lack of evidence-​ based practices for effective, optimal dissemination of messages to vulnerable populations (Brown, Haun, & Peterson, 2014). Enhancing disaster literacy along the disaster literacy spectrum among older people should be one of the main objectives of risk communications. The goal is to enable them to exert greater control and personal responsibility along with increased awareness of personal, social and environmental factors that might affect the outcomes of disaster resilience and responses.

Global standards for relief Humanitarian responses are dynamic processes and continuous evaluation and updates are crucial to assessing the experience of affected people in a changing environment in various disastrous situations. Not all individuals have equal capability to respond during disaster. Women, especially pregnant women, children, persons with physical and mental disabilities and older people are considered to be vulnerable and at increased risk in disaster. For older people, isolation and physical weaknesses such as degenerations and comorbidities are significant factors contributing to their high vulnerability/​susceptibility in disastrous situations. This vulnerability reduces the access to all relief aids including water and sanitation, food and nutrition, shelter and non-​food items and health services. One of the protection principles of Sphere is to ensure people’s access to impartial assistance in proportion to need and without discrimination. The Sphere standards have integrated the standard guiding principle for older people since the 2004 version. Sphere emphasises the importance of vulnerable group identification and special needs assessments. It provides recommendations of special arrangements for older people. For example, on the subject of water and sanitation, toilets should have a seat or handrails for comfort and safe use of the toilet. Older people may need smaller or specially designed water carrying containers for clean water delivery. On the life-​saving

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CASE BOX 7.4  SPHERE: A PROTECTIVE UMBRELLA FOR OLDER PEOPLE IN DISASTERS Cheuk-​pong  Chiu Older people have been recognised as a priority group in the humanitarian response since 2014, and some up-​to-​date discussion was observed in the Sphere Handbook 2018. For water, sanitation and hygiene promotion (WASH), two new sections have been introduced. The new section called “WASH and Communicable Diseases Outbreak” gives recommendations for the implementation of infection prevention and control (IPC) in community and household levels. Older people are more vulnerable to vector-​related communicable diseases. Therefore, older people should be involved in the community/​ household vector-​control programme and act as key participants, as they can bring knowledge and experience of coping strategies into the programme. Their valuable experience may be a great asset for such a programme. The Sphere Handbook emphasises once again in 2018 that older people should be consulted and involved in each step of humanitarian response. For nutrition and food security, measurement of mid-​upper arm circumference (MUAC) is typically used in rapid nutrition assessments for children of six to 59 months in nutritional emergency. However, no specific tools or guidelines exist for older people and they may be at risk of malnutrition in emergencies. MUAC is an independent criterion for acute malnutrition and is one of the best predictors of mortality, although there is only a single set of cut-​offs in MUAC measurement to differentiate the nutritional status for all children under five years old (11.5cm and 12.5cm as cut-​offs for admission and discharge criteria for severe and moderate acute malnutrition). MUAC can also be applied to pregnant women for feeding programmes as MUAC does not significantly change through pregnancy. The 2018 version of the Sphere standards proposes the use of MUAC for measuring malnutrition among older people and provides preliminary cut-​offs information, although research on appropriate cut-​offs is still in progress. The former non-food items in “Shelter, Settlement and Non-Food Items” have been re-​structured and also included in “Household Items” in the 2018 edition. It takes the household as a unit and focuses on supporting the household. Household items suggested to be essential for response need include essential elements for daily activities such as sleeping, cooking and food storage. Types, quantity, quality and delivery mechanism of the household items should be specified according to the cultural norms and tradition, intended period of use and the categories of the affected population such as person with disabilities and older people. For building of shelters and settlements, as older people might have difficulties in some construction activities, volunteer community labour teams are encouraged to offer complementary assistance

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to households headed by older people. Safety of shelter and settlement is not only based on how well the shelter is constructed but also the presence of contingency plans especially in disastrous situations. The Sphere Handbook 2018 recommends that local authorities and communities should include older people in planning, particularly those facing mobility or accessibility barriers. For example, in the collective centre, alternative escape routes must be present and clearly indicated for emergency. In addition, older people are one of the clinically high-​risk groups. The pre-​disaster health needs and service availability for older people should be determined and prepared. Older people are more vulnerable to the impact of communicable diseases, for instance cholera, because of lower physiological resilience and comorbidities. When designing any treatment protocols, healthcare services/​ facilities and training of healthcare providers, capacity of older people must be considered. Palliative care is a new proposed area in Sphere, and it becomes an essential health service to be included in the Sphere Handbook 2018. It recommends the establishment of guidelines and policies on end-​of-​life care, integration of palliative care into all levels of the healthcare system, provision of training to medical personnel, maintenance of essential medical supplies and support for the service networks to patients and caregivers in the community. The latest Sphere standards also emphasise the importance of availability of information for health promotion and education. Information should be accessible by older people and in formats and languages that address their needs and capabilities. Sources: Sphere (2011, 2017, 2018).

aspect of food and nutrition, older people should be able to access the food resources easily and safely. Food accessibility can be achieved by setting older people as a target and establishing a formal registration of households to ensure no gaps in food distribution. Special actions, such as outreach food delivery, may also need to ensure the older people with low mobility and living in rural regions can receive food and entitlements. Public food distribution points should be safe, and should have easy to implement crowd control policy, as food distribution can create security risks. Supervision of the distribution is crucial. Older people are at risk of losing entitlement and getting injured in a chaotic environment. In addition, type and size of eating utensils should be suitable for older people and food must be easy to prepare and consume. For instance, tough meat with bones is not an option, as strong teeth and chewing are needed. For the quality and nutritional value of food, extra protein and micronutrients may be needed to meet the additional requirements of older people. Considering shelter and non-​ food items, older people are prone to heat loss and additional clothing, bedding and blankets may be required. Due to the population ageing, the disease profile is shifted from communicable diseases to

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non-​communicable diseases (NCDs) in many low-​and middle-​income countries and these countries are more vulnerable to disaster compared with high-​income countries. People with NCDs need long-term medication and follow-​up. However, owing to the interruption of medical care or drug supply during disaster, older people with chronic diseases are vulnerable to exacerbations of their condition. Management of non-​ communicable/chronic diseases is thus another essential health service, and it should be included in disaster health responses according to the Sphere recommendations (Sphere, 2011) (see Case Box 7.4).

Conclusion This chapter describes key disaster responses and implications of the health and well-being management of older people in emergencies. Additional post-​disaster response and recovery needs of the older population will be discussed in the next chapter.

References Australian and New Zealand Society for Geriatric Medicine. (2011). Obesity and the older person (Position Statement No. 19). Retrieved from www.anzsgm.org/​documents/​ ObesityandtheOlderPerson11Sept113.pdf Barakat, S. (2003). Housing reconstruction after conflict and disaster (Network Paper No. 43). Retrieved from Humanitarian Practice Network, ODI website: http://​odihpn.org/​wp-​ content/​uploads/​2004/​02/​networkpaper043.pdf Bolton, P. & Burkle, F. M. (2013). Emergency response. In C. Guest, W. Ricciardi, I. Kawachi, & I. Lang (Eds.), Oxford handbook of public health practice (3rd ed.). Oxford: Oxford University Press. Brown, L. & Haun, J. (2014). Literacy and disaster preparedness for seniors. In C. A. Cefalu (Ed.), Disaster preparedness for seniors: A comprehensive guide for healthcare professionals. New York: Springer. Brown, L., Haun, J., & Peterson, L. (2014). A proposed disaster literacy model. Disaster Medicine and Public Health Preparedness, 8(3), 267–​275. doi: 10.1017/​dmp.2014.43. Chan, E.Y.Y. (2017). Public health humanitarian responses to natural disasters. London: Routledge. Chan, E. Y. Y., & Griffiths, S. (2009). Comparison of health needs of older people between affected rural and urban areas after the 2005 Kashmir, Pakistan earthquake. Prehospital and Disaster Medicine, 24(5), 365–​371. Chan, E. Y. Y., Huang, Z., Mark, C. K. M., & Guo, C. (2017). Weather information acquisition and health significance during extreme cold weather in a subtropical city: a cross-​ sectional survey in Hong Kong. International Journal of Disaster Risk Science, 8(2), 134–​144. doi: 10.1007/​s13753-​017-​0127-​8 Chan, E.Y.Y., & Sondorp, E. (2008) Including chronic disease care in emergency responses. Humanitarian Exchange Magazine, 41, 43–49. Retrieved from https://odihpn.org/ magazine/including-chronic-disease-care-in-emergency-responses/ Chan, E. Y., Yue, J., Lee, P., & Wang, S. S. (2016). Socio-​demographic predictors for urban community disaster health risk perception and household based preparedness in a Chinese urban city. PLOS Currents Disasters. doi: 10.1371/​currents.dis.287fb7fee6f9f452 1af441a236c2d519

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Checchi, F., Gayer, M., Grais, R. F., & Mills, E. J. (2007). Public health in crisis-​affected populations: A practical guide for decision-​makers (Network Paper No. 61). Retrieved from http://​ odihpn.org/​wp-​content/​uploads/​2008/​05/​networkpaper061.pdf Connolly, M. A., Gayer, M., Ryan, M. J., Salama, P., Spiegel, P., & Heymann, D. L. (2004). Communicable diseases in complex emergencies: Impact and challenges. The Lancet, 364, 1974–​1983. Elia, M. (2003). The ‘MUST’ report: Nutritional screening for adults: A multidisciplinary responsibility: Development and use of the ‘Malnutrition Universal Screening Tool’ (MUST) for adults (Project Report). Redditch: British Association for Parenteral and Enteral Nutrition (BAPEN). Food and Agriculture Organization of the United Nations. (n.d.). About FAO. Retrieved from www.fao.org/​about/​how-​we-​work/​en/​ Frahm, K. A., Brown, L. M., & Gibson, M. (2011). The importance of end-​of-​life care in nursing home settings is not diminished by a disaster. Omega, 64(2), 143–​155. Gibson, M. (2014). Seniors, disaster mortality, and end-​of-​life care. In C. A. Cefalu (Ed.), Disaster preparedness for seniors: A comprehensive guide for healthcare professionals (pp. 73–​88). New York: Springer. HelpAge International. (2000). Older people in disasters and humanitarian crises: Guidelines for best practice. London: Author. Inter-​ Agency Standing Committee. (2005). Guidelines for gender-​ based violence interventions in humanitarian settings: Focusing on prevention of and response to sexual violence in emergencies. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Retrieved from https://​docs.unocha.org/​sites/​dms/​Documents/​GBV%20Guidelines%20 %28English%29.pdf Inter-​ Agency Standing Committee. (2008). IASC guidelines on mental health and psychosocial support in emergency settings: Checklist for field use. Retrieved from https://​ interagencystandingcommittee.org/ ​ s ystem/ ​ f iles/ ​ l egacy_ ​ f iles/ ​ C hecklist%20for%20 field%20use%20IASC%20MHPSS.pdf International Committee of the Red Cross (ICRC). (2006). Mobile health units: Methodological approach. Retrieved from www.icrc.org/​eng/​assets/​files/​other/​icrc_​002_​0886.pdf International Federation of Red Cross and Red Crescent Societies (IFRC). (2012). Shelter coordination in natural disasters. Retrieved from www.humanitarianlibrary.org/​sites/​ default/​files/​2014/​02/​shelter_​coordination_​in_​natural_​disasters-​02.pdf Knaul, F. M., Farmer, P. E., Krakauer, E. L., De Lima, L., Bhadelia, A., Jiang Kwete X., et al. (2017). Alleviating the access abyss in palliative care and pain relief—​An imperative of universal health coverage:The Lancet Commission report. The Lancet, 391(10128), 1391–​1454. McGwin, G., Jr., Melton, S. M., May, A. K., & Rue, L. W. (2000). Long-​term survival in the elderly after trauma. Journal of Trauma and Acute Care Surgery, 49(3), 470–​476. Office of the United Nations High Commissioner for Refugees (UNHCR). (n.d.a). About us. Retrieved from www.unhcr.org/​pages/​49c3646c2.html Office of the United Nations High Commissioner for Refugees (UNHCR). (n.d.b). Shelter. Retrieved from www.unhcr.org/​pages/​49c3646cf2.html Oxfam. (2007). Oxfam technical brief: Excreta disposal for people with physical disabilities in emergencies. UNICEF. Retrieved fromwww.unicef.org/​cholera/​Chapter_​9_​community/​17_​ OXFAM_​Excreta_​Disposal_​for_​Physically_​Vulnerable_​People_​in_​Emergencies_​2.pdf Pan American Health Organization/​WHO Regional Office for the Americas (PAHO/​ WHO). (2003). WHO-​PAHO guidelines for the use of foreign field hospitals in the aftermath of sudden-​ impact disasters. Retrieved from www.who.int/​hac/​techguidance/​pht/​ FieldHospitalsFolleto.pdf Peters, C.W., Beyth, R.J., & Bautista, M.K. (2009). The geriatric patient. In A. Gabrielli, A.J. Layton, & M. Yu (Eds.), Civetta, Taylor, & Kirby’s critical care (4th ed., pp. 1505–​1533). Philadelphia, PA: Lippincott Williams.

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Phillips S. J., & Knebel A. (Eds.) (2001). Mass medical care with scarce resources: a community planning guide (AHRQ Publication No. 07-​0001). Rockville, MD: Agency for Healthcare Research and Policy. Runkle, J. D., Brock-​Martin, A., Karmaus, W., & Svendsen, E. R. (2012). Secondary surge capacity: a framework for understanding long-​term access to primary care for medically vulnerable populations in disaster recovery. Am J Public Health, 102(12), e24–​32. Sphere. (2011). Humanitarian charter and minimum standards in humanitarian response (3rd ed.). Geneva: Author. Sphere. (2017). Draft 2 of the Sphere handbook. Retrieved from www.sphereproject.org/​ handbook/​revision-​sphere-​handbook/​draft-​ready-​for-​feedback/​ Sphere. (2018). The Sphere handbook: Humanitarian charter and minimum standards in humanitarian response (4th ed.). Geneva: Author. Retrieved from www.spherestandards.org/ handbook-2018/​ Stuke, L. E., Greiffenstein, P., Marr, A. B., & Hung, J. P. (2014). Geriatric Trauma. In C. A. Cefalu (Ed.), Disaster preparedness for seniors: A comprehensive guide for healthcare professionals. New York: Springer. UNICEF. (2006). Water, sanitation and hygiene. Retrieved from www.unicef.org/​wash/​index_​ 3951.html UNICEF. (2012). Nutrition glossary: A resource for communicators. Retrieved from www.unicef.org/​tokyo/​jp/​Nutrition_​Glossary.pdf United Nations. (1948). The Universal Declaration of Human Rights. Retrieved from www.ohchr.org/​EN/​UDHR/​Documents/​UDHR_​Translations/​eng.pdf United Nations International Strategy for Disaster Reduction (UNISDR). (2012). UN System Task Team on the post-​2015 UN Development Agenda Thematic Think Piece: disaster risk and resilience. May 2012. Retrieved from www.un.org/​millenniumgoals/​pdf/​Think%20 Pieces/​3_​disaster_​r isk_​resilience.pdf United Nations Office for Disaster Risk Reduction (UNDRR). (2015). Sendai Framework for Disaster Risk Reduction 2015–​2030. New York: UNDRR. Winter, J. E., MacInnis, R. J., Wattanapenpaiboon, N., & Nowson, C. A. (2014). BMI and all-​cause mortality in older adults: A meta-​analysis. American Journal of Clinical Nutrition, 99(4), 875–​890. World Food Programme. (n.d.a). About WFP. Retrieved from www.wfp.org/​about World Food Programme. (n.d.b). UN Humanitarian Air Service. Retrieved from www.wfp.org/​ logistics/​aviation/​unhas-​current-​operations World Health Organization (WHO). (2000). The management of nutrition in major emergencies. Retrieved from http://​whqlibdoc.who.int/​publications/​2000/​9241545208.pdf?ua=1 World Health Organization (WHO). (2013). Classification and minimum standards for foreign medical teams in sudden onset disaster. Retrieved from www.who.int/​hac/​global_​health_​ cluster/​fmt_​guidelines_​september2013.pdf World Health Organization (WHO) (2018). WHO definition of palliative care. Retrieved from www.who.int/​cancer/​palliative/​definition/​en/​ World Health Organization, Public Health England, & partners (WHO, PHE, & partners). (2017a). Health emergency and disaster risk management: Nutrition. Retrieved from www.who.int/​hac/​techguidance/​preparedness/​r isk-​management-​nutrition-​ december2017.pdf World Health Organization, Public Health England, & partners (WHO, PHE, & partners). (2017b). Health emergency and disaster risk management: Water, sanitation and hygiene. Retrieved from www.who.int/​hac/​techguidance/​preparedness/​r isk-​management-​wash-​ december2017.pdf?ua=1

8 POST-​DISASTER RESPONSE AND RECOVERY TO MEET HEALTH NEEDS OF OLDER PEOPLE: II

The previous chapter discussed main disaster response principles to ensure survival and maintain the basic health and well-being of older people in a disaster-​affected community. Although these general response principles apply to people of all ages, when compared with their younger counterparts, older people are more likely to face more vulnerabilities and require additional considerations and support. As stated in the United Nations guiding principles for older people, it is important to ensure and uphold the independence, participation, care, self-​fulfilment and dignity of older members of modern society. After disasters and emergencies, gaps and challenges in ensuring older people might enjoy equal chance of well-​being and survival may be further complicated by limited resources and challenges related to the context. This chapter will further examine other issues specific to older people, as a demographic subgroup, to be addressed in order to ensure well-​being in response and recovery contexts.

Emergency preparedness Identification of vulnerability “Vulnerability” is a complex concept, and vulnerable subgroups might be found in any age. Published literature and field reports have already pointed out that age alone may not be a reliable determinant on an individual’s vulnerability. Social context (e.g. living alone), disability, and the resulting physical incapacities of an individual might be more significantly associated with vulnerability than age alone. Moreover, among older people, there are subgroups with different levels of vulnerability (HelpAge International, 2000) (see Knowledge Box 8.1). When compared with their younger counterparts, older people are more likely to experience challenges and more vulnerabilities in emergencies and crisis.

