Characterization of complex emergencies
The characterization of complex emergencies has evolved over time, with different individuals and different organizations favoring particular definitions to highlight specific characteristics. However, there are important key features of complex emergencies that have been well documented across a wide range of crisis settings, and these are more universally accepted than any one particular definition.
Common characteristics of complex emergencies:
Conflict and warfare are at the core of complex emergencies with most originating from widespread violence or loss of life and involving massive population displacements, as well as pervasive and extensive damage to societies, their infrastructures, and their economies.
The underlying causes of complex emergencies are usually multifaceted and dynamic throughout the course of the crises and include political, environmental, economic, and demographic instability.
Complex emergencies are often prolonged, with the average civil war now lasting at least 10 years.
Delivery of humanitarian assistance is often hindered by political and military constraints, leading to security risks for relief workers.
The majority of victims are civilian with morbidity and mortality highest among vulnerable and unprotected children, women, the elderly, and the disabled. In fact, civilians account for 90% of war-related deaths from civil strife, genocide, and other violations of the Geneva Conventions.
As of early 2014, there were 60 countries in the world at war, involving an estimated 531 militias and separatist movements. The majority of these were internal nation-state wars. State and nonstate perpetrators in these conflicts wantonly violate the Fourth Geneva Convention, which mandates the protection of civilians from attack and inhumane treatment and prohibits attacks directed at civilian hospitals and medical teams. Within these contemporary wars, civilian lives are often strategically targeted through the destruction of livelihoods, forced displacement, and direct physical violence, and there is now a wealth of evidence substantiating the massive effect that war has both on individual and public health. , Direct health effects include injuries, deaths and disabilities, human rights and international humanitarian law abuses, and psychological stress. Indirect health effects actually contribute to the majority of mortality and morbidity and arise from population displacement, disruption of food supplies, and the destruction of health facilities and public health infrastructure.
A comprehensive understanding of complex emergencies requires consideration of the politics surrounding the underlying conflicts. In present-day intrastate war, there are frequently multiple warring factions with unique ideologies often inscrutable to the outside world. The combination of many armed actors, with individual identities driven by enigmatic beliefs, has prompted the international community, its policy makers, and its media to designate these conflicts generically as chaos . The Second Congo War in the Democratic Republic of Congo (DRC) was a prime example, with at least 20 armed factions actively engaged at the height of the conflict. But contemporary conflicts are sometimes intended to be confusing, and it is important to recognize the underlying motivations for war. Chaos, for instance, can serve as a strategic cover for political and economic manipulation and for carrying out self-aligned agendas. Wars are almost always functional: they serve a purpose for one or more involved parties, and those parties may have little interest in ending a conflict from which they are directly benefitting.
All manner of players within a complex emergency can manipulate humanitarian services for political purposes and self-gain. For instance, relief is sometimes withheld for economic purposes or in a malicious attempt to deprive the opponent, or perceived supporters of the opponent, of life-sustaining aid. This has been a common occurrence in Syria where the government’s denial of humanitarian access has greatly exacerbated and perpetuated civilian suffering. Such manipulation of humanitarian aid places relief workers at significant personal risk; undertaking humanitarian response thus requires a politically informed approach. Geoff Leone of the International Committee of the Red Cross (ICRC) advises, “Know the politics, so you can negotiate the minefield.” By pushing aid through to those in need, the delivery of relief services also becomes a political act that has the potential to challenge power structures. In this politically complex environment, aid organizations must balance humanitarian access with bearing witness to war crimes and crimes against humanity, understanding the stark reality that publically denouncing witnessed atrocities risks being denied future access to those in critical need. Additionally, aid organizations responding to complex emergencies must always bear in mind that relief work is intended to relieve suffering and to save lives among affected populations, and that it will never be a substitute for a political solution to the underlying crisis.
Mass Population Displacement
Mass population displacement and its effects on health have been increasingly recognized since the end of the Cold War. According to a 2013 midyear report, the total “population of concern” to the United Nations (UN) High Commissioner for Refugees (UNHCR) was 38.7 million, representing the highest number on record for the agency. Of these, approximately 10.5 million are refugees, defined by international conventions as “persons who cross international borders due to fear of persecution on the basis of race, religion, nationality or membership in a particular social or political group.” The Refugee Convention entitles those who meet this legal definition to access services that sustain health and well-being—food, water, shelter, sanitation, and health care—and assigns them certain rights within their host countries. While repatriation is usually the long-term goal for refugees, it must be on a voluntary basis when deemed safe to return to the country of origin. In international law, the principle of non-refoulement dictates that no refugee should be forced to return to any country where he or she is likely to face persecution or torture.
