Geneva Health Forum Archive

Browse and download abstracts, posters, documents and videos from past editions of the GHF

The Sphere Project Handbook: Standards for Humanitarian Response Address Growing Problem of Chronic Diseases

Author(s): Cecilia Furtade1, Mesfin Teklu2
Affiliation(s): 1Sphere Project Office, Geneva, Switzerland, 2World Vision International, Nairobi, Kenya
1st country of focus: Not applicable
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): The Sphere Handbook 2011 edition addresses the impact of demographic changes on the management of non-communicable chronic diseases in emergencies.  With the unprecedented growth in the number of older people worldwide - from 7% of people over 60 worldwide in 2004 to 11% in 2011 - the demographic and epidemiological profile of disaster-affected populations has also changed significantly, prompting full revision of the wording on non-communicable diseases in the Sphere Handbook 2011 edition which is now the first set of standards to include guidance on management of chronic diseases during disasters. The Sphere Handbook is an internationally recognized set of standards for delivery of quality humanitarian assistance.
Background (max 200 words): Acute complications and exacerbations of chronic diseases have become a common problem in many disasters: *   During the response to the 2004 tsunami in Aceh, emergency health centres did not have chronic disease medications and staff were not trained to diagnose or treat chronic health conditions (Help Age International, 2005). *   Chronic illness accounted for 33% of clinic visits, peaking 10 days after hurricane Katrina's landfall in 2005 (Miller C, Arquilla B 2008) Generally, older people are disproportionately vulnerable during disasters because they are more likely to have chronic illnesses, functional limitations and sensory, physical and cognitive disabilities than those of younger age. Chronic diseases—mainly cardiovascular disease, cancer, chronic respiratory diseases, and diabetes—were estimated to cause more than 60% of all deaths in 2005. More than 80% of these deaths occurred in low-income and middle-income countries, where chronic diseases are creating a double burden on top of infectious diseases (Dale O Abergunde et al. The Lancet Vol 370, December 8, 2007). Yet, no generally accepted guidance on the management of chronic diseases during disasters has previously been established. The 2011 edition of the Sphere Handbook has provided standard and guidance on addressing the growing burden of chronic non-communicable diseases during disasters.
Objectives (max 100 words): The outcome of this presentation is to:• Highlight the growing burden of NCD and the changing needs in humanitarian relief operations. • Contribute to the reduction of mortality and morbidity from life threatening exacerbations and acute complications of chronic non-communicable diseases during disasters.  Changing demographics are one important factor of increased need to focus on chronic NCD but not the only one. Urban settings are also important to consider. All actors involved, including donors, must give increased focus to NCD.
Methodology (max 400 words): The Sphere Handbook, which was produced through a broad process of collaboration within the humanitarian sector is an internationally recognized set of standards in key life-saving sectors. The Sphere minimum standards are evidence-based and represent sector-wide consensus on best practice internationally recognized set of common principles and universal standards for the delivery of quality humanitarian assistance. Like all the standards included in the Sphere Handbook, the standards related to the inclusion of chronic disease are the results of an extensive, collaborative and consultative process, engaging a considerable number of humanitarian actors around the world. The Handbook revision process was led by a group of focal points for the technical chapters and cross-cutting themes, supported by resource persons for emerging issues.
Results (max 400 words): Conditions created by disasters such as lack of access to health care, food, water and sanitation could exacerbate chronic health conditions. The linkage between chronic health condition and age is well established. Humanitarian actors must recognize the risk of exacerbation of chronic health conditions during disasters, and they must take appropriate measures during preparedness and humanitarian responses in order to prevent life threatening exacerbations. Furthermore, there is increasing evidence of the link between acute complications from chronic diseases in disaster and disability as a result of these complications.  Given the increase of the number of people affected by chronic non-communicable diseases, chronic medical conditions have become too significant a burden to ignore during emergency responses and can, if inadequately controlled, present a threat to life and well-being.
Conclusion (max 400 words): Because of increasing recognition of the importance of NCD, The 2011 edition of the Sphere Handbook supports and encourages the focus on NCD in order to reduce excess morbidity and mortality from exacerbations of existing NCDs by:  *   Maintaining treatment for chronic diseases in an emergency and avoiding sudden discontinuation of treatment *   Ensuring treatment for people identified with acute complications and exacerbations of chronic diseases during an emergency that endangers their immediate health (e.g. severe hypertension to stroke) *   Identifying and facilitating referral options, where relevant services for chronic disease are provided *   Disaggregation of data by age  to adequately managing-age related illnesses and conditions *   Documentation of key chronic disease burdens among the disaster-affected population so as to highlight health gaps that need to be addressed

