Chapter 88 Global Humanitarian Medicine and Disaster Relief
Health care professionals engaging in wilderness medicine have many personal and professional qualities ideally suited for international humanitarian and disaster medicine. These individuals are able to cope with environmental extremes and rugged situations, and they are by nature adaptable and practical (Figure 88-1). Such health care providers appreciate human diversity and thrive through altruism.
(Courtesy Damien Follet, Médecins Sans Frontières.)
This chapter outlines many of the major medical and nonmedical issues pertinent to serving as an aid worker in humanitarian emergencies, disasters, and related crises. It is geared to medical providers from all related allied disciplines. This field is in constant evolution; readers are encouraged to consult the cited online references for up-to-date information.
The aid work community is rife with differing opinions and debate on critical issues. The concepts and opinions written in this chapter should serve to foster personal and professional reflections. The chapter is a framework to exploring humanitarian and disaster work. It is important to realize that comprehensive graduate studies are dedicated to this topic. It is our hope that this chapter will inspire readers to engage in aid work, which is a unique, important, and rewarding component of wilderness medicine.
Events and disasters requiring humanitarian support have occurred throughout human history and will continue to occur. These events vary in location, impact, and responses. This section of the chapter provides an overview of some of the more notable types of events.
Humanitarian work began in 1859 with the Battle of Solferino in northern Italy. Franco-Sardinian and Austrian forces engaged in combat, leaving 6000 persons dead and 35,000 wounded or missing. A young Swiss businessman, Henry Dunant, and the local population did their best to care for the injured in the Castiglione Church. Dunant’s experiences led him to create an organization called the International Committee of the Red Cross (ICRC), which would go on to protect and assist persons wounded in war. Dunant’s work eventually led to the Red Cross and Red Crescent Movement, which is composed of the ICRC, the International Federation of the Red Cross and Red Crescent Societies (IFRC), and national societies from virtually every country in the world. The principles that governed these societies later became the basis of the Geneva Conventions.11 The Geneva Conventions outline the protection and care for civilians and prisoners in times of armed conflict. The ICRC led the provision of humanitarian emergency aid in the 20th century, but transport and diplomatic formalities slowed down aid. In the 1960s, the ICRC increased its focus on providing medical aid primarily to civil wars in postcolonial countries.
Western awareness of far-off disasters was heightened by the televising of suffering in Nigeria in 1968.22 In Nigeria’s Biafran region, conflict raged as rebels seceded and the population faced starvation, with an estimated 1 million deaths by the end of the conflict. Ironically, the Biafran rebels manipulated the situation to gain international sympathy by blocking food shipments traveling through government territory, thus starving their own population. French doctors working for the ICRC in Biafra reflected on the organization’s passivity during the Holocaust of World War II. These feelings, combined with their experiences in Biafra, led these doctors to oppose the organization’s confidential, reserved style of operations. In December 1971 in Paris, French physicians and journalists founded Médecins Sans Frontières (MSF), or Doctors Without Borders (http://msf.org/).22
The Cold War also had a major impact on humanitarian events, as proxy wars were fought in such nations as Mozambique, Angola, Afghanistan, Ethiopia, and Somalia. These conflicts led to an explosion of refugees crossing international borders. Refugee camps swelled in the 1980s and 1990s, and still persist. Many aid organizations “cut their teeth” and matured serving these needy populations. Beginning in the 1950s, destabilization occurred as colonial powers left numerous nations; unrest in these newly independent nations was often fueled by conflicts based on ethnic rivalries. Events that followed the Vietnam War led to the mass exodus of hundreds of thousands of “boat people,” refugees from Cambodia, Laos, and Vietnam.22
At times, aid has not been easily rendered for reasons that have not always been immediately made public. In the 1984 famine in Ethiopia, during which 1 million people died, the Ethiopian government forcibly moved its people from drought-prone areas. Later, it was learned that this was done for political reasons to suppress a rebel movement. In North Korea from 1996 to 1998, famine killed 1.2 million people. Aid agencies have found it very difficult to work with the North Korean government, which has thwarted effective and transparent assistance. In the catastrophic refugee camps of the eastern Democratic Republic of Congo (DRC), formed after genocide in Rwanda in 1994, some aid agencies came to believe that the aid provided was being manipulated by the same forces that had conducted the genocide. In these examples, aid agencies have withdrawn their services after believing that resources were being misused for political ends and not to genuinely help those in greatest need. Strong-arm regimes persist to this day to the extent that aid organizations face difficult choices between complete and public reporting of what they are seeing on the ground and the need to retain government permission to continue providing aid to suffering populations.22
The notion of “military humanitarianism” grew from crises in Rwanda, the Balkans, Iraqi Kurdistan, and Somalia, where Western militaries became increasingly involved in the provision of aid. In 1991, following the ousting of the Iraqi regime from Kuwait, the Kurdish exodus to the north of Iraq led to a massive relief operation involving foreign governments. In 1991, inter-clan warfare in Somalia led to an ill-fated U.S. military–led operation to secure the region and deliver aid. The Rwandan genocide in 1994 was marked by an absence of military involvement, except for the French government’s Operation Turquoise, which created a path for perpetrators of the genocide to flee to eastern DRC. In Rwanda during the genocide, a few aid agencies tried to maintain operations, but they saw their staff members slaughtered alongside the population. In this situation, the rendering of medical aid was almost meaningless, and it became clear that doctors and nurses could not stop genocide.22
The 1990s were marked by the rupture of the former Yugoslavia, the war in Bosnia, and the war in the former Serbian province of Kosovo. Events included the July 1995 execution of 7000 persons in the United Nations (UN) “safe haven” of Srebrenica. Later, a “humanitarian war” consisting of aerial bombing was led by Western governments to aid the former Serbian territory of Kosovo. However, their use of the word humanitarian to justify their actions on behalf of governments has been disputed.22
The Rwandan genocide in 1994 led to the chronic emergency that persists in the eastern DRC today (Figure 88-2, online). This conflict has involved many surrounding nations and has been fueled by regional politics, ethnic tensions, lack of proper governance, and the international scramble for the country’s rich natural resources, such as gold, diamonds, and columbite-tantalite (coltan). Immediately following the Rwandan genocide, the massive refugee camps in DRC saw the deaths of 50,000 persons due to cholera. Despite the presence of the world’s largest UN peacekeeping force, conflict and lack of basic social services have led to the death of over 5 million persons. Resultant instability has spilled into neighboring Great Lakes nations, including Uganda, Rwanda, and Burundi.22
(Courtesy B. Press, Médecins Sans Frontières.)