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KNOWLEDGE BOX 8.1  CATEGORIES OF VULNERABLE OLDER PEOPLE To conceptualise vulnerability in older people and its variation in definition, HelpAge International (2000) has provided the following categories: • • • •

I​solated single older people who are frail and disabled Isolated older couples or couples where one or both partners are disabled ​Isolated older people living with young dependants ​Isolated older people living in non-​supporting families

Published literature and field reports show that vulnerability may result from multifactorial reasons. Instead of being determined by age alone, an individual’s vulnerability depends on social context (e.g. living alone or in poverty), disability status, and the resulting physical incapacities due to the crisis. Physical, mental, economic and mobility problems may also place older people in a vulnerable position in their community. In emergencies and disaster contexts, even if older people are recognised as a vulnerable group, their needs frequently remain unmet by service providers. Thus, in addition to recognition of “vulnerability status”, the objective in disaster and emergency support of older people is to maximise their equal access to all mainstream services (refer to Chapter 7).

Exclusion Discrimination and marginalisation of older people are often the result of failure to recognise the needs or contributions of older individuals. Extreme events and disasters may exacerbate economic constraints and social exclusion, which are threats identified as affecting the well-​being of older people. For older people without income-​generating capacity, a crisis can easily bankrupt their financial resources. Disaster-​related physical injury and disabilities might drastically reduce social engagement and self-​care of older people. The death of a spouse, family or friends might eliminate the psychological and social support network. Poverty and isolation can easily result in invisibility and exclusion for older individuals, and this renders them powerless after a disaster. Older widows in traditional communities, who may be dispossessed upon their husband’s death for cultural reasons, are often the most marginalised (HelpAge International, 2000). Socially, these older women are less likely to remarry than widowers, and they remain isolated; economically, without any income sources, they are left to the goodwill and charitable support of neighbours and relatives. In a disaster context, their capacity to rebound and fend for themselves is very limited. As discussed in previous sections, the experiences and outcomes of the older population in extreme events may be masked if analysis is conducted without

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due attention to the impact of age and gender. Sex-​and age-​disaggregated data (SADD) should always be collected where possible, for an overview of the potential impact of how an incident or extreme context might affect older age groups. Such information collection should be done across all levels of the health system and its interlinked systems to provide a comprehensive perspective of the actual situation. In addition to examining quantitative data, qualitative data should also be collected, through field visits, focus groups and stakeholder interviews. Not being consulted or given the opportunity to participate can further impede the likelihood that older people’s needs and well-​being will be taken into consideration. To be age-​sensitive, needs assessments should always consult older people for their opinion. Evidence and patterns should be used to formulate, identify and understand the specific needs and constraints of the local context. The negative image of older individuals as inflexible, unproductive and dependent on assistance should be carefully managed and redirected through highlighting their potential contribution to the relief efforts.

Access to services and resources If health, social services and relief material delivery are organised in a distant and centralised manner, limited mobility and access to information, a role as the sole caregiver for dependants, concern about security of their limited possessions (e.g. guarding their property or livestock from theft), and cost of transportation might further exclude homebound/​housebound older people. Older people are less likely to have the physical strength to queue and compete with their physically able counterparts. In addition, older people might be systematically excluded from post disaster/​emergencies rehabilitation programmes if a certain age-​cap is established for participation in important post disaster livelihood skills training and micro-​credit entitlement programmes. For those who have lost most of their assets during the disaster and crisis, facilitation and priority should be given to older people for accessing livelihood programmes and for allocation of housing reconstruction. In addition, the type of services and supports required for older individuals to maintain health and well-​being are usually different from those of the younger population. Physical and psychological health of older people might improve if resources that enable more self-​sufficiency, autonomy and independence may be channelled. For example, the provision of assistance devices (e.g. walking support and hearing aids) might significantly enhance self-care and engagement in economic and income generating activities for the household after disasters. In addition, financial and material support of non-​geriatric items (e.g. clothing and shoes for children and school fees/​uniforms for the children) and training in childcare skills or medical skills to support other dependants might be important for older people who might be the sole family or childcare providers after an emergency.

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Emergency health and medical care service Disasters may disrupt a medical system by destroying infrastructure, injuring medical staff and obstructing normal operation of regular and emergency services (refer also to Chapters 4 and 7). Collapsed or destroyed houses would aggravate victims’ living conditions and sanitation and thereby increase the health risks of the general public indirectly. For some environmental disasters (nuclear accidents) and chronic emergency contexts (war and conflict), the health risks may last for a long time and even across generations, and may pose a medical burden on the health system of the affected community. For example, victims might be exposed to radiation in nuclear accidents and not only will their own risk of cancer be increased, their offspring might also suffer from an increased risk of developing cancers and genetic abnormalities. In emergencies and disasters, health service organisation and delivery tend to be limited or non-​existing immediately post impact and during the acute rescue emergency phase. Even in a community with well-​rehearsed emergency preparedness, services might suffer from set-​backs that vary among disaster subtypes and contexts. Organisation priorities in health might shift from individualisation to those of essential care and public health.

Geriatric care in triage During the rescue phase, most medical and health services focus on life-​saving procedures. Triage is typically used in an emergency to redirect services to the patient who might benefit from the service most (refer to Chapter 7). While the clinical criteria of triage might be beyond the discussion of this book, it is important to point out that there are issues that emergency responders and planners should examine and consider with caution when managing disaster-​affected older people. These are also important considerations on which rescue workers and people working with older people should seek clarification as far as possible to prepare their approach in emergency. For instance, the typical advance medical directives of “do not resuscitate” orders of older people in case of medical decision-​making might be different from “do not rescue” directives in a crisis situation (Gibson, 2014; Lugosi, 2007). Preference and needs of older people as well as individuals who require palliative care should also be sought to ensure patient dignity is respected and any legal implications are understood. Even for individuals who might not require immediate medical support, the post-​clinical discharge management might have important implications for future service use. For example, a frail old individual might go through triage and be found with no significant injury or illness. Nevertheless, their discharge from emergency triage might not mean they have no health needs and service support requirements. An older individual with cognitive impairment or disability could experience rapid physical functioning deterioration and decline in a suboptimal environmental context. Establishment of safe zones or soft care areas that support older people’s health needs might be useful.These zones might be managed by clinical (e.g. nurses) or allied

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health workers who help supervise proper care and management of older people who might be disconnected from their family, caregivers or long-​term care facilities in emergencies. It also provides the opportunity for coordinated care and a platform for follow-​up. The set-​up might provide and ensure proper food, shelter, personal hygiene and drugs (which require special administration and storage) for older individuals (Ahronheim, Arquilla, & Greene, 2009;Yandle & deBoisblanc, 2014). In order to avoid mis-​use or under-​utilisation, the policies and plan of such service should be organised as preparedness efforts. Criteria and guidelines for service-​user eligibility should be communicated as specifically, transparently, and explicitly as possible. In developing contexts where underlying regular medical and health service development has been suboptimal, age-​friendly services might be not available unless there are targeted considerations and personnel to coordinate for the population subgroup. In a post-​disaster context, services might collapse the system entirely. To a disaster-​affected community, access to post-​disaster health and medical service might only be available at the primary level. Secondary-​level services (hospital or specialised care) might be likely to be entirely absent, or the referral system might be inactive. When compared with an urban context, the time required for re-​activation of pre-​existing services is likely to be much longer for rural communities. Specifically, in the context of a rural community, where older people tend to reside disproportionally, especially for older people who have limited self-​care possibilities or require mobility assistance, arrangement of provision of resources (e.g. transportation and subsidies) to facilitate caregivers who might accompany the older help-​seeking individuals might be crucial to ensure they obtain the appropriate level of care.

Suboptimal health systems in disasters Disasters may cause the breakdown of the medical system. Destruction of infrastructure, medical staff injury and obstruction of normal operation of services may hamper a health system’s resilience to respond to crisis (refer also to Chapter 2). Collapsed or destroyed houses aggravate victims’ living conditions and sanitation, thereby increasing the health risks of the general public indirectly. The health risks of some disasters last for a long time, even across generations, and they place a medical burden on the health system of the affected community. For example, during nuclear disasters, victims are exposed to radiation and their offspring thus suffer from an increased risk of developing cancers and a defective reproductive system. Lack of properly trained and competent human resources to address older people’s needs and care is of particular concern in the post-​disaster emergency response phase. Knowledge of health needs, communication skills and proper clinical management skills, which might address the needs of older people, should be offered for relief workers and responders who might have the responsibility to manage health and welfare of older people. In communities that have the experience of managing an ageing population, knowledge of their health needs, appropriate communication methods, relevant re-​ adaptation of clinical management

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guidelines, equipment (medicine and diagnosis tools), and clinical skills for emergency geriatric use might determine the survival and well-​being of older people. Relevant drug and medical supplies are essential to ensure health and medical needs might be addressed. For older people who might require specific drug dosage and medications for chronic diseases or maintenance of basic health and survival, ensuring access to adequate medication, consumables and treatment (e.g. dialysis for patients with chronic renal failure) is crucial to preventing premature mortality. In addition to maintaining the availability of relevant and essential drug supply for older people, drug quality (e.g. expiration dates, appropriate storage method) and training in related information (e.g. how to use) should be made readily available. For the older population, sensory support (visual and hearing aids) and mobility aids are important to minimise accidents and injury as well as to maximise self-​care potential. Specialised health service delivery tends to be limited or non-​existing at least during the acute emergency phase. Age-​friendly services might be unavailable, especially in developing contexts where regular services development are suboptimal. In addition, in rural community contexts where older people tend to reside disproportionally, services might be only available at the primary level. Secondary-​ level services (hospital or specialised care) might be absent or referral systems might be inactive. Mobile clinics might thus be an important care modality to ensure older people who are enclaved in remote areas (such as mountains) receive care and support. In recent years, technology has enabled telemedicine in developed contexts. However, although such technology-​assisted systems might expand healthcare access, unless some pre-​existing planning is in place (e.g. stockpiling of medicine and relief supply within a remote community so that community members can mobilise and use with tele-​consultation), drugs delivery and simple interventions (e.g. minor surgeries) still require physical contact between healthcare providers and the patients. Moreover, information, health education and advice should be tailored according to the literacy level and cultural acceptability of the older population. Mechanisms of service accountability towards quality of care should also be included to ensure that older people receive a reasonable standard of services and care in time of crisis. Healthcare and service financing mechanisms in disasters and emergencies should be pre-​planned to allow implementation in disasters. Even in communities where primary care development may be incomplete, network and partner agencies and organisations that might bridge medical and health service gaps should be established to ensure that older people have access to basic health and care support during crisis.

Protection As a vulnerable subgroup, older people need to be protected from abuse and isolation. Reducing the risk of elderly abuse could be addressed by raising awareness of physical, sexual, emotional and economic abuses of older people. Community awareness of problems with robbery and intimidation of older people should be heightened (for HelpAge International best practices, see also Case Box 8.1). In

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CASE BOX 8.1  PROTECTION OF OLDER PEOPLE IN HUMANITARIAN CRISIS: OLDER CITIZEN MONITORING Older people face many risks of exclusion in crisis. Stigmatisation, household power dynamics, language and literacy barriers, gender bias and social isolation might hinder older people’s access to, understanding of, and response to public information. Access to resources for older people might be neglected or hindered (by physical distance). Programme feasibility analysis, designs and monitoring should assess risks and impact for older people before, during and after the crisis and the programme intervention. Training older people in the terminology and the approach to monitoring and reporting of key issues might facilitate monitoring and support dialogue regarding the protection of the rights of older people in such contexts. In addition, older people should be included and play an active part in gathering data on their access to services and advocate for service providers to improve their access to services. Sources: HelpAge International (2011, 2013).

view of the likelihood of abuse both in cases of older people living in multi-​ generation households and in cases of isolated older individuals, protection of older people should be a core issue of multi-​stakeholder analysis (Hutton, 2008).

Tracing Isolation is one of the most important precursors to vulnerability of older people. Death of family members, abandonment by family members and caregivers during crisis, and destruction of lifeline infrastructure that displaces older people from their familiar living environment can all cause vulnerability in crisis. Family post-​disaster/​ crisis search services facilitate protection for both extreme age groups (young and old). Family tracking services or tracing programmes may help to reunite older people with their families and care network, and can enhance survival and protection of well-​being. If reunion with lost family members is not possible, development of foster links (neighbours and families who are willing to support these orphaned elderly) should be attempted. Reunification and adoption services are frequently organised for unaccompanied children.Yet unaccompanied older people might be left without support and may end up in chronic institutionalisation and neglect (HelpAge International, 2000).

Caregivers with appropriate skill training and network for older people To address the needs of older people after a disaster, caregivers with appropriate skill training need to be identified, organised and trained. Clinical and care guidelines

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with relevant standardised assessment instruments also need to be developed and disseminated to support clinical and social care in crisis for older people. Assessment of cognitive status, mental health status (depression), and physical functional status, together with the socio-​economic demographic description, are among the core information to support and help facilitate the development of clinical management plans for older people. Needs assessment scales should be adopted in emergency field settings (with no assumption of information availability of previous clinical and care history when information might be lost or unavailable from older patients with dementia). Regardless of the nature of the programme (health or non-​health), users and planners with responsibility to support older people in post-​disaster recovery and rehabilitation programmes should understand the application of these tools.

Informal care In emergency, informal caregivers and spontaneous volunteers with no prior training in medicine, health or care experiences might constitute the major service and care providers, at least during the acute phase of the disaster or emergencies (Chan, 2009; Twigg & Mosel, 2017). To ensure basic quality of care and appropriate management for older people or relevant target groups, even with time constraints, basic training should always be attempted by relevant health agencies if the disaster-​ affected context has a significant proportion of older people in its community profile. Skills training (e.g. older people-​centred disaster preparedness seminar for older people) on how to identify, register and access disaster-​related information is essential. In an emergency, triage of geriatric needs and subsequent delivery of relevant medical and social services should be attempted. If the disaster-​affected context has a significant proportion of older people in its community profile, additional refresher training on geriatric issues for health and medical work will be useful for service providers. In areas where older people might have a low literacy level, responders and programme planners should consider the use of symbols and dialect, and should show gender, religious and cultural sensitivity (e.g. taboo colours) to maximise potential engagement and communicate the intended message to their older stakeholders. In addition, most palliative care might be delivered by community volunteers, a general awareness should be promoted and guidelines should be developed to provide users with insights and skills to support older people in crisis. It should be emphasised that instead of being patients/​service users, older people are often also identified and recruited as informal care providers, volunteers and staff during emergencies (WHO, 2015). Older subgroups might have the necessary skills (as formal or informal family caregivers) and coping experiences to handle the technical and psychological demand required of post-​disaster work. They can be essential volunteer helpers as they may have better understanding of their own needs, as well as local culture and local context. Many of the older people affected in disasters also serve as the caregivers of children, injured adult family members and other dependants. Additional support and recognition should be provided to these older caregivers to facilitate their roles.

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Irrespective of experience and age, basic health or medical training should always be offered (whenever possible) by relevant health agencies to volunteers (regardless of age) (Chan, 2009, Twigg & Mosel, 2017). Yet, although older people may serve as significant providers and spontaneous volunteers of informal caregiving responsibilities, relevant mobilisation and duty adjustments (e.g. arranging older people to work on shifts) should be planned carefully with recognition of the physical limitations of older volunteers to prevent exhaustion (e.g. allocating emergency duty similarly for an 80-​year-​old volunteer and a 20-​year-​old).

Recovery and rehabilitation Livelihood support Poverty is often compounded by the lack of economic means for older individuals to recover their well-​being from the catastrophic impact of a disaster. If delivery points for health, social services and relief material are organised in a distant and centralised manner, homebound/​housebound older people might be excluded, owing to their limited mobility and access to information, their role as the sole caregivers for dependants, their concern about the security of their limited possessions and the cost of transportation. Older people are less likely to have the physical strength to queue and compete with their physically able counterparts. In addition, they might be systematically excluded from post disaster/​emergencies rehabilitation programmes if an age cap is placed for participation in important skills training and micro-​credit entitlement programmes.

Relocation For older people, relocation after a disaster might be as traumatic as the disaster event itself. Research has indicated that in nursing homes, evacuation, such as forced change within a short period of time, might pose an increased risk of adverse effects on well-​ being, disease deterioration (Spiegel, 2006), hospitalisation (Thomas, Dosa, Hyper, Brown, Swaminathan, Feng, & Mor, 2012) and even death (Brown, Dosa, Thomas, Hyer, Feng, & Mor, 2012) for residents who had underlying cognitive impairment at 30 and 90 days post evacuation period. Unless relocation decisions are taken with care and sensitivity, frail older people might face increased risks of morbidity and mortality. Service preparedness, maximising stability and familiarity, and social and psychological support maintenance might be useful to prevent adverse health outcomes to physical relocation in the event of disaster evacuation and response (Kawasaki, 2014).

Capacity at the individual, organisational and community levels Personal and public risk awareness and risk literacy are essential to maximise resilience capacity for both the potential affected older people and their carers (Stiefel, Scalingi, & Nicogossian, 2014). As highlighted by statistics, in the United States

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people aged 80 or above are eight times more likely to have a disability when compared with the younger group. Older people with a visual or hearing impairment or another physical handicap require supporting devices such as wheelchairs and walking sticks to facilitate evacuation and self-​care. Service continuity, surge capacity management at elderly homes, communal clinics and hospitals are crucial to ensure that older people can return to normality in times of crisis. Communication systems, remote storage of clinical records (which may support clinical care), and staff and capacity training to handle the older population in emergency procedures all require preparedness and investment by the at-​r isk community. Plans and procedures that describe preparedness, response and recovery should also attempt to include the older population and their special needs in planning, updates and ongoing evolution. As older people’s voices, experiences, needs, concerns and welfare are often forgotten, programmes and policy-​makers who have accumulated experiences, skills and information (SADD) should help share and exchange their knowledge and recommendations with the wider community to enable awareness building in the sector and to focus on helping older people in disasters.