Do Friends Make a Difference? Youth Mental Health and Violence in Ibadan, Nigeria

Author(s): Hamidu Oluyedun1
Affiliation(s): 1Oyo State Hospital Management Board Secretariat, Ibadan, Nigeria
1st country of focus: Nigeria
Relevant to the conference theme: Emergencies
Summary (max 100 words): Mental health is not simply the absence of mental disorders and the absence of mental disablement (i.e. impairments, disabilities and handicaps) but it is also the mental and social well-being of the individual. Over 90% of the youths in the various motor parks are engaged in various drugs usage from Indian hemps to heroin. 70% revealed that they have taking part in various political violence that claims thousands of lives in the recent past and that the violence is being sponsored by big wigs in the society including politicians and rich people.  Peer groups influence each other in the area of drugs and substances abuse, cult initiation, hired killers, political thugs and various violence on the society.
Background (max 200 words): The Nigerian society is today characterized by numerous social problems prominent among which is mental HEALTH/ILLNESS and VIOLENCE. Killer diseases such as smallpox and cholera no longer threaten our people as they used to. Thus to cater for this vulnerable group, the family receives the burden since the government support is lacking or grossly inadequate. More so, because of what is generally perceived as moral decadence, some youths have turned to alcoholism and drugs and consider this as a normal way of life. All these activities and many more social cultural phenomena have triggered a trend towards mental disability in Nigeria. Today, there are no fewer than 30 million Nigerians who are suffering from one mental disability or the other
Objectives (max 100 words): To understand the prevalence, causes and effects of peer groups on mental health and sporadic violence in Ibadan, Nigeria. The study, also wants to understand what attracts youth to drugs, deviance and violence in the society
Methodology (max 400 words): The etic approach and the emic approach were utilised.  The first approach recognizes the universality of mental illness and assumes that mental illness is similar across societies and that the measuring instruments and models designed in the West are universally applicable.  The second approach, known as emic approach argues that mental disorder categories need to be generated within cultures.  This approach evaluates phenomena from within a culture and its context, aiming to comprehend the contribution of cultural factors in the development and maintenance of mental illness. The two methods will be used together for better outcomes of the results.  The etic approach will be used quantitatively while the emic will be explored quantitatively in form of the snow ball technique. In all 500 questionnaires were served to the youths in 10 various motor parks in Ibadan and the 20 locations harder to reach were engaged through snowball technique.
Results (max 400 words): Over 90% of the youths in the various motor parks are engaged in various drugs usage from Indian hemps to heroin. 70% revealed that they have taking part in various political violence that has claimed thousands of lives in the recent past and that the violence were all being sponsored by big wigs in the society including politicians and rich people. The results from snowball technique showed that some of the miscreants are Government pay agents who receive backing from Government and law enforcement agents. Also, they get their weapons from law enforcement agents and politicians. They see violence as necessary for some people to maintain the status co.
Conclusion (max 400 words): The major determinants of violence continues to be socio-demographic and determinative socio-economic factors such as being young, male, and of  lower socio-economic status.  Substance abuse appears to be a major determinant of violence and this is true whether it occurs in the context of a concurrent mental illness or not. Those with substance disorders are major contributors to community violence, perhaps accounting for as much as  two-third of violent acts, and seven out of every 10 crimes