Some emergencies have lasted for years. The conflict in south Sudan spanned from 1983 to 2005, and there are persisting concerns about the future security of this region. Aid agencies have worked continually in this region since the 1970s. Long-term conflicts have persisted in countries throughout the world, including Somalia (since 1991), northern Uganda (since the 1980s), and Colombia (dating back to the 1960s). Instability and armed conflict continue in each of these regions. Even after war ends, postconflict states lack basic health services and the rule of law. Neglect and lack of access to care persist in nations such as Burundi, the Central African Republic, and Angola.22
In the last decade a long list of nations and regions have undergone brutal wars, resulting in exceptional losses of human life, privation, suffering, and absence of human dignity. In Europe, this has included the Russian Caucuses region. In Africa, areas affected have included Congo-Brazzaville, Angola, Somalia, south Sudan, the Central African Republic, Sudan’s Darfur region, DRC, Ethiopia, Sierra Leone, Ivory Coast, and Liberia (Figure 88-3). In Asia, conflict has occurred for decades in northern Sri Lanka, and conflict continues in Afghanistan, with insecurity spilling into Pakistan. In South America, Columbia has experienced unrest for decades. The Middle-Eastern conflict in the Palestinian Territories has also continued for decades, and two major wars have recently occurred in Iraq. The recent conflicts in Iraq, Somalia, and Afghanistan have been marked by extreme insecurity for aid workers. These three crises also typify the polarized and growing anti-Western context in which Western coalition military forces are operating or seeking influence.22
(Courtesy Espen Rasmussen, Médecins Sans Frontières.)
In response to armed conflict over decades, specialized medical and surgical skills have been developed and refined. The importance of improved logistical abilities of aid organizations has had a significant impact on their effectiveness. Public health–oriented approaches (such as pre-emptive measles vaccination), epidemiologic tools to detect epidemics, and curative medical approaches have evolved enough that significant morbidity and mortality can be predicted, prevented, and treated. The medical care available in complex conflict settings has improved to the extent that HIV/AIDS and tuberculosis have been successfully treated in settings such as eastern DRC and south Sudan.22
Refugee crises continue today, with the number of displaced persons totaling 42 million.23 The greatest numbers of those living outside their home countries are from the Palestinian Territories, Afghanistan, Iraq, Colombia, Sudan, and Somalia. Others are internally displaced, seeking refuge within their own borders. The greatest numbers of these are in Sudan, Colombia, Iraq, DRC, Uganda, and Somalia. The “top 10” priorities in refugee emergencies promoted by MSF identify some of the key interventions required in these settings; these are outlined later in this chapter.15
Major natural disasters (see Chapter 86) have occurred throughout human history.33 International nongovernmental organizations (NGOs) previously played minor roles while militaries provided most of the aid. This scenario has changed dramatically in recent years—the massive presence of NGOs in Haiti following the 2010 earthquake (discussed in more detail later) illustrates the extent of this change.
The history of natural disasters is one of devastating losses of life. The three deadliest natural disasters in history have occurred in China. Floods in 1887 and 1931 combined to kill between 2 to 4 million persons, and an earthquake in 1556 killed 830,000. Major cyclones also plague Asia. In India, a 1737 cyclone killed 300,000 persons; in 1839 another 300,000 were killed in a cyclone. The list of devastating cyclones in Asia is a long and deadly one, including these notable events: in 1876 in Bangladesh, 200,000 killed; in 1970 in Bangladesh, 500,000 killed; in 1975 in China, 210,000 killed; in 1991 in Bangladesh, 138,000 killed; and in 2008 in Burma (Myanmar), 146,000 killed.33
In December 2004, a major earthquake in the Indian Ocean resulted in a tsunami that affected numerous Asian countries and killed 230,000 persons. Although some national governments were able to care for their own populations, the international response was massive. In fact, international donations were so high that some aid agencies believed the money could not all be spent on the current crisis, and donors were asked to make unrestricted contributions that could be designated for other emergencies. Despite fear-mongering about disease outbreaks, which almost always follow natural disasters, no such outbreaks occurred after the 2004 tsunami.
Earthquakes have devastated populations over millennia in all regions of the world. The highest recorded death tolls include an earthquake in Turkey in 526 AD that killed 300,000 persons, and two in China, in 1920 and 1976, killing 234,000 and 242,000, respectively. Unfortunately, the list of earthquake-related fatalities goes on: in Mexico in 1985, 10,000 persons killed; in Iran in 1990, 50,000 killed; in Armenia in 1998, 25,000 killed; in Turkey in 1999, 45,000 killed; in India in 2001, 19,000 killed; in Iran in 2003, 26,000 killed; in northern Pakistan in 2005, 79,000 killed; and in China in 2008, 68,000 killed.33
In January 2010 an earthquake devastated Haiti, a nation that was already perhaps the most desperate and neglected nation in the Americas (Figure 88-4, online). During the disaster, 60% of the country’s existing health care facilities were destroyed and 10% of medical personnel either were killed or left the country. The human death toll was 220,000, and much of the infrastructure of the nation was lost. Although the immediate focus was on major surgical and intensive medical care, basic primary care was needed for thousands with minor injuries and chronic medical problems. MSF reported that less than 10% of surgeries were amputations and these were performed as a last resort.16 Psychological trauma was widespread, especially due to aftershocks. Food, shelter, sanitation, and non-food items such as soap and other personal hygiene items were needed. Medical care after the initial response to trauma dealt mostly with the consequences of poor living conditions: diarrhea, respiratory tract infections, and skin infections. Violence (sexual and otherwise) spread rapidly. Haiti remained in crisis despite international pledges of assistance. For some of the population, access to health care improved, but it is doubtful whether this can be maintained solely by international assistance.
