PM2ch43.pdf

Complex Emergencies

Chapter 43

COMPLEX EMERGENCIES

TRUEMAN W. SHARP, MD, MPH

INTRODUCTION

CRITICAL HEALTH INFORMATION IN COMPLEX EMERGENCIES

Principal Tools

Rapid Assessments

Targeted Surveys and Special Studies

Surveillance

Crude Mortality Rate

Nutritional Surveys

PRINCIPAL CAUSES OF MORBIDITY AND MORTALITY

TEN CRITICAL EMERGENCY RELIEF MEASURES

Rapidly Assess the Health Status of the Affected Population

Establish Disease Surveillance and a Health Information System

Immunize Against Measles and Provide Vitamin A in Situations of Food

Shortage

Institute Diarrhea Control Programs

Provide Elementary Sanitation and Clean Water

Provide Adequate Shelter, Clothes, and Blankets

Ensure Food Supplies Are Adequate and Reach Intended Recipients

Establish Appropriate Curative Services

Organize Human Resources

Coordinate Activities of All Local Authorities and Relief Agencies

PRISONERS OF WAR AND OTHER DETAINEES

SUMMARY

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Military Preventive Medicine: Mobilization and Deployment, Volume 2

T. W. Sharp, Captain, Medical Corps, US Navy; Officer in Charge, US Naval Medical Research Unit 3, PSC452, Box 5000, FPOAE

69835-0007

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Complex Emergencies

INTRODUCTION

In the post–Cold War era, much of the world’s

population is deeply affected by armed conflicts and

their closely related complex humanitarian emer-

gencies (see Chapter 41, The Challenge of Humani-

tarian Assistance in the Aftermath of Disasters).

Through the first half of the 1990s, over 30 armed

conflicts raged. 1,2 Primarily as a result of this armed

violence and its consequences—famine, destruction,

population displacement, epidemic diseases—com-

plex humanitarian emergencies occurred in 23 coun-

tries, including Somalia, Rwanda, Bosnia and

Herzogovina, Liberia, Sudan, Mozambique, and

Afghanistan. 3 Because of these situations, almost 1%

of the world’s population, approximately 41.5 mil-

lion people, were either refugees or displaced from

their homes (Figure 43-1). Many millions more had

not fled their homes but were also profoundly af-

fected by these crises. 4

Each complex emergency is unique, with its own

causes and dynamics; however, many of these situ-

ations follow a somewhat predictable sequence of

events. 5 A brief review of the evolution of a com-

plex emergency will give a sense of many of these

disasters. The place is usually a developing nation

with many fundamental problems, including wide-

spread poverty and a politically repressive, corrupt,

and tenuous government. Political instability, the

persecution of certain minorities, and human rights

abuses lead to unrest and violent insurrection

against the government. Further repression in turn

breeds more violence and the development of a

well-armed anti-government faction, often more

than one. Escalating armed confrontation leads to

extensive damage to social infrastructure, economic

collapse, and deterioration of medical services. This

is followed by population displacement as people

seek safety and food. The medical treatment facili-

ties that survive are typically understaffed and

undersupplied and are overwhelmed by trauma

victims. Preventive programs and routine medical

care may cease to exist, which leads to extensive

communicable disease outbreaks. In extreme cases,

such as in Somalia and Liberia, that part of the

economy involved in producing, transporting, and

marketing food is totally destroyed, which causes

severe food shortages and their devastating conse-

quences. Widespread human rights abuses and

callous manipulation of international relief efforts

occur, which exacerbates the conflict. Schools, police,

courts, and other basic institutions of society may

cease to function altogether. Violence and a vicious

anarchy reign. The international community often

recognizes these situations and attempts to intervene

only once they have reached an advanced stage.

Between 1990 and 1997, the US military was in-

volved in complex emergencies in northern Iraq, So-

malia, Rwanda, Haiti, and Bosnia and Herzegovina.