The Impact of an Invasive and Interventional Cardiology Program in Eastern Nepal: A Preliminary Evaluation

Author(s): N. R. Shrestha1, P. Karki1, A. Basnet1, P. Shah1, K. Sherpa1, T. Pilgrim2, S. Cook3, P. Urban4
Affiliation(s): 1B.P. Koirala Institute of Health Sciences, 2Swiss Cardiovascular Centre, Bern, Switzerland, 3University and Hospital. Fribourg, Switzerland, 4Hopital de la Tour, Geneva, Switzerland
1st country of focus: Nepal
Relevant to the conference theme: Emergencies
Summary (max 100 words): We compared the in-hospital outcome of patients admitted for acute coronary syndrome (ACS) to a tertiary referral hospital in Eastern Nepal, before (2008) and after (2011) the availability of an invasive cardiology program. In 2008 153 patients were admitted with ACS. The in-hospital mortality was 14%.  From January 2011 until October 2011 177 patients were admitted with ACS. 78 patients (45%) underwent coronary angiography and 24 (36%) underwent angioplasty. The in-hospital mortality was 7%. These preliminary results are encouraging and indicate that the availability of invasive techniques is associated with an increasing number of admissions for ACS plus improved in-hospital outcomes.
Background (max 200 words): Ischemic heart disease (IHD) and acute coronary syndrome (ACS) continues to be the major cause of morbidity and mortality globally. While there has been a decline in the age-adjusted death rates in developed countries, the burden of ischemic heart disease (IHD) in developing countries is increasing and this trend is attributable primarily due to the social and economic changes that have occurred with urbanization and industrialization, leading to a higher prevalence of the main cardiovascular risk factors. The problem is compounded by low availability of evidence-based therapies and interventions for the great majority of patients, and their outcome, both in terms of morbidity and mortality, is thus often poor. Furthermore, patients in South Asia are often afflicted with IHD at a relatively young age, thus impacting more severely upon the working-age population with major consequences for  families who lose wage earners and national development due to the adverse effects of lost productivity.
Objectives (max 100 words): The objective of the present study was to assess the outcome of patients presenting with ACS to B.P. Koirala Institute of Health Sciences (BPKIHS) a tertiary referral hospital in eastern Nepal  after the cardiac catheterization laboratory services commenced from January 2011 till present (October 2011) and to compare their in-hospital outcomes with those patients who presented with ACS in 2008 when interventional procedures were not available at our centre.
Methodology (max 400 words): B.P. Koirala Institute of Health Sciences (BPKIHS) is a university hospital in Dharan, eastern Nepal, established in 1993 with undergraduate and postgraduate medical and paramedical programs, The hospital has 750 beds and hosts over 30,000 patients per year. About 180,000 patients consult the out patients department yearly. The town of Dharan has a population of 1.2 million, and the hospital is the only referral center outside Kathmandu for the inhabitants of eastern Nepal, and also serves parts of neighboring states of West Bengal and Bihar in India. The coronary angiography laboratory at BPKIHS became functional in January 2011.  The main operator had been fully trained in invasive techniques in a high volume centre in Switzerland, and continued on-site training was given by experienced visiting physicians from Geneva and Berne, Switzerland. Since then routine coronary angiography, angioplasty and primary percutaneous coronary interventions for ACS have been performed and are available to patients presenting to our centre. Prior to this there were only two such cardiac catheterization laboratories in Nepal which were both located in Kathmandu, more than 500 kilometers away. A cross sectional descriptive study was conducted on consecutive patients presenting to BPKIHS with acute coronary syndrome from January 2011 to October 2011 and compared to similar data collected from January to December 2008. All patients admitted to the 6-bed Coronary Care Unit (CCU) and the medicine ward of the hospital with a clinical diagnosis of ACS were included, and assigned to one of 3 