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Posts Tagged ‘prevention’

The Heat and Health Series published recently by The Lancet focuses on the devastating effects of heat on human beings. It is estimated that “54% of the global population [will be] exposed to more than 20 days of dangerous heat per year by 2100”. A strategy of disaster risk reduction (DRR) is needed because “Society must adapt in ways that not only enable it to survive, but thrive, in a much hotter future.”

Fighting heatwaves has brought up another example of the divide between rich and poor societies, as well as between rich and poor individuals within societies. Air conditioners are by far the preferred tool in fighting heat. But they are an expensive tool. Most vulnerable societies and people cannot have access to an environmentally cooled area, whether it is because they cannot afford it or because their living or working conditions make it impossible to cool the living/working environment. Think about the homeless or those working outdoors.

Another factor making air conditioning a tool that should be put on hold, is the environmental vicious circle created by its use. Most scientific literature recognizes that global warming is here to stay. Air conditioning runs on electricity, the production of which results in CO2 emissions contributing to global warming. A secondary effect is the anthropogenic waste heat they produce, contributing to the urban heat island effect.

A more long-term strategy for heat DRR should focus on the individual, coupled with permanent changes in urban planning. In the first centuries of the past millennium in southern Spain, Arabs put nature to work to cool the environment. Some of their ideas are being used in city planning today, introducing urban gardens and fountains to fight the heat island effect.

As for the individual, electric fans are more environmentally friendly than air conditioners, but above all, a good target communication strategy should be designed so as to reach the population more at risk. Workers laboring outside, such as those in agriculture or construction, have special needs. Not only access to water but also shelter and resting times. A strategy to match their needs and those of the employer can only be attained through a well-designed communication tool directed at employees and employers.

We should think more in long term changes to our DRR heat strategy, less air conditioning and more environmentally friendly solutions and communication.

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In 2019 the WHO released the document “Health Emergency and Disaster Risk Management Framework” (Health-EDRM)[1]. At that time no one had heard of SARS-CoV-2 while, at the same time, it was a premonition of things to come.

A recent paper by Emily Ying Yang Chan et al[2] points out the need to reinforce a bottom-up approach to Health-EDRM in line with my previous post “Citizens’ role in hazard management[3].

A quick review of the Health-EDRM document (see Bullet 5.9) shows how the authors understood the role of the community in an emergency: “Participation of communities in risk assessments to identify local hazards and vulnerabilities can identify actions to reduce health risks prior to an emergency occurring. … The local population will also play the lead role in recovery and reconstruction efforts.”

It is clear that a year and a half after the explosion of Covid-19, “the local population” has been at best a passive actor in the fight against the pandemic. Its participation in the prevention, preparedness, readiness, response, and recovery continuum has been marginal.

I argue in the above-mentioned post, “Citizens’ role in hazard management”, that the involvement of the population should be based on its ability to identify a hazard before it becomes a real risk. For that it is necessary to involve the population by developing diffusion tools covering an array of specific hazards. To my knowledge, nothing existed in this area for a pandemic and, what is even worst, nothing is being done.

If anything has to be learnt from the development of the pandemic, it is that none of the actors were prepared to fight it effectively. But the population was taken completely by surprise, going from normal day to day business to complete lockdown. The population collaborated passively throughout this situation. The problem remains that, having an almost complete lack of knowledge of what the full consequences of the pandemic are, a large percentage of the population has embraced the so called “freedom” with open arms.

The whole structure of population involvement has fallen into pieces. Embracing with open arms the new “freedom” is the exact opposite of what involvement of the population in fighting the pandemic should mean. A large percentage of the population is, with “open arms”, exercising its “freedom” to help spread the SARS-CoV-2.


[1] https://www.who.int/hac/techguidance/preparedness/health-emergency-and-disaster-risk-management-framework-eng.pdf accessed 23/07/21

[2] https://doi.org/10.1016/S0140-6736(21)01233-2  accessed 23/07/21

[3] https://cgarciamanagement.wordpress.com/2021/07/22/citizens-role-in-hazard-management/ accessed 23/07/21

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Successful hazard management means a perfect working of the flow of identification – communication – early-warning – early-response – reaction. No flow is possible if the first stages of it are missing: identification, communication, early-warning, and early-response.