Building partnership As most disaster-​or crisis-​affected communities have limited resources, maximising the possibility of addressing older people’s needs requires harnessing community resources and building partnerships. Emergency health interventions for specific groups should also always aim to be integrated with the general health responses to ensure access and planning. In communities with a significant proportion of older victims, targeted geriatric services might need to be developed during emergency contexts. Private–​public partnership, knowledge transfer training of geriatric skills, ensuring working and communication platforms for multi-​disciplinary staff to work together, provision of funds/​venues, and communicating opportunities and needs are typical examples that might exemplify the impact of partnership involvement. Case Box 8.2 shows how public health capacity might be strengthened to address issues associated with ageing by fostering academic and non-​government organisation partnerships in Myanmar.

Conclusion With a vulnerable state of health, older people are physically more vulnerable to injury risks. Minor conditions and suboptimal living and environmental context can easily become significant risks or handicaps for the basic survival and health maintenance of older persons during a disaster. For example, simple hypothermic state caused by the lack of blankets, immobility due to loss of eyeglasses and walking sticks, and the lack of assistive devices (wheelchairs) in relief settings can all affect self-​care possibilities and even cause injury and trauma in older people. Chronic disease status may deteriorate rapidly if accompanied with suboptimal living conditions, loss of routine medications and inaccessibility of healthcare services.

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CASE BOX 8.2  STRENGTHENING THE PUBLIC HEALTH CAPACITY TO RESPOND TO MYANMAR’S AGEING CONCERN Carol Ka-​po Wong In 2015, HelpAge International Myanmar in partnership with University of Public Health (UPH), University of Medicine 2 and Thammasat University of Thailand implemented a five-​year European Union project to contribute to the process of health reform in Myanmar with goals of equitable and “universal health coverage of health services for the whole population” by 2030. Myanmar’s population is ageing rapidly, and the spread of non-​communicable diseases (NCDs) is accelerating sharply, accounting for 59% of total deaths in the country (WHO, 2018). According to a study in Thanlyin township of Yangon, Myanmar (Lwin & Oo, 2018), NCD presence increased with age, from 21.5% among 60–​64 year olds, to 21.7% among 65–​69 and 37.8% among people over 70 years old. NCDs impose a heavy economic burden from loss of productivity from death or illness, treatment paid out-​of-​pocket, and investment in high-​end technology. The healthcare system urgently needs to anticipate the growing NCD disease burden in order for the country’s health vision to be realised. The project addresses the issue of institutional and technical capacity, which is needed to absorb and effectively channel new resources to address the growing burdens of NCDs and the ageing population. It follows systematic steps in addressing these shortcomings: researching evidence-​based policy analysis to inform the government’s response to health transition, creating greater knowledge among policy-​makers and public health implementers, increasing in-​country policy dialogue and consultation, and creating a stronger and more effective UPH academic and operational capacity while activating professional linkages with health institutions across the world.

Effective disaster and emergency response and recovery sometimes means more than clinical care and physical supplies. Protecting the dignity and social well-​being of the older people, coordinating NCD management, and ensuring intact health and social service models for continuity of care of older people will significantly improve overall quality of life for older people. Systems and approaches for identifying, tracking and monitoring older individuals post disaster are important areas to be established to support the older population in disasters.

References Ahronheim, J. C., Arquilla, B., & Greene, R. G. (2009). Elderly populations in disasters: Hospital guidelines for geriatric preparedness. Retrieved from http://​citeseerx.ist.psu.edu/​viewdoc/​ download?doi=10.1.1.468.704&rep=rep1&type=pdf

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Brown, L. M., Dosa, D. M., Thomas, K., Hyer, K., Feng, Z., & Mor, V. (2012). The effects of evacuation on nursing home residents with dementia. American Journal of Alzheimer’s Disease & Other Dementias, 27(6), 406–​412. Chan, E.Y.Y. (2009).Why are older peoples’ health needs forgotten post-​natural disaster relief in developing countries? A healthcare provider survey of 2005 Kashmir, Pakistan earthquake. American Journal of Disaster Medicine, 4(2), 107–​112. Gibson, M. (2014). Seniors, disaster mortality and end-​of-​life care. In C. A. Cefalu (Ed.), Disaster preparedness for seniors: A comprehensive guide for healthcare professionals (pp. 73–​87). New York: Springer. HelpAge International. (2000). Older people in disasters and humanitarian crises: Guidelines for best practice. Retrieved from www.helpage.org/​silo/​files/​older-​people-​in-​disasters-​and-​ humanitairan-​crises-​guidelines-​for-​best-​practice.pdf HelpAge International. (2011). Older people citizens monitoring. Retrieved from www.helpage.org/​silo/​files/​older-​citizens-​monitoring.pdf HelpAge International. (2013). Protection interventions for older people in emergencies. Retrieved from www.globalprotectioncluster.org/​_​assets/​files/​tools_​and_​guidance/​age_​gender_​ diversity/​HelpAge_​Older_​People_​Best_​Practices_​EN.pdf Hutton, D. (2008). Older people in emergencies: Considerations for action and policy development. World Health Organization. Retrieved from https://​apps.who.int/​iris/​bitstream/​handle/​ 10665/​43817/​9789241547390_​eng.pdf?sequence=1&isAllowed=y Kawasaki, L. (2014). Disaster and the frail elderly. In C. A. Cefalu (Ed.), Disaster preparedness for seniors: A comprehensive guide for healthcare professionals (pp. 53–​63). New York: Springer. Lugosi, C. I. (2007). Natural disaster, unnatural disasters: the killings on the life care floors at Tenet’s Memorial Medical Center after Hurricane Katrina. Issues in Law and Medicine, 23(1),  71–​85. Lwin, K. T., & Oo, W. M. (2018). Self-​reported prevalence of non-​communicable diseases among elders in Thanlyin township, Yangon region, Myanmar: A cross-​sectional study. European Journal of Pharmaceutical and Medical Research, 5(7), 107–​110. Spiegel, A. (2006, March 1). Katrina’s impact on elderly still resonates. National Public Radio. Retrieved from www.npr.org/​templates/​story/​story.php?storyId=5239019 Stiefel, J., Scalingi, P. L., & Nicogossian, A. (2014). Contributing to geriatric health and well-​ being through improving community resilience capacities. In C. A. Cefalu (Ed.), Disaster preparedness for seniors: A comprehensive guide for healthcare professionals (pp. 217–​228). New York: Springer. Thomas, K. S., Dosa, D., Hyper, K., Brown, L. M., Swaminathan, S., Feng, Z., & Mor, V. (2012). Effect of forced transitions on the most functionally impaired nursing home residents. Journal of the American Geriatrics Society, 60(10), 1895–​1900. Twigg, J., & Mosel, I. (2017). Emergent groups and spontaneous volunteers in urban disaster response. Environment and Urbanization, 29(2), 443–​458. doi: 10.1177/​0956247817721413 World Health Organization (WHO). (2015). World report on aging and health. Retrieved from https://​apps.who.int/​iris/​bitstream/​handle/​10665/​186463/​9789240694811_​ eng.pdf?sequence=1 World Health Organization (WHO). (2018). Noncommunicable diseases country profiles 2018. Retrieved from www.who.int/​nmh/​publications/​ncd-​profiles-​2018/​en/​ Yandle, G. M, & deBoisblanc, B. P. (2014). Triaging acute care patient during a disaster. In C. A. Cefalu (Ed.), Disaster preparedness for seniors: A comprehensive guide for healthcare professionals (pp. 11–​20). New York: Springer.

9 HEALTHY AGEING, DISASTER MITIGATION AND DISASTER RISK REDUCTION Individual, programmatic and global policy levels

A single emergency or crisis event may regress decades of hard-​won gains in the development, economic, public health and other sectors. Globally, approximately 190 million people are directly affected annually by emergencies. Over 77,000 deaths have resulted from natural and technological hazards (IFRC, 2016) and it was estimated a further of 172 million were affected by conflict (CRED, 2013). While many global communities are prone to annual seasonal return of hazards (e.g. monsoonal floods, cyclones, disease outbreaks), most countries are likely to experience a large-​scale emergency approximately every five years (WHO, 2008). More than 1,200 outbreaks, including those due to new or re-​emerging infectious diseases, have occurred in 168 countries since 2011 (WHO, n.d.). Research has indicated that the expected annual economic loss from pandemic risk through its effects on productivity, trade and travel is about 6% of global income (US$500 billion) (Fan, Jamison, & Summers, 2018). Emergencies caused by natural and technological hazards with an average global economic loss of US$300 billion annually (World Bank, 2017) and the cost of armed conflicts are deemed to be in trillions of dollars. In addition to direct mortality, morbidity and economic loss, emergencies often result in severe disruptions of the health system, interference of health service delivery through damage and destruction of health facilities, interruption of health programmes, loss of health staff and overburdening of clinical services, which also lead to major long-​term financial implication on health systems. To address the impact of emergency and disaster events, effective disaster risk reduction (DRR) that targets emergency hazards and health risks might save lives, protect community and safeguard community development in a society (Vorhies, 2012; WHO, 2019). Although DRR strategies have been preventive by nature and intended to cover all ages, vulnerability and capacity disparities for older people among the target population are often neglected and deserve attention (HAI, 2014a, 2014b). This chapter

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will discuss how older people might benefit from and contribute to DRR, and how Health-​EDRM might be applied to the older population at the individual level.

Disaster risk reduction and older people The United Nations Development Programme (UNDP) has estimated that economic losses from disasters can be reduced by US$7 for every US$1 spent on DRR measures (UNDP, 2007). Unfortunately, less than 0.7% of relief aid globally has gone to DRR-​related activities in the past 20 years. In recent years, disaster risk reduction (DRR) has become one of the main global themes for emergency and crisis management. In health, Health Emergency and Disaster Risk Management (Health-​ EDRM, also refer to Chapter 2) becomes a direction for health practitioners and researchers to link in the effort of disaster risk identification, preparedness, response and rehabilitation efforts. To reduce the health impact of disasters and reduce the burden of post-​disaster response, employing mitigation measures and building up pre-​disaster preparedness that take the specific vulnerabilities and needs of older people into account are particularly important. Disaster preparedness is the term for “activities taken in advance of a disaster to ensure an effective response to the impact of hazards, including issuing timely and effective early warnings and the temporary evacuation of people and property from threatened locations” (Sphere, 2011). Resilience is the ability of a system, community or society that is exposed to hazards to resist, absorb, accommodate and recover from the effects of a hazard in a timely and efficient manner (UNISDR, 2009). Raising disaster preparedness increases resilience, but other circumstances, such as previous exposures to disasters or having a stable healthcare workforce, are also factors that enhance resilience. Disaster resilience is multifaceted and requires collaborative efforts among international organisations, local governments and civil societies. “Health” is considered as one of the core resilience dimensions, and the health sector’s core responses usually take place during emergencies and disasters. As highlighted in Chapter 2, public health emphasises the concept of “prevention is better than cure” as its underlying principle of action. When applied in a disaster/​emergency context, disaster prevention refers to “the outright avoidance of adverse impacts of hazards and related disasters through actions taken in advance” (UNISDR, 2009). The notion suggests that it is always possible to minimise the adverse impact of disasters. Three levels of prevention may be considered during action planning. Primary disaster prevention refers to activities that aim to prepare and enhance resilience before the disaster. Secondary prevention actions proactively address the health risk and response during the disaster. Tertiary prevention actions focus on minimising the health impact and damage after the disaster (Chan, 2017). Disaster preparedness activities might be organised at the individual, household, community and global levels. In recent years, strategies and policies to address disaster preparedness have evolved from pure “top-​down” to increasingly “bottom-​up” approaches. While the formulation of the Hyogo Framework for Action (HFA) and the Sendai Framework are examples of top-​down approaches to resilience

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building at the global level, promotion of community disaster health risk literacy and implementation of early warning systems are examples of community-​based, bottom-​up disaster preparedness activities. The notion of disaster health risk management proposed by the World Health Organization (WHO), Public Health England (PHE), and partners (2013) highlights the need for proactive management and prevention of the health impact of disasters by both health and non-​health sectors. The all-​hazard approach encourages the formulation of a standard, comprehensive emergency management system that would address the health needs common to all types of emergencies. The introduction of the “public health emergencies” concept in the International Health Regulations by the WHO (2005a) signifies the formal and legally binding regulation of natural and man-​made hazards that is of unique significance to disaster preparedness at the global level. It attempts to minimise unnecessary loss of health resulting from service gaps and the lack of coordination of relief assistance in more fragmented, hazard-​specific, emergency response systems. Last but not least, the human security approach to health provides a highly relevant paradigm for conceptualising public health emergency and disaster preparedness in the development of global policies that have direct influence on the allocation of relief resources, and the rights of states to claim such resources to meet the rising challenges in medical and humanitarian response in the decades to come. As discussed in previous chapters, older people have specific needs in emergency and crisis. PAHO (2012) has suggested four key action strategies to ensure older people have a voice in disaster and development policies and programmes (see Knowledge Box 9.1). These include accommodation and inclusion, education, communication and coordination. For accommodation and inclusion, policies, activities and strategies should consider needs, capacities and vulnerabilities and respect the perspectives and preferences of older people. Education efforts and initiatives should be developed for increasing disaster awareness, knowledge and capacities of older people. Relevant training and skill updates should be provided. Risk communication should be developed in a timely manner, with accurate and practical information, and tailored to the literacy level of older people. As most of the needs of older people require multi-​sectoral support (e.g. health, social, economic and legal sectors), coordination should be organised to ensure older people’s needs and voice are included.

Health Emergency and Disaster Risk Management (Health-​EDRM) Health risks management is vital to protecting people’s health from emergencies and disasters. Risk may be defined as “the combination of the probability of an event and its negative consequences” (UNISDR, 2009). More specifically, emergency or disaster risk is defined as “the potential loss of life, injury, or destroyed or damaged assets which could occur to a system, society or a community in a specific period of time, determined probabilistically as a function of hazard, exposure, vulnerability and capacity” (UNDRR, 2017). Hazard-​related risks cannot be completely

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KNOWLEDGE BOX 9.1  MAINSTREAMING OLDER PEOPLE’S CONSIDERATIONS IN DEVELOPMENT AND DISASTER POLICY-​MAKING PAHO (2012) suggested four key actions to give older people a “voice” in disaster and crisis: • • • •

Accommodation and inclusion Education Communication Coordination

By adopting the participatory approach in policy and strategy development, the goal of these actions is to mainstream older people’s needs into policies that address development and disasters.

eliminated, but they can and should be managed. When emergency and disaster risk management (EDRM) activities are designed specifically to reduce the probability of events and to minimise health consequences, the term Health Emergency and Disaster Risk Management (Health-​EDRM) can be used. Even large-​scale emergencies, such as prolonged conflicts, often have significant health consequences and pose challenges to the delivery of even the most basic health services; health systems must adapt and prioritise services, including assistance from national and international actors, to address the health needs of affected populations and respective sub-​populations. This assistance is most likely required in fragile, conflict-​affected and vulnerable (FCV) settings. They may also be required to plan and implement strategies to support, strengthen and restore local capacities during protracted crises and in post-​disaster or post-​conflict periods. Health risks management matters to local, national and global health security, the attainment of universal health coverage (UHC) and resilience building of communities, countries and health systems. Effective health risk management is an essential safeguarding development and global strategy in health and other sectors, in particular for implementing the Sustainable Development Goals (SDGs) including the pathway to UHC and Goal 3d (i.e. “strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks”) (UNGA, 2015), the Sendai Framework for Disaster Risk Reduction 2015–​2030 (UNDRR, 2015), the International Health Regulations (IHR) (2005) (WHO, 2005a) and the Paris Agreement on Climate Change (UNFCCC, 2015). Specifically, the intersection of health and disaster risk reduction (DRR) has emerged in recent years as an interdisciplinary field with paramount human consequences.Throughout several landmark UN agreements adopted

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in 2015–​2016, including the Sendai Framework for Disaster Risk Reduction 2015–​ 2030, the 2030 SDGs, the Paris climate agreement, and the New Urban Agenda (Habitat III), health is recognised as an inevitable outcome and a natural goal of disaster risk reduction, and the cross-​over of the two fields is no doubt essential for the successful implementation of the Sendai Framework. Health Emergency and Disaster Risk Management, as a joint venture of this cross-​over, has emerged as an umbrella field that encompasses emergency and disaster medicine, DRR, humanitarian response, community health resilience and health system resilience. Health-​EDRM is derived from a range of disciplines, principally risk management, emergency and disaster management, epidemic preparedness and response, and health systems strengthening. Health-​EDRM serves as a bridge between the multi-​sectoral emergency and disaster risk management community and the health community (WHO, 2019). It aims to provide a common language and an adaptable approach that can be applied by all those in health and other sectors who are working towards improving health outcomes and well-​being for communities at risk of emergencies and disasters. It argues that in order to minimise health consequences and improve health, well-​being and societal outcomes, concerted efforts from many systems and sectors are required to prevent and mitigate risks, prepare for emergencies, ensure effective response and recovery, and collectively contribute to the resilience of communities and countries. Health-​EDRM builds on the past achievements and the trends evident in public health and emergency risk management practices worldwide. It is fully consistent with, and helps align policies and action for, health security, disaster risk reduction, humanitarian reform, climate change and sustainable development agendas. The ability to achieve optimal health outcomes related to emergencies has been hindered by fragmented approaches to different types of hazards, an over-​emphasis on reacting to events instead of preventing and preparing properly, and gaps in coordination across the entire health system and between health and other sectors. In view of current and emerging risks to public health and the need for more effective coordination, utilisation and management of resources, there is a need to consolidate contemporary approaches and practice through the conceptual framework or paradigm of Health-EDRM. Key concepts and characteristics of Health-​EDRM are as follows. Policies and programmes to minimise the health risks and consequences of emergencies and disasters should be based on a risk management approach. Health-​ EDRM consists of a continuum of measures in which the emphasis is placed on managing the risks of the potential emergency or disaster and building the resilience of communities and countries not solely responding to the event or crisis. Comprehensive Health-​EDRM addresses a wide scope of natural, biological, technological and societal hazards: a range of risk management measures are employed (e.g. primary prevention and recovery, in addition to emergency preparedness and response) with the broad engagement of the health system and multiple sectors, and a strong community focus. The strengthening of health systems, the implementation of the IHR, and development of multi-​hazard disaster risk management strategies, together with

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the increased attention to climate change adaptation, provide good examples of progress that has been made to better manage the health risks associated with emergencies. Nevertheless, many communities, sub-​ populations and countries remain highly vulnerable to emergencies and disasters. Health-​EDRM is built on the foundation of health system capacities for the management of routine or day-​to-​day risks. Health systems (consisting of primary care, disease surveillance, pre-​hospital care, mass casualty management, chemical and radiological safety, mental health, risk communication, etc.) play a significant role in reducing hazards, exposure and vulnerabilities and in establishing capacities that prevent the occurrence or reduce the consequences of hazardous events that may lead to emergencies. They should also ensure that they have additional capacities in place for managing the non-​routine or emergency-​related risks, e.g. event-​based surveillance, specialised emergency health teams, building standards for infrastructure in high-​risk areas, emergency response plans and simulation exercises. As such, Health-​EDRM recognises the roles, responsibilities and contributions of all health system actors, the critical role of primary healthcare, and the delivery of primary, secondary and tertiary healthcare, in effectively reducing health risks and consequences of emergencies and disasters. Progress has been made by countries in reducing the health and other consequences of emergencies. The most successful and cost-​effective strategies often employ a comprehensive risk management approach that aims to prevent, mitigate, prepare for, respond to and recover from emergencies. This overall approach should be applied in all emergency circumstances regardless of the cause, while incorporating specificities relevant for each hazard (e.g. biological, geological, chemical, hydro-​meteorological and societal). Applying the Build Back Better principle, countries have also used “after-​action” reviews and recovery experience from emergencies and disasters to catalyse policy changes, strengthen health systems at all levels of healthcare, and build capacities in ways to reduce the risk of future emergencies. In summary, Health-​EDRM is a significant step forward in the transformation of the prevailing policy, practice and culture to promote and protect health, keep the world safe and serve people with vulnerabilities so that “no one is left behind”. The essence of the change in approach is summarised in the following section.