groups: ST Segment Elevation Myocardial Infarction (STEMI), Non ST Segment Elevation Myocardial Infarction (NSTEMI) and Unstable Angina (UA). During the first period, all patients were treated medically and/or transferred to Kathmandu. During the second period, patients were either managed by an invasive procedure (coronary angiography with or without angioplasty) or were treated conservatively depending on delays, clinical presentation and the patient’s financial resources. We collected data regarding the modes of presentation of ACS, age, gender, treatment during hospital stay, need for invasive evaluation and intervention and in-hospital outcome.
Results (max 400 words): In 2008, 153 patients were admitted with ACS and a diagnosis of STEMI was made in 58 patients (38%), NSTEMI in 28 patients (18%) and UA in 67 patients (44%). 20 (34%) patients with STEMI were treated with streptokinase. The mean hospital stay at BPKIHS was 5 days, and 6 patients were transferred to Kathmandu emergently. There were 22 (14%) deaths in hospital and the mortality was highest for STEMI patients (17%) but was also high for NSTEMI (14%) and UA (12%). From January 2011 till October 2011, 177 patients were admitted with ACS. A (34%) diagnosis of STEMI was made in 69 patients (40%), NSTEMI in 46 patients (26%) and UA in 62 patients (34%). These 177 patients admitted to the medical ward of cardiovascular disease represented 18% of all hospital admissions at BPKIHS during the same period. There is no national health insurance system in Nepal so therefore the vast majority of people must pay for medical services and treatment themselves. Thus among these 177 patients who presented with ACS, 78 (45%) of them underwent invasive evaluation with a coronary angiography with or without angioplasty.  It was noted that among 69 patients who presented with STEMI, 48 (70%) underwent coronary angiography, 24 (36%) underwent percutaneous coronary intervention (PCI) with one or more stents and 3 (4%) patients were referred for surgical revascularization.  Of the 46 patients who were diagnosed to have NSTEMI, 6 (13%) underwent coronary angiography and only one underwent angioplasty. Coronary angiography was performed in 23 (37%) patients who presented with UA, and none of them underwent PCI. The remaining 99 patients (55%) who were diagnosed to have ACS did not undergo invasive evaluation. This cohort had STEMI as a diagnosis in 21 (30%) patients, NSTEMI in 40 (87%) patients and UA in 38 (63%) patients. 166 (93%) patients were discharged after a mean stay of 4 days in the hospital, and there were 11 (7%) deaths. Three deaths (3.8%) occurred in the group that underwent invasive evaluation and 8 deaths (8%) occurred among patients treated conservatively. In the invasive group, all three patients who died had a diagnosis of STEMI and had been admitted in cardiogenic shock. Among those treated conservatively five deaths occurred in STEMI patients and there was one death in the NSTEMI and two deaths in the UA group respectively.
Conclusion (max 400 words): This preliminary analysis highlights two main findings: 1) There is an encouraging trend toward a lower overall crude hospital mortality with the introduction of invasive and interventional techniques (14% in 2008 vs. 7% in 2011).  2) The absolute number of patients admitted with ACS appear to be increasing (+ 39% for 2008 vs. 2011), possibly because the availability of interventional treatment has encouraged people with chest pain to reach the ER earlier.  During the first 10 months of 2011, however, only 177 patients were admitted with a diagnosis of ACS to the single coronary angiography laboratory available in eastern Nepal. It is thus fair to assume that this patient group only represents the tip of the iceberg, and that the overall incidence of ACS must be larger. As Nepal is a resource-poor country with no or little health insurance, the costs of treatment are borne by the patients themselves. This largely explains why only 45% of all patients presenting with ACS underwent coronary angiography with or without angioplasty. However, it is noteworthy that 70% of patients who presented with STEMI, the subset most likely to benefit from timely revascularization, did actually undergo invasive evaluation of their coronary anatomy and 36% of them were treated with PCI.