By definition, disease epidemics occur when new or resurgent cases of a certain disease, in a given human population and during a given period, substantially exceed what is expected based on recent experience. Medieval history recounts epochs of plague killing millions of persons. Influenza in the early 1900s killed between 50 million and 100 million persons; from 1956 to 1958, flu epidemics killed another 4 million. Smallpox swept across the world for centuries before vaccination resulted in its eradication. Measles continues to kill approximately 164,000 persons annually and remains a serious concern in regions with crowded and malnourished populations. In some refugee camps, measles vaccine is provided along with vitamin A, which reduces the impact of the infection. Malaria epidemics persist worldwide, particularly in sub-Saharan African. Rapid antigen detection tests and artemesinin-based antimalarial medications have improved diagnosis and disease management (Figure 88-5).
(Courtesy Peter Casaer, Médecins Sans Frontières.)
Numerous other disease epidemics have occurred and continue to occur. Global cholera pandemics have killed millions across all continents. Meningococcal meningitis can be epidemic in the “meningitis belt” of sub-Saharan Africa (from Senegal to Ethiopia) during the dry season between December and June. The latest severe meningitis epidemic was in 2009, involving 14 sub-Saharan nations, with 78,000 cases and 4000 deaths. Mass vaccination campaigns have sometimes been launched once the disease burden hits epidemic proportions. Research continues into long-lasting conjugate vaccines, rather than relying on current polysaccharide vaccine, which provides protection only for up to 3 years.
The current HIV/AIDS pandemic is certainly a global emergency, with at least 33.4 million infected persons.29 The majority of the pandemic affects sub-Saharan Africa, which bears 67% of all infected persons worldwide. In Zimbabwe, for example, HIV/AIDS kills approximately 4000 victims every 10 days. The number of people with access to treatment is roughly 4.7 million, with 700,000 in high-income countries and 4 million in low- and middle-income countries. Global outrage about the high cost of HIV/AIDS treatment inspired a surge of concerted activism. Subsequently, the price of antiretroviral drugs has been dropped from about $15,000 to $150 per year, significantly improving access to treatment. Unfortunately, because one-third of persons with HIV/AIDS are co-infected with tuberculosis, a resurgence of TB has also become a global problem.
Victims of disasters and humanitarian crises around the world continue to face sexual violence and mental illness (Figure 88-6, online). MSF treated 6700 victims of rape in eastern DRC in 2008. MSF acknowledges that statistics are incomplete because patients experience shame, fear, stigma, and logistic problems in seeking care. Due to armed conflict, displacement, neglect, and disaster, persons in crisis are increasingly recognized to suffer mental health consequences. Psychosocial care and psychiatric care must be culturally appropriate.
Famines continue to cause significant mortality and morbidity (Figure 88-7). Malnutrition contributes to one-third of the 8 million annual deaths of children under 5 years of age. Chinese famines in 1876, 1907, 1936, and 1958 killed at least 70 million people. Famines in India in 1769, 1876, and 1896 led to the deaths of 44 million persons. In 1998, famine struck southern Sudan, killing 60,000 persons. One of the major developments from the 2005 famine in Niger was the implementation of ready-to-use therapeutic foods (RUTFs) such as Plumpy’nut (a peanut-butter–like food requiring no water) available on an outpatient basis (Figure 88-8, online). This intervention became a substitute for admitting patients to traditional therapeutic feeding centers, where they would have obtained a watery milk-based refeeding treatment. Despite these improvements, UNICEF estimated that in 2010, 195 million children would suffer the consequences of malnutrition.17
Rare and neglected diseases also cause serious crises in various parts of the globe. Because these diseases are not as well known and receive less media attention, they often do not represent an enticing or lucrative market for commercial drug companies. Hence there are often few options available for treating victims of neglected diseases, such as human African trypanosomiasis (African sleeping sickness), Chagas’ disease, and leishmaniasis.
New contexts requiring humanitarian intervention continue to arise. Ideologic wars in primarily large rural refugee camp settings are being replaced by wars fought over control of increasingly scarce land and natural resources. Rapid urbanization has led to increased violent conflict in the vast slums of cities such as Port-au-Prince in Haiti, Rio de Janeiro in Brazil, and Tegucigalpa in Honduras. Street children and marginalized populations are victims of such settings. These contexts are in part driven by criminal violence. However, in some countries, such as Colombia, urbanization and slum growth are driven as much by political conflict as by criminal elements, both leading to indigenous people leaving rural areas for cities.
People can be affected by a crisis in many ways, resulting in a variety of needs with varying degrees of acuity. This depends on the nature of the disaster and vulnerability of the population. Depending on these variables, a population’s capacity to cope with the disaster and level of need will change over time. For instance, the 2010 Haiti earthquake resulted in extremely high numbers of wounded requiring immediate medical care. Haitian neighbors banded together to provide first aid, refer the injured to medical care, clear bodies from the rubble, and rescue trapped persons (Figure 88-9). In other situations, such as armed conflict, communities can disintegrate along ethnic or religious lines, as was seen in former Yugoslavia. Displaced populations may have changing vulnerability over time. In the African Sahel, when food is in short supply or excessively expensive, the savings or other resources available to a family tend to decrease, leading to rationing and use of less nutritious foods. Displaced populations, such as those affected by fighting in Western Sudan, are uprooted from their normal survival networks, and become exposed to natural elements and new disease pathologies, which lead to increased risk for disease outbreaks. However, as they adapt to their environments and form support networks within their host communities or within camps, their level of need may decrease.