Approaches in Health-​EDRM and its relevance to the older population Individual level Disaster risk literacy is a term that describes the ability of an individual to comprehend, analyse, understand and respond to disaster-​related risks and information. It can be conceptualised as the disaster resilience capacity at the individual level. The underlying idea is to empower and support individuals to initiate self-​help behaviour in emergency and disasters. Evidence-​based interventions should be

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conducted to enhance personal capacity to mitigate and respond to disasters. For the older population, disaster risk literacy training and preparedness education for older people are important. Although the general principles of disaster preparedness are similar for older people as they are for the general population, additional and supplementary support should be given to the specific needs of older people due to their physical vulnerabilities (e.g. immobility and suboptimal sensory capacity). Older people’s well-​being in a disaster might also be associated with the awareness and sensitivity of their needs by the general population. General awareness-​raising of the capacities and constraints of the older population for emergencies may enhance the preparedness, relevant response and recovery planning of their caregivers and community network to ensure coordinated preparedness. Families should aim to communicate and inform older household members of relevant supplies, plans and resources to ensure older people can take appropriate action in emergencies. Evacuation planning drills and exercises should include older people’s needs and training. With rapid urbanisation and development that may change the urban landscape or community context, routes of escape and the procedure for evacuation should be reviewed and updated regularly to ensure the evacuation plan and agreements might be relevant and appropriate. In addition, as older people might experience health status changes with time, it is important to have periodic reviews of an older individual’s capacity to evacuate, in order to avoid mistaken assumptions. Planning and community support networks should establish and communicate regularly any updated plans. Specific age-​ friendly information platforms should refer to the most updated plans and coordination authority. Support and facilitation should always be attempted, in order to encourage participation of older people in mock drill exercises where they can familiarise themselves with their options and role in crisis.

Household level In the modern era, the household is one of the basic functional social units in communities. Household preparedness is especially critical for enclaved communities (e.g. urban context and remote areas) where official external help is limited in emergencies and crises. In countries where rapid urbanisation has led to major socio-​economic disparity, household preparedness might be the only help rural communities can rely on in the face of disaster. Unfortunately, knowledge about effective preparedness at the household level is limited, and academic research is still in its infancy in this area. Household stockpiling and material preparation has been advocated. Traditionally, household disaster preparedness often involved stockpiling of materials that might ensure well-​being and health. Special consideration should be given to older people when preparing for emergency evacuation materials (such as a disaster grab bag). For older subgroups, a household stockpiling effort might mean survival (e.g. life-​maintaining drugs) and maintaining of basic well-​being (e.g. food and water), especially for those with underlying health issues and frailty.

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Health

Emergency blanket

Flint First aid equipment Picture of current Guide on first aid and common drugs medica ons and ORS prepara on

Mul -purpose: pocketsized knife/card

Manual dynamo torch

Food & nutrion

Informaon Non-perishable food Family portrait

Whistles

Copy of iden ty document

Pe y cash

Emergency contact informa on

FIGURE 9.1   Suggested

Dietary guidelines for people with chronic condi ons

Water & sanitaon

1.5L water bo le

Soap

Towel

items to include in the general household disaster

preparedness bag Sources: Chan (2017); Chan, Ling, Wong, Liu, and Lee (2016).

Clean water, in particular, might have important bearing towards health maintenance and the need of evacuation from some chronic emergency-​affected locations. Life maintaining medication, basic first aid kits, and sanitation supplies are some common materials. Equipment such as walking aids, additional reading glasses and hearing aids are all important items to be included to help individuals maintain independence, in addition to regular relief supply for the general population. Older people should be encouraged to prepare specifically for themselves, in addition to household stockpiling for times of crisis. Household-​based disaster preparedness materials (extra water and food) and personal drugs (chronic diseases) should be prepared and updated regularly (to avoid expiration dates) according to changes of needs. There are variations of what should be put in an emergency household disaster bag (Pickering, O’Sullivan, Morris, Mark, McQuirk, Chan, et al., 2018). Figure 9.1 describes items that could be included in general disaster bags. For households with older people, disaster preparedness bags should include geriatrics items. In addition to the general health and well-​being maintaining items (as highlighted in Figure 9.1 and Chapter 6), some geriatric-​specific items are highlighted in the disaster preparedness bag for older people in consideration of the group’s vulnerabilities. Hearing aids with related extra batteries and eyes glasses enable older people to reach distribution points and access assistance more easily as well as prepare their own food (HAI, 2014a). Emergency stockpiles must include common medications for diabetes and heart diseases that are relevant to older people (HAI, 2014a). It is noteworthy that the body temperature of older people tends to be lower because of their reduced ability to regulate temperature (Fox, Woodward, Exton-Smith, Green, Donnison, & Wicks, 1973). To prevent

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Health

Shelter

Warm blanket and clothes Spare glasses

Personal Hearing aids and baeries medicaons

(for one week)

Informaon

Food & nutrion Adjusted requirements with age, weight, underlying health issues (e.g. NCDs) and dental situaon

Water & sanitaon Identy documents

Contact details of friends and family, and home address

FIGURE 9.2   Specific

Sanitary supplies, e.g. nappies, garbage bag, hand saniser

items for older people in disaster preparedness bag

Sources: Chan (2017); HAI (2014a).

hypothermia, a warm blanket and warm clothing are a must. As older people are more likely to have urinary incontinence (Diokno, Brock, Brown, & Herzog, 1986) and as lower limb injuries are common as health consequences after earthquake, sanitary wares like nappies are recommended. Figure 9.2 illustrates an example of disaster preparedness bag for older people (refer also to HAI, 2012a). For developed contexts, studies in the United States indicate that older people subgroups (>50) have three days’ worth of food supply, medication and water when compared with the younger age group. However, such proactive preparedness was not reported for older people of ethnic minorities in the same studied community (CDC, 2012). Older people were the most likely group to have a communication plan with family members and the least likely to have a place to meet if there is an event (Greenberg, 2014). Preparedness activities for older people are less documented in developing contexts. Regardless, an “ageing lens” should be encouraged for health and emergency risk assessment of older people. At its minimum, the population data should be disaggregated by age and sex to ensure the DRR plans reflect the vulnerabilities and capacities of the different groups. It is difficult to examine ageing issues without a clear understanding of the local context, specific analyses (e.g. age-​and gender-​aggregated data analyses), integrating evidence into context, and constructing response and monitoring accordingly. Training of staff/​ stakeholders to recognise health needs and gaps through the “ageing lens” might be the first step to the inclusion of older people in response to crisis. Besides, for the older population group, a number of them, especially the oldest and frail group, might tend to live in old-​age nursing homes and institutions. Case Box 9.1 describes the focus group findings in the Caribbean by PAHO on the issues of how older people might be supported or forgotten in DRR planning and health emergency and disaster risk management (PAHO, 2012).

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CASE BOX 9.1  WELL-​BEING OF OLDER PEOPLE AFTER A DISASTER: THE ISSUE OF SHELTER Changes of family structure and the increasing number of frail older persons with longevity have increased the use of residential facilities and nursing homes. These homes tend to be very vulnerable to disaster impacts. A rapid telephone interview conducted in Barbados, Grenada, Trinidad and Tobago and British Virgin Island (BVI) with the Disaster Management Office of BVI revealed that there was little available information on disaster response plans or their capacity to cope in a disaster among the 31 private residential facilities and two government facilities in Barbados, 12 in Grenada, 131 in Trinidad and Tobago, and two in BVI. Telephone interviewees also specifically identified shelters that were inappropriate and uncomfortable for older persons. Source: PAHO (2012, p. 8).

Community level Depending on the cultural and community context, Health-​EDRM efforts vary between communities. Common community-​level preparedness activities include education and training. Education and training are important to promote preparedness in civil society. In recent years, there has been some literature on the effectiveness of training experiences. Disaster health risk education and promotion should cater for the reality older people might face (e.g. the limitation of their mobility, vision, nutritional need and literacy level). Topics chosen for such work should be respectful and sensitive to the cultural needs and age and gender appropriate for the purpose. Moreover, training courses that intend to support community preparedness, response and rehabilitation should not have an age-​cap or arbitrary age discriminatory criteria of participation. With population ageing, older populations are valuable assets and probably the main target audience of these training courses in many of the disaster-​affected communities. With the changes of demographic structures, older people might have no family or social network to depend on in crisis and skills training might be the only way to help them obtain or access support and assistance. Community stockpiling for emergency materials should always include provision for the older population. It is important to point out that even in developed contexts with well-​structured information systems distribution plans for stockpiled goods need special arrangements for older people, especially for those with ambulatory limitations. Access points that are easy to reach, special consideration for waiting (e.g. seats and covered shelters during days in extreme temperature), registration procedures for older people who have no formal identification documents, and ensuring protection for older people who have received their supplies/​emergency rations are all important considerations. Attention should be given to geriatric

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essential life-​maintaining medications (e.g. insulin and analgesics), self-​care support supplies (e.g. reading glasses, walking frames and sticks), food portions that are easy to swallow and digest for older people with dental issues, and appropriate basic supplies and utensils (e.g. equipment of appropriate size and water containers that older people can carry) (HAI, 2012b; refer also to Chapter 6).

Evacuation plan In an emergency, at-​r isk populations might face additional challenges in evacuation. It is thus important to identify older people who might be living alone, immobile, or with mobile and sensory problems as community preparedness strategies. With an ageing community, consideration should be taken to ensure sensitivity to issues of varying status of mobility, mental health capacity and self-​care capacities when undertaking emergency preparedness and response planning. Regular risk communication, mock evacuation drills, and plan updates are necessary in communities where active urbanisation/​development might change the context. After a disaster, relevant trained personnel and public health officers should authorise review of the safety, integrity and health risks of the infrastructure before its residents are allowed to move back into housing. Networks and locations of clusters of older people, who might be living alone or in institutions, should be mapped and reviewed regularly to minimise risks of potential death and morbidity during the response and evacuation process. Disaster response planning should always attempt to map out emergency resources (electricity, water supply, life-​sustaining treatment such as dialysis units), availability of personnel (who might be on duty in time of crisis as well as in the backup roasters), appropriate facilitation (e.g. signage for route and meeting locations, with clear visual and audible support especially for older people) and back-​up facilities for accommodation and life-​sustaining treatment of the older population. With physical vulnerability and constraints that might hamper mobilisation, evacuation preparation for the older age group is a significant DRR planning activity. The mobility constraints of the older population subgroup require sensitivity in identification of locations for evacuation centres. For frail older people, support and transportation need to be pre-​planned or organised in emergency. There are examples of how community organisation of a buddy system might support an older population. Disaster response plans should consider the proportion of older people who might require response services and support. If possible, older people, like children, should not be separated from their families to ensure stability in social support in crisis.Those older people with specific health needs (with underlying NCD and life-​maintaining treatment, impaired sensory needs) should always be given special attention. Advance directives (e.g. “Do not resuscitate”) should be clearly differentiated from “Do not rescue” during emergency and crisis. Moreover, post-​disaster recovery plans would need to take into consideration the specific social and physical limitations faced by older people who have no family/​links and capacity. In addition to an age-​friendly evacuation plan, age-​friendly shelter planning arrangement can affect the well-​being and health of older people. Evacuation locations should ensure privacy and dignity of older people (e.g. provide gender-segregated areas). Toilet facilities should be

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step-​free to enable access for caregivers and wheelchair users, with non-​slip services, appropriate lever handles and rails, and ramps.

Healthcare facilities Hospitals and healthcare facilities (such as primary care centres, laboratories, pharmacies and blood banks) are core assets in communities, which ensure health is maintained and the population is supported when disaster strikes (WHO & PHE, 2017). Not only can health facilities provide medical services to the crisis-​affected community, but they also serve as platforms for crucial services (e.g. diagnosis, surgery and hospitalisation) and care coordination, as well as the link to health supply chains, from storage to the supply of vaccine, medicines and other healthcare items (see Knowledge Box 9.2). Loss of facilities may hinder response and divert responders and response away from the community. For care facilities that expect usage by older patients after disasters, the design and plan should be sensitive to and suit the needs of older people. To avoid additional injuries and traumas (e.g. those resulting from falls), the need for age-​friendly infrastructure (e.g. ramps, lighting and latrines) should be catered for whenever possible. While typically older people are evacuated and sent to adult emergency facilities, their special social and dietary needs (e.g. those of older people with underlying non-​communicable diseases or with dental problems) should not be forgotten.

Programme level With their experience and status, older people might exert power and influence to change how older people’s well-​being is supported and advocated (Age Action Ireland, 2014). However, due to gender and culture (e.g. older women, poor old), some might experience discrimination and have very limited opportunities to participate. To protect and empower these subgroups, expert committees of older people should always be included in discussion, planning, implementation, policy-​ making and evaluation of programmes. Core membership should be made up of older people in disaster preparedness and planning contexts. Older people’s associations should be developed to facilitate the participation of older persons and to support disaster management, from vulnerability mapping to participation in drills and disaster planning (Chan, Hung, & Chan, 2017). The needs as well as the contribution of older people in disaster reduction and management plans should be mainstreamed (Chan et al., 2017). People taking care of older people, policy-​makers and humanitarians should be sensitised to issues of the ageing population: the relationship between healthy ageing and disasters, the health impact of disasters on older people, and the vulnerabilities and potential for contribution of older people (Chan et al., 2017). Economic self-​sufficiency should be encouraged: The poverty rate among working older people is much lower than among those who are economically inactive; with financial resources at their disposal, working older people are in a much better position to cope with their health needs when facing disasters (Chan et al., 2017).

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KNOWLEDGE BOX 9.2  WHO SAFE HOSPITAL INITIATIVES Hospitals are also important symbols of social well-​being. Destruction of or damage to a hospital may result in a loss of trust in local authorities as well as exposing patients and health workers to further vulnerabilities. Acts of violence, including direct attacks, have increased the threats to the security of hospitals, health workers, patients and health services. Older age groups are the most likely users of health service facilities. The Safe Hospital Initiative (WHO, 2015) is considered as one of the core initiatives to support the Sendai Framework for Disaster Risk Reduction (UNDRR, 2015). Among health facilities, hospitals can absorb up to 70% of ministry of health budgets, which can be lost when poorly constructed hospitals are destroyed or damaged. The initiative (WHO, 2015) has three major proposed targets: i) by 2030, all new hospitals and 80% of other new health facilities are to be built to withstand hazards, in accordance with the safety and building codes of the country; ii) by 2030, 50% of existing hospitals and healthcare facilities requiring improved safety are to be retrofitted, in accordance with the safety and building codes of the country; and iii) by 2030, all hospitals and health facilities will have emergency response plans for continuing healthcare in disasters. The initiative also suggests the following success indicators: i) whether safe hospitals are included in national health sector emergency and disaster management programmes; ii) whether a national safer hospitals programme is put in place; iii) the number of critical hospitals that have been assessed and for which recommendations have been made for enhancing safety and emergency preparedness; iv) the number of existing health facilities that have implemented activities to improve safety of buildings and equipment as well as emergency and disaster management; and v) the number of new hospitals and other health facilities that have been built to withstand local hazards and have taken measures to improve safety, functionality and emergency preparedness.