Internally displaced persons (IDPs) are individuals who leave their homes out of fear of being persecuted for reasons similar to those of refugees, but they do not cross an international border. The world’s IDP population is estimated to be in excess of 20 million, far outpacing the number of refugees over the last 10 years. Because they have not crossed an international border, IDPs legally remain under the protection of their own governments, even though those same governments may be responsible for their forced displacement. Therefore, IDPs are among some of the world’s most vulnerable individuals. Although they do not technically fall under the mandate of the UNHCR and are therefore not guaranteed the same protections and rights as refugees, the UNHCR has been variably lending assistance to IDPs for many years.
The acute phase of mass displacement and forced migration typically results in mortality rates significantly increased above the baseline mortality rates of the population prior to displacement. Mortality surveillance systems implemented by aid agencies attempt to capture numbers of deaths, but inevitably under-report given the degree of insecurity on the ground. This is especially true for IDP mortality figures in which national authorities may prohibit access to the displaced population. The high mortality associated with this acute phase derives both directly from injuries incurred from the violence preceding or during flight, and indirectly from food scarcity, siege, and communicable disease outbreaks. One of the highest refugee mortality rates ever documented was among the almost 1 million Rwandans who fled into eastern Zaire in 1994. A cholera outbreak in the refugee camps near Goma largely contributed to this catastrophe, with a crude mortality rate of 54.5 deaths/10,000 daily (prewar crude mortality rate in Rwanda was 0.6 deaths/10,000 daily).
Political instability and insecurity can have a significant adverse impact on national and local economies, including the agricultural industry. Fighting can damage irrigation systems, warring parties may intentionally destroy crops or loot harvests, and distribution systems that connect rural production zones and urban populations may completely collapse. Cumulatively, these factors can lead to food scarcity and/or compromise a population’s reliable access to food, and during complex emergencies the prevalence of acute malnutrition and micronutrient deficiencies can be extremely high, particularly in developing countries. Such conditions may contribute to other coincident factors of food scarcity—drought, ill-fated government policy, crop failure—that result in famine, a state of widespread food scarcity accompanied by acute malnutrition, micronutrient deficiencies, and elevated mortality rates. Such has been the case in recent conflicts in Somalia, Ethiopia, and Sudan.
Documentation of wartime sexual violence has improved in recent years, leading to a focused appreciation for the magnitude of the problem. Recent conflicts in the former Yugoslavia, DRC, Darfur, Liberia, and Sierra Leone were all characterized by extensive sexual violence that was both strategic and systematic in nature. Sexual violence is used to terrorize civilian populations, forcing them to rapidly flee from their homes, leaving their belongings and livelihoods behind. In conflicts motivated by ethnic cleansing, sexual violence is sometimes used as a means of “polluting” bloodlines and forcibly impregnating women to produce “ethnically cleansed” children. , In modern, intrastate warfare, sexual violence has established itself as a cheap, low-technology, and yet highly effective weapon.
Not all conflict-related sexual violence is systematic, however. Sexual abuse and exploitation by relief workers have also been reported, and, in recent years, there have been multiple interventions to address these concerning issues. Furthermore, preexisting sexual violence is often heightened during times of war. Intimate partner violence (IPV) is one of the most common forms of gender-based violence (GBV) in displaced camp settings and in complex emergencies. Overall rates of IPV tend to be much higher than rates of sexual assault outside the home. It is important to note that men and boys are also targets of sexual violence. ,
In the early post-Cold War period, humanitarian assistance was believed to be the key to effectively intervening in complex emergencies. Relief organizations, drawing on international treaties and covenants such as the Geneva Conventions, based their work on neutrality, impartiality, and the right to assistance based purely on need and without political discrimination. The global community soon realized, however, that sustained peace and development would never occur without a political solution, and that the “humanitarian imperative” driving humanitarian responses was simply not enough to adequately protect the health and well-being of civilian populations during conflict. At about the same time, variable quality of relief delivery, lack of professional standards, and lack of evidence-based practices challenged the ability of humanitarian organizations to work effectively in field operations, creating further frustration for donors, governments, and humanitarian organizations alike.