Non-Communicable Diseases and Emergencies: A Call for Renewed Action


Author(s): Alessandro Demaio1, Rebecca Horn2, Jennifer Jamieson3, Maximilian de Courten1, Ib C  Bygbjerg1, Siri Tellier1
Affiliation(s): Copenhagen School of Global Health, University of Copenhagen, Denmark1, ChronAid International, Washington DC, USA2, The Alfred Hospital, Melbourne, Australia3
Name your project or intiative: Non-Communicable Diseases and Emergencies: A Call for Renewed Action
1st country of focus: Denmark
Additional countries of focus: Global
Relevant to the conference theme: Non-communicable chronic diseases
Summary: In the aftermath of the 2011 United Nations High Level Meeting on Non-Communicable Diseases (NCDs), there is now an unprecedented opportunity for a renewed call to action on the management of NCDs during and following emergencies (including natural disasters, conflict and non-conflict related emergencies). Despite some good progress in recent years, there continues to be significant gaps in the scientific evidence and technical guidelines with regards to the health effects and mitigation strategies for NCDs and emergencies. This call offers a way to advance the prevention and management of Non-Communicable Diseases in emergencies. It emphasises that NCDs should not have a token inclusion in emergency preparation and management, but rather a meaningful and integrated one that addresses the existing care gap for this vulnerable population.
What challenges does your project address and why is it of importance?: Recent years have demonstrated the devastating health consequences of emergencies and highlighted the importance of a comprehensive and collaborative approach to humanitarian responses. Simultaneously, NCDs are now increasingly recognised as a real and growing threat to population health and development: a threat that is magnified during and following emergencies.  Avoiding excess morbidity and mortality is a primary goal for humanitarian responses both in the acute phase and post-disaster phase of an emergency. NCDs, however, continue to receive limited attention from humanitarian organisations in the preparation for, and management of emergencies. To ensure continuity of care for people with NCDs in emergencies it is necessary to have a health infrastructure with resilience to disasters. This however requires some background population knowledge about prevalence of and treatment modalities for NCDs to undertake preparedness planning. Such information may often be unavailable.
How have you addressed these challenges? Do you see a solution?: This abstract calls on all sectors to recognise and address the gaps in scientific evidence with regards to NCDs in emergencies and the serious challenges posed by these two concomitant threats to health and development. More specifically, it calls for:• Systematic reviews relating to the sources and magnitude of excess morbidity and mortality from NCDs linked to emergencies;• Increased monitoring and reporting of morbidity and mortality patterns from NCDs both in the acute and post emergency phases; • Incorporation of NCDs (prevention and management) into existing emergency-related policies, standards, and resources; • Greater integration and preparation for NCDs and in health service provision including the development of evidence-based global and national guidelines on the management of NCDs in the acute and post emergency phases; • Inclusion of NCDs into training of humanitarian and emergency-response workers and planners.
How do you know whether you have made a difference?: In order to address the problems of NCDs in emergencies and minimise excess morbidity and mortality, we encourage international research, humanitarian and governing sectors to recognise and address NCDs in emergency situations. We want to facilitate research to quantify the impact NCDs have and will have on the consequences of emergency in specific countries, populations and globally; and vice versa to quantify the impact of emergencies on NCD exacerbation and complications. We furthermore call for evidence-based, global technical guidelines for the management of NCDs during and following emergencies. We urge governing and advisory bodies to incorporate NCDs into global practice in emergencies and to allocate specific funding and resources for the prevention and management of NCDs during and following emergencies. As an outcome, following our presentation, we hope to promote and facilitate a network of likeminded researchers, planners and field workers to further the agenda and contribute to the above action points.
Have you or the project mobilized others and if so, who, why and how?: The compounding morbidity and mortality burden created by NCDs during and following emergencies continue to be under-recognised, under-researched and under-resourced. We call for all sectors, including health, government, non-government and community sectors, to further acknowledge, understand, study and address the structural determinants of NCDs within emergencies. We are currently publishing a specific call to action on the theme of NCDs and emergencies, which outlines key ways forward for achieving these. In addition, we already are engaged in discussions with colleagues at the WHO Chronic Diseases Prevention and Management (CPM), Geneva; the WHO Disaster Risk Management for Health Unit, Geneva; Copenhagen School of Global Health Masters of Disaster Management Programme; ChronAid, USA; and the International Federation of Red Cross and Red Crescent Societies, Community Based Health and First Aid Unit, Geneva in ways to collaborate on this topic.
When your donor funding runs out how will your idea continue to live?: As we are essentially aiming at improved planning, policies and guidelines for NCD prevention and management related to emergencies – such achievements will continue once agreed upon, adopted and implemented. The funding for research on the quantification of the compounding of NCDs and emergencies will depend on time limited research grants.