Programmatic and policy-​level topics on healthy ageing, disaster mitigation and disaster risk reduction should include disaster mitigation for older people. Coordinated informal care, including home care and self-​care, and capacity building in geriatrics and gerontology among the health and social care workforce should be developed. Proactive service-​planning strategies should be developed for psychosocial support and to ensure the quality of care received by older people during the recovery phase. In particular, health-​system planning of dementia care and palliative care for orphaned older people is essential (refer also to Chapter 10). Moreover, there is significant diversity in capacity, resilience level and vulnerability when this group faces extreme events. Older people who are well-​supported by relatives and with formal social protection might not only be as resilient as the

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general population, they might serve as experts to support community crisis with their experience and knowledge of traditional coping strategies (refer to Chapter 5). Older people with knowledge and experience of the geographic location might possess important awareness of hazards, previous experience, warning signals, etc. Especially with regard to natural disasters and climate change-​related stresses (e.g. floods, droughts) in agricultural communities, the insights of older people might provide planning tools (e.g. hazard maps) to capture/​document previous related climate impact in areas where historical data might be absent or incomplete. For programme development that might involve older users, age sensitivity is necessary. For example, although the use of technology has become mainstream in supporting disaster response, communication and relief distribution, this mode of communication might not be the most appropriate for older people who might have limited technological literacy. If a technology programme were to be implemented to support needs, additional training may need to be offered to train up relevant skills and capacities of the older population to streamline utilisation and avoid unintended access barriers. In addition, as disability and sensory impairment increase with age, programme developers might need to adjust their programme activities according to the varied capacities of older people (e.g. 60–​75 years old vs. 75 or above). It is also important to highlight, however, that vulnerable subgroups have a tendency to have limited confidence in DRR planning and preparedness unless their voices are being treasured and the community gives them a chance to speak out through appropriate discussion contexts and opportunities (e.g. consultation). Moreover, as knowledge of older individuals might be affected by memory distortion, bias and uncertainty, policy-​makers and planners should always attempt to triangulate information with additional sources. Information collection methods and specific techniques (e.g. storytelling and community walks) might be required for the older age subgroup. International agencies such as HAI have extensive experience in engaging older community member support for participatory risk assessments; details may be found in their published literature. There has been published literature of how intergeneration disaster learning and planning may maximise the potential impact.

Risk communication Effective communication during a disaster can significantly reduce the human health impact, can empower and mobilise communities as well as build community resilience and may reduce public anxiety during a disaster. The communication strategy should be pre-​planned and proactive, and interactive communication with a wide range of communication channels and media coverage is essential. The World Health Organization (WHO) has proposed seven steps (assessing media needs; developing goals, plans and strategies; training communicators; preparing messages; identifying media outlets and activities; delivering messages; and evaluating messages and performance) for effective communication during public health emergencies (WHO, 2005b).To address the needs of older people, specific attention

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should be placed on the language use and comprehensibility of disaster-​related preparedness and response education. Ensuring information, disaster warning and communication system access for older people is of paramount importance.

Early warning system (EWS) Mitigating disaster risk is possible with good preparedness and disaster risk literacy. Early warning, as a disaster preparedness intervention, may provide timely and effective information to support actions and decision making in emergency situations (UNEP, 2012). Early warning systems are applicable to various hazards, such as geophysical and biological hazards, as well as complex socio-​political emergencies (Chan, 2017; Phaiju, Bej, Phokharel, & Dons, 2010). An effective EWS provides people with information that is relevant to their needs and is sensitive to their available resources. It saves lives and reduces economic and material losses from disasters. In general, early warning systems should include the following four elements: risk knowledge, collecting data and undertaking risk assessments systematically; monitoring and warning service, developing hazard monitoring and early warning services with a sound scientific basis; information dissemination, communicating risk information and early warnings to populations at risk; and building national and community response capabilities, through conducting systematic education and preparedness programmes for communities (UN, 2006). For older people, the warning should be designed in ways that an older population might access (taking into account mental, sensory and mobility limitations), have the capacity to understand (with appropriate repetitive level and visual aids), and have been empowered with the ability to react and take specific actions (e.g. taking actions with evacuation support) according to their risk context (HAI, 2012a, 2012b).

Technology, eHealth and social media for older people Technology, eHealth monitoring, distance diagnosis and treatment and utilisation of technology to strengthen disaster resilience are increasingly common for rural communities where older people tend to reside. For instance, the British Red Cross has launched an online platform named “Everyday First Aid”, which aims to empower people with first-​aid skills. A mobile application was also developed to provide basic first-​aid knowledge to guide emergency response and preparedness for non-​disaster phases. In addition, a location-​based approach using satellite/​GPS technology can help provide individual warnings to personal devices depending on owners’ locations. While these technologies might help bridge the distance and human resource gaps in communities, the capacity to use the technology and the continuous technical upgrading needs present to communities’ major challenges. Exposure to early warnings alone is inadequate to mitigate disaster risks. By providing well-​simulated and up-​to-​date information, individuals can gain a good understanding of natural disasters and get enough background to make quick decisions that help prevent and reduce damage. In addition to traditional media like television and radio, the effective and appropriate uses of mobile phones, the internet and social media are areas of

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future development for disaster risk communication. Social media platforms such as Facebook, Twitter and Instagram have become an essential part of human lives in the past decade. Exploring of the use of new media like the internet, SMS, Reverse 911 (call) and social media (e.g. Facebook and Twitter) might provide up-​to-​date information, and quicker diffusion through citizen co-​production (retweeting) is urgently needed. For example, the Twitter Tsunami Early Warning Civic Network used by the Indonesian government reached 4 million Twitter users in 15 minutes during an earthquake in 2012 (Chatfield, Scholl, & Brajawidagda, 2013).The United Nations “space-​based information for crowdsource mapping” is an example of how the internet and social media can be used as tools to facilitate disaster response and build disaster resilience by disseminating information about disasters to recruit volunteers and to empower public action. For example, following the Great East Japan earthquake in 2011, many Japanese citizens used social media as a source of communication. Facebook in Japan reached over 17 million users during the disaster, and Facebook, Twitter and Mixi (a popular Japanese social media site) were used to share information, spread warnings and broadcast requests for assistance. However, it is uncertain if the popularity of technology and social media usage might be applicable to the older population. Unfortunately, currently there lacks an integrated, comprehensive and well-​recognised approach in the care of older people in emergency situations globally and regionally. Significant portions of the at-​r isk older population may not have regular access to new technologies. Digital exclusion of the most vulnerable people (e.g. older people, people with no/​limited technological literacy) (IFRC, 2013) is not frequently highlighted. Moreover, maintenance of information accuracy and credibility on various social networks remains a challenge and an important research topic with policy implications for the years to come. In addition, for conflict contexts and in complex emergencies where complex issues of security are involved, how information should be disseminated and to whom might be subject to significant debate. For risk communication to be effective, communities need to improve disaster literacy and preparedness in knowledge, skills, attitude and competency development.The potential application of technology, eHealth and disaster preparedness for older people should be explored carefully.

Global policies In recent years, the global community has shifted its emphasis from acute response to proactive management of disasters through efforts in disaster risk reduction (DRR). DRR refers to the systematic analysis and management of health risks posed by emergencies and disasters, through a combination of hazard and vulnerability reduction to prevent and mitigate risks, preparedness, response and recovery measures. It highlights the need for prevention, mitigation and preparedness, while sustainable development, robust health systems and multi-​sectoral actions are the key underlying principles of disaster risk management in health. Disaster risk management is an essential element in sustainable development. Disasters delay development programmes as they destroy available assets and increase

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a population’s vulnerability to health risks. The integration of disaster risk management into sustainable development is one of the key strategies to develop in the post-​ 2015 international DRR framework. In recent years, a number of global policies have emerged that facilitate the understanding of and address older people’s needs in disasters. These include the Madrid International Plan of Action and Political Declaration, WHO’s approach in ageing and health, and the Inter-​Agency Standing Committee’s brief for humanitarian actors on “Humanitarian Action and Older Persons” issued in 2008 (IASC, 2008).The healthcare system is a core element of disaster risk management for health.Well-​organised and well-​managed primary healthcare systems could improve the health status of a community and increase its resilience. Safe hospital programmes encourage the building of health facilities that can withstand disasters (WHO, 2015). The healthcare system also needs to develop an adaptable and resilient system to maintain health services in emergency situations.The health system cannot function properly without the support of other systems, such as water and sanitation, food and nutrition, logistics, communication and security. Multi-​sectoral action is necessary to ensure the continuity of health services. Cross-​sectoral collaboration is also required to reduce the health risks of disasters at all levels. Knowledge Box 9.2 discusses the Safe Hospital Framework advocated by WHO to facilitate disaster risk reduction efforts.

Disaster risk reduction in health The health-​related risks faced by older people in disasters should be managed pro-​ actively to avoid escalation of poor medical outcomes and avoidable risks and to prevent complications (WHO & PHE, 2017). During emergency preparedness, older people who are at risk should be identified by their location and according to their specific needs and requirements. Their voice should be included in the planning process and preparedness activities and providers should be trained and at least made aware of the vulnerabilities and care needs of older people. In addition to medical service support, the planning process should also include consideration for transport, special requirements for warning, support service activation, evacuation transport, emergency shelter and nutrition needs. When an emergency occurs, older people’s situation and evolving needs should be re-​evaluated regularly. Drugs, services and support (e.g. that helps with access to fuel and water) for older people should attempted whenever possible. Access to quality mental health and social support services is also pertinent to older people who are alone or orphaned. In a post-​disaster recovery and rehabilitation phase, continuity of medical/​social support and follow-​up care and service are necessary, especially for those who might be permanently displaced due to the crisis.

Barrier-​free humanitarian services Four main criteria for developing barrier-​free humanitarian services and support for the older population, i.e. adaptability, accessibility, equity and gender equality, have been proposed by a number of non-​government agencies that have experiences in supporting older people in times of humanitarian crisis (HAI, 2012a) (see Knowledge Box 9.3).

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KNOWLEDGE BOX 9.3  BARRIER-​FREE HUMANITARIAN SERVICES Adaptability Programmes should be designed with consideration of context and need analysis that addresses the specific vulnerabilities, needs and capacities of the addressed demographic subgroups.

Accessibility Physical and financial accessibility, availability of quality service, and access to information and communication are typical accessibility dimensions to be considered. For physical accessibilities, location, timing of service availability, and age-​friendliness of facilities are primary indicators. Financial capacity and means should not be a criterion for access to service in emergencies for older people. Availability of good quality service should be ensured while accessing basic medical and nutritional needs. Quality clinical service should include relevant drugs for chronic medical conditions for continuity of treatment and appropriate food for specific medical needs (e.g. diabetic patients). Access to information and communication should take into account older people’s information access and utilisation patterns. Access to critical life-​saving, self-​ protection and resource availability information should be ensured.

Equity Equal access to programmes, services, resources and support should be ensured for vulnerable groups at all ages.

Gender equality Services should be designed to meet the needs of both genders and with sensitivity towards cultural norms. Gender issues should be considered in programme design, implementation and monitoring, and it should be emphasised that both genders can benefit equally from training and capacity-​building activities. Source: HAI (2012a).

Conclusion Globally, all countries, regardless of the status of economic and social development, are affected by the increasing frequency and severity of emergencies.With the ageing of the global population, clear policies, strategies and age-​related programmes need to be developed and implemented to minimise health risks and their associated consequences.

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Health-​EDRM is proposed as one of the latest global paradigms that facilitate the development of multi-​faceted strategies. It highlights the evidence need and actions to manage the wide range of emergency risks. Capacity development for Health-​EDRM at country and local levels may be built on existing global programmes and frameworks, including the International Health Regulations (IHR) (2005), the Sendai Framework for Disaster Risk Reduction (2015–​2030), the Sustainable Development Goals and the Paris Agreement on Climate Change (WHO, 2019). The low level of visibility of older people in disasters frequently means an absence of disaggregated data for analysis, limited research and low awareness of the relevant issues. Attempts to improve individual DRR programmes in Health-​EDRM should take older people into consideration. Age-​friendly DRR programmes will enhance specific age-​aware risk assessment, risk communication, disaster risk literacy, early warnings systems, stockpiling, responder training, evacuation planning, protection and psychosocial response, as well as health and nutrition planning. Policies for improving the current age-​gap in policies and approaches for disaster and emergency should be inclusive, participatory, gender-​sensitive and able to raise visibility and promote self-​sufficiency of the older people.

References Age Action Ireland. (2014). Guidelines for including ageing and older people in development and humanitarian policy and practices. Retrieved from www.ageaction.ie/​sites/​default/​ files/ ​ a ttachments/ ​ g uidelines_ ​ f or_ ​ i ncluding_ ​ o lder_ ​ p eople_ ​ i n_ ​ d evelopment_ ​ a nd_​ humanitarian_​policy_​and_​practice_​2.pdf Centers for Disease Control and Prevention (CDC). (2012). Section 11: Epidemic disease occurrence (Lesson 1: Introduction to epidemiology). In Principles of epidemiology in public health practice: An introduction to applied epidemiology and biostatistics (3rd ed.). Retrieved from www.cdc.gov/​ophss/​csels/​dsepd/​ss1978/​ss1978.pdf Centre for Research on the Epidemiology of Disasters (CRED). (2013). People affected by conflict 2013: Humanitarian needs in numbers. Retrieved from http://​reliefweb.int/​sites/​ reliefweb.int/​files/​resources/​PubID303ConflictReport.pdf Chan, E. Y. Y. (2017). Public health humanitarian responses to natural disasters. London: Routledge. Chan, E.Y.Y., Hung, H., & Chan, G. K.W. (2017). Policy implications for managing older people in disaster (Policy Brief). Retrieved from www.ccouc.ox.ac.uk/​_​asset/​file/​policy-​brief-​4.pdf Chan, E. Y. Y., Ling, K. W. K., Wong, C. S., Liu, K. S. D., & Lee, P. Y. (Eds.). (2016). Training manual on health and disaster preparedness in rural China. Hong Kong, China: CCOUC and WZQCF. Retrieved from http://​ccouc.org/​_​asset/​file/​public-​health-​manual-​eng-​ small.pdf Chatfield, A.T., Scholl, H. J. J., & Brajawidagda, U. (2013).Tsunami early warnings via Twitter in government: Net-​savvy citizens’ co-​production of time-​critical public information services. Government Information Quarterly, 30(4), 377–​386. Diokno, A. C., Brock, B. M., Brown, M. B., & Herzog, A. R. (1986). Prevalence of urinary incontinence and other urological symptoms in the noninstitutionalized elderly. Journal of Urology, 136(5), 1022–​1025.

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Fan, V. Y., Jamison, D. T., & Summers, L. H. (2018). Pandemic risk: How large are the expected losses? Bulletin of the World Health Organization, 96(2), 129–​134. doi: 10.2471/​ BLT.17.199588 Fox, R. H.,Woodward, P. M., Exton-​Smith, A. N., Green, M. F., Donnison, D.V., & Wicks, M. H. (1973). Body temperatures in the elderly: A national study of physiological, social, and environmental conditions. British Medical Journal, 1(5847), 200–​206. Greenberg, M. R. (2014). Protecting seniors against environmental disasters: From hazards and vulnerability to prevention and resilience. London: Routledge. HelpAge International (HAI). (2012a). Health interventions for older people in emergencies. Retrieved from https://​reliefweb.int/​sites/​reliefweb.int/​files/​resources/​Health-​ Interventions.pdf HelpAge International (HAI). (2012b). Older people in emergencies: Identifying and reducing risks. Retrieved from www.helpage.org/​silo/​files/​older-​people-​in-​emergencies-​-​identifying-​ and-​reducing-​r isks.pdf HelpAge International (HAI). (2014a). Disaster resilience in an ageing world: How to make policies and programmes inclusive of older people. Retrieved from www.unisdr.org/​2014/​iddr/​ documents/​DisasterResilienceAgeingWorld.pdf HelpAge International (HAI). (2014b). Minimum standards checklist: Including older people in disaster risk management. Retrieved from www.unisdr.org/​2014/​iddr/​documents/​ MinimumStandards-​AgeInclusiveDRR.pdf Inter-​Agency Standing Committee (IASC). (2008). Humanitarian action and older persons: An essential brief for humanitarian actors. Retrieved from www.globalprotectioncluster.org/​_​ assets/​files/​tools_​and_​guidance/​IASC_​HumanitarianAction_​OlderPersons_​EN.pdf International Federation of Red Cross and Red Crescent Societies (IFRC). (2013). World disaster report 2013: Focus on technology and the future of humanitarian action. Retrieved from www.ifrc.org/​PageFiles/​134658/​WDR%202013%20complete.pdf International Federation of Red Cross and Red Crescent Societies (IFRC). (2016). World disasters report: Resilience: Saving lives today, investing for tomorrow. Retrieved from www.ifrc.org/​ G lobal/​ D ocuments/​ S ecretariat/​ 2 01610/ ​ W DR%202016- ​ F INAL_​ web.pdf Pan American Health Organization (PAHO). (2012). Guidelines for mainstreaming the needs of older persons in disaster situations in the Caribbean: A contribution to World Health Day 2012: Ageing and health. Retrieved from www.who.int/​hac/​events/​disaster_​reduction/​guide_​ for_​older_​persons_​disasters_​carib.pdf Phaiju, A., Bej, D., Phokharel, S. & Dons, U. (2010). Establishing community based early warning system: Practitioner’s handbook. Retrieved from www.preventionweb.net/​files/​19893_​ 19866cbewspractionershandbooktraini.pdf Pickering, C. J., O’Sullivan,T. L., Morris, A., Mark, C., McQuirk, D., Chan, E.Y., et al. (2018). The promotion of ‘grab bags’ as a disaster risk reduction strategy. PLOS Currents Disasters. doi: 10.1371/​currents.dis.223ac4322834aa0bb0d6824ee424e7f8 Sphere. (2011). Humanitarian charter and minimum standards in disaster response. Retrieved from www.sphereproject.org/​handbook/​ United Nations (UN). (2006). Global survey of early warning systems: An assessment of capacities, gaps and opportunities towards building a comprehensive global early warning system for all natural hazards. UNDRR. Retrieved from www.unisdr.org/​2006/​ppew/​info-​resources/​ewc3/​ Global-​Survey-​of-​Early-​Warning-​Systems.pdf United Nations Development Programme (UNDP). (2007). Fighting climate change: Human solidarity in divided world. Human development report 2007/​2008. Retrieved from http://​ hdr.undp.org/​sites/​default/​files/​reports/​268/​hdr_​20072008_​en_​complete.pdf