It does not matter how many fancy devices, based on artificial intelligence (AI) and machine learning, are designed to detect hazards; the best device will always be the human being. It has built-in intelligence and is a natural learner.

We should then aim at putting the citizen in the centre of the flow of identification, communication, early-warning, and early-response.

The population should be able to identify a hazard before it becomes a real risk.  It is necessary to involve the population at large by developing diffusion tools covering specific hazards. Those tools should be deployed geographically according to the hazard which applies to that particular area. For instance, flood dissemination tools should be deployed mainly in Central Europe, while fire dissemination tools would be deployed mainly in the Mediterranean areas. The aim is to make the population aware of the most likely hazard in their area and teach them how to act to minimise risks.

Special attention should be given to X-Events[1], the unknown unknown of an entirely unexpected event suddenly befalling an unsuspecting hapless community. Weak signals, such as the lone wolf terrorist, are difficult to identify using ICT-based systems. A network of “objective antennas” should be in place.  They will be people specially instructed to identify and evaluate threats, similar to those volunteers watching the local weather and acting as a network to provide reliable and valuable information about weather events. Only human “objective antennas” will identify weak signals on the ground and, also as importantly, filter fake news.

Identification is followed by communication. There is no need to encourage the use of social networks; as of 2020 the percentage of active social media users (16-74 years old) in the European Union is 55%[2], with countries like Denmark at 85%. The problem is the reliability of the information, or lack of it. People follow people, as the quick spread of fake news has proved many times.

There are very useful human based systems combating fake news, such as the one carried out by the Virtual Operation Support Team (VOST Europe)[3] association. Their objective is to support emergency services social media accounts, by diffusing their messages, and at the same time combating fake news.

The use of ICT tools should be but a complement to the work of humans if our aim is for effective and efficient hazard management.


[1] The X-Events Index. John Casti. The X-Center, Vienna. http://globalxnetwork.com/wp-content/uploads/2017/01/X-eventsIndex.pdf accessed 17/07/21

[2]https://www.statista.com/statistics/276767/social-network-usage-penetration-of-european-populations/ accessed 13/07/21

[3] https://vosteurope.org/

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It was late July 2003 in the city of Auxerre in Burgundy. Authorities had been warning of very high temperatures for August, exceeding 40ºC during the day and no less than 20ºC at night.

M. Collardelle is in his early seventies. He is a healthy person with no more ailments than the usual for his age. He lives downtown, not far from the river, in a two storey-house with a nice small garden around it. With that setting, M. Collardelle does not worry about temperatures; he knows that the river and the garden will make life a lot more pleasant for him than for those who live in apartment houses on the outskirts of the city.

He had just received a telephone call from his only child who is vacationing in Spain with her husband and kids. They had a nice conversation and, to reassure his daughter, he reminded her that he had fought in the Algerian War, where he had endured much more than those forecasted 40ºC. They said goodbye, with M Collardelle telling his daughter not to call again. They would be back in France on the 15th.

So, the first of August arrived and with it, the dreaded 40ºC. And the second was the same and so forth and so on; and M. Collardelle realized that he was not in his twenties but some 45 years older, and he could not cope with the heat. He just sat in his armchair, with the windows open in hope of some respite, but what came from outside was more heat. He didn’t even have the energy to go to the kitchen to fetch a glass of water.

The 15th of August his daughter rang the bell, and as there was no answer, she opened the door and found her lifeless father in his beloved armchair. M. Collardelle had joined the more than 70.000 people who died from the heat wave that summer. 70.000 dead that would never have occurred if proper measures had been in place.

Hazards become real risks when the flow of early-warning-surveillance-preparedness- reaction breaks down for some reason. In the case at hand, it is clear that the early-warning system in place was not enough and that the flow never started; no surveillance, preparedness, or reaction were put in place.

Since 2003 things have improved; the European Climate Adaptation Platform[i] is a good example of how much things have changed. Today most countries have Heat-Health Action Plans to ensure that something like that will never happen again. Nevertheless, most plans focus on the activities that institutions at national, regional, and local levels have to carry out in case of an emergency. The diffusion and communication with citizens is mostly one way, from the institution to the public, at most an open line for people to report back, but with no real engagement or tracing whatsoever.

A comprehensive system for preventing a hazard from becoming a real problem is lacking. To start with, most plans are limited to a specific hazard or to a particular respondent. Very rarely is there a comprehensive focus on a situation that, in many cases, involves the occurrence of various simultaneous hazards.