The number of agencies responding to humanitarian crises has greatly increased in the last three decades. However, it is common to see a “standard” set of organizations and actors in a crisis zone. These include the affected population, national government and local groups, the UN, armed actors, foreign governments, the Red Cross, NGOs, religious or faith-based organizations, private corporations, donor agencies, and academic institutions. Each organization has specific capabilities, limitations, and niches. Usual agencies responding to medical needs include the State Ministry of Health (MOH), the World Health Organization (WHO), and medical NGOs.
First and foremost, it is the MOH that is officially responsible for health care of the population. If humanitarian medical agencies are operating, it must be assumed that the MOH has been overwhelmed in one or more of its capacities. In certain cases, MOH staff may be unable, uninterested, or unwilling to work in the affected area because of the level of violence or the presence of hostile antigovernment forces. In other circumstances, the MOH may have been virtually nonfunctional before the crisis. This is most often true for provision of accessible, quality primary health care. The MOH may not have the level of expertise or the required human, financial, and material resources to provide medical care required to adequately respond to the crisis.
The WHO is often present in the affected country before a crisis. This organization provides technical advice and supports training. It sometimes provides administrative capacity or medical and logistic resources to the MOH. During a crisis, the WHO continues in this advisory role while taking on other responsibilities. Most prominently, it works with the MOH to coordinate emergency response. At times, the WHO takes the lead on the coordination role, especially in the first phases of the emergency or in nations where the MOH lacks capacity or interest.
Medical NGOs, such as MSF, MERLIN, International Rescue Committee, International Medical Corps, and Médecins du Monde, usually focus on patient treatment during a crisis. These organizations have well-developed logistic supply systems for drugs and medical materials managed by logistics staff and pharmacists. NGOs have pools of international medical staff, including nurses, general physicians, and specialists such as epidemiologists, psychologists, and surgeons. Activities are coordinated by experienced operations staff that oversee the assignments and manage relations with other actors (Figure 88-10). When possible, the majority of NGO workers, medical or nonmedical, are nationals from the affected country, and they often work within MOH hospitals and clinics (Figure 88-11, online). NGOs frequently pay stipends to MOH staff in these facilities. This compensation provides extra motivation to support the increased workload and to enable quality control and greater efficiency. Higher international NGO salaries run the risk for creating a “brain drain” from local health systems. NGOs ensure a constant supply of essential medical materials and drugs, and help to improve water and sanitation systems of health care facilities. They seek to maintain a constant power supply and work in other essential sectors necessary to ensure safe and quality health care management within the facility. In many cases, the NGO essentially takes over management of the hospital, although striving to be tactful and to respect preexisting management structures.
(Courtesy Robin Meldrum, Médecins Sans Frontières.)
In cases in which an MOH hospital has been abandoned or destroyed, medical NGOs will usually either take over the abandoned facility until the MOH can return, or will convert existing suitable buildings into temporary health structures. In some cases, NGOs set up full medical services in an inflatable or container-based hospital. In some settings, such as during cholera outbreaks, NGOs set up separate medical structures outside the hospital to ensure proper disease containment.
In certain circumstances, medical NGOs provide primary health care through mobile clinics (Figure 88-12). This is essentially outpatient care to a population spread out in smaller groups within the affected region. Mobile clinic teams can be converted into mass vaccination teams when there are outbreaks of contagious diseases, such as yellow fever, measles, or meningitis.
(Courtesy Francesco Zizola, Médecins Sans Frontières.)
NGOs do more than curative care. Depending on their mandate, they may be equipped for preventing deterioration of the overall health condition of the population. They do this by providing shelter, water, sanitation, food and nutrition, non-food items (e.g., soap, sanitary napkins, buckets, blankets), education, and protection.
Humanitarian UN organizations specialize in specific types of essential services and populations. The UN Children’s Fund, or UNICEF, supports activities such as the provision of vaccines to the MOH for access by NGOs. UNICEF also provides medications to health care facilities and increasingly supports therapeutic treatment of acutely undernourished children.
The UN High Commission for Refugees (UNHCR) coordinates relief activities and provision of essential services to refugees and internally displaced populations. As much as possible, it funds NGOs to provide basic services to the refugee population. UNHCR also supplies shelter support, such as tents and other essential material, and often offers expert advice. UNHCR negotiates living space for refugees, protects refugee rights in the host country, and undertakes assessments when new displacements occur.
The World Food Programme (WFP) provides foods such as maize, oil, sugar, and pulse (food crops harvested for their dry seeds) to populations in crisis. Most of these foods are donated by donor countries, but increasingly, food is purchased locally or regionally. WFP normally oversees food transport from its source to the disaster zone. In line with this often massive logistics network, WFP can take the lead in providing air transport for UN and NGO aid workers to areas that are difficult or hazardous to reach by road.
The UN Population Fund (UNFPA) is involved in reproductive health, gender equality, and strategies to promote healthy population growth. It specifically supports the MOH and other government sectors in providing safe maternal care. The International Organization for Migration (IOM) assists displaced people, often through provision of shelter and the orderly and humane migration of persons in transit.
To varying degrees, all UN agencies limit the scope of their direct implementation of field operations because of high personnel costs, high levels of bureaucracy, and security restrictions. NGOs are therefore seen as essential service providers that take contacts from UN agencies to implement and provide basic services to populations in need.
Certain NGOs have developed specializations in certain sectors. Action Contre la Faim (ACF), or Action Against Hunger, specializes in food distribution and nutrition activities. CARE (originally known as the Cooperative for American Remittances to Europe) has developed expertise in camp management, food and non-food item distributions, and shelter provision. Save the Children and Plan International focus on education, child protection, and primary health care services. The German government organization GTZ is often involved in logistics and mechanic support to UN and NGO vehicle fleets.