Considering Chronic Diseases in Resources for Disaster Response

Author(s): Rebecca Horn1
Affiliation(s): 1Rebecca B Horn, ChronAid, Elkins Park, United States
Name your project or intiative: Considering chronic diseases in resources for disaster response.
1st country of focus: United States
Additional countries of focus: Global
Relevant to the conference theme: Non-communicable chronic diseases
Summary: In an effort to address chronic diseases in emergencies an emerging NGO, ChronAid, is dedicated to advocating for the inclusion of chronic diseases and related disabilities and dependence in disaster and emergency preparedness and response.
What challenges does your project address and why is it of importance?: By 2005, chronic diseases were the leading cause of mortality in six out of seven WHO regions but to date disaster and humanitarian responses have not fully addressed chronic diseases. Several factors are contributing to changing needs in humanitarian relief efforts worldwide, among them the aging population and an increasing prevalence of chronic diseases worldwide. Further, seemingly unrelated topics such as the HIV epidemic and child feeding programs, are contributing to the growing numbers of chronic diseases worldwide, compounding the importance of this initiative. Yet, in our current model of humanitarian relief, targeted response has not included those with chronic disease.
How have you addressed these challenges? Do you see a solution?: An example of ChronAid’s initiatives is a novel proposal of a Supplementary Unit for Chronic Disease (SUCD) to the existing WHO Interagency Emergency health kit as a proposed solution to resource provision specifically for those with chronic diseases. This is a current and feasible solution that would begin to address the issue, however is only one specific measure in a global call to action to address this growing vulnerable population.
How do you know whether you have made a difference?: As of yet, the data about morbidity and mortality associated with chronic diseases in disasters and emergencies has yet to be formalized. Part of the SUCD includes a data collection system to further quantify and demonstrate the existing need. Anecdotally, there are countless stories, however, recounting the burden of chronic diseases in emergencies including Hurricane Katrina and the recent earthquake in Haiti.
Have you or the project mobilized others and if so, who, why and how?: The SUCD was proposed in the most recent WHO review. Although it has yet to be implemented or incorporated into the IEHK, the proposal opened the discussion regarding chronic diseases.
When your donor funding runs out how will your idea continue to live?: not applicable

Establishing Pre-hospital Emergency Medical System in Sri Lanka

First D.D.M.Lakruwan
Last Dassanayake
Name your project or intiative Establishment of Pre-Hospital  Emergency Medical System in North Central Sri Lanka: Gaining some thing from nothing in a resource poor setting

1st country of focus

Sri Lanka

Relevant to the conference theme

Summary By the year 2009 there wasn’t a pre-hospital Emergency Medical System in Anuradhapura. This project was designed fulfill that requirement. There were no local institutions providing training on developing, management and monitoring Pre-hospital EMS. The knowledge was gained through a training program arranged by JICA at Osaka. Establishment of pre-hospital EMS was achieved by fulfilling a set of objectives. Operations of pre-hospital EMS were monitored during first 6 months to understand the technical, logistic and legal issues. During initial 6 months they provided emergency health care to 213 patients and trained 650 population in suburbs on basic life support
What challenges does your project address and why is it of importance? Trauma has become a leading course of hospital admissions in Sri Lanka. Annually average 600,000 admitted to government sector hospitals following trauma. The contribution of the private sector is unknown. During the last 3 decades road traffic accidents have increased by 249%. Therefore an effective pre hospital EMS is essential to reduce morbidity, mortality and secondary injuries.

