Nongovernmental Organizations in Disaster Medicine





NGOs serve a vital role at the local, State, and national levels by performing essential service missions in times of need. National Response Framework (2008)


Disaster medicine specialists are expected to respond to the most catastrophic human events and attend to the medical and health care needs of those affected. Yet they are only part of the response team and cannot perform optimally without the collaboration and engagement of other essential elements. It is incumbent upon medical care providers to know who constitutes the team; their respective roles, strengths, and weaknesses; and how best to work with them for successful disaster management.


The ultimate responsibility for management of a disaster rests with the local or national government in the jurisdiction where the disaster occurs. Because disasters, by definition, overwhelm the emergency response capability of the affected community, assistance from “outside” is the rule rather than the exception. Whether we examine the historic 1889 Johnstown, Pennsylvania, disaster that took 2200 human lives or the recent 2014 Ebola outbreak in West Africa, humanitarian volunteers from “outside” collaborate with local and other government personnel on both the front lines and behind the scenes ( Fig. 19-1 ). In all disasters, multiple stakeholders are involved in all aspects of disaster response—treating victims, caring for families, communicating vital lifesaving information to communities, and consoling the bereaved. Whether in the case of an earthquake, tsunami, typhoon, terrorist attack, or volcanic eruption, the work of humanitarian aid agencies and charities—that is, nongovernmental organizations (NGOs)—is vital to the success of the deployment. In the case of the Ebola outbreak, the United Nations (UN) Office for the Coordination of Humanitarian Affairs (OCHA) reported that “NGOs had provided many essential services in this relief effort.” But what are these NGOs? Which essential services do they provide? How are their activities coordinated in disaster management? What are their major challenges? These are the questions that will be addressed in this chapter.




Fig 19-1


NGOs Response to the West African Ebola Outbreak.

(From the UN Office for the Coordination of Humanitarian Affairs, New York, New York, © [2014] United Nations. Reprinted with the permission of the United Nations.)


Historical perspective


Historically, there is evidence of both Eastern and Western humanitarian gestures, that is, the will and action to alleviate the suffering of others in response to natural and human-made disasters. Conceptually humanitarian work roughly parallels human history itself as it seems reasonable to postulate that family members, friends, relatives, and tribal brothers of the victims must have mounted some kind of relief effort based on the situation. Tribal customs and religious traditions probably dictated the response of the community to the survivors and to the disposal of the dead bodies in the aftermath of natural tragedies and war. When the first groups organized themselves to deal with such events, the involvement of NGOs in disaster management was born. Asian history points to the Han Dynasty as having one of the earliest recorded humanitarian systems with specific disaster and famine relief functions dating back to the Southern Song Dynasty (1127-1279 ad ).


In western history, Christians established hospitals in Jerusalem to serve traveling pilgrims centuries ago. Peter, the Patriarch of Jerusalem, requested funds from Emperor Justinian to establish a hospital in the holy city in the sixth century, and Pope Gregory I founded a hospice near the Church of the Holy Sepulcher in 603 ce . Other records show that specific humanitarian systems were later designed to deal with the effects of natural disasters and wars in Europe. In 1767, a Society for the Recovery of the Drowned was established in Amsterdam, and by the early 1800s, humane societies specializing in the rescue and resuscitation of victims of drowning and shipwrecks had been founded on every continent. The goal of these “Humane Societies” was the dissemination of new resuscitation techniques, whereas the Royal Jennerian Society (another humane society founded in 1803) had as its objective the speedy extermination of smallpox through the newly discovered methods of vaccination.


Organized international humanitarian aid shows itself in the late nineteenth century in response to the Northern Chinese Famine of 1876-1879 and simultaneously the Great Famine of 1876-1878 in India, both brought about by a severe drought that claimed the lives of as many as 10 million people in China alone. The Shandong Famine Relief Committee was established with the participation of diplomats, businessmen, and Protestant and Roman Catholic missionaries in response to a plea from British missionary Timothy Richard, and led to collected donations of between $7 million and $10 million for the relief work in China.