Many religious or faith-based NGOs, such as World Vision, Catholic Relief Services, Adventist Development and Relief Agency, Lutheran World Relief, and the Mennonite Committee, are active during the crisis phase of emergencies. These organizations tend to have a longer-term, developmental approach to their interventions and are well suited to receive project handover from the more immediately responsive humanitarian medical agencies that focus on the emergency phase of a crisis.
During a crisis, the Red Cross can often mobilize volunteers to assist with the response. National Red Cross or Red Crescent Society members are involved in many sectors and phases of emergency response, including non-foods item distribution, primary health care, food distribution, shelter, water, and sanitation. The International Federation of Red Cross and Red Crescent Societies specializes in rapid response to natural disasters. In conflict zones, the International Committee of the Red Cross (ICRC) is also involved in a variety of activities. Most notably, these include emergency surgical response for war wounded, reuniting separated families, and monitoring conditions of prisoners of war and prisons. The ICRC is not an NGO, but rather a charter organization with a special international mandate to monitor the respect of International Humanitarian Law in armed conflict.
Other organizations focus on advocacy and human rights protection. Oxfam International (originally, the Oxford Committee for Famine Relief) increasingly specializes in advocacy and in-depth analysis of vulnerability of affected populations. Organizations such as Human Rights Watch and Amnesty International collect testimony and research the human plight of persons affected by crises, especially in cases where abuse occurs. The International Crisis Group (ICG) provides detailed analysis of a given crisis situation and the factors that contribute to its deterioration or improvement.
Foreign governments provide funding for many of the activities mentioned. Most NGOs and all UN organizations rely on this funding. A few organizations, such as MSF, are (at least for the most part) financially independent from government-sourced funds.
Armed groups can figure prominently in a crisis zone (Figure 88-13). These can include UN or other foreign forces, domestic military forces, and domestic or foreign police forces. Also present may be non-state actors such as antigovernment forces or forces who are involved in armed action in many states. For the most part, armed groups allow relief agencies to operate unobstructed. Police and military forces, whether foreign or domestic, can play an important role in providing stability to the affected region. At the same, time, armed elements can also destabilize any context and create fear and suffering in the host population—especially if they rob, rape, steal, and kill, as has occurred in eastern Congo. Foreign troops, including UN forces, have an interest in facilitating and sometimes even undertaking relief activities. Aid agencies often appreciate the remarkable logistics capabilities of these forces, but are often reticent to collaborate too closely with an armed group.
(Courtesy Espen Rasmussen, Médecins Sans Frontières.)
Undisciplined armed groups, or armed actors hostile to the objectives of the aid agency or the aid agency donors, can hinder the provision of aid. The threat of armed robbery, extortion, or physical violence from such groups imposes security risks that restrict the movement of aid workers and the procurement and provision of essential supplies and materials.
Organizational motivations to be involved during crises and disasters influence theoretical and practical objectives. The overall vision of an organization dictates how it will prioritize precious resources and time. It influences interactions with the affected population and other actors. It affects how and from whom organizations raise funds. For example, some aid organizations have few reservations about using “flies in the eyes” advertisements portraying starving children on full-page ads to aggressively raise money. Other organizations advertise beneficiaries with greater dignity and strive to raise only the funds they can immediately spend. Both approaches have merits and challenges. An organization’s goals influence the choice of field contexts in which to operate (e.g., strictly emergencies, development, or the transition between the two) and with whom the organization affiliates or partners. Goals influence public positioning, as well as how and with whom organizations conduct advocacy.
A variety of motivating factors stimulate organizational involvement in crises. As with any organization, there are sometimes detailed objectives and operational priorities that may work at cross-purposes. For example, agencies involved in medical assistance or public health in a crisis share a common purpose—to save lives through provision of essential health care services. However, interpretation of this purpose is rarely straightforward because it is influenced by the traditions, culture, and motivation of the agency. For example, some NGOs strongly believe in hands-on provision of medical care to individual patients. In contrast, other NGOs would rather build capacity or train operators, leaving the day-to-day medical care to local actors. Both approaches have legitimacy; prospective aid workers should align themselves with an approach they prefer. Another tension occurs between curative care and public health approaches. For example, some aid organizations believe that the best way to address the HIV pandemic is directly treating infected persons, whereas others place more emphasis on public education and prevention efforts.
Some medical aid actors, for example, Médecins du Monde (Doctors of the World), are motivated to raise public awareness of the plight of the population. This is equal in importance and sometimes even of greater impact than the provision of medical care, depending on the context. This tension poses a dilemma for most medical relief personnel. Should the organization undertake advocacy and public condemnation of abuses and gross neglect? Doing so could compromise the agency’s neutrality in the face of armed actors that control violence, making it more difficult to safely provide medical services. Speaking out can result in the organization being expelled by a government not wanting to face criticism.
Other NGOs, such as Save the Children Fund, are rights-based organizations; that is, they are motivated to uphold human rights. These organizations view the provision of their services as meeting the basic rights of the affected population and affording some protection to the population against abuse.
The ICRC was founded on International Humanitarian Law. Members are the primary defenders of the Laws of War and proactively promote respect for these laws among armed groups. They favor neutrality and thus do not take sides in a conflict. While this affords them unparalleled access, it limits their public advocacy.
Other organizations are motivated by religious beliefs and principles. Christian Aid, World Vision, Catholic Relief Services, and Islamic Relief are examples. By and large, these agencies do not have the objective to proselytize, other than by example.