In early UN emergency responses, peacekeeping forces were deployed under Chapter VI of the UN Charter to help quell the conflict and provide some semblance of security for intervening UN agencies and relief organizations. Under Chapter VI, peacekeepers lacked the resources and legal mandate to use military force in achieving their objectives and ensuring “humanitarian space.” As this protected working zone became more tenuous and health care workers assumed more extraneous roles (contributing to a perception of less neutrality and less impartiality), there was an alarming increase in intentional violence and banditry against humanitarian relief agencies and peacekeeping forces. This violence contributed to a decision to replace UN peacekeeping forces with peace enforcement troops under UN Charter Chapter VII. Peace enforcement troops have the resources to stop violence in order to protect civilians and are permitted to use military action to restore international peace and security. The transition from peacekeeping to peace enforcement was slow, but all UN military interventions have since been authorized under Chapter VII.
After a slow and inadequate humanitarian response in Darfur in 2004, the UN Emergency Relief Coordinator and Under-Secretary General for Humanitarian Affairs commissioned the Humanitarian Response Review , which was aimed at closing operational gaps and augmenting the timeliness, effectiveness, and predictability of aid delivery. In the 2005 Review , three networks were identified to which most relief organizations belonged: UN network, Red Cross/Red Crescent Movement, and nongovernmental organizations (NGOs). Additionally, to close the identified gaps and improve the delivery of humanitarian assistance, four pillars of humanitarian reform were introduced: (1) the Cluster Approach, (2) Strengthening the Humanitarian Coordination System, (3) Adequate, Flexible, and Predictable Humanitarian Financing, and (4) Building Partnerships. Within the Cluster Approach, “clusters” are groups of organizations, both UN and non-UN, designated by the Inter-Agency Standing Committee (IASC) to lead response coordination within each of the main sectors of humanitarian action ( Fig. 7-1 ).
It is not uncommon for NGOs and other relief organizations to be established in an unstable country long before violence garners the attention of the international community. The broader, multinational humanitarian response begins with a decision to intervene, a decision that is usually prompted by increasing violence and by mass displacement of refugees and IDPs. It is also usually preceded by weeks or months of debate within the UN Security Council before a resolution is passed directing the scope of the humanitarian assistance and defining the participating actors.
Humanitarian assistance usually comes from assets contributed by the UN Office for the Coordination of Humanitarian Affairs (OCHA) and other field operational UN agencies such as the World Food Program (WFP), the World Health Organization (WHO), and the UN Children’s Fund (UNICEF). The response typically also includes the Red Cross Movement, relief organizations, and donor agencies that primarily represent the governments of industrialized nations, such as the United States Agency for International Development (USAID), the Canadian International Development Agency (CIDA), and the United Kingdom’s Department for International Development (DFID). Without good coordination between the relief organizations delivering assistance, there can be many gaps and overlaps in the response.
Concern about the lack of standards and accountability among humanitarian relief personnel peaked in the mid-1990s following the Rwandan genocide. To address these growing concerns, the Humanitarian Charter and Minimum Standards (Sphere Project) was initiated in 1997 under the joint management of InterAction and the Steering Committee for Humanitarian Response (SCHR). The objective of the Sphere Project is to “improve the quality of assistance delivered to people affected by disaster or conflict” and to improve “the accountability of humanitarian agencies and states towards their constituents, donors and affected populations.” The Sphere Handbook provides standardized guidelines, continually revised according to empiric evidence and consensus, for addressing the core areas of water and sanitation, nutrition, food aid, shelter, and site planning as well as health services.
Evolution of Civilian Medical Needs in Complex Emergencies
In the early phases of complex emergencies, the most urgent health concerns are often injuries resulting from direct violence. Although there will continue to be traumatic injuries, with time other health priorities will emerge. For instance, if displaced populations are sheltered in overcrowded and unsanitary conditions, it is common for air-, water-, and vector-borne communicable diseases, particularly those endemic to the region, to break out and propagate easily. The threat of preventable communicable diseases, such as measles and polio, is further exacerbated by interruptions in routine vaccination as a result of the crisis. With time, mental health and psychological distress become a priority for the population in general and medical responders in particular. With more time, food insecurity will lead to acute malnutrition, particularly among children, the disabled, and the chronically ill. In less developed countries where food insecurity and chronic undernutrition is the norm, cases of malnourishment emerge sooner. And finally, with the passage of more time, an increasing number of individuals will seek care for chronic, preexisting medical problems such as hypertension, cardiac disease, and diabetes, especially in more developed countries with advanced health systems and a high prevalence of these conditions precrisis.