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United Nations Environment Programme (UNEP). (2012). Early warning systems: A state of the art analysis and future directions. Retrieved from http://​na.unep.net/​siouxfalls/​ publications/​Early_​Warning.pdf United Nations Framework Convention on Climate Change (UNFCCC). (2015). Paris Agreement. Retrieved from https://​unfccc.int/​sites/​default/​files/​english_​paris_​ agreement.pdf United Nations General Assembly (UNGA). (2015). Transforming our world:The 2030 Agenda for Sustainable Development.Resolution adopted by the General Assembly on 25 September 2015, A/​RES/​70/​1. Retrieved from www.un.org/​ga/​search/​view_​doc.asp?symbol=A/​ RES/​70/​1&Lang=E United Nations International Strategy for Disaster Reduction (UNISDR). (2009). 2009 UNISDR terminology on disaster risk reduction. Retrieved from www.unisdr.org/​files/​ 7817_​UNISDRTerminologyEnglish.pdf United Nations Office for Disaster Risk Reduction (UNDRR). (2015). Sendai Framework for disaster risk reduction 2015–​2030. Retrieved from www.preventionweb.net/​files/​43291_​ sendaiframeworkfordrren.pdf United Nations Office for Disaster Risk Reduction (UNDRR). (2017). Terminology. Retrieved from www.unisdr.org/​we/​inform/​terminology#letter-​d Vorhies, F. (2012). The economics of investing in disaster risk reduction. UNDRR. Retrieved from www.unisdr.org/​files/​32357_​drreconomicsworkingpaperfinal3.pdf World Bank. (2017). Climate insurance. Retrieved from www.worldbank.org/​en/​results/​ 2017/​12/​01/​climate-​insurance World Health Organization (WHO). (n.d.). Emergencies preparedness, response: Disease outbreaks by year. Retrieved from www.who.int/​csr/​don/​archive/​year/​en/​ World Health Organization (WHO). (2005a). International health regulations (3rd ed.). Retrieved from www.who.int/​ihr/​publications/​9789241580496/​en/​ World Health Organization (WHO). (2005b). Effective media communication during public health emergencies: A WHO handbook. Retrieved from https://​apps.who.int/​iris/​bitstream/​ handle/​10665/​43511/​WHO_​CDS_​2005.31_​eng.pdf?sequence=1&isAllowed=y World Health Organization (WHO). (2008). Global assessment of national health sector emergency preparedness and response. Retrieved from www.who/​int/​hac/​about/​Global_​survey_​ inside.pdf World Health Organization (WHO). (2015). Safe hospital initiatives: Comprehensive safe hospital framework. Retrieved from www.who.int/​hac/​techguidance/​comprehensive_​safe_​ hospital_​framework.pdf World Health Organization. (2019). Health emergency and disaster risk management framework. Geneva: World Health Organization. World Health Organization (WHO) & Public Health England (PHE). (2017). Safe hospitals: Prepared for emergencies and disasters (Health Emergency and Disaster Risk Management Fact Sheets). Retrieved from www.who.int/​hac/​techguidance/​preparedness/​r isk-​ management-​safe-​hospitals-​december2017.pdf World Health Organization (WHO), Public Health England (PHE), & partners. (2013). Emergency risk management for health: Overview (Emergency Risk Management for Health Fact Sheets). Retrieved from www.who.int/​hac/​techguidance/​preparedness/​r isk_​ management_​overview_​17may2013.pdf

10 CHALLENGES AND GAPS IN DISASTER PUBLIC HEALTH AND ISSUES AROUND SUPPORTING OLDER PEOPLE

Supporting older survivors of disasters and emergencies often requires different considerations from those of other age groups. In addition to health and medical response, many other relevant and complementary sectors that might support older people’s well-​being and care are often overlooked and underdeveloped. This chapter will attempt to describe these challenges.

Disaster preparedness and mitigation Promoting healthy ageing and developing an age-​friendly community are important for building the resilience of the population. However, with potential physiological and economic constraints, older populations might face barriers in access to service, information and social participation. To bridge this gap, policies that promote healthy ageing should be strengthened. Addressing the health needs of older people in disasters should be considered. When planning for disaster preparedness and mitigation strategies, promotion and implementation should be based on underlying service and information utilisation patterns of older people. Approaches and risk communication plans should be based on information access patterns and capacity of each of the demographic subgroups. Community networks (e.g. buddy systems) and relevant emergency and disaster strategies should involve developing programmes with specific information on access and social network patterns of older people to ensure services and information may reach and be used by older people. Regular updates of such networks and plans should also be attempted, since the social capital of older people might change as their capacity (e.g. independence and health status) and network of friends evolve (due to death and incapacitation by illnesses/​accidents or population movement, e.g. older people moving to institutions and rural communities).

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Older people with chronic diseases Older people are often affected by chronic non-​ communicable diseases and would need some form of regular treatment or care. The status of these diseases is often worsened in crises and emergencies. To enhance and improve chronic disease management and self-care during crises, clinical and healthcare providers for older people should remind their patients of disaster preparedness advice and measures to facilitate better healthcare during emergencies. Specifically, training is important in the following areas: drug (extra medication) and medical equipment (e.g. home-​based blood pressure machines) stockpiling; ways to report medical and health needs (e.g. the way to report clinical status to health and medical workers in emergency through telecommunication); and relevant dietary adjustment (e.g. in response to disruption of lifeline infrastructure like water, sanitation and food supply). Public health education should focus on the impact of stress and physical exertion on chronic conditions, and information on potential emergency service locations should be disseminated to communities. Agencies/​care providers of the older population should also aim to inform their community stakeholders to update their information and keep up with guidelines regularly.

Socially vulnerable older people Poverty, low education level, disadvantaged gender status, life changes and family living arrangements are all important social factors that may render older people vulnerable in crises (PAHO, 2012). Typically, the social service sectors might be working with and have the most up-​to-​date information to help monitor these demographic subgroups. Poverty alleviation programmes that bridge the poverty gaps should also examine and stress the importance of safety and emergency preparedness for older people. Housing subsidy schemes should take into account the potential disaster risks of living arrangements. Legislation that facilitates socio-​economic advancement should also aim to strengthen older people’s access to resources and information. The application of new technological media (e.g. internet/​social media) improves accessibility of those who live in geographic isolation. However, such programmes may benefit younger people who are more likely to be technologically literate, rather than older people who have no or limited technological literacy and might be excluded from access to information entirely if only internet-​based information is provided during crises. Social network maintenance, service arrangement and response preparedness are needed to ensure resilience and support are given to these older people. Information regarding shelters and evacuation plans, emergency communication channels for isolated older people, and emergency hotline/​call support systems are examples of such social support. In addition, regarding evacuation plans, special arrangements and agreements should be pre-​organised and sought before emergencies since many older people have special needs and requests for emergency evacuations (e.g. being evacuated with family members, pets, or assets).

Challenges and gaps  215

Risk communication for older people To issue early warnings with targeted messages that are comprehensible and practical for the older people, physiological and sensory capacity, education level, mobility and mode of media use are essential factors to be considered. Older people tend to have a different pattern of warning-​receiving preference when compared with their younger counterparts. Literacy, technological competence and information awareness are some of the common gaps that need to be bridged if it is attempted to enhance older people’s capacity to adopt new technology and apply them in time of crisis. Figure 10.1 shows the preferred channels for receiving weather warning information in an urban context.

Rescue and relief Needs assessment tool limitations Older people might lack proper paper documentation of identification, as it might be lost or there may simply be no government record of the person. Demographic tools and up-​to-​date population-​based local data are needed to assess the population size of older people when crises occur. In rural communities and urban enclaves where demographic characteristics tend to be of age extremes, their older population frequently rely on community resources to survive. Participatory needs assessment as well as community resources mapping that targets older people with disaggregated data and records of health conditions from the register are crucial for identifying orphaned and missing older people who are often not accounted for in general census data. A lack of awareness and absence of the relevant tools for assessing needs of older people might be another barrier to accurately reflecting the needs in a community. Interagency collaboration and data sharing might facilitate the development of a common needs assessment tool to facilitate the identification of the needs of older people in crisis. Pre-​assigned coordinating systems or advocates of older people’s affairs during crisis planning and decision-​making are important to ensure older people’s needs are not forgotten.

Rescue and relief issues Many issues affect effectiveness of the relief and rescue of older people in disasters and emergencies. In addition to challenges in tracking isolated older people during the process, the risks of evacuating frail, incapacitated older people, the logistics of reaching relevant medical information and drug records of patients, and the lack of suitable host facilities for evacuated older people might complicate the decision-​making process (Benson, n.d.). Many issues complicate rescue efforts. For example, one of the main reasons for evacuation refusal in the face of imminent life-​threatening danger is the issue of accompanying pets during evacuation. Although there are no specific data on the number of older pet owners and

newgenrtpdf

Preferred channels of populaon aged 15–64

Preferred channels of populaon aged 65 or above

29.5%

65.6%

TV

52.8%

15.1%

Smartphone 7.0%

14.1%

Radio

8.1%

1.0%

Website 1.5% 0.9%

1.6%

HKO Hotline

1.6%

News

0.3% 60%

50%

40%

FIGURE 10.1   Preferred

30%

20%

10%

0%

1.0%

Others

0%

channels for weather information acquisition

Source: Adapted from Chan, Huang, Mark, and Guo (2017).

10%

20%

30%

40%

50%

60%

70%

Challenges and gaps  217

evacuation patterns, older adults, especially those living alone, are more likely to have strong bonds with their pets and are unwilling to evacuate without them (Garrity, Stallones, Marx, & Johnson, 1989; Heath, Kass, Beck, & Glickman, 2001). Reports show households with pets are almost twice as likely not to evacuate as those without pets (Whitehead, Edwards,Van Willigen, Maiolo, Wilson, & Smith, 2000).

Building up healthcare system resilience and integrating health needs of older people into mainstream healthcare services Community-​based healthcare services for older people should be developed so as to reduce the burden of older people occupying public hospital bed spaces over a long period of time during and after disasters. In addition, a register should be set up, with records on where the older people live and details of their health conditions (e.g. chronic diseases, disabilities and nutritional needs), to facilitate disaster planning and effective response. The register should be able to generate age-​ and sex-​disaggregated data to facilitate needs assessment and to record mortality and morbidity information in the post-​disaster stage. Case Box 10.1 shows gaps, which may explain why older people’s needs are forgotten by healthcare providers in post-​earthquake relief. The needs of older people in assistance programmes should be mainstreamed to maximise their access to assistance during disaster. With the physiological changes among ageing people, the clinical management of disease might be different from that for the general adult population. Nevertheless, there is a general lack of specific clinical guidelines and relevant training to medical and health personnel for the

CASE BOX 10.1  WHY OLDER PEOPLE’S NEEDS ARE FORGOTTEN BY HEALTHCARE PROVIDERS IN POST-​EARTHQUAKE  RELIEF A study was conducted after the 2005 Kashmir Earthquake in Pakistan to understand why older people’s needs seemed to be forgotten by healthcare providers. Results indicated that although most of the studied health-​related agencies claimed that they were age non-​discriminating, only one among the 15 agencies had specific programmes and service planning for older people. Although most responding agencies regarded it as valuable to have age-​related guidelines for clinical and health-​related (e.g. dietary) services, awareness or possession of relevant clinical and service guidelines among the responding agencies was low. Most agencies claimed to have a lack of expertise, medication and material resources (e.g. visual and hearing aids and walking devices) to support older patients in their service domain. Source: Chan (2009).

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management approach of older people in emergencies. When compared with the younger population, older patients tend to have multiple morbidities, multiple medications and different metabolic rates and thus might require a different dosage or management protocol in emergencies. In addition, age-​relevant emergency clinical guidelines for nutritional management, physiotherapeutic management support, mental health management, and personal emergency kits for older people are needed to ensure supplies of basic medical and health resources in times of disaster (e.g. medicines for chronic diseases and other geriatric medicines, medical records and prescriptions under use, walking sticks and eyeglasses). As mentioned in Chapter 6, palliative care is an important but often neglected care subtype for providing comfort and support as well as protecting the dignity of an individual who might be at the last stage of their life journey. While the approaches and principles of palliative care may be applied to people of all ages who might experience severe health-​related sufferings and life-​limiting conditions (e.g. cancer), older people are the major demographic recipients of such services. In extreme contexts, when resources are limited and treatment options are constrained by circumstances, palliative care might be the only option available to support people to live their last moments with dignity. Currently, access to palliative care is very limited and unevenly distributed globally as 50% of the global population (who tend to be the poorest, with the least access to resources) receive less than 1% of the morphine distributed globally (Knaul, Bhadelia, Rodriguez, Arreola-​Ornelas, & Zimmermann, 2018). Training should be offered to emergency workers regarding how to best manage cases that require palliative care support in crisis. In addition to special consideration of the physical vulnerability and needs of older people, the difficulty in locating the vulnerable subgroups when pre-​existing knowledge of their whereabouts is meagre, the limited trust older people have in the uncertainty of the response plan and the underlying medical conditions of the older people (e.g. suffering from dementia and having limited capacity to make decision at the time of crisis) are some reasons why relief workers might have difficulty evacuating older people. With rapid urbanisation and population movements, disaster planning and regular discussions with the relevant community are crucial to ensure relief is carried out efficiently and individual choices are truly respected. Sensitivity should be developed in order not to confuse the difference between, say “Do not resuscitate” and “Do not rescue”, in emergency. Advanced directives should be developed, and relevant plans must be updated regularly. In addition to access to food distribution, adequate health-​maintaining nutrition should also be part of the emergency planning of a community. Maintenance of continuous provision of healthcare services may address the special needs of older people, in particular treatment of chronic diseases that are common old-​age health issues. Patients might be homebound, and access to them (e.g. transportation and accompanying services, mobile clinics and outreach services) may be hampered and thus should be ensured and monitored. In recovery and rehabilitation, coordination should be established between emergency clinical services and nursing homes. Dental care is often overlooked in emergencies, and is frequently presented

Challenges and gaps  219

as an unmet need that affects the well-​being of older people in crisis. Especially in chronic conflict contexts, the lack of dental care support could affect the nutrition and quality of life of older people. Nutrition and feeding programmes should develop sensitivity towards the ways in which dental status might affect food and nutrition intake. In emergencies, triage of needs and awareness of resources and services availability would facilitate subsequent delivery of medical and social services in a proper, orderly and prioritised way. For instance, since most palliative care might be delivered by community volunteers, general awareness of such service need should be promoted and guidelines should be developed to support potential providers with the skills and insight to support older people in crisis. In addition, older people tend to live in enclaves, and the well-​being and the potential for being rescued of those who are living alone, with limited social capital and support, might be hampered by their low visibility on regular records and maps. Moreover, advanced medical directives such as networks and support systems should be developed, updated periodically, and mobilised properly and in a timely manner.

Other health-​related emergency supporting needs Traditionally, after any major disaster, the public health sector tends to focus on health services for acute injury (i.e. trauma care), safe water, sewage disposal and food safety; rarely do people consider the disaster impact on chronic conditions and the extra medication and devices needed on a daily basis by patients with chronic diseases –​ a large proportion of whom are of older age. Following a disaster, chronic illness can easily worsen due to the lack of food and water, extreme heat or cold, stress and exposure to infection (Chan, 2017; Fernandez, Byard, Lin, Benson, & Barbera, 2002; Mudur, 2005). Moreover, emergency food support and rations may not take into account the special needs of older people (e.g. dental issues; refer also to Chapter 6). Older people might not be able to compete with younger people in relief supplies and they might lack the strength to queue for or carry heavy loads of food and water back to their shelters. In addition, older people may find it challenging to travel to relief distribution points, which are often located on higher ground away from inhabited areas to facilitate frontline assistance workers to gauge the number and movement of the displaced population. As a result, many older people tend to share scarce food rations with younger members of their family. Access to water for cooking might be hampered, as older people cannot collect enough water. Usually, no allowance and consideration are given to the difficulty older people might have in chewing and digesting food and absorbing sufficient nutrients. Non-​food items and clothes distributed by relief workers may not always be culturally appropriate or warm enough for older people who tend to have less capacity to endure cold temperature than the younger. The footwear distributed is also not always suitable for older people who find it harder to walk, especially on uneven ground. As reported in Banda Aceh, the area most damaged by the 2004 Indian Ocean tsunami, temporary shelters distributed by aid agencies were rarely suitable

220  Challenges and gaps

for older adults as they had steep staircases with no handrails and poor lighting. Older people might struggle to carry heavy tents or mattresses and some struggle to walk at all. Of the 4,000 older displaced in Darfur surveyed in 2005, 61% had difficulty collecting aid for reasons including impaired vision and being housebound.

Protection of older people The protection of older people is an important area that tends to be forgotten in emergency.Thefts may be the most frequent crimes against older people. Especially for homes left empty (e.g. in case of emergency evacuation), burglary might lead to major economic loss for vulnerable older people. In addition to communal support systems (e.g. pairing up of living alone older people in a “buddy system” to strengthen community support), informing older people about how to confirm the appropriateness of giving personal information to strangers in emergencies, how to secure homes/​households, how to maintain appropriate lighting when the electricity supply is halted, and how to avoid household fire might help them to protect themselves during an emergency. Moreover, older people should be advised not to accept unsolicited drugs and donations (with concern of expiration dates and medication appropriateness) or new medication from agencies who might not be qualified to provide medical treatment (PAHO, 2012).

Recovery and rehabilitation When older people are affected by disasters, it is important to provide sufficient and appropriate follow-​up healthcare services and to provide outreach services to monitor the health conditions of those who are immobile. It is also important to launch campaigns and activities to increase visibility of the older people in relation to the disaster (including their needs and contributions during the disaster and their post-​disaster life), to continue to evaluate the effectiveness of such services, and to ensure provision continuity of suitable rehabilitation services and assisting devices, e.g. wheelchairs/​hearing aids. Equally important is enlisting the support of older people in the rebuilding and rehabilitation efforts, developing post-​disaster income generation programmes that cater for the needs and abilities of older persons, and providing incentives to encourage employment of older people.