Foreign governments are motivated by a combination of “enlightened self-interest,” public pressure, and quasi-humanitarian motivations. In a major natural disaster, the citizens of a nation may desire to see their government doing something to help. In other cases, the foreign government may be expressing a humanitarian ideal they feel is intrinsic to their culture and society; however, if the stakes are high, self-interest will always prevail. The notion of enlightened self-interest simply means, “by helping others, we help ourselves.” For example, military medical personnel may be required to provide services to a population located in a strategic region or area. In this case, the primary motivation to provide the service may be to gather intelligence and to garner the sympathy of the population (to win “hearts and minds”). In this way, the foreign governments can also isolate insurgents trying to use the population as cover, as well as fulfilling other strategic purposes.
The UN can follow a similar logic, although its motivation is one of collective security, well-being, and stability. Depending on the circumstances, the UN may proactively align its agencies and (as much as possible) the NGOs, so that all efforts contribute to the desired end. This integration of efforts may be criticized by more reactionary NGOs conditioning aid on strategic objectives rather than on existing needs of the population.
An example of a more reactionary NGO is MSF whose actions are guided by a motivation to minimize the loss of life in the crisis by impartially reacting to the morbidities and medical trauma existing within the population (Figure 88-14, online). Organizations such as MSF attempt to remain neutral to the strategic visions of other groups. The aim of such impartial operational choices is to gain wider acceptance by those controlling violence.
Humanitarian crises most often happen in the countries least able to deal with them, because of underlying poverty, political instability, and/or lack of resources and infrastructure. Thus the needs in a crisis situation go well beyond medical care. The following is an outline of needs commonly seen during crises and disasters.15,21
Prior to undertaking any humanitarian intervention, a thorough, rapid assessment must be conducted. This initial assessment addresses each of the sectors listed below and identifies the current situation, existing and necessary resources, interventions needed, and possibilities for specific interventions. The first phase of an initial assessment occurs within a matter of days and includes collection of both quantitative and qualitative data. Further details on how to conduct an initial assessment will follow later.
Depending on ambient conditions, human beings without water to drink will die from dehydration in a matter of hours to days. Consumption of contaminated water leads to transmission of pathogens, often leading to fatal diarrhea and other infectious diseases. Transmission of disease most often occurs from drinking water contaminated by human feces; thus water and sanitation are intimately linked. The Sphere Project (described in more detail later) sets out the following guidelines for water and sanitation.26
Each individual should have, on average, 15 L/day of clean water for drinking, cooking, and personal hygiene (Figure 88-15). In an emergency situation, one may start by providing 5 L/day, making provisions to supply more water as soon as possible. In a stabilized setting, the goal is to supply each individual with 20 L/day. Water gathering points must be within 500 m (1640 feet) of each household, with individuals queuing no longer than 15 minutes and able to fill their 20-L containers in 3 minutes or less. Taste and cultural acceptability of the water source must be taken into consideration.
A maximum of 20 people should use each toilet. Toilets, generally latrines, should ideally be provided for each household and segregated by sex (Figure 88-16). In an acute emergency, it may be necessary to build large pit latrines until more private, permanent structures can be built. Toilets should be no more than 50 m (164 feet) from homes, and they should be clean and well maintained.
(Courtesy Stephan Grosse Rueschkamp, Médecins Sans Frontières.)
Cultural acceptability is crucial when constructing latrines. If men, women, and children do not feel comfortable using the toilets provided, they will defecate elsewhere, near homes and water sources, leading to the spread of disease. Additionally, security concerns must be taken into account when latrines are constructed. In multiple refugee settings, women have been sexually assaulted while using poorly lit, insecure public latrines.24
Food shortages and acute malnutrition are common in humanitarian crises. Often, crises occur in areas with a high baseline prevalence of malnutrition prior to the emergency. Providing adequate, culturally appropriate nutrition is a key part of any humanitarian response. This includes not only providing an adequate supply of food (estimated to be approximately 2100 Kcal/day by Sphere guidelines),26 but also identifying those populations suffering from acute micro- or macronutrient malnutrition and designing programs to address the needs of these populations.
The initial assessment should identify the global acute malnutrition (GAM) rate, in order to determine what sort of supplementation programs are needed and to identify populations at risk (e.g., children under five years of age, pregnant and nursing mothers, the chronically ill). Micronutrients, such as vitamin A, should be provided to populations exhibiting symptoms or at risk for deficiency. Whenever possible, local food sources should be used to provide nutrition to the population in crisis. The ICRC’s Nutrition Manual for Humanitarian Action provides an excellent reference for the provision of nutrition and treatment of malnutrition.19
Hundreds, if not thousands, of people can be displaced by conflict or natural disaster. One of the first priorities of any humanitarian response is to provide adequate shelter, essential non-food items and adequate security to the displaced population. Sphere standards suggest that temporary shelters provide a minimum of 3.5 m2 of covered space per person, ensure adequate access to essential needs, such as water, toilets, and health care facilities, and keep families and social networks intact whenever possible.
Provision of culturally acceptable non-food items, including clothing, bedding, pots, plates, utensils, soap, and burial materials, is required where appropriate. Adequate lighting, gender-separated latrines, and adequate camp security are essential (Figure 88-17, online). Camps must be protected from invading forces and onsite crime. The site on which the camp will be built must also meet specific criteria, including no more than a 6% gradient, proximity to water supply and transport route.26
Health care needs in a crisis can result from epidemic, acute, and chronic medical illness, malnutrition, and traumatic injuries resulting from natural disaster or conflict (Figure 88-18, online). MSF suggests a health care system be constructed to provide necessary curative treatment, to reduce suffering from disease, and to be capable of carrying out case finding. The health care system should have the ability to treat a large number of patients, provide access to various levels of care, and contribute to public health surveillance. Finally, it should provide both preventive and curative services and be flexible enough to adapt quickly to a highly dynamic situation.15 Health care facilities should be equipped to care for various types of disease, including surgical disease, mental health disorders, obstetric conditions, and chronic diseases such as HIV and tuberculosis. Staff members should have a working knowledge of diseases commonly seen in refugee and crisis settings.