The terms nongovernmental organization (NGO) and civil society organization (CSO) were created in the UN charter to describe certain nonstate entities to be awarded observer status at UN assemblies and other meetings. The UN further established the Committee on Non-Governmental Organizations as a standing committee of the Economic and Social Council (ECOSOC) by Council resolution 3(II) on June 21, 1946, with original terms of reference in 1950 and subsequent revisions in 1968 by resolution 1296 (XLIV) and 1996 by resolution 1996/31. NGOs have been actively engaged with the UN since its inception. “They work with the United Nations Secretariat, programs, funds and agencies in various ways, including in consultation with Member States. NGOs contribute to a number of activities including information dissemination, awareness raising, development education, policy advocacy, joint operational projects, participation in intergovernmental processes and in the contribution of services and technical expertise” ( Box 19-1 ).



Box 19-1

Examples of NGOs’ Primary Purposes, Scope of Action, Philosophical or Practical Orientation and Representative Objectives


Primary Purpose





  • Development



  • Advocacy



  • Disaster relief



  • Advisory



  • Operations



  • Education and training



  • Business development



  • Watchdog



  • Humanitarian aid



  • Medical services



  • Technology sharing



  • Cultural enrichment



  • Human rights



  • Law and justice



Scope of Action





  • International



  • Local



  • Regional



  • National



Orientation





  • Faith-based



  • Secular humanitarian



  • Political



  • Professional: technology, health, legal



Areas of Activity





  • International relief and development



  • Democracy promotion and electoral support, human rights, and good governance



  • Conflict mitigation, management, and resolution



  • Civil society support and community-based services



  • Education, medical, and state service replacement (traditionally formed locally to substitute or enhance lacking or nonexistent government services




In general terms, an NGO is civilian-based, independent of government, and staffed by volunteers who share a common background or motivations; has a primary mission that is not commercial; and depends on funding and materials from external sources. Ball and Dunn outlined some of the common traits of NGOs as follows: (1) formed voluntarily; (2) they are independent of government; (3) they do not exist for private profit or gain; and (4) their principal objective is to improve the circumstances and prospects of disadvantaged people. NGOs also tend to be highly practice-oriented, prize neutrality (i.e., giving nonpartisan assistance), and are decentralized and somewhat resistant to centralization as they value their independence and have strong commitments to “their” cause.


Classifying NGOs is difficult. One useful system was described in 1989 by Brown and Korten, who divide all NGOs into one of four types: (1) voluntary organizations (VOs); (2) people’s organizations (POs); (3) hybrid governmental and nongovernmental organizations (co-opted NGOs, or CONGOs); and (4) public service contractors (PSCs). Yet there is a virtual alphabet soup of differing combinations and flavors of ideologies, activities, and main and subsidiary foci that defies simple characterization of NGOs ( Box 19-2 ).



Box 19-2

Adapted from Vakil AC. Confronting the classification problem: toward a taxonomy of NGOs. World Develop. 1997;25(12):2057-2070.

NGO Alphabet Soup: A Symptom of Classification Confusion





  • BINGOs: big international nongovernmental organizations



  • CBOs: community-based organizations



  • CB-NGOs: community-based nongovernmental organizations



  • CSOs: civil society organizations



  • DOs: development organizations



  • DONGOs: donor nongovernmental organizations



  • GONGOs: government-sponsored nongovernmental organizations



  • GROs: grassroots organizations



  • GRSOs: grassroots support organizations



  • IDCIs: international development cooperation institutions



  • INGOs: international nongovernmental organizations



  • NGDOs: nongovernmental development organizations



  • NNGOs: northern nongovernmental organizations



  • NPOs: nonprofit organizations



  • PANGO: party nongovernmental organization



  • POs: people’s organizations



  • PSCs: public service contractors



  • PVOs: private volunteer organizations



  • QUANGOs: quasi-nongovernmental organizations



  • SCOs: social change organizations



  • SNGOs: support nongovernmental organizations



  • TSOs: third sector organizations



  • TNGO: transnational nongovernmental organization



  • VOLAGs: voluntary organizations



  • VOs: volunteer organizations



  • WCOs: welfare church organizations




Common NGO ideologies include the golden rule, that all possible steps should be taken to alleviate human suffering arising out of calamity and conflict, an emphasis on human rights and dignity, health care as a right not a privilege, that people affected by disaster have a right to life with dignity and therefore a right to assistance, democracy for all, those who can must help those who can’t help themselves, no life is less valuable than any other, technical knowledge is a means to escape poverty, and geography is no fault of anyone.


Their diversity of focus spans a wide spectrum of issues: social, cultural, environmental, educational, developmental, technological, peace-building, human rights and dignity, health (public health, health services, and access), humanitarian assistance, shelter, children and youth, law and justice, disaster relief and management, and resiliency. Regarding the NGOs that have disaster relief and management as their primary focus, their scope may be local, regional, national, or international, and their competencies may be specifically well developed in one or more areas: for example, procurement and distribution of clothes, blankets, and appropriate supplies; disaster awareness and preparation; building community resiliency; assisting in search and rescue exercises; providing first aid and medical assistance to the wounded; providing shelter to disaster victims; providing psychosocial and psychospiritual care to victims, survivors, bystanders, and response personnel; assisting with or providing disaster response and recovery logistics; facilitating or providing transportation (to victims and/or response and recovery workers) for relocation or evacuation; providing or facilitating food and water procurement and distribution; assisting in and garnering help for postdisaster sanitation and mortuary services; caring for lost children; attending to animals and pets; vector control; and linking donors with disaster relief activities.




Current practice


Despite sovereign governments having the ultimate disaster management responsibility, NGOs often fill response gaps when conventional local or national emergency response personnel are negatively impacted by the disaster itself. The link between disaster medicine and NGOs is special as most expatriate medical and other health care personnel who respond to a disaster do so through or in conjunction with an NGO, be it an international NGO, a church group, or an academic or community medical facility. However, use of NGOs to provide a quick fix for short-term relief is a thing of the past. Instead, through coordination and collaboration with all stakeholders, NGOs are often involved with facilitating sustainable recovery and development which, in turn, empowers local communities to manage their own environments.


Whether national or international, NGOs improve relief efforts and capacity to address a wide range of victims’ needs, especially in dealing with complex emergencies. NGOs may be deployed to provide direct assistance (e.g., distribution of goods and services directly to the people), indirect assistance (e.g., services one step removed from the people, like transporting relief supplies and personnel), and even infrastructure and logistical support that may be entirely invisible to the people. Sometimes one large NGO has a diverse skill set and a great capacity, but often multiple smaller NGOs, each focused primarily on their individual mission, complement each other, are more flexible, and collaborate better with an integrated approach. In 2002, a Regional Workshop on Networking and Collaboration among NGOs of Asian Countries in Disaster Reduction and Response was held, in which the participants agreed on a number of steps aimed at promoting and strengthening networking and collaboration among NGOs in Asia for disaster reduction and response “in recognition of the important role played by NGOs especially in Asia (the most natural disaster prone region on the planet).”


As of 2008, worldwide humanitarian work was being accomplished by an estimated 210,800 humanitarian aid workers as calculated by the Active Learning Network for Accountability and Performance (ALNAP), a research and analysis agency serving organizations working in the humanitarian system. This total workforce comprises roughly 50% workers from NGOs, 25% Red Cross/Red Crescent personnel, and 25% workers from the UN system. In 2014 there were more than 4 million NGOs worldwide and about 1.5 million in the United States alone. Their cumulative size, scope, and diversity make their impact almost inestimable. From the small two- or three-person local organization acceptable by U.S. law, to the gigantic international and multinational behemoths such as BRAC International, which has 120,000 staff touching the lives of more than 135 million people, and the International Co-operative Alliance with approximately one billion individuals in its member organizations ; NGOs encompass a wide array of endeavors and represent an enormous amount of resources.


The International Federation of Red Cross/Red Crescent Societies (IFRC), perhaps the most recognizable disaster-related NGO worldwide (with 189 recognized national societies, one in almost every country in the world and supported by 17 million volunteers, 80 million members, and 430,000 staff globally), and other large disaster-related NGOs typically establish alliances and develop an international presence almost on par with the UN itself. The IFRC even has special status in transgovernmental international relief and disaster management circles. Large NGOs like the IFRC develop strong, long-lasting local institutional collaboration and networks that increase their influence and capacity to provide or procure immediate and highly effective response services. Smaller NGOs tend to address single needs or sets of related needs around which they have focused and refined their abilities and/or niche. This allows major humanitarian aid organizations to fund response and recovery by financially supporting “niche NGOs” that respond to the given disaster, rather than trying to do the same work using their own staff and resources. Over time, the work of the NGOs has improved the efficiency and efficacy of emergency management operations at the local, national, and, most significantly, international levels.


Nongovernmental Organizations and Volunteers


Volunteers remain essential to the functioning of many NGOs, but may or may not be of assistance in a specific circumstance depending on their background, training, and familiarity with disaster management schema. NGOs are involved in recruiting volunteers, donors, and experts from the private sector; they help orient volunteers to the field of disaster management, assist in outfitting them for the field, and provide or arrange for transportation, lodging, and sustenance in the hot zone, allowing medical and health care volunteers to “work without worry.” Volunteers with unique skills who have specialized training (e.g., Community Emergency Response Team [CERT], Federal Emergency Management Agency [FEMA], Incident Command System [ICS], National Incident Management System [NIMS], OCHA, and/or International Search and Rescue Advisory Group [INSARAG] standardized procedures) are invaluable assets in disaster response. NGOs may incur liability when the spontaneous attraction of well-meaning untrained and/or unlicensed health care volunteers to disaster response efforts (convergent volunteerism) also includes people who are actually imposters; this can be avoided if licenses and background checks are required and volunteers documented. When “appropriate” and vetted volunteers are not available, NGOs (and governments) may turn to paid contractors or business partners, or develop contractual arrangements with freelance experts, academic institutions, and even “niche NGOs.”


As a group, NGOs address almost every aspect of response and recovery. At the time of this writing, the websites Relief Web ( www.reliefweb.int ), National Volunteer Organizations Active in Disasters ( www.NVOAD.org ), and InterAction ( www.interaction.org/crisis-list/ ) track NGOs that respond to disasters, describe specific functions carried out by each, and provide public relations and other information about the NGOs. Fig. 19-1 shows the activity of NGOs responding to the Ebola epidemic in the West African countries of Liberia, Sierra Leone, Guinea, and Nigeria and their key interventions: health promotion, case management, communication and social mobilization, contact tracing and monitoring, and coordination and support of local health teams.


When Disasters Occur


NGOs usually shine in the response and recovery phases of disaster management. In the United States, all emergencies, regardless of size or type, are local events. However, when a community’s resources are insufficient to respond to an incident, local government may call upon county, state, and federal governmental agencies and also NGOs for assistance. “As required under Homeland Security Presidential Directive (HSPD)-5, the NIMS enables responders from different communities with a variety of job responsibilities to better work together. Everyone has a role to play in NIMS implementation—fire and rescue, law enforcement, hospitals and health care systems, transportation systems, public works, voluntary agencies, private industry, nongovernmental organizations, and many others—not only in responding to an event, but in ongoing preparedness activities as well.”


According to the National Response Framework (NRF), “NGOs collaborate with responders, governments at all levels, and other agencies and organizations” and contribute to the following:




  • Training and managing volunteer resources



  • Identifying shelter locations and needed supplies



  • Providing critical emergency services to those in need, such as cleaning supplies, clothing, food and shelter, or assistance with postemergency cleanup



  • Identifying those whose needs have not been met and helping coordinate the provision of assistance



The NRF builds upon NIMS and describes how communities, the federal government, NGOs, and other voluntary agencies (VOLAGs) collaborate to coordinate the national response. “Some NGOs are officially designated as support elements to national response capabilities. E.g. American Red Cross and National Voluntary Organizations Active in Disasters (NVOAD).” Some U.S. federal agencies fund disaster relief outside of the NRF, which falls exclusively under the Stafford Act. Notable recent events falling outside of the direct provisions of the NRF include the 2010 Gulf of Mexico oil spill; the responses to this event were coordinated under the provisions of the National Contingency Plan (NCP). This directly impacts the funding and availability of resources for response efforts.


In an international disaster, the government of the affected nations will invoke its national disaster response program either formally or informally. The government agency responsible for disaster management may also request international assistance from allied governments and the UN Disaster Assessment and Coordination (UNDAC) unit. UNDAC was created in 1993 and designed to:




  • Help the UN and governments of disaster-affected countries during the first phase of a sudden-onset emergency as part of the international emergency response system for sudden-onset emergencies



  • Assist in the coordination of incoming international relief at national level and/or at the site of the emergency.



  • Provide teams that are able to deploy at short notice (12 to 48 hours) anywhere in the world



  • Respond upon request of the UN Resident or Humanitarian Coordinator and/or the affected government



  • Provide services without cost to the disaster-affected country



International NGOs may assist in information gathering and assessment in coordination with UNDAC teams in the field and assist in the overall response effort with permission or by invitation of the government of the affected country. Local NGOs assist as capacity and ability warrant and permit.


After and in Between Disasters


Because of the cyclic nature of disasters, vulnerable communities are always predisaster or postdisaster when not involved in an active event. Nonetheless, research shows that there is a low level of priority placed on disaster mitigation and preparedness. Recently, Houghton stated, “… disaster preparedness/mitigation is cited as the most important issue to emerge from recent (humanitarian assistance) evaluations.” Interestingly, NGOs have not been as visible in the phases of preparation and mitigation or prevention as they are in response and recovery. Reasons for this were described in a Tearfund study in 2003 on donor practice and policy in natural hazard reduction. The study echoes other literature which suggests that donors still see these phases as low priority, which is reflected in relief and development planning and processes as well. The study offers three possible explanations: (1) poor understanding of what risk reduction really is; (2) lack of obvious ownership of preparedness and risk reduction; and (3) competition for mind share within the phases (response, health care, and education are much more visible and pressing). Progress in this arena has been made with the formation of NGOs specifically addressing preparedness and mitigation, for example, the Los Angeles Emergency Preparedness Foundation ( www.laemergencypreparednessfoundation.org ), which accomplishes its mission by fostering collaborative preparedness efforts with business, government, academic institutions, other NGOs, and the communities it serves.


In the United States, all responding organizations including NGOs are expected to apply the concepts of hazard vulnerability analysis (HVA) to identify risk, estimate risk probability, and establish key components of an operative response plan. Combined efforts and pooled resources are then employed as measures to reduce potential loss of life and property. NGOs fill gaps in the local planning and in the resource pooling. The organized activities of VOLAGs, including NGOs, permit more robust planning and preparation for disaster ( Table 19-1 ). VOLAGs participate in all aspects of the disaster cycle: some create disaster plans and train responders; others make disaster areas habitable again; still others help displaced families regain some semblance of normalcy post-event. Interweaving NGOs’ activities with governmental responses as complementary or supplementary actions helps to stretch limited federal or state resources.


Aug 25, 2019 | Posted by in EMERGENCY MEDICINE | Comments Off on Nongovernmental Organizations in Disaster Medicine
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