Public Health Priorities
Complex emergencies have a severe impact on the health of entire communities. Malnutrition coupled with infectious disease, lack of access to emergency care, and the targeting of health care facilities/providers are all known to shorten life expectancy within crisis-affected populations. , A series of four mortality surveys in the DRC between 2000 and 2004 showed a crude mortality rate (CMR) of 2.2 deaths per 1000 persons per month, up 70% from preconflict values, indicative of excess mortality generated from the breakdown of public health infrastructure. The CMR was found to be higher still, at 2.6 deaths per 1000 persons per month, in the most affected areas of the country.
Both endemic diseases and illnesses once nearly exterminated must be monitored when planning treatment programs. Malaria is such a common disease in areas affected by complex emergencies that WHO includes both rapid testing supplies and basic antimalarial treatment in their Interagency Emergency Health Kit, a prepackaged kit designed to provide basic health care for up to 10,000 people for 3 months. However, other rarer conditions can also be encountered and require monitoring. For instance, although Syria declared polio eradicated within its borders in 1999, in 2013 and 2014 it had at least 27 confirmed cases of polio in the midst of its ongoing conflict. Large outbreaks of meningococcal meningitis have been documented in DRC, Sudan, and Rwanda, highlighting the need to screen for previously sporadic diseases, to rapidly treat individual cases, and to implement effective monitoring and control strategies.
Public Health Indicators
Although often challenging to implement, public health and communicable disease monitoring must be integrated into initial rapid assessments in complex emergencies. Rapid assessments provide initial estimates of death rates using simple measures such as the CMR and under-5 mortality rate, which are derived from household surveys, remaining vital registration systems, grave counts, and other creative measures like distribution of burial shrouds. , , , These “quick and dirty” evaluations have improved since the 1990s and, despite being done quickly under difficult conditions, have gained a reputation for quality. With advancements in indicator identification, epidemiological analysis, data retrieval technologies, and training of relief personnel, these critical rapid assessments continue to improve as an art and a science.
As resources and time permit, more sophisticated public health measures should be implemented. The WHO Interagency Emergency Health Kit contains materials for recording distribution of medicines and other medical supplies as they are used; the Sphere Handbook outlines benchmarks for health care delivery with emphases on required medical staff and facilities, essential medications, mortality rates, standardized case management for common infections, newborn/childhood health, vaccine-preventable illnesses, and mental health access. Furthermore, the concept of excess deaths in a complex emergency is a critical epidemiological tool, especially in the setting of conflict and mass population movement.
It is imperative to measure the prevalence of specific diseases to allow for early intervention and targeted treatment. When diagnostic resources are limited and/or qualified health personnel are lacking, it may not be possible to specifically diagnose each case of a particular disease. For example, in Goma in 1994, cases of Vibrio cholerae and Shigella dysenteriae were differentiated simply by descriptions of “watery diarrhea” and “bloody diarrhea.” Similarly, if rapid malaria testing is not available, then recording the incidence of “fever and chills” is often used as a proxy for diagnosing malaria. As more resources become available, greater diagnostic accuracy can be expected. Rates of acute malnutrition should also be recorded; frequently used nutrition indicators include weight/height index and middle upper arm circumstance (MUAC) for young children and body mass index (BMI) for adults. Clinical signs of severe acute malnutrition such as edema are also used as markers of malnutrition among children.
In some complex emergencies diarrheal outbreaks have caused up to 40% of deaths. Many factors play into the spread of diarrheal illnesses including contaminated water sources and water transport vessels, lack of latrines, overcrowded living conditions, lack of soap, and poor hygiene. Diarrheal outbreaks can be prevented or addressed by providing acceptable latrines and encouraging their primary use for defecation, maintaining a clean water supply, providing safe water vessels, and issuing adequate soap supplies. Each case of diarrhea should be classified and reported as watery or bloody as well as by patient age and gender. Patients with diarrhea should be treated with oral rehydration therapy (ORT). Critical to ORT success are the implementation of rehydration centers and the availability of skilled staff to instruct caretakers on the quantity and rate of rehydration.