The MSF Refugee Handbook estimates that up to 95% of deaths among refugees in crisis are due to preventable diseases such as measles, diarrhea, respiratory illnesses, and malnutrition.15 Epidemics can be caused by these diseases, as well as by malaria, meningococcal meningitis, typhus, hepatitis, encephalitis, and hemorrhagic fevers such as yellow fever and dengue. These communicable diseases may arrive in the camp with the host population, or they may be new to the displaced persons and endemic to the area of the encampment. Overcrowding, malnutrition, and poor sanitation lead to increased transmission, which can have devastating consequences.
In order to prevent epidemics, mass vaccination campaigns, particularly for measles, must be carried out early in the crisis. Robust and sensitive surveillance systems must be implemented, and protocols for prevention, diagnosis, and treatment of potentially epidemic disease must be widely available. Laboratories to identify potentially epidemic disease must be identified early, and adequate medications and medical supplies must be readily available. Refer to Communicable Disease Control in Emergencies: A Field Manual by the WHO for further guidance.7
According to the U.S. Centers for Disease Control (CDC), “Public health surveillance is the ongoing, systematic collection, analysis, and interpretation of data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those responsible for prevention and control.”5
A public health surveillance system should collect demographic, mortality, morbidity, needs, and program activity data.15 The system should be as simple as possible and allow for rapid identification of threats to public health. Additionally, this system should assist in the planning of the intervention, including what populations are most at risk, what areas to target, the size of the impending threat, etc. A robust public health surveillance system should allow for the ongoing monitoring and evaluation of the program at the field level, and all information gleaned from the system should be easily and rapidly used at the program level. Most often, data will be collected at health centers and selected community centers. For a detailed discussion of public health surveillance systems, refer to the “Surveillance” section in Communicable Disease Control in Emergencies: A Field Manual by the WHO.7
Adequate numbers of trained staff are crucial for a successful response to a humanitarian crisis. Unfortunately, in the acute phase, adequate staff is often lacking. Generally, a mixture of national and expatriate personnel will work together during a given response, with the assistance of selected staff from the refugee/displaced population. This draws from MSF’s Refugee Health: An Approach to Emergency Situations.15
As with any sector, the first step is to perform an assessment to determine needs, based on planned interventions. For example, staff will likely be needed for each of the sectors mentioned in this section, including for health centers, feeding centers, security, surveillance, and community outreach. The recently displaced will often include many potentially qualified staff. However, it is important to seek proof of qualifications whenever possible and to respect local employment laws when hiring refugee/displaced staff. The recently displaced may, quite understandably, be tempted to overstate qualifications in order to obtain more resources.
Once appropriate staff members have been recruited, an assessment of needed training is the next step. For example, training on mass vaccination campaigns for measles can be implemented. Training can take on the form of formal classes or apprenticeships as necessary. It is important to clearly outline salary, days off, hours, vacation, and so on in a contract for each employee, in accordance with national/local laws.
Almost all modern humanitarian operations will have a field logistician to manage a refugee/displaced camp’s needs. The number of staff members on the logistics team can equal or exceed that of the medical staff. Logistics is defined as the science of organization, planning, and implementation. Logisticians are responsible for keeping medical and nonmedical inventories stocked, ensuring the function of camp facilities, coordinating transportation of materials and staff, and providing security. Without adequate logistic support, a program is doomed to fail (Figure 88-19). The importance of the work of the logistics team, which often takes place behind the scenes, cannot be overstated. Courses on logistics in emergencies are provided by many organizations, including MSF, ICRC, RedR UK, Massachusetts Institute of Technology, and a number of other universities and NGOs.
Information gathering is recognized as the crucial first step in assessing the needs of a disaster-affected population.4 Initially, a limited amount of information obtained on-site will suffice to guide relief efforts.28 This information must be obtained quickly and must include health indicators. The art and science of this public health intelligence is the disaster application of “rapid epidemiologic assessment” (REA), which, when related specifically to health, is termed the “rapid health assessment” (RHA).
Over the last two decades, REA protocols have been standardized and specialized for use in natural disasters and complex humanitarian emergencies (CHEs) and are now incorporated into all major humanitarian organizations’ field manuals (Box 88-1). In addition to collecting information on disaster impact, displaced persons, health care facilities, and entire health sectors, REAs provide estimates of population size and composition, mortality rates, nutrition and health status, and environmental risks that may impact future health.4 Assessing the impact of disasters on health, REA information enables mapping affected communities, examining the public health impact of the emergency, and reviewing availability of local resources.4 These data serve as the initial step in development of an ongoing health information system and in design of targeted and appropriate health interventions. Additionally, the data collected in ongoing REA assessments permit humanitarian organizations to evaluate and monitor programs, and to advocate and build capacity for affected populations.
List of Organizations with Rapid Health Assessment Protocols*
CDC, Centers for Disease Control and Prevention; ICRC, International Committee for the Red Cross; IFRC, International Federation of the Red Cross; Sphere, Sphere Project; MSF, Medècins Sans Frontières; OsFDA, Office of U.S. Foreign Disasters Assistance; UNHCR, United Nations High Commissioner for Refugees; UNICEF, United Nations Children’s Fund; WHO, World Health Organization.
The objective of a health-related humanitarian intervention during the acute phase of an emergency is to reduce excess mortality and to stabilize the population’s health situation. In order to do this, data must be rapidly collected. Exacerbation of baseline health needs, additional health needs, and emerging health needs (Figure 88-20) must be differentiated. Health indicators, such as mortality and malnutrition rates, must be determined in the early stages of the emergency. The RHA is a key instrument in all these processes. It is a collection of subjective and objective information that measures the damage and identifies the needs and the level and type of response.25 RHA is based more on qualitative than quantitative data and thus can be subject to biases, as well as measurement and sampling errors.25 However, it is the first step in a continuous process and provides the basis for comprehensive follow-up assessment missions.