Rapid urbanization had disrupted the organic solidarity in many cities of Sri Lanka with in few decades, that prevailed for centuries giving minimal or no time to flourish a reasonable mechanical solidarity to compensate. Furthermore increased life expectancy and demographic transition had increased the proportion of the elderly in community who are with more non communicable chronic disorders and emergencies related to them in urban societies
In suburbs it was found on a survey the knowledge and practice of proper and safe initial care and transport of a trauma victim is less than 10% which would lead to secondary injuries even though there volunteerism is high. Furthermore on direct observation it was seen vehicles like three wheelers and motorcycles are used more and more in transporting trauma victims to hospital with little or no care regarding secondary injuries
How have you addressed these challenges? Do you see a solution? Establishment of the emergency ambulance service in the municipality of Anuradhapura

An initial survey was carried out by direct communication and site visits with the potential pre hospital care providers of the municipality of Anuradhapura. The possible institutions with the capability of generating the human resource and the infrastructure were
1. Teaching Hospital Anuradhapura
2. Municipal fire and rescue team
3. Red cross Anuradhapura
All these three institutions had the some extent of infrastructure that can be used in the pre-hospital emergency services and the man power that can be trained for that purpose. Yet the institutions were not engaged in the pre hospital emergency medical services due following reasons
1. Not adequate knowledge in pre-hospital EMS system:
2. Inadequate resources
3. No proper training
4. Different motives and working objectives
5. No interest
There were no academic institutions in Sri Lanka as per 2009 providing a formal education on Pre-hospital EMS, developing, management and monitoring Pre-hospital EMS. Required knowledge was gained by attending a relevant group training program in Pacific Resource center, Osaka, Japan and studying the EMS of Senri emergency and critical care center and the pre-hospital EMS of Osaka fire department.
Establishment of the pre-hospital emergency medical system was achieved by fulfilling a set of fine objectives which included community mobilization communication, developing community and institutional pressure groups, Public private partnership to obtain training and equipments, telecommunication, identification and strategic collaboration with the key partner institutions ( Police, Teaching Hospital Anuradhapura, Australian Sri Lanka Charitable Health fund, Medical Teams International (MTI), human resource development, infrastructure development, acquisition of equipments, formulations of standard operations plans, establishment of codes of practice and designing the EMT documentation formats, studying the possible legal implications and preventive methods through brain storming sessions with relevant expert panels.
Community training on Basic life support
This was designed under the umbrella of the pre hospital EMS of Anuradhapura to increase the chances of survival of the rural population until they are transported to the hospitals from their remote locations following medical or surgical emergencies considering the fact the high level of volunteerism of the village community and low skill levels. This program was developed to run as a collaborative program with the national blood service of Sri Lanka. The stake holders are usually the blood donors of the village community who usually having the higher tendency in volunteering in such emergencies
How do you know whether you have made a difference? During the first six months (01/06/2010 to 30/11/2010) the Pre-hospital EMS had dispatched 211 victims followed by medical and surgical emergencies. It had conducted 14 basic life support skill development programs targeting the rural communities with a participation 645 villagers. In additions it had provided emergency medical care in 4 mass population gatherings during that period