During the 1980s, measles was a major cause of morbidity and mortality in complex emergencies with case fatality rates as high as 33%. However, since the institution of widespread vaccination programs, the virus has been much better controlled. Overcrowded conditions result in higher infectious inoculation of the virus and thus transmission, and coincident malnutrition correlates with greater disease morbidity. It is imperative to institute mass immunization campaigns, regardless of prior immunization history, for all individuals aged 6 months to 15 years. This will require an intact cold chain and proper needle disposal to prevent transmission of blood-borne pathogens. Measles further depletes vitamin A stores in already malnourished individuals; vitamin A supplementation, shown to reduce mortality in low-income nations, should be considered at the time of measles vaccination.
Malaria prevalence increases and malaria epidemics occur either when a population moves from an area of low endemicity to higher endemicity areas or when a population migrates from a hyper-endemic region to a less endemic area. Overcrowding and poor shelter provide further hazards. Sites for refugee camps should be selected with local vector-borne risk in mind. Bed nets and other impregnated materials will help prevent the spread of disease, as does washing livestock with permethrin and eliminating standing bodies of water. Further study is required to understand if pregnant women should be empirically treated with antimalarials or if there is utility in mass malaria prophylaxis at the time of measles immunization. Treatment, which is included in the WHO Emergency Kit, should consider national treatment guidelines of the host country. Diagnosis should be confirmed when possible, but empiric treatment is often the norm in emergency settings.
Acute respiratory infections cause a great deal of morbidity and mortality in complex emergencies. Overcrowding, inadequate shelter, inadequate blankets in cold environments, and exposure to indoor cooking fires and smoke promote the spread of respiratory infections. Diphtheria and pertussis vaccination programs can be initiated as indicated by surveillance measures. Tuberculosis (TB) is becoming increasingly common in complex emergencies particularly in areas with high HIV/AIDS prevalence. Given the complexity of TB control programs, they are typically only instituted once emergencies have stabilized. Vitamin A supplementation will promote innate immune defenses and protect against respiratory infections independent of measles infection.
Although it is rarer, a high degree of suspicion must be maintained for bacterial meningitis. Outbreaks have been documented in complex emergencies, especially in the sub-Saharan Africa “meningitis belt” where Neisseria meningitides A and C (and increasingly serogroup W135) are the main causes. Epidemic control measures are typically instituted when the incidence rate is in excess of 15 per 100,000 people per week for 2 weeks or with a doubling of cases weekly for 3 weeks. Once an epidemic is confirmed, mass immunization should be conducted; if the outbreak is among a displaced population, the host community should be vaccinated as well. Prophylactic treatment has not proven effective and should not be done. In Africa, treatment of meningitis has been successful with single-dose chloramphenicol in oil.
Conflict can lead to mental health consequences for individuals and for entire communities, with depression, anxiety, and post-traumatic stress disorder (PTSD) being most commonly noted. There is, however, disagreement surrounding the diagnosis of PTSD. Some argue that significant proportions of a population will suffer from PTSD, while others maintain that the response to warfare and displacement is a social phenomenon that should not be “medicalized.” Nevertheless, most agree that there is almost always a small percentage of the population who may have been exposed to more extreme violence or torture and who will require more intensive mental health treatment than the remainder of the population. The WHO Interagency Emergency Health Kit anticipates the need for treatment of both newly diagnosed as well as preexisting psychiatric disease and provides antipsychotics, antidepressants, and anxiolytics.
All individuals have the right to reproductive health, even in conflict settings. Women and girls are highly vulnerable in emergency settings, not only because they are at high risk for sexual violence but also because they may not be able to advocate for their rights and may not be able to access desired reproductive health services. This is particularly true in contexts where preexisting gender norms undervalue women’s role in society. In some complex emergencies, dire economic need leads women and adolescent girls to engage in commercial sex work, placing them at risk of unplanned pregnancies, sexually transmitted infections, and HIV/AIDS. The Inter-Agency Working Group on Reproductive Health in Crisis has published a minimum standard of reproductive health services that should be made available to all females affected by complex emergencies and has prepackaged kits available containing the drugs and supplies required to implement priority reproductive health care.