Policy and research gaps While there are different programme models to address older people’s needs, a requirement for appropriate programmes is to have a coordinated multidisciplinary planning and response platform, which may advocate for and support issues of older people. Good models of care tend to have robust tracking systems (e.g. chronic diseases and nursing home registries) and databases to both identify needs and check and monitor resources to meet the needs. In addition, official recognition of long-​term care facilities as essential post-​disaster services can also help bring older people’s needs to public

Challenges and gaps  221

attention. For example, in the US state of Florida, patients requiring dialysis, ventilators and other electric devices are granted the first priority of evacuation (Benson, n.d.). However, policies and response approaches to protect and address older people’s needs and welfare are yet to be fully developed in either developed or developing contexts globally. Even with the global discussion (refer to Chapter 9), guidelines relating to the needs of older people remain piecemeal and area-​specific at best. Although older people’s health issues are themes relevant across all areas of disaster preparedness, response, rehabilitation and mitigation, specific guidelines for supporting older people are yet to receive their well-​deserved specific multidisciplinary support and coordination. The issues faced by older people are typically discussed in conjunction with other policy initiatives and issues such as disability and non-​communicable diseases (WHO, 2017). Older people’s needs remain a cross-​ reference sub-​area to addressing the needs of patients with non-​communicable diseases or people with disabilities, and these constraints may predispose issues to be overlooked and forgotten. Case Box 10.2 shows that there is a major literature gap in examining older people’s needs and identifying evidence-​based health emergency disaster risk management for older people (Chan, Man, & Lam, 2019).

Conclusion The issues of older people are of growing importance in the twenty-​first century. Health, rights and protection are all important dimensions to be considered and included in disaster management. Major gaps in addressing older people issues have been identified in preparedness, needs assessment, response and rehabilitation in crises and emergencies. In addition to addressing their health gaps and social needs, harnessing their potential contributions as resources in efforts from disaster preparedness to disaster responses will maximise community capacity for emergency preparedness and response. Although most of the challenges and gaps discussed in this chapter are not unique for the older population in emergencies, emergency responders and stakeholders are more likely to encounter these issues when their target of support is the older age group. As discussed throughout the previous chapters, older people are more likely to be affected by disasters. They are less likely to be prepared, receive relief supplies and recover from the impact of crisis. People from disadvantaged backgrounds, those in poorer countries, those with the fewest opportunities and the fewest resources to call on in older age, are also likely to have the poorest health and the greatest needs (WHO, 2015). It is important however to emphasise that older people represent a mosaic population that spans from healthy, agile individuals to those completely relying on others’ care and support to maintain life. Communities should put weight on including the older people on the agenda in disaster and emergency preparedness to ensure inclusiveness so that “no one is left behind”. Involving older people and their networks (services provider and community network) in planning, and a robust system for tracking chronic diseases and isolated older people would improve identification of the most vulnerable older people and direct services and care towards them.

222  Challenges and gaps

CASE BOX 10.2  INTERVENTIONS FOR HEALTH, EMERGENCY AND DISASTER RISK REDUCTION Health-​EDRM interventions or practices surrounding health and disaster aim to minimise and mitigate health risks before the onset of disasters and immediately after the occurrence of disasters, and to treat and manage those already affected by the disaster. The review by Chan, Man and Lam (2019) indicated that although efficacies of primary interventions, such as vaccination, have been examined in the context of armed conflicts and displaced populations, their effectiveness for natural hazards was rarely reported. Potential lack of baseline data for vaccination coverage of the general adult or older population is likely to create an opportunity for an otherwise preventable disease outbreak. Most of those disaster risk reduction (DRR) practices have not been quantified or evaluated beyond knowledge assessments in non-urbanbased communities. Publications about secondary interventions tend to focus on short-​term impact of evacuation, owning disaster kits (or grab bags), and awareness of disaster risk. Yet, a seven-​year follow-​up study found personal/​ household hygiene and waste management knowledge delivered by health promotion interventions could be maintained. A review of grab bags also identified that apart from knowledge gaps, the availability and accessibility of the items to pack may also create barriers to the adoption of this preventive measure. Tertiary interventions tend to revolve around medical treatments such as patient management and disease control. Nevertheless, during non-disaster periods, community livelihood and resilience building does not usually take into account the implications of demographic patterns and trends for post-​disaster needs. A paper reported that despite the push for geographically balanced development in China, doctor density in rural areas has declined rather than increased and there was a general lack of expertise in geriatric or gerontological issues. In addition, to generate evidence for directing and supporting best practices, especially in floods and typhoons, data on morbidity and mortality should be disaggregated by demographic parameters and diagnoses. Post-​traumatic stress disorder (PTSD) overwhelmingly dominates the mental health research field but no assessment tools for older people with specific needs (e.g. patients of dementia) or treatment options were reported. Better clinical management and deployment of multiple medical disciplines are common suggestions but not standard practices in Asia due to the lack of evidence-​based support. Furthermore, there is currently a lack of documentation of the needs of marginalised groups such as older women and indigenous older people and the relevant evidence-​ based interventions to better prepare older people in times of crisis. Overall, this review also indicated that most evidence-​based research was related to earthquakes, while whether interventions delivered in different hazards might have the same outcomes has yet to be explored. For example,

Challenges and gaps  223

is household oral rehydration solution (ORS) useful for reducing risks of diarrhoea-​related death in floods, typhoons, or earthquakes? The review also reinstated that paradigms on health and DRR mostly assumed top-​ down government-​level responses to save lives, while Health-​EDRM argued for an all-​ society engagement approach to bridge the gap between the delivery of disaster interventions and the adoption by targeted recipients. For the older age group specifically, when most of their care and needs are based on community facilitation and participation, how to harness and facilitate older people’s care post disaster remains uncertain in current evidence. Emergency and disaster contingency plans must factor in the vulnerabilities of older people. An all-​ hazards approach should be considered, as hazards may cascade risks and rarely result in only a single event.

References Benson,W. F. (n.d.). CDC’s Disaster Planning Goal: protect vulnerable older adults. Retrieved from www.cdc.gov/​aging/​pdf/​disaster_​planning_​goal.pdf Chan, E.Y.Y. (2009).Why are older peoples’ health needs forgotten post-​natural disaster relief in developing countries? A healthcare provider survey of 2005 Kashmir, Pakistan earthquake. American Journal of Disaster Medicine 4(2),107–​112. doi: 10.5055/​ajdm.2009.0016 Chan, E.Y.Y. (2017). Public health humanitarian responses to natural disasters. London: Routledge. Chan, E. Y. Y., Huang, Z., Mark, C. K. M., & Guo, C. (2017). Weather information acquisition and health significance during extreme cold weather in a subtropical city: A cross-​ sectional survey in Hong Kong. International Journal of Disaster Risk Science, 8(2), 134–​144. doi: 10.1007/​s13753-​017-​0127-​8 Chan, E. Y. Y., Man, A. Y. T., & Lam, H. C. Y. (2019). Scientific evidence on natural disasters and health emergency and disaster risk management in Asian rural-​based area. British Medical Bulletin, 129(1), 91. Fernandez, L. S., Byard, D., Lin, C. C., Benson, S., & Barbera, J. A. (2002). Frail elderly as disaster victims: Emergency management strategies. Prehospital and Disaster Medicine, 17(2),  67–​74. Garrity, T. F., Stallones, L. F., Marx, M. B., & Johnson, T. P. (1989). Pet ownership and attachment as supportive factors in the health of the elderly. Anthrozoös, 3(1),  35–​44. Heath, S. E., Kass, P. H., Beck, A. M., & Glickman, L. T. (2001). Human and pet-​related risk factors for household evacuation failure during a natural disaster. American Journal of Epidemiology, 153(7), 659–​665. Knaul, F. M., Bhadelia,A., Rodriguez, N. M.,Arreola-​Ornelas, H., & Zimmermann, C. (2018). The Lancet Commission on Palliative Care and Pain Relief: Findings, recommendations, and future directions. The Lancet Global Health, 6,  S5–​S6. Mudur, G. (2005). Aid agencies ignored special needs of elderly people after tsunami. BMJ, 331(7514), 422. doi: 10.1136/​bmj.331.7514.422 PAHO. (2012). Guidelines for mainstreaming the needs of older persons in disaster situations in the Caribbean: A contribution to World Health Day 2012. Retrieved from www.who.int/​hac/​ events/​disaster_​reduction/​guide_​for_​older_​persons_​disasters_​carib.pdf Whitehead, J. C., Edwards, B., Van Willigen, M., Maiolo, J. R., Wilson, K., & Smith, K. T. (2000). Heading for higher ground: factors affecting real and hypothetical hurricane

224  Challenges and gaps

evacuation behavior. Global Environmental Change Part B: Environmental Hazards, 2(4), 133–​142. World Health Organization (WHO). (2015). World report on ageing and health. Luxembourg: Author. Retrieved from https://​apps.who.int/​iris/​bitstream/​handle/​10665/​186463/​ 9789240694811_​eng.pdf?sequence=1 World Health Organization (WHO). (2017). Depression and other common mental disorders: Global health estimates. Geneva: Author. Retrieved from http://​apps.who.int/​iris/​ bitstream/​handle/​10665/​254610/​WHO-​MSD-​MER-​2017.2-​eng.pdf?sequence=1

11 CONCLUSION

Older people, as a demographic subgroup, have strengths, vulnerabilities and health needs that are associated with their stage of physiological journey in life. During emergencies and crises, older people are more likely to experience adverse impacts in physical, mental and social well-​being. After a disaster, they are more likely to face socio-​economic marginalisation, isolation, inaccessible information and lack of relevant post-​emergency support services and access to resources. Meanwhile, numerous examples have shown older people are likely to have survived countless catastrophic events and crises throughout their lives. Most of the older age groups have also significantly contributed to disaster preparedness, response and recovery efforts in their community during their economically active life period. The main argument of this book is not to carve out a separate realm for geriatric care and services for older people in emergencies, but rather to actively include and support the needs of older people as an essential service requirement and maximise their capacity to contribute in times of crisis. Not only should disaster risk reduction policies and programmes include older people in planning and execution, but also the disaster-​related health needs of older people should be foregrounded. Global efforts should review their current approach to disaster response and rehabilitation strategy to allow the older community members to participate and contribute skills and capacities that are often under-​utilised and under-​recognised. New tools and analyses of how new technologies might facilitate needs identification, care and management of older people should also be explored and developed. The strongest imperative for investing in better care and support for older people perhaps stems from our gratitude for their contributions to our current society. Addressing older people preparedness, needs and rehabilitation can reflect our respect towards human dignity and how much we are willing to pay tribute to the lifetime contributions of our older counterparts. Their experience in disasters and crises will reveal how civilised and developed our modern society truly might

226 Conclusion

be.The survival and well-​being of older people, in times of crisis, represents the true human resilience, development and solidarity of civil society. More fundamentally, if efforts are invested into protecting and building robust systems to ensure the well-​ being of older demographic subgroups, younger members of society will also reap the benefits of such effort. If we commit to building for our older population, we are also building a better version of our own future.

INDEX

Note: page numbers in italic refer to figures, page numbers in bold refer to tables and page numbers in bold italic refer to boxes. abuse 51, 53–​54, 90, 129, 165, 185–​186 accessibility 26, 58, 94, 124, 127, 131, 148, 165, 173, 176, 189, 208, 209, 214, 222 acute stress disorder 93–​94 adolescents 12 affordable 26, 28 age-​friendly cities 57, 58–​59 Age-​Friendly Cities Project (WHO) 58–​59 age-​friendly communities 57, 213 age-​friendly domains  57, 58 ageing population 1, 4, 34, 35, 36, 37, 47, 54, 63 age-related macular degeneration 42 air pollution 47, 136 air quality 16, 49, 141 anxiety disorders 12, 94 Asia 78, 129, 130, 139, 141, 166, 172, 222 Bangladesh 78, 117, 149 Barillo, D. J. 147 barrier-​free humanitarian services 209 biological disasters 72, 80, 134 blindness 42; see also vision BMI (body mass index) 161 Bolivia 118 Bolton, P. 91 Bosnia 90 Brazil 35, 134 breast cancer 132 Buffalo Creek event (United States, 1970) 143 Burkle, F. M. 91

Cambodia 112, 116 cardiovascular system 39–​40 care: levels of 28–​30; pathways 14, 28; quality 30 caregivers 12, 43, 53, 128, 171, 184, 186–​188; Cambodia 116; China 116; older people 110, 114–​115, 187–​188; Philippines 116;Vietnam  116 Caribbean 200, 201 case fatality 156, 9, 10 cataracts 42 Centre for Research on the Epidemiology of Disasters see CRED (Centre for Research on the Epidemiology of Disasters) CFSs (child-​friendly spaces) 117 Chan, E.Y.Y. 91, 222–​223 Cheng, Y.  49 Chernobyl accident (U.S.S.R., 1986) 90 child-​friendly spaces see CFSs (child-​ friendly spaces) children 12, 53, 76, 117, 119, 120, 145, 160 China 35, 37, 51, 58–​61, 129, 140–​141, 222; air quality 49; caregivers 116; natural disasters 77–​78; OPAs 112, 116 Chinese University of Hong Kong JC School of Public Health and Primary Care 44–​45 Chinese University of Hong Kong –​STroke Registry Investigating cognitive DEcline study see

228 Index

CU-​STRIDE (Chinese University of Hong Kong –​STroke Registry Investigating cognitive DEcline) study cholera 103, 125 chronic diseases 48, 50, 59–​60, 63, 129, 166, 214, 219 Clark, E. G. 16 climate 72, 74; definition of 72 climate change 19, 72, 74, 79, 81, 135–​136, 137, 138, 139, 141, 142, 143, 144, 147, 196, 197; definition of 72; Paris Agreement on 103, 195, 196, 210 climate change-​related disasters 72, 73, 74, 123, 136–​137, 146–​147, 205 climatological disasters 72, 73, 77, 78, 80, 144, 149 cluster approach 101–​102, 164, 166 CMR (crude mortality rate) 83 cold waves 137–​138, 139 combatants 98 communicable diseases 10–​11, 19–​20, 21, 81, 125, 134–​135, 136, 139–​141, 146, 156, 163, 176; transmission routes of 20, 21 community canteen 64 community health clinics 88 comorbidities 50 complex emergencies 71–​72, 74, 75, 76–​77; definition of 75 conflicts 119–​120, 148, 192, 195, 219 coping 55, 81, 82, 92, 114, 115, 116, 118, 119, 120, 149, 175, 187, 205 CRED (Centre for Research on the Epidemiology of Disasters) 141 crises 1, 2 critical incident stress debriefing 95 crude mortality rate see CMR (crude mortality rate) CU-​STRIDE (Chinese University of Hong Kong –​STroke Registry Investigating cognitive DEcline) study 44 Cyclone Eline (Mozambique, 2000) 117 Dahlgren, G. 7 DALYs (disability-​adjusted life years) 9, 11 Darfur conflict (2005) 220 decline: cognitive 42–​43; sensory 41–​42 dementia 40, 43, 44–​45, 48, 53, 125, 171, 187, 204, 218 demographic transition 87 demography 8–​9, 138 dengue fever 18, 21, 140, 156, 158 dental health 42, 48, 169, 218–​219

dependency 35, 38, 41, 43, 47, 50, 52, 53, 54, 57, 58, 60, 62, 109, 118, 126, 169, 180, 182, 199; intergenerational 126, 205 depression 12, 148 depressive disorders 12, 94, 148 diet 14, 15, 16, 22, 38, 46–​47, 60, 64, 146, 157, 160, 161, 162, 165, 199, 203, 214, 217 direct health impacts 90, 91, 92 disabilities 16, 35, 38, 48, 51, 124, 188–​189, 205 disaster: classification of 71; definition of 70–​71; myths of 86 disaster advice 127, 155–​156, 171, 172, 174 disaster cycle 84 disaster duration 87 disaster losses 90–​91 disaster management 85, 92, 124, 129, 221, 222–​223 disaster mitigation 4, 204, 206, 213–​215 disaster planning 118, 128, 203, 217, 218 disaster policies 194, 195–​196, 210, 220–​221 disaster preparedness 71, 82, 84, 85, 172, 188–​189, 193–​194, 197–​200, 201–​203, 206; definition of 193; for older people 115, 174, 198–​200, 203, 207, 213–​215, 221, 225 disaster prevention 82, 85, 99, 101, 193 disaster recovery 84, 85, 89, 190; older people 115, 119, 120, 188, 220 disaster relief 89, 96–​97, 99, 162–​164, 194 disaster resilience see resilience disaster response 81, 84–​85, 86, 87, 101, 180, 190, 194, 202, 207; cycle 84–​85; older people 118, 120, 123, 172, 202, 221, 225 disaster risk 1, 3, 81, 82, 84, 171, 194–​195 disaster risk literacy 197–​198, 206 disaster risk management 194, 207–​208 disaster risks reduction see DRR (disaster risks reduction) disasters 1, 2–​3, 4, 70–​72, 77–​79, 80, 81, 86–​89, 90–​91, 92, 104, 123–​124, 209, 217–​218 disaster situations 2, 16, 18 disaster warnings 85, 126–​127, 155–​156, 171, 172, 174, 205–​207, 215 disease distribution see epidemiology disease epidemiology see epidemiology disease prevention 9, 14, 15, 16, 17, 19, 87 droughts 144, 145–​146 DRR (disaster risks reduction) 1, 4, 82, 103, 192–​193, 195, 202, 204, 205, 207, 208, 210, 222, 223, 225

