A Supermarket of Disaster

Merapi, one of the greatest and most active stratovolcano located on the border between Central Jawa and Yogyakarta, Indonesia; is now globally known for its ability to place fears and terror in the 21^st century by unleashing her hot molten lava and spewed ashes across the region of Yogyakarta.

Merapi is the youngest in a group of volcanoes in southern Java. It is situated at a subduction zone, where the Indo-Australian Plate is sliding beneath the Eurasian Plate. It is one of at least 129 active volcanoes in Indonesia, part of the Pacific Ring of Fire – a section of fault lines stretching from the Western Hemisphere through Japan and South East Asia.

Cutaway diagram of subduction zone and an associated stratovolcano.

Stratigraphic analysis reveals that eruptions in the Merapi area began about 400,000 years ago, and from then until about 10,000 years ago, eruptions were typically effusive, and the out flowing lava emitted was basaltic. Since then, eruptions have become more explosive, with viscous andesitic lavas often generating lava domes. Dome collapse has often generated pyroclastic flows, and larger explosions, which have resulted in eruption columns, have also generated pyroclastic flows through column collapse.

Typically, small eruptions occur every two to three years, and larger ones every 10–15 years or so. Notable eruptions, often causing many deaths, have occurred in 1006, 1786, 1822, 1872, and 1930—when thirteen villages were destroyed and 1400 people killed by pyroclastic flows.

A very large eruption in 1006 is claimed to have covered all of central Java with ash. The volcanic devastation is claimed to have led to the collapse of the Hindu Kingdom of Mataram; however, there is insufficient evidence from that era for this to be substantiated.

The 2006 Merapi eruption which was quickly accompanied by a 6.3 Richter Scale earthquake roughly 50 km (30 miles) southwest of Merapi, devastated Yogyakarta and its residence. The districts most affected were Bantul and Gunung Kidul. Even the Immigration Office and the Adisutjipto airport were also affected by the destructive forces of the quake. The earthquake killed 5,000 people and leaving 200,000 people homeless. Many lost their love ones and also their home for shelter. Although this catastrophic event had come to past for almost 4 years, the people Yogyakarta will never forget what struck them on May 27, 2006.

Recently, on 25 October 2010 Merapi erupted three times, spewing lava down its southern and south-eastern slopes. Following the next day, the eruptive events of 26 October were classified as an explosive event with volcanic bursts of ejected material, visible flame and pyroclastic hot air flows. A column of smoke rose from the top to a vertical distance of 1.5 kilometres (0.93 mi) from the summit of the Mount Merapi.

The eruption at 05:55 on the morning of 4 November was reported as being five times stronger than the initial eruption on 26 October 2010. On 4 November Merapi had been erupting for 24 hours without stopping. Heat clouds of 600 to 800 degrees Celsius spread as far as 11.5 kilometres from the crater reaching toward the edge of the then 15 kilometres (9.3 mi) exclusion zone, and lava flowed into the mountain’s rivers.

Merapi erupted early on Friday 5 November 2010. Volcanic ash fell at Cangkringan village and its surroundings 10 kilometres (6.2 mi). Due to continuous large eruptions, the government extended the safety zone to 20 kilometres (12 mi) radius and Yogyakarta's airport was closed again for 3 hours in the morning. Volcanologists reported the eruptions of Friday 5 November to be the biggest since the 1870s and officials announced by loudspeaker that the mountain's danger zone had been expanded to 20 kilometres from the crater. Bronggang, a village 15 kilometres from the crater, had streets blanketed by ash up to 30-centimeters deep. By 5 November more than 100,000 people had been evacuated and the scientists monitoring the events were withdrawn from their posts to a safer distance.

This is just one volcano eruption in Central Jawa and prior to this volcanic activity, 21 other active volcanoes in the Jawa island also show signs of increasing activity recently. The ones that I read about is in Maluku, Sulawesi, Krakatoa island and Bromoh in Surabaya. Not forgetting the Mentawai earthquake plus tsunami that already destroyed hundreds of homes, schools, churches and mosques leaving many homeless and casualties. Therefore, my tutorial doctor once told me about Indonesia being the supermarket for disasters which I could not agree more and actually I would like to change it into A Hypermarket of Disasters.

Not only Indonesia is suffering from the wrath of disasters but other places around the world as well. Iceland just had its eruption of Eyjafjallajokul volcano in April this year and New Zealand also just had its earthquake on September 4.