Nutritional assessments are typically performed with population convenience samples in which newly arriving refugees or displaced persons are screened, or through cluster sample surveys in lieu of population lists. The malnutrition rate for children under age 5 ranks just below the CMR as the most specific indicator of a population’s health. , The malnutrition rate helps determine the urgency for food ration delivery and requirements for supplementary feeding and therapeutic feeding centers. Except in the case of severely malnourished children with acute complications, community-based therapeutic care (CTC) is now the standard of care, and commercially prepared ready-to-use therapeutic foods (RTUF) have become the preferred feeding products. The most common RTUF in acute emergencies today is Plumpy’Nut, which requires no preparation and no water or refrigeration, contains 500 kcal per pouch, and has a 2-year shelf life. Micronutrient deficiencies are also important in acute emergencies, particularly in developing countries, where they have profound effects including infection, blindness, adverse birth outcomes, growth stunting, mental retardation, and increased risk of death. The most important micronutrients requiring supplementation are thiamine, riboflavin, niacin, folic acid, iron, iodine, and vitamins A, C, and D. As mentioned, vitamin A supplementation is particularly critical for children; its benefits are now so well established that it is a routine intervention.
The quantity and quality of food rations are also important determinants of health outcomes in emergency-affected populations. A minimum of 2100 kcal/person is generally adopted as a reference for the daily energy requirement, although ration size needs to consider the demographics of the population, climate, and access by the population to alternative sources of food and income. Food rations in developing countries generally consist of a staple cereal such as wheat, maize, or rice, in additional to a source of dense fat such as vegetable oil and a protein source such as beans, lentils, groundnuts, or dried fish. In more developed countries, food rations typically include cheese, meat, powdered orange juice, and fruit. In high-income countries, food vouchers are sometimes distributed rather than actual food items. Specific needs of at-risk groups must also be considered (for instance, pregnant and lactating women, young children, those with chronic diseases, and the disabled), and breast-feeding should be strongly encouraged for children younger than 2 years of age. The Sphere Project is internationally recognized as providing benchmark levels of performance with regards to food security and nutrition.
Shelter is a primary consideration in complex emergencies because mass population displacements are common. If families are to be housed in formal settlements, smaller camps are preferred as they tend to be more secure, less crowded, and easier to manage. In some instances, local politics can contribute to inappropriate decisions about camp locations. Considerations for camp sites must prioritize safety of the residents and access to clean water and cooking fuel. In some conflicts, it is important to be mindful of where landmines have been laid. Because food and non-food items will have to be delivered, it is critical to have road access to the area in all climatic conditions. At times, it is favorable to have displaced individuals integrated into the host community, although if there are a large number of refugees scattered in many different locations, the task of identifying and providing relief services on a regular basis can be quite challenging.
Ideally, houses should be constructed from local materials using traditional designs for the given context. Plastic sheeting or tarpaulins may be required for waterproofing. In warmer, humid climates, shelters should have optimal ventilation and should offer protection from direct sunlight. In colder climates, houses need to provide insulation and sufficient bedding with auxiliary heating. Death from hypothermia, particularly in young children and the elderly, has been documented in some emergencies when weather-appropriate shelter was lacking. It is preferable, for privacy reasons, for individual families to be housed separately, and camps are often divided into sections of 5000 persons to ease service administration. The Sphere Handbook provides standards as to the recommended size of shelters (3.5 to 4.5 m 2 of covered area per person).
Water and Sanitation
The Sphere Project also provides minimum standards for water and sanitation, with the recommended minimum quantity of water being 15 L per person per day for all domestic needs. Sphere standards also recommend the provision of at least one water collection point for every 250 people, that people should not have to walk further than 500 m to the nearest collection point, and that the maximum queue time to collect water should not exceed 30 minutes.
Options for supplying water in collective settlements include surface water such as lakes, rivers, and streams in addition to springs and wells. Water can be trucked in from external sites, although this introduces additional costs and can be logistically challenging. Surface water is often the most abundant (and readily available) source, but it needs to be treated before use. Shallow wells and springs need to be protected in order to ensure that the water is clean, and pumps or other mechanisms for drawing water need to be installed and maintained. Deep bore wells offer the advantage of providing clean water with the convenience of having it onsite, but require drilling expertise, time to build, and specialized equipment. Recently introduced programs for the disinfection and safe storage of water at the household level in combination with behavioral change in sanitation and hygiene practices show promise in conflict-affected populations. ,
Because diarrhea is the second leading cause of death among children under the age of 5 years and because 88% of these deaths can be attributed to inadequate sanitation and poor hygiene, sanitation is a primary concern in emergencies, particularly in large, overcrowded camps. To address these risks, the Sphere Handbook recommends a minimum of 20 people per latrine, that latrines be segregated by sex, and that for security reasons latrines be located within 50 m of other dwellings. Hand washing with soap, distribution of at least 250 g of soap per person per month, and community hygiene awareness programs are also of key importance.