The military in the post–Cold War world is likely

to continue to become engaged in places where con-

flicts and complex emergencies occur—this will

Fig. 43-1. Complex Emergencies, Refu-

gees and Internally Displaced Persons,

1983-1995. There have always been com-

plex humanitarian emergencies but in

the late 1980s and early 1990s, the num-

ber of these emergencies increased mark-

edly worldwide. Concomitantly, there

was a rapid rise in the number of refu-

gees and internally displaced persons,

almost all of whom were victims of com-

plex humanitarian emergencies. Inter-

vening in post–Cold War emergencies of

this type has been extremely difficult

because of the almost intractable politi-

cal, economic, social, legal, logistical,

and security issues involved and because

the large numbers of refugees and inter-

nally displaced persons have severely

strained limited humanitarian relief resources. Data sources: (1) Office of Foreign Disaster Assistance. Annual Report

FY 1995 . Washington, DC: US Agency for International Development, 1996: 10 and (2) the United States Mission to

the United Nations. Global Humanitarian Emergencies, 1996 . New York: United States Mission to the United Nations,

1996: 5.

Refugees and internally

displaced persons

(in millions)

Complex humanitarian

emergencies

Year

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Military Preventive Medicine: Mobilization and Deployment, Volume 2

probably be unavoidable. 6,7 The specific roles the

military will play in these missions and to what

extent the military will engage in humanitarian as-

sistance missions in the post–Cold War era are not

clear (see also Chapter 45, The International Hu-

manitarian Response System and the US Military). 8–11

The diversity of missions in the 1990s shows that

those missions can assume many different forms,

from providing security to providing emergency

medical care.

Preventive medicine personnel who become in-

volved in complex emergencies are entering dan-

gerous and confusing territory. It is a formidable

challenge to understand what the mission is, who is

in charge, what plans have been made, what resources

are available, what the scope of responsibilities is,

and who are the many other organizations involved.

When military medicine has been called on to pro-

vide health services directly to civilian populations

in complex emergencies, preventive medicine has

usually played a pivotal role because so much of

the relief revolves around public health concerns.

Even in operations in which military forces do not

provide direct medical services, preventive medi-

cine has been relevant because whatever the mili-

tary does is likely to have significant repercussions

on the overall relief effort and public health. If, for

example, the military is tasked to provide only lo-

gistical support to international relief agencies,

military commanders still need advice on the scope

of the disaster, public health consequences, relief

priorities, relief procedures, and other public

health–related matters to make sound decisions.

This chapter provides a three-part framework for

understanding and coping with the public health

aspects of complex emergencies. The first section

describes the critical information needed to make

effective health interventions and how this infor-

mation can be obtained. The second describes the

principal causes of morbidity and mortality in com-

plex emergencies. The third lists the ten most im-

portant basic relief priorities.

This chapter provides only a basic framework

because responding to complex emergencies can

seem as complex as the emergency itself. The de-

tails of program implementation and the specifics

of clinical management of common disease prob-

lems, such as malnutrition, malaria, and diarrheal

diseases, are beyond the scope of this chapter. Many

other important dimensions of complex emergen-

cies—political, social, cultural, and economic—are

also beyond this chapter’s purview. Other chapters

in this book and other published resources discuss

these topics in detail. 12–21 Excellent practical guides

on public health needs in complex emergencies have

been published by the Centers for Disease Control

and Prevention (CDC), the International Commit-

tee of the Red Cross (ICRC), and Medicins sans

Frontieres. 5,13–15 Also of note, military publications

address doctrine and operational aspects of hu-

manitarian assistance operations. 22–24 Institutions

such as the Centers for Naval Analysis in Alexan-

dria, Va, and the US Army Peace Institute in Carlisle

Barracks, Penn, also have published a number of rel-

evant reports on humanitarian assistance and, spe-

cifically, the role of the military in it. 25,26

CRITICAL HEALTH INFORMATION IN COMPLEX EMERGENCIES

One of the most important roles for military

preventive medicine in complex emergencies is to

interpret the essential public health data that char-

acterize the crisis and to use that information to help

establish and guide the most appropriate relief mea-

sures. Conducting effective relief operations with-

out timely, reliable, accurate, and integrated health

information is extremely difficult, if not impossible.

The history of disaster medicine has innumerable

examples of well-intentioned but inefficient, inap-

propriate, and counterproductive relief efforts un-

dertaken in the absence of good information. 27,28

Gathering and using information in the setting of

a complex emergency is a formidable task. Complex

emergencies are dangerous, confused, and chaotic;

good data are rarely readily accessible. Collecting

sound epidemiologic data presents many method-

ological and logistical challenges. 29–31 Collecting

information requires dedicated resources, but com-

manders and key decision makers may view data

collection as an unnecessary luxury and a waste of

limited assets. Once data are obtained, they must

be analyzed, sometimes in austere field conditions.