Lastly, I would like to say that our earth is on its way to its tipping point and if humanity don’t find or reach their tipping point to change soon, we might be able to see the events and images from the 2012 movie.

References:

www.thestar.com.my ( Indonesia volcano shoots new blasts; 21 more rumble)

www.thestar.com.my ( Indonesia volcano forces flight cancellations)

www.wikipedia.com ( Mount Merapi, Stratovolcano)

www.detiknews.com (Merapi Masih Erupsi, Penutupan Bandara Adisutjipto Diperpanjang Hingga 20 November)

http://www.bbc.co.uk/ (New Zealand earthquake damaged 100,000 homes)

http://www.telegraph.co.uk/expat/ (Experiencing the New Zealand earthquake)

What is System Thinking?

System Thinking

What is a system? I am sure there were many who asked this question during Professor Laksono’s lecture.

A system is a set of interacting or interdependent system components an integrated whole, or “whole compounded of several parts of members, system”, literary “composition”.

The concept of an “integrated whole” can also be state as a system embodying a set of relationships which are differentiated from relationships of the set to other elements, and from relationships between an element of the set and elements not a part of the relational regime. The scientific research field which is engaged in the study of the general properties of systems include systems theory, cybernetics, dynamical systems, thermodynamics and complex systems. They investigate the abstract properties of the matter and organization, searching concepts and principles which are independent of the specific domain, substance, type, or temporal scales of existence.

Most systems share common characteristics, including:

· Systems have structure, defined by components and their composition;

· Systems have behaviour, which involves inputs, processing and outputs of material, energy, information, or data;

· Systems have interconnectivity: the various parts of a system have functional as well as structural relationships between each other.

· Systems have by themselves functions or groups of functions.

In this post, I would like to share some concepts on system. There are 7 concepts about system and each describing different ideas and concepts about the function and view of the system.

Environment and Boundaries

Systems theory views the world as a complex system of interconnected parts. We scope a system by defining its boundary; this means choosing which entities are inside the system and which are outside - part of the environment. We then make simplified representations (models) of the system in order to understand it and to predict or impact its future behaviour. These models may define the structure and/or the behaviour of the system.

Natural and Man-made systems

Natural systems may not have an apparent objective but their outputs can be interpreted as purposes. As for man-made systems, it is made or designed with purposes that are achieved by the delivery of outputs. Their components must be related; they must be designed to work as a coherent entity or else they would be two or more distinct systems

Theoretical Framework

An open system exchanges matter and energy with its surroundings. Most systems are open systems; like a car, coffeemaker, or computer. A closed system exchanges energy, but not matter, with its environment; like Earth or the project Biosphere2 or 3. An isolated system exchanges neither matter nor energy with its environment; a theoretical example of which would be the universe.

Process and Transformation process

A system can also be viewed as a bounded transformation process, that is, a process or collection of processes that transforms inputs into outputs. Inputs are consumed; outputs are produced. The concept of input and output here is very broad. E.g., an output of a passenger ship is the movement of people from departure to destination.

Subsystem

A subsystem is a set of elements, which is a system itself, and a component of a larger system.

System Model

A system comprises multiple views such as planning, requirement, design, implementation, deployment, operational, structure, behaviour, input data, and output data views. A system model is required to describe and represent all these multiple views.

System Architecture

A system architecture, using one single coalescence model for the description of multiple views such as planning, requirement, design, implementation, deployment, operational, structure, behaviour, input data, and output data views, is a kind of system model.

Lastly, I would like to say that systems are everywhere and their application in human lives has played a significant role in the development and evolution of science as well as other areas like engineering and physics, social and cognitive sciences, management research, economics, strategic thinking, information and computer sciences and many other more. Therefore it is very important for us to understand systems and how we can apply its concept and theories into our daily lives or more importantly in the area of sciences and medical field.

References:

1. Wikipedia (keyword:system, systems theory)

2. Block 4.2 lecture notes

Audit audit audit.......

Clinical Audit

Seriously, I do not have the slightest idea on the topic called clinical audit when I first attended the lecture two weeks ago. As usual, paying attention on what Dr. Adi Utarini says in lecture about the introduction to clinical audit practical session is crucial in the understanding of clinical audit. The lectures were brief and easy to understand and finally after attending the lecture I walked out the hall with a glimpse of some ideas about what clinical audit is.

