The complex humanitarian emergency: an update on priorities€¦ · • DR Congo 2.7 million •...
Transcript of The complex humanitarian emergency: an update on priorities€¦ · • DR Congo 2.7 million •...
The complex humanitarian emergency:
an update on priorities
Mike Toole
IEC Symposium
5 September 2013
Complex Humanitarian Emergencies
“Situations affecting large
civilian populations
which usually involve a
combination of factors
including war or civil strife,
food shortages, and
population displacement,
resulting in significant
excess mortality”
Burkholder BH, Toole MJ (1995)
The Lancet, Volume 346, Issue 8981,
Pages 1012 - 1015, 14 October 1995
Rwandan refugees flee into Zaire, 1994
More than one million fled to Goma within one week
Democratic Republic of Congo, November 2008
More than 200,000 people displaced in eastern DRC
Internally displaced Tamils, Sri Lanka 2009
More than 400,000 displaced
North West Frontier Province, Pakistan, 2009
An estimated 2.8 million people were internally displaced
by conflict
Refugees from conflicts in the Arab world