It is also symptomatic that crisis management is only put in place once the crisis has reached a certain level. Those moments, from the occurrence of the event till the recognition by the relevant authorities that the event is in place, are mostly wasted. In fact, there is a lack of co-responsibility on the part of the citizenry in the response to an event.


[i] http://climate-adapt.eea.europa.eu/about accessed 12.07.21

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The idea comes from a podcast by The Economist, “The New Old”, in which Andrew Scott from the London Business School discusses the importance of acting rather than reacting.

The point is that there are millions of ideas developed for old people. Few have moved from the drawing board into everyday life. This lack of adoption of new ideas seems to stem from the fact that it is too late for old people to adapt to new inventions and/or methods. And also, it is too late once morbidity has already developed.

As the title clearly expresses, what we should aim for is helping people to develop healthy habits that will make ageing a lot more bearable and enjoyable.

Prevention has traditionally been the black sheep of the socio-health sector. There is a lot of talk about it and very little action. Dare to type “self-help” in Google or in Amazon, and the number of entries is in the range of the thousands. But still, there is no action from the public socio-health system.

It is usually the case in organizations that they tend to put out fires, while forgetting the most vital step:  preventing the fire. Acknowledging that fact, it is no consolation to see that the socio-health sector acts in the same manner: attending those already sick and forgetting about preventing sickness.

So the trend continues, and what the formal public sector does not provide, falls into the hands of the private sector: filling the gap started years ago with the self-help books, and which today has moved from books to apps and ICT tools of all kinds.

Of course, I am not against the private sector coming to the rescue; on the contrary. What I would very much like is for the public socio-health sector to integrate into their system those apps and other prevention tools that would, in the long run, ameliorate pressure on the socio-health system. In short: to integrate the concept of helping people to age better.

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Rehabilitation is mostly understood as a side order of a full-blown treatment of an illness. Should it be so? The first casualty of that point of view is rehabilitation itself. Rehabilitation is “a set of interventions needed when a person is experiencing limitations in everyday physical, mental, and social functioning due to ageing or a health condition, including chronic diseases or disorders, injuries, or trauma”[i] The definition does not imply that rehabilitation should be linked to the treatment of an illness. My point is that rehabilitation should be linked to maintaining one’s physical or mental health: a prevention tool more than a cure.

If we take that approach, rehabilitation would become part of primary care as against being a by-product of specialist care. Primary care is the point to which a person will turn when feeling something is wrong with his/her health. That does not mean necessarily that the person is ill; that the person is a “patient”. I resent very much that word. The label “patient” is diminishing any way you look at it. Does it mean you must be tolerant with the health professional who is treating you? Or is it that you must endure your suffering? The use of the word “patient” limits also the scope that rehabilitation should have since it links rehabilitation to illness.

Rehabilitation should take a bigger role in humans’ wellbeing. A recent paper[ii] points out that almost one in three people on the planet needs some kind of rehabilitation. If we narrow the focus, 1.71 billion people have musculoskeletal conditions that could benefit from rehabilitation. Narrowing even more, around 30% of the population in the European Region has musculoskeletal problems.

With an ageing society, that percentage is only going to increase and the health system, or primary care for that matter, is not and will not be able to cope with the problem. A different approach must be taken to devise a system that relies more on prevention and less on after- the fact- cure. The situation represents a unique opportunity for developing easy to use ICT tools that help primary care professionals address the growing demand for preventive and curative rehabilitation therapies.


[i] Cieza A. Rehabilitation the health strategy of the 21st century, really? Arch Phys Med Rehabil 2019; 100: 2212–14. Cited by Cieza A. et al Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. thelancet.com on December 4, 2020

[ii] Cieza A. et al Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. thelancet.com on December 4, 2020. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2932340-0 Accessed 08.12.20

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A few weeks ago, in September 2019, Spain’s south-east was hit by a coldfront, flooding several villages and cities along the Segura basin. The images of devastation were breath-taking. One of the areas that suffered the most damage was the San Javier-Los Alcázares villages in El Mar Menor.

By no means was it an unexpected event. The Spanish Meteorological Agency had warned of the possible devastating effect of the coldfront. Was the damage due to the fact that the area is not considered floodable?