At first, I thought clinical audit is about financial auditing or accountancy in clinical settings in the hospital but I was wrong after attending the lecture by Dr. Adi Utarini. Thus, I would like to clarify the term clinical audit first by defining the meaning of audit. Audit is an evaluation of a person, organization, system, process, enterprise, project, or product. The term commonly refers to audits in accounting, but similar concepts also exist in project management, quality management, and energy conservation.

Another term that caught my attention while reading more about audit is the term quality audit. Quality audits are performed to verify conformance to standards through review of objective evidence. A system of quality audits may verify the effectiveness of a quality management system. This is part of certifications such as ISO 9001. Quality audits are essential to verify the existence of objective evidence showing conformance to required processes, to assess how successfully processes have been implemented, for judging the effectiveness of achieving any defined target levels, providing evidence concerning reduction and elimination of problem areas and are a hands-on management tool for achieving continual improvement in an organization.

To benefit the organization, quality auditing should not only report non-conformances and corrective actions but also highlight areas of good practice and provide evidence of conformance. In this way, other departments may share information and amend their working practices as a result, also enhancing continual improvement.

As for clinical audit, the term is defined as a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the review of change. Aspects of the structure, process and outcome of care are selected and systematically evaluated against explicit criteria. Where indicated changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery. (UK’s National Institute for Health and Clinical Excellence, NICE)

Others, like the authors of the Cochrane Review on audit and feedback offer a narrower definition which is “The provision of any summary of clinical performance over a secified period of time. The summary may include data on processes of care, clinical endpoints, and clinical practice recommendations.”

In brief, clinical audit provides a method for systematically reflecting on and reviewing practice.

In the literature about clinical audit methods, the following terms are often mentioned: criteria based audits; adverse occurrence screening; critical incident audits; peer reviews; and case note analysis. These are used inconsistently by different authors and tend to add to the general confusion about the clinical audit process. For now, I recommend it is best to forget all this terminology since there is only one clinical audit method – the clinical audit cycle.

Lastly, the overarching aim of clinical audit is to improve service user outcomes by improving professional practice and the general quality of services delivered.

References:

· Clinical audit: a comprehensive review of the literature, Centre for Clinical Governance Research in Health, Faculty of Medicine, University of New South Wales, Sydney NSW 2052 Australia (2009)

· Lecture Notes titled Clinical Audit and Quality Tools

· Wikipedia (keyword: audit, clinical audit)

Globalized Health Risk…

Globalization in Health

We can see that as borders disappear, people and goods are increasingly free to move, creating new challenges to global health. These cannot be met by national governments alone but must be dealt with instead by international organizations and agreements.Every year, the same ritual takes place at changing locations in the Western world. While the heads of the eight leading industrialized nations meet at their annual G8 summit to discuss the global state of affairs, a wide variety of organizations and protesters meet in parallel to decry what they see as the negative effects of globalization.

One major problem is the increasing internationalization of health risks. How-ever defined, this term has many dimensions, including economic, technological, political, social, scientific and cultural aspects. The links between globalization and health are complex and globalization is a multifaceted phenomenon that can affect health in myriad ways. Its consequences can be either direct, at the level of whole populations, individuals and healthcare delivery systems, or indirect, through the economy and other factors, such as education, sanitation and water supply. Given the enormous complexity and breadth of the issues, my post cannot hope to cover the entire range of topics that link globalization to health. Instead, we focus on those risks to health and health care that are related to central aspects of the globalization process, namely trade, and travel.

Increased trade and foreign investment through liberalization can increase economic growth. Growth can be used to sustain investment in necessary public goods, such as health care, education, women’s empowerment programs and so on. Especially in poorer countries, growth may also reduce poverty, leading to desirable change in the determinants of health. Improved population health, particularly amongst the world’s poorest countries, is increasingly associated with improved economic growth, and so the circle virtuously closes upon itself.

Although increasing trade is certainly good for economies, it also leads to a globalization of health risks. Important examples of such risks include tobacco, alcohol, global epidemics of non-communicable diseases and trade in health services. There are studies proving that in poor countries, there is an increased in consumption of alcohol and tobacco. Lung cancer, cardiovascular diseases (CVDs), lung diseases, diabetes and many other tobacco-related ailments, will occur in developing countries. There is a strong relationship between alcohol consumption and liver cirrhosis, some cancers, and most causes of injuries and violence, although minimal amounts of alcohol are sufficient to reduce the risk of CVD.