Index  229

early warnings 126–​127, 215 Early Warning System see EWS (Early Warning System) earthquake (Haiti, 2010) 93, 118, 130 earthquakes 130–​131 Ebola virus disease (West Africa, 2014) 134 economic contributions 109–​110 economic marginalisation 2, 125–​126 EDRM (emergency and disaster risk management) 195 eHealth 206, 207 elder abuse 51, 53–​54, 185–​186 elderly trauma 52, 156–​157 EM-​DAT Emergency Database (CRED) 71, 74 emergency threshold 83 emergency and disaster risk management see EDRM (emergency and disaster risk management) Emergency Relief Coordinator, UN see ERC (Emergency Relief Coordinator, UN) emergency situations 2, 4, 70–​71, 83, 91, 92, 104, 157–​158, 192, 208 empathy clubs,Vietnam  116 empty-nest households 53 endemics 135, 137 end-of-life care 172, 176 environment 78–​79, 88–​89, 156, 183 epidemics 135, 137 epidemiological health indicators 8, 10, 86 epidemiologic triangle 19–​20 epidemiology 9, 10–​13, 86 ERC (Emergency Relief Coordinator, UN) 102 evacuation 156, 157, 202, 214, 217 extremes of age 13, 109, 115, 123, 139, 157, 186, 215 EWS (Early Warning System) 206 exclusion 47, 126, 181–​182, 186 exposure 82, 124; definition of 82 extra-​terrestrial disasters  72 extreme temperature events 137–​139, 140 extreme weather events 146–​147, 149 famines 144–​145, 146 FAO (Food and Agriculture Organization of the United Nations) 160, 162 field hospitals 167 fires 147 flood relief (Rajasthan, India, 2006) 119 floods 119, 141–​143, 146–​147 food 144–​145, 160, 162–​163, 177, 218, 219

Food and Agriculture Organization of the United Nations see FAO (Food and Agriculture Organization of the United Nations) food-​borne diseases 21, 141 food security 74, 101, 145, 175 forced displacement 76–​77, 103 four-​layer pyramid, mental health 94–​95 fragile states 75, 76 frailty 43, 50 fuel poverty 138 Fukushima accident (Japan, 2011) 76, 89, 116, 124, 132, 207 gastrointestinal system 40 gender 7, 9, 43, 53, 54, 63, 70, 94, 114, 123, 128–​129, 131, 148, 159–​160, 164, 165, 169, 171, 182, 186, 187, 201, 202, 203, 209, 210, 214; difference 128, 131; equality 169, 208, 209 gender-​based violence  148 generalised anxiety disorder 94 geological disasters 77, 80 geophysical disasters 130–​131, 132–​134 geriatric 48, 50, 57, 182, 222; care 183, 225; medications 201–​202, 218; needs 187; services 168, 189, 225; syndromes 48; trauma 156; visual problems 168–​169 geriatrics items 199 globalisation 81 global policies 208 global population 1, 4, 35, 36, 37, 51, 54 Global Strategy and Action Plan on Ageing and Health (WHO, 2016) 57 Goode, R. 147 governance 26, 27 Great East Japan earthquake (2011) see Fukushima accident (Japan, 2011) Guo, S. 49 Guo, Y. 49 GVP (Global Volcanism Program, Smithsonian) 133 Haiti 93, 118, 125, 130 hazardous materials 89 hazards 70, 71, 82; classification of 71; definition of 71, 82 health 6, 9, 13, 14, 23, 91, 193; definition of 6; right to 127–​128 healthcare: primary 17, 28–​29, 88, 94, 95, 116, 197, 208; secondary 29, 88, 197; services 14, 28, 203–​204, 217–​218, 220; tertiary 29, 88, 197 healthcare system 26, 28–​30, 63, 208 health centres, maternal and child 88

230 Index

health communication 24–​25, 27 health determinants 6–​8, 23, 38 Health-​EDRM (Health Emergency and Disaster Risk Management) 4, 99, 101–​103, 193–​200, 201–​203, 210, 222–​223 health financing 26, 27 health impacts 4, 8, 87–​88, 104, 123, 129; direct 90, 91, 92; indirect 91, 92; negative 87, 92 health improvement 6, 15, 16 health literacy 59–​60, 174 health measurements 8, 9 health outcomes 6, 8, 10, 14, 38, 86 health promotion 9, 14, 15, 19, 22–​25 health protection 6, 14, 15, 16–​17, 19, 22, 87 health risks 1, 2, 4, 13–​15, 24, 50, 129, 156, 189, 192, 209 health risks management 194–​196 health risk transition 14–​15 health security 195, 196 health services 6, 15, 26, 27, 28–​30, 88, 125, 157, 165–​169, 171, 183–​184, 185, 192 health systems 25–​26, 27, 28, 172, 184–​185, 192, 197 health workforce 26, 27 healthy ageing 4, 47, 54, 55, 56, 57, 58–​59, 203, 204, 213; see also Age-​Friendly Cities Project healthy settings movement 25 hearing 41–​42, 48, 125 heatwave (France, 2003) 124 heatwaves 138, 139 HelpAge International Report (2000) 148 HFA (Hyogo Framework for Action) 193 high wind speed events 143, 146–​147 Hiroshima (Japan, 1945) 90 HIV (human immunodeficiency virus) 10, 20, 45, 90, 115, 116, 135 home-​based care  169 Hong Kong 50, 64, 72, 125, 127, 129, 138–​139, 140, 173 household preparedness 198–​200 human-​caused hazards and disasters 71, 74–​75, 88, 147–​148, 194 human-​induced hazards and disasters see human-​caused hazards and disasters human immunodeficiency virus see HIV (human immunodeficiency virus) Humanitarian Charter (Sphere, 1997) 97–​98, 99 humanitarian crises 1, 2–​3 humanitarian principles 96–​97

humanitarian response 99, 101–​102, 174, 175–​176, 177–​178, 208 humanitarian services 208, 209 human security 75, 118, 194 human survival 91 humanity 97 Hurricane Katrina (New Orleans, United States, 2005) 124, 143 hydrological disasters 72, 73, 80 hydro-​meteorological disasters  72, 73 hygiene promotion 158, 159 Hyogo Framework for Action see HFA (Hyogo Framework for Action) hyperthermia 139 hypothermia 139 IASC (Inter-​Agency Standing Committee) 54, 55, 75, 101–​102, 208 IDPs (internally displaced persons) 76–​77, 148; Bosnia 90; definition of 77 IFRC (International Federation of Red Cross and Red Crescent Societies) 164 impact phase 84, 89 impartiality 97, 99 inaccessibility see accessibility incidence rate 8, 10 inclusion 56, 57, 58, 59, 118, 194, 195, 200 independence see dependency independence (humanitarian principle) 97, 99 India 35, 51, 129 Indian Ocean Tsunami (Aceh, Indonesia, 2004) 88, 118, 119, 219–​220 indirect health impacts 91, 92 infection control 20 infectious diseases 10–​11, 19–​20, 21, 81, 134–​135, 192 influenza 20, 21, 134, 135, 137 informal care 88, 187, 204 information 26, 127, 155–​156, 171, 172, 174, 205–​207, 216 infrastructure support 125, 155 injuries 12–​13, 48, 129, 156–​157; intentional 12; unintentional 12 Institute of Medicine 96 integrated health services 29–​30 Inter-​Agency Standing Committee see IASC (Inter-​Agency Standing Committee) intergenerational approach 117 internally displaced persons see IDPs (internally displaced persons)

Index  231

International Federation of Red Cross and Red Crescent Societies see IFRC (International Federation of Red Cross and Red Crescent Societies) International Health Regulations 19, 194, 195, 210 IPCC (Intergovernmental Panel on Climate Change) 72, 74, 144 isolation 126, 181, 186 Japan 35, 90, 129 Japan earthquake (2011) see Fukushima accident (Japan, 2011) Kan, L. 49 Kashmir Earthquake (Pakistan, 2005) 125, 131, 217 knowledge transfer 205; older people 110, 115–​116, 120 Lam, H. C.Y. 222–​223 latrines 159–​160 leadership 26, 27, 110 Leavell, H. R. 16 Lebanon 120 Lebanon War (2006)  148 LGBT older people 45 Li, H. C. 49 Li, J. 49 Li,Y. F. 49 life course 13 life expectancy 13, 34, 35, 37, 39, 50, 63 lifeline resources supply 156 life with dignity, right to 97–​98 Liu, C. 49 Liu, J. Y. 49 Liu, Y.  49 McGuire, W.  J.  24 Madrid International Plan of Action on Ageing and Political Declaration (MIPAA, 2002) 54, 55, 208 major depressive disorder 94 malaria 18, 20, 21, 78, 136, 140, 141, 156, 158 malnutrition 64, 145–​146, 160 Malnutrition Universal Screening Tool see MUST (Malnutrition Universal Screening Tool) Man, A.Y. T. 222–​223 manageability 82, 83; definition of 83 man-​made disasters see human-​caused disasters marginalisation 129

MCH (maternal and child health) 13, 88 medical ethics 6, 30 medical teams 166–​167 mental health 11–​12, 21–​22, 61, 89–​90, 93–​96, 147, 167–​168, 208 mentorships 110 meteorological disasters 72, 73, 80 mid-​upper arm circumference see MUAC (mid-​upper arm circumference) mitigation 84, 115–​116 mobile applications 206 mobile clinics 167, 185 morbidity 10, 50, 87; definition of 87 morbidity rate 8 mortality 10, 87; definition of 87 mortality rate 8, 9, 10, 83, 85, 87 Mozambique 120, 143 MUAC (mid-​upper arm circumference) 175 musculoskeletal system 40–​41 MUST (Malnutrition Universal Screening Tool) 161 Myanmar 78, 149, 189, 190 Nagasaki (Japan, 1945) 90 National Institute of Mental Health 96 natural disasters 71, 72, 73, 77–​78, 80, 86–​87, 88, 144, 149, 205; droughts 144, 145–​146; famines 144–​145, 146; floods 119, 141–​143, 146–​147 natural hazards 72, 82, 84, 123–​124, 149, 192, 194 NCDs (non-​communicable diseases) 10, 11–​12, 14, 20–​22, 48, 81, 125, 141, 156, 178, 214; Myanmar 190 negative health impacts 87, 92 neglect 51, 53, 90, 126, 128, 170, 186, 192 neurological system 40 neutrality 97, 99 New Urban Agenda (Habitat III) 196, 103 noncombatants 98 non-​refoulement, principle of 98 Northridge earthquake (United States, 1994) 130 nuclear incidents 83, 90, 183 nutritional concerns 46–​47, 48, 64, 160, 161, 162–​163, 218, 219 OCM (older citizens monitoring) 114 old age 2, 34–​35, 43, 47, 123 older people 1–​3, 4, 34, 35, 37–​38, 63, 104, 109, 115, 120, 220, 225–​226; caregivers 110, 114–​115, 187–​188; disaster preparedness 115, 174, 198–​200, 203, 207,

232 Index

213, 221, 225; disaster recovery 115, 119, 120, 220; disaster response 118, 120, 123, 172, 202, 221, 225; health risks 13–​14; injuries 12; knowledge transfer 110, 115–​116, 120; social capital 2, 120, 129, 148, 213, 219; unaccompanied 186; work 110, 111, 125, 129 older women 126, 128–​129, 181 OPAs (older people’s associations) 112, 113–​114, 119, 203; Bangladesh 117; Cambodia 112, 116; China 112, 116; Philippines 116 oral health see dental health osteoarthritis 41 Ottawa Charter for Health Promotion 22–​23, 25 outbreaks 137 over-​nutrition  160 PAHO (Pan American Health Organization) 51, 194, 195, 200 Pakistan 117, 125, 131, 217 palliative care 169, 170, 172, 176, 218, 219 pandemics 135, 137 partnerships 110 pathway of care 14 people-​centred health services 29 PFA (psychological first aid) 96, 168 Philippines 77–​78 physical capacity 38–​41, 54, 59–​60, 124–​125 physical injuries 146–​147 physiological capacity 38–​41, 46–​47, 156–​157 Po Leung Kuk (charity service) 64 population ageing see ageing population population structure 8–​9 post-​disaster recovery 202–​203, 208, 220–​221 post-​disaster response 100–​101, 155, 157–​160, 162–​169, 171, 183–​184, 202–​203, 208; see also disaster relief post-​impact phase see disaster recovery post-​traumatic stress disorder see PTSD (post-​traumatic stress disorder) poverty 43, 47, 79, 81, 112, 113, 125–​126, 128, 138, 144, 181, 188, 203, 214; see also fuel poverty pre-​impact phase  84 presbyopia 42 prevalence rate 10 prevention: hierarchy of 16, 17, 18; paradox 24; pre-​primary  16; primary 16, 17, 18, 19, 60, 196; primordial 16, 17; secondary 16, 17, 18, 60, 165, 193; third

14, 16, 17, 18, 60, 193; primary healthcare 28–​29, 88 Principles for Older Persons (UN, 1991) 62–​63 psychological first aid see PFA (psychological first aid) psychological health 89–​90, 93–​96 psychosocial approach 94–​95 psychosocial health 50, 59, 89–​90, 96 PTSD (post-​traumatic stress disorder) 94, 222 public health 1, 3–​4, 6–​8, 14, 15, 16, 30–​31, 86, 91, 92, 193, 219; definition of 6; three domains of 15 public health information 126–​127, 214 public health policies 25, 38, 54, 208 public health responses 91–​93, 104, 194 Qian, Z. M. 49 Rainbow Model of health determinants 7–​8 Rakhine refugees, Myanmar (Burma) 149 refugees 76–​77, 98, 103, 148, 149; definition of 77 rehabilitation see disaster recovery reliance see dependency relief 156, 215, 217, 219–​220 relocation 188 renal system 41 rescue phase 156, 183, 215, 217 resilience 193–​194, 195, 204–​205, 206; definition of 193; healthcare system 217–​219 respiratory diseases 163 respiratory system 40 risk 24, 81–​83, 194–​195; definition of 82 risk communication 194, 205–​207, 213, 214–​215 risk formula 82–​83 Rohingya crisis, Myanmar 78 Rose, G. 24 Ruan, Z. 49 rural community 35, 37, 57, 101, 110, 115, 128, 138, 145, 176, 184, 185, 198, 206, 213, 215, 222; in China 58–​61, 112, 116; in Pakistan 131 Rwanda 148 Safe Hospital Initiative 204, 208 SARS epidemic (Hong Kong) 139 secondary healthcare 88 Sen, A. 144–​145

Index  233

Sendai Framework for Disaster Risk Reduction (2015–​2030) 193, 195, 196, 210 sensory deterioration 41–​42, 125, 168–​169, 205 sexuality 43 sexual violence 90 shelters 163–​165, 175–​176, 201, 214, 219–​220 skin 41 SMPH (summary measures of population health) 8 social exclusion 47, 126 social health see psychosocial health social media 206, 207 social well-​being 60–​61, 89–​90, 96 Song, W.  M.  49 Sphere 97–​98, 158 Sphere standards 99, 100–​101, 174, 175, 176 state fragility see fragile states storms 143, 146–​147 STroke Registry Investigating cognitive DEcline study see CU-​STRIDE (Chinese University of Hong Kong –​STroke Registry Investigating cognitive DEcline) study summary measures of population health see SMPH (summary measures of population health) Sun, Q. 49 support services 182, 208 Sustainable Development Goals 13, 25, 28, 103, 195, 210 Tao, N. N. 49 technological disasters 74–​75, 89, 192 technologies 26, 205–​207, 214, 225 telemedicine 185 temperature-​related disasters 124, 137–​139 temporary accommodation see shelters terrorism 147–​148 tertiary healthcare 88 traumatic brain injuries 156–​157 tsunamis 130, 142, 171 tuberculosis 20, 21, 135, 156 Twitter Tsunami Early Warning Civic Network, Indonesia 207 U5MR (under-​5 mortality rate) 83, 87 UHC (Universal Health Coverage) 26, 28, 195

UN (United Nations) 2, 34, 57, 144, 180, 207 unaffordable see affordable under-​nutrition 146, 160 UNDP (United Nations Development Programme) 193 UNDRR (United Nations Office for Disaster Risk Reduction) 71 UNHCR (Office of the United Nations High Commissioner for Refugees) 164 UNICEF (United Nations Children’s Fund) 159 United States 77–​78, 129, 147, 188–​189, 221 Universal Declaration of Human Rights 97–​98 UNPFA (United Nations Population Fund) 54, 56 urban 35, 37, 54, 76, 78, 81, 99, 110, 128, 132, 136, 137, 138, 142, 145, 148, 173, 184, 198, 215; health 140; heat island 138, 140; in China 58–​59; in Pakistan 131; planning 139 urbanisation 15, 25, 37, 72, 79, 81, 126, 165, 198, 202, 218 VBDs (vector-​borne diseases) 21, 140–​141, 146, 158, 163 Vietnam 142 violence 12, 90, 129, 148, 159; elder abuse 51, 53–​54, 185–​186 vision 42, 125, 168–​169 volcanic eruptions 132–​134 volunteer 187, 207, 219, 62, 64, 85, 96, 116, 147, 171, 175 vulnerability 1, 82–​83, 124, 180–​181, 189, 205, 214, 218; definition of 82 warnings see disaster warnings wars see conflicts WASH (Water Supply, Sanitation and Hygiene Promotion) 158–​160, 175 water 158–​159, 219 water-​borne diseases 141, 146, 158 weather; definition of 72 weather information (Hong Kong) 127 West Darfur conflict 148 WFP (World Food Programme) 160 Whitehead, M. 7 WHO (World Health Organization) 6, 13, 51, 54, 96, 124, 137, 166, 194, 208; Age-​Friendly Cities Project 58–​59; BMI 161; complex emergencies 75;

234 Index

disaster 71; field hospitals 167; Global Strategy and Action Plan on Ageing and Health 57; health promotion 23; health risks 14, 15; health systems 26, 27; mental disorders 12; palliative care 170; risk communication 205; UHC 28; WASH 158; World Report on Ageing and Health 55 widows 128–​129, 181 wildfire incidents 147 Woodward, A. 49

work, older people 110, 111, 125, 129 World Food Programme see WFP (World Food Programme) World Report on Ageing and Health (WHO, 2015) 55 Yang, Y.  49 Zheng, Y.  49 Zika virus disease 134 Zimbabwe 125