Directive 2007/60/EC of the European Parliament and of the Council, of 23 October 2007, on the assessment and management of flood risks states in Article 7.5 that “Member States shall ensure that flood risk management plans are completed and published by 22 December 2015”. Spain in general, and the Confederación Hidrógráfica del Segura (entity in charge of the management of the basin) in particular, has complied with the provision of the article and, in March of 2014, issued the flood risk maps.

Let’s have a look at the one for the area in question in which the red marks mean more floodable areas:

And know have a look at Google maps of the area:

Just notice that the red on the first picture coincides almost exactly with the built-up areas of the villages of San Javier and Los Alcázares. So, the area was clearly floodable.

Maybe this event has been an isolated one and that is why nothing has been done to prevent flooding. Wrong again! In 2016 there was also extensive flooding in the area and six historical floods have been reported in the area according to the flood risk maps.

So, why has nothing been done? Why do residential buildings exist in an area that is floodable and that has gone through extensive damage several times in recent years? It may not be due to climate change but, whatever the underlying reason, the fact is that Spain is going through a period of more heat waves and more flooding. And, sadly, the fact is that nothing has been done and nothing is being done.

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Dealing with the unexpected is always difficult. It is difficult for the individual, and it is more difficult for society. Faced with the unexpected, predicting how people behave becomes almost impossible.

Imagine a building on fire. A lot of individuals will shout out the window for help, making the situation more problematic. Others will run to save their relatives, endangering more lives. Some individuals will even try to be heroes, but with out the proper training and equipment they will end joining the body count. Hopefully, some of the individuals will stay calm, close all windows and doors, and wait for the fire department to arrive; these will be the ones who will, most probably, survive. There is another group of individuals, those who will have their minute of glory in the evening news, reporting on all the things that they haven’t seen and spreading false information or, if you prefer, “fake news”.

How can we make a mass of people behave in a rational way? How can we be certain that people, when faced with the unexpected, will react in a way that will not cause more harm?

I can only think of one solution, and it is something that has been tried for centuries: teaching people how to behave. In other words: prevention. Certainly, prevention has been on the menu for a long time and, still, few people act rationally. We must conclude that the way we are trying to bring prevention to people is not the correct way or, alternatively, we are not reaching most individuals.

Since public authorities and NGOs spend quite a few euros on prevention campaigns, let’s not assume they do not know what they are doing. As a matter of fact, there are quite a few examples of very good media campaigns. We are going to focus on the second cause: not reaching most people. We have reached a level of information about almost anything that, to say the least, is overwhelming. But most of the time we must look for the information, the information does not come to us. The information is there but we will seek it out only if we are aware of our needs.

Take earthquakes: Unless we live in certain areas of the world, no one will seek information about how to behave in case of an earthquake. The result is that in San Francisco only very strong earthquakes cause human casualties, but a mild earthquake in south-eastern Spain in 2011 caused 9 deaths and 324 injured. Why? Because we, as a society, have failed to reach out to every individual in the region.

Reaching out to each individual and transmitting proper behavior in case of an unexpected situation should be the main objective of Civil Protection (Civil Defense in some countries). It means making effective use of the risk maps that most countries have; identifying the most vulnerable individuals within the area; and reaching out to those individuals and the population at large so that they know how to behave in case of emergency. No small task, but until we devise an effective system to accomplish that, every time there is an incident, there will be talk about “we should update our protocols for emergency response” and real prevention will be, again, forgotten.

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And it looks like we are losing the battle. According to “Healthcare expenditure statistics” from Eurostat, “[The] highest share [of total healthcare expenditure] of current healthcare expenditure [related to preventive care] in 2014 was recorded in Italy and the United Kingdom (both 4.1 %), while at the other end of the range, shares of less than 1.0 % were recorded in Romania (0.8 %) and Cyprus (0.6 %).” At the other end “curative care and rehabilitative care services incurred more than 50.0 % of current healthcare expenditure in the vast majority of EU Member States”

It may be that this is the right balance, but allow me to doubt it. And my doubts grow as I focus on the demographic change taking place in Europe. The baby-boomers are getting older and we are not doing anything about it, despite the fact that it is probably a generation ready to embrace a healthier and more active life than previous older generations.

I have been wondering, since I started working for the healthcare and social sectors, why it is that prevention does not get the attention of our policy makers.