Trade and movement of infected cattle and poultry across national borders may also have contributed to recent outbreaks of mad cow disease in the Northern hemisphere and avian influenza in Asia.

Travelling in this era became more convenient and more affordable which result in far-reaching air travel, aided by improvements in aircraft technology that allow longer non-stop flights, facilitates the spread of communicable diseases. It is entirely possible that a person in the early stages of an infectious disease could be halfway around the world in 12–15 hours and thus function as a vector for that disease, aiding its spread, perhaps into vulnerable, non-immune populations. The recent epidemic of severe acute respiratory syndrome (SARS) is the best contemporary example of the rapid spread of a hitherto unknown and virulent viral pathogen through travel of infected humans. SARS was first recognized in February 2003 in Vietnam where cases of atypical pneumonia with an unknown cause began to appear. By the first week of May 2003, 30 countries on six continents had reported a total of more than 7,000 probable cases with more than 500 deaths.

As pointed out above, globalization will not go away. It is therefore important to anticipate future challenges for global health and to consider how to react effectively.

References:

Globalization and risks to health, by Tikki Pang & G. Emmanuel Guindon

Block 4.2 lecture notes titled Globalization in Health.

Globalization of Trade in Health Services and Workforce

International Trade in Health Services

There are 4 illustrations that I would like to highlight on the trade in health services internationally, which are:

1. Cross-border trade

2. Consumption abroad

3. Commercial presence

4. Natural presence

Cross border trade is a worldwide phenomenon where services such as customer-interaction centre, medical transcription and medical consultation as well as many more are being done in countries where the payment of labour is cheap. One of the countries that have this affiliation is India where radiographic X-rays are being sent to be consulted there and the result of the findings is sent back to the party that pays them. From this scenario, we can see that cross border trade can increase the revenue for the healthcare provider as well as offer extra income for those who provide the services.

Consumption abroad is where local patients travel abroad to benefit healthcare services of the country of their choice. An example is depicted here by a pie chart below:

From a statistic data, Indonesians spend more than 1 billion US dollars annually for medical expenses overseas. The reason is because medical services such as heart by-pass graft surgery, liver transplant, neurosurgery and many other are being provided by expertise of better quality than the local experts plus the price of the surgery done in overseas is relatively cheaper after calculating the expenses of air travel as well as the expenditure used in travelling on another country. So why not have a surgery done in overseas and you can also have a travelling experience of that country. It is like killing two birds with one stone. ^^

From this scenario, we can see that neighbouring countries of the South East Asia regions are trying their best to promote and upgrade their healthcare facilities and medical services so that revenues from outside the country will flow in when citizens from other countries come in to purchase their healthcare services. This is a phenomenon known as health tourism.

Commercial presence touched on the aspects of foreign investment as well as foreign hospitals providing healthcare services to local population. Their presence causes internal brain drain from public/government hospitals to private hospitals. This in turn causes shortages of health workforce in rural areas as they would prefer to work in a private sector for better remunerations as well as working conditions. In Indonesia, foreign hospitals are estimated to account for 1% of total hospital beds. In Philippines: two of 19 Health Maintenance Organizations (HMOs) are foreign-owned. As in Thailand: foreign investment is estimated to account for 3% of total investment in private hospitals in Thailand.

Lastly is natural presence, where health workers are being exported out of the country to develop countries. This form of trade is driven by shortages of healthcare workers in countries which are developed and has richer economies. The ASEAN (Association of South East Asian Nations) region hosts 2 of the world’s largest exporters of healthcare workers. Philippines and Indonesia send large numbers of nurses and midwives to countries around the world. Many countries around the world has shortages of doctors, midwives and nurses and from a survey done, three main reasons why health workforce choose to migrate to developed countries are the following:

· Better remunerations

· Safer environment

· Better living conditions

In the end, to solve these problems, a few policies can be made to improve the conditions.

References:

Block 4.2 lecture notes titled Globalization of Trade in Health Services and Workforce.

Health System and Its Essential Components

Health System

Block 4.2 is about health system and disaster management in which the two of them shares a relationship that is dependent on each other. Therefore, I would like to take this opportunity to talk about health system as my first post for this blog. Enjoy!