Considering the cohort of victims there was a gradual rise in the number of victims with the advancing age until the third decade of the life. There was a relative reduction in fourth and fifth decades and rise again in the sixth decade attributing to the retiring age. After that the number gradually reduces
Medical emergencies (52.5%) were slightly out numbering surgical emergencies (44.13%). Obstetric cases represented only 2.3% . Two cases were obviously dead according to the working criteria when approaching the scene which account for 0.9% of the cases. Two patients were in cardiac arrest when team reaching the incident (Acute collapse had been witnessed by the bystanders). They were brought to hospital while continuing cardiopulmonary resuscitation. One was confirmed death at the out patient department and the other admitted to Emergency treating unit and diagnosed as an acute myocardial infarction and survived in the acute phase
The majority of the surgical emergencies were road traffic accidents (32) that accounted for 34% of the total surgical emergencies. There had been significant bleeding in 32 cases representing 15% of the total victims which necessitated vigorous active measures to arrest the bleeding. Spinal stabilization was done in 54 cases representing 24.8% of the total number of victims
Considering the medical emergencies the main cause for dispatch was chest pain and difficulty in breathing (34) the key words leading to urgent cardiac or respiratory emergencies. This accounted for 30.4% of all the medical emergencies.
In three instances the advice of the doctor was requested over the phone by the EMTs in the field which is 1.5% of the total cases. Since the multiple casualties were hypothesized doctors of the unit in person attended to mass population gathering during “Pichchmal pooja” and “poson” religious ceremonies held in the municipality and directly involved in managing 16 critical cases which represent 7.5% of the cases
30 % of the cases were attended in less than 5 minutes form the call and 69.7% of the cases were attended with in 10 minutes from the call
Have you or the project mobilized others and if so, who, why and how? A strong community mobilization, formulation of a pressure group with in the institution and the community and obtaining the support of the local and the regional health administrators and the other collaborative bodies were prime objectives of this project.

Convincing the necessity of the pre-hospital EMS to municipality of Anuradhapura to the local and the regional health authorities was the key to the successful commencement and the continuity of the project. Evidence based data, national level annual data of the Ministry of health regarding the current trauma admissions and the trauma management and the health benefits in line with the health master plans that could be expected form the pre hospital EMS considering the effectiveness of the Pre- hospital EMS of the Osaka prefecture were used as the solid information. Multiple levels of health management were invited (local, regional, national) for the initial discussions to obtain the liaison and come in a collective decision in order to prevent the complexities. The initial discussions were conducted in a non directive manner as round table discussions and lectures. Director Teaching Hospital Anuradhapura, Regional Director Health Services, Anuradhapura, National Coordinator, Disaster Preparedness and Response Unit, Ministry of Healthcare and Nutrition Sri Lanka, Governor of North central Province, Mayer of Municipality of Anuradhapura were the invited participants for the initial discussions. In the discussions it was agreed that the pre-Hospital EMS is an important element missing in our health system. It was agreed Pre-Hospital EMS need to be established to cover the entire district of Anuradhapura and as a pilot project to proceed with a service to cover the municipality with a population with 70000 or an area of 5km radius from the town center.
A separate series of lectures were arranged to the hospital workers regarding the EMS in Osaka convincing them this is another area of healthcare and it can increase the chances of the survival of victims. This communication was extended to the community leaders (politicians, influential clergy), professional groups (lawyers, General Medical Officer’s association), and Business community of the municipality. It was expected to develop a pressure group for this project by this communication which ensures the continuation of the program.
When your donor funding runs out how will your idea continue to live? Since the Teaching hospital Anuradhapura was the largest health care institution of the municipality with a large human resource out numbering other small institutions it was selected as the host institution to establish the Pre-Hospital EMS. Municipality and the Fire and rescue were also evaluated as the potential hosts. Yet due to lack of man power, difficulty in establishing the monitoring methods in those two institutions and more importantly the less success in the Fire department based pre-hospital EMS in Colombo lead to select Teaching Hospital Anuradhapura as the host organization. And a separate unit was established in the hospital to carry out this function as Disaster Preparedness and Response Unit which later developed to Disaster Preparedness and Triage Unit. Nurses are working as the EMTs and the EMT level two raining was provided to them by collaboration of Medical Teams International. During that training 5 doctors in the hospital were trained as trainers who could carry out this trading in the hospital for more nurses if necessary with out external support. The Ambulance to the Unit was donated by the Australian Sri Lankan charitable health fund and it was incorporated to the regular ambulance fleet of the hospital and through that it was deployed to the unit so it is maintained as a regular ambulance in the hospital.

Even though at the beginning the project needed assistance from the donor agencies it was designed as such it can be maintained by Teaching Hospital Anuradhapura with out much external support to ensure the sustainability