Many explanations come to mind. Of course, simply saying “they are stupid” is the easy one but I refuse to fall for it. I strongly feel that anybody who has attained a position of responsibility may have many faults, but being stupid cannot be one of them; they would never have reached that position of responsibility.

The urgency of solving the immediate problem may be one of the reasons; after all, if somebody has an acute illness something urgent has to be done. It is a plausible explanation but, if that were the case, policy makers would never plan for the future building new roads or housing developments since they would be too busy repairing the existing road network or the old houses in inner cities.

I am afraid that highways are built because they make the news. I am afraid that most of the things that our policy makers do are geared towards a 30 second appearance in prime time national TV news. If that assumption is right, then it is clear that the opening of a new hospital (curative and rehabilitative care) is a better news item than the establishment of a prevention scheme that does not require any new buildings, or any new expensive and photogenic equipment. It requires only brains and hands, probably the least photogenic tools of the healthcare process and, probably too, the most ignored by policy makers.

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Why is it so difficult to convince older people to adopt gadgets and new behavioural patterns that are meant to make their lives healthier and richer? A person who has not ever read will find it difficult to enjoy reading when turning 65. Behaviour is one of the most difficult things to change; ask any smoker or drinker. And it gets more difficult as we age. Habits form our core identity. As we age we tend to rely more and more on our way of doing things and tend to confront any change with the utmost suspicion.

This behavioural inertia is also ingrained in society. Almost every socio-health care system is based on a pattern of attending social and health problems. Care systems are traditionally designed to repair our ailments. If you have a problem we will take care of you. Don´t bother us if you just feel that probably you will have a problem in the near future; we don’t have time for it!

The combination of both behavioural patterns, personal and social, results in a rejection to adopting anything that means to change our old ways. Change then comes forcefully, meaning we have to change because there is no other way. Any change is, then, a public proclamation of some kind of unavoidable evolution in our system. If I am using a walking stick, it means that I am now frail. I am telling everybody that now I am frail, everybody assumes I am going downhill. Outcome: I will not use that dammed walking stick even if I fall!

If walking sticks became fashionable, as they were in the last century, my ailments would be stealthy; I would be using the walking stick just like everybody else, only I really need it.

If care systems insist on putting all their efforts into solving problems – tackling mainly acute problems-, there is no chance that we can incorporate new habits into the population. I know that for years there has been talk about the need to introduce prevention into our care systems. I know also that very little has been done. If you are in doubt, compare the amount that any system is investing in obesity induced illnesses and the amount spent on preventing obesity. I recognize also that the opening of a new acute hospital makes headlines with a nice picture of the Minister of Health, while a program for changing eating habits in children in an out of the way school does not make even a tiny article on page 45 of the local newspaper. Nevertheless, we all know that prevention is the only way to face a brighter future.

Prevention means that, as soon as possible in the person’s life, the system will help to change habits in order to avoid future complications. With that in mind, we will be able to introduce say, healthy eating apps that will be assimilated into our everyday life. The person will rely on the app when feeling at loss for ideas for tomorrow’s lunch. The odd search will become a habit, and the app will start recording what food is chosen, and letting the person know when he/she is eating more meat than necessary.

Compare this process with today’s. Today, I would go to the doctor when I felt sick, he will spot that I am eating a very unhealthy diet and recommend a complete overhaul of my eating habits. He may recommend an app to help me keep track of what I eat. I will struggle to follow the diet and will not use the app. My mind is telling me that I have been eating a lot of meat ever since I was young and I have enjoyed every minute of it. I will keep it that way till the grave, even if it means the grave closes nearer.

I think that the only way to success is to be able to induce a behavioural change in our target population. We know that behavioural changes are easier the younger the person is. We should then aim at incorporating as soon as possible into daily life those elements that will contribute in the future to a longer and healthier life. Get your walking stick today; do not wait for when you really need it. Or in a more up-to-date fashion, start getting acquainted with apps and other ICT gadgets today, before you really need them and feel old and battered.

From the developer/entrepreneur point of view, your customers are the social-health care systems; convince them that only by prevention will they have spare resources to attend the ageing society; change their behavioural pattern from solving acute problems to preventing problems. I know it is a long and burdensome process but it is the only way that your products will make it to the market, to those who need them.

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