A good health system delivers quality services to all people, when and where they need them. The exact configuration of services varies from country to country, but in all cases requires a robust financing mechanism; a well-trained and adequately paid workforce; reliable information on which to base decisions and policies; well maintained facilities and logistics to deliver quality medicines and technologies. (WHO, 2010)

The acting components or the key components of health system consist of health financing, health services, regulation, community empowerment and human resources for health. Besides that, a well functioning health system responds in a balanced way to a population’s needs and expectations by:

· Improving the health status of individuals, families and communities

· Defending the population against what threatens its health

· Protecting people against the financial consequences of ill-health

· Providing equitable access to people-centred care

· Making it possible for people to participate in decisions affecting their health and health system

1. Leadership and Governance

Every country exercises different leadership and governance based on their country’s specific context and history, but common ingredients of good practice in leadership and governance can be identified. Which include:

a. Ensuring that health authorities take responsibility for steering the entire health sector and for dealing with future challenges as well as with current problems.

b. Defining, through transparent and inclusive processes, national health policies, strategy and plan that set a clear direction for the health sector.

c. Effective regulation through a combination of guidelines, mandates, and incentives, backed up by legal measures and enforcement mechanisms.

d. Effective policy dialogue with other sectors.

e. Mechanisms and institutional arrangements to channel donor funding and align it to country priorities.

2. Health Information Systems

Without good information on health challenges, there would not be good governance in this sector. This is because on the broader environment which the health systems operate and on the performance of health system, timely intelligent is require on:

a. Progress in meeting health challenges and social objectives, including but not limited to household surveys, civil registration systems and epidemiological surveillance.

b. Health financing, including through national health accounts and an analysis of financial catastrophes and of financial and other barriers to health services for the poor and vulnerable.

c. Trends and needs for HRH; on consumption of and access to pharmaceuticals; on appropriateness and cost of technology; on distribution and adequacy of infrastructure.

d. Access to care and on the quality of services provided, like national monitoring and evaluation plan that specifies core indicators (with targets), data collection and management, analyses and communication and use; plus also arrangements to make information accessible to all involved, including communities, civil society, health professionals and politicians.

3. Health Financing

Health financing can be a key policy instrument to improve health and reduce health inequalities if its primary objective is to facilitate universal coverage by removing financial barriers to access and preventing financial hardship and catastrophic expenditure.

4. Human Resources for Health

The health workforce is central to achieving health. A well performing workforce is one that is responsive to the needs and expectations of people, is fair and efficient to achieve the best outcomes possible given available resources and circumstances. Countries are at different stages of development of their health workforce but common concerns include improving recruitment, education, training and distribution; enhancing productivity and performance; and improving retention. All this requires:

a. Arrangements for achieving sufficient numbers of the right mix.

b. Payment systems that produce the right kind of incentives.

c. Regulatory mechanisms to ensure system wide deployment and distribution in accordance with needs.

d. Establishment of job related norms, deployment of support systems and enabling work environments.

e. Mechanisms to ensure cooperation of all stakeholders.

5. Essential medical products and technologies

Accessibility to health care is highly dependent on access to affordable essential medicines, vaccines, diagnostics and health technologies of assured quality, which are used in a scientifically sound and cost-effective way. Economically, medical products are the second largest component of most health budgets (after salaries) and the largest component of private health expenditure in low and middle income countries.

6. Service delivery

Health systems are only as effective as the services they provide. These critically depend on:

a. Networks of close-to-client primary care, organized as health districts or local area networks with the back-up of specialized and hospital services, responsible for defined populations.

b. Provision of a package of benefits with a comprehensive and integrated range of clinical and public health interventions, that respond to the full range of health problems of their populations, including those targeted by the Millennium Development Goals.

c. Standards, norms and guidance to ensure access and essential dimensions of quality: safety, effectiveness, integration, continuity, and people –centeredness

d. Mechanisms to hold providers accountable for access and quality and to ensure consumer voice.

As a summary, all six components mentioned above are crucial or vital in the proper functioning and the overall performance of providing healthcare to individuals in a population. The components are dependent on each other during the process of service delivery and each of these components must function properly in order to produce a good outcome which will benefit the health system itself.

References:

• WHO website www.who.int (keyword: health system)
• WHO article titled Key components of a well functioning health system.pdf
• Block 4.2 lecture notes