FIGURE 88-20 The “Ocean of Needs” in a humanitarian emergency.
(From Michael M: Global health cluster rapid health assessment guidelines, 2007. http://www.google.ca/#hl=en&source=hp&q=michael+2007+global+health+cluster+rapid+assessment+guidelines&btnG=Google+Search&aq=f&aqi=&aql=&oq=michael+2007+global+health+cluster+rapid+assessment+guidelines&gs_rfai=&fp=72381a018f4e0477.)
The type of disaster and its context both affect the assessment. Because each type of disaster is associated with different consequences (e.g., floods are often associated with food shortages that can impact baseline malnutrition rates) the RHA should be tailored to the disaster. According to the UN Global Health Cluster, there are six categories of disaster and complex humanitarian emergencies that have a far-reaching negative impact:25
To undertake an RHA, four main basic preconditions must be fulfilled that affect all frameworks for humanitarian action.25 These preconditions are unimpeded access, security, relevant expertise, and availability of funding for the intervention(s).
Visas and security clearance must be obtained for both national and international staff. Local customs must be respected and local authorities contacted for permission to conduct the assessment. Teams must be briefed on security protocols and provided with evacuation plans and maps with GPS coordinates if possible. Site visits may be day trips or longer, according to the number of sites and distances, and transportation, including drivers and fuel, may need to be arranged.
The assessment team should be a multifunctional, multidisciplinary group whose members have various areas of expertise and organizational representation. The group should include a mix of genders, nationals/internationals, and insiders/outsiders.18,25 The team should be deployed to perform the assessment within hours to days after the alert. Sufficient time must be reserved for in-country briefing of the whole team and familiarization with the RHA tools. This is especially important if the team includes translators. In most cases, team members should be properly identified with badges from their organization and should travel in vehicles marked with the organization’s logo; however, for security reasons, this is not always the case. Gender issues may need to be considered; female team members may be required to interview female respondents. Teams must be briefed on local customs and clothing. Women may be required to cover their heads, and clothing must always be modest.
RHA consists of data gathered from a number of sources. In this way, information can be triangulated, which helps to minimize the potential for bias and measurement error. The RHA framework includes reviewing existing information, interviewing, observation, and rapid health surveys.25
Existing information includes reports by the UN agency, NGO, and other groups; maps; demographic statistics from census data; and administrative data (e.g., Ministry of Health data, clinical records, and health indicators gathered by health services and programs).25
Interviews are semistructured and normally held with key informants, selected because they possess specific information or are representative of a category of the affected population.25 Focus group interviews may also be conducted. These provide a large body of information in a relatively short period of time.
Observation is also called “direct observation” and entails examining the environment, infrastructure, events, relationships and people in order to produce information on the general status of the population and to provide context.25 A useful form of direct observation is a “transect walk,” which is a relaxed stroll with key informants through an area of interest. This provides an opportunity for observation and discussion.25
Surveys are crucial for developing figures that inform the report. They are used to inquire into morbidity, mortality, case fatality ratio, and nutritional status.25 Crude mortality rate (CMR) and the nutritional status of children under 5 years of age (“under-5s”) are the recognized basic indicators to be measured in emergencies.
Data collection starts before the team arrives at the site of the emergency. The initial assessment involves gathering cross-sectional, qualitative data to provide a snapshot of the affected population. It uses information assembled from the Internet, government, UN agencies, and NGOs. Once the team is on the ground, information on the affected population is acquired using other qualitative methods, including participant observation, informant style interviews, and focus groups. Available materials from the local government ministries, international agencies, and community-based organizations are still sought. Information gathered according to a predetermined checklist includes population density and composition, family size, environmental conditions such as vector breeding sites, food availability, and morbidity.4
Cross-sectional household surveys are a key component of REAs (Table 88-1). Survey questions are based on the objectives and outcomes that need to be measured, including mortality and malnutrition.
Sampling methods include probability and non-probability sampling. The two most common categories of non-probability sampling are convenience sampling and purposive sampling. Convenience sampling relies on sampling respondents most easy to assess. Consequently, this is the type most often used in emergency situations.25
Probability sampling methods comprise simple random sampling, systematic random sampling, stratified random sampling, and cluster sampling. The first three methods require lists of individuals, households, or the population at hand. These lists are often difficult to obtain in a complex emergency because of the high level of disorder and movement of people. The fourth method, cluster sampling, only requires a map of the area with approximate estimates of the relative sizes of the population units. This method of sampling is also valued for its simplicity, reasonable validity, and precision. For these reasons, cluster sampling is the most commonly used method of probability sampling in humanitarian emergencies.35
Cluster sampling methods require estimation of the population. This can be obtained from census data, maps, aerial photographs, or satellite imagery. For example, using aerial photographs to map a refugee camp will provide a visual layout of the entire area. This area is then divided into smaller sections. The density is determined by counting the number of people populating one of the smaller segments. The total population is then determined by multiplying the number of sections in the total area by the number of people counted in the first segment. This method has been found to have reasonable accuracy and is commonly used in the field by MSF and other major NGOs.
Cluster sampling that has been validated for immunization and nutrition studies uses the 30 × 30, two-stage sampling methodology, or some derivative of this method.35 The first stage requires grouping the population into smaller geographic units, such as villages, and then choosing these units, or clusters, proportional to the population size (the recommended number of clusters is at least 30, but this can be increased if subgroup analysis is intended). The second stage requires selection of households and then individuals, who will be asked to participate in the survey within each cluster; the recommended number is at least 30. The choice of 30 clusters is based on statistic considerations for stability and distribution of means and proportion, whereas the choice of 30 individuals per cluster is based on the number of individuals necessary to have sufficient precision and the number who can be reasonably measured in a single day.35