Then, and this is very important, timely informa-

tion and recommendations must be disseminated

to decision makers in a format that they can under-

stand and use. 32

Principal Tools

The principal methods of gathering data in

complex emergencies are obtaining available

background health data and then conducting rapid

assessments, targeted surveys, standardized sur-

veillance, and special investigations. While the ba-

sic underlying principles of collecting and using

data are well described in many articles and text-

books, unique techniques and procedures have been

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Complex Emergencies

developed for disasters and complex emergencies. 28

Background data on a population in crisis, and

on the areas to which it has migrated, are useful to

interpret the current health situation and to plan

appropriate relief interventions. For example, a

population that has had prolonged food scarcity

before a crisis may have little capacity to cope with

sudden food deprivation. Or a population from a

nonmalarious area moving into an endemic area, as

has occurred in refugee crises in southeast Asia, will

probably have many cases of malaria. Knowing this

background should focus relief planning accordingly.

Background data are available from many

sources (Table 43-1). The CDC, the World Health

Organization (WHO), the United Nations (UN)

Children’s Fund, and the World Bank are examples

of governmental organizations with information

describing immunization status, nutrition status,

endemic diseases, and other basic health parameters

of affected populations. Various US Government

agencies, such as the Central Intelligence Agency

and the State Department, also have materials on

other countries that are relevant to health. 33 Local

governments, refugee leaders, and local health care

TABLE 43-1

VARIOUS SOURCES OF BACKGROUND DATA AND INFORMATION ON DISASTERS, CON-

FLICT, AND COMPLEX EMERGENCIES *

Agency

Telephone Number and Internet Address

US Agency for International Development .................. (202) 647-4000; http://www.info.usaid.gov

Bureau for Humanitarian Response and the Office

for Foreign Disaster Assistance .................................... (202) 647-8924; http://www.info.usaid.gov/hum_response/

OFDA Field Operations Guide for Disaster

Assessment and Response ............................................. http://www.info.usaid.gov/hum_response/ofda/fog/foghme.htm

Centers for Disease Control and Prevention ................ (404) 639-3311; http://www.cdc.gov

CDC International Emergency and Refugee

Health Unit ........................................................................ (770) 488-1033

Federal Emergency Management Agency .................... (202) 647-8924; http://www.fema.gov/

US Committee for Refugees ............................................. (202) 347-3507; http://www.refugees.org

Interaction ............................................................................. (202) 667-8227; http://www.interaction.org/ia/

Armed Forces Medical Intelligence Center

Bulletin Board ................................................................... (301) 619-7574; (800) 325-0195 (sysop 3883)

United Nations .................................................................... (212) 963-1234; http://www.un.org

UN Children’s Fund ........................................................... (212) 326-7000; http://www.unicef.org

UN Development Program ............................................... (212) 963-1234; http://www.undp.org

UN High Commissioner for Refugees ........................... (212) 963-6200; http://www.unhcr.ch

UN Office for the Coordination of Humanitarian

Affairs (ReliefWeb) ........................................................... (212) 963-6821; http://www.reliefweb.int/

World Health Organization .............................................. 41-22-791-2111; http://www.who.ch

International Committee of the Red Cross ................... (212) 599-6021; http://www.icrc.org

CIA Publications and Handbooks ................................... http://www.odci.gov/cia/publications/pubs.html

The Carter Center ............................................................... (404) 331-3900; http://www.emory.edu/CARTER_CENTER

Project Ploughshares .......................................................... (519) 888-6541; http://watserv1.uwaterloo.ca/~plough/

Center for Excellence in Disaster Management and

Humanitarian Assistance † ................................................... (808) 433-7035; http://coe.tamc.amedd.army.mil/

* This is not a comprehensive list but has most major resources. Other resources can be found through links on the Internet. The

ReliefWeb in the UN Department of Humanitarian Affairs allows access to much useful data, such as the World Factbook , country-

specific immunization coverage, and other health statistics.

†

This sight has an excellent source:“Disaster-related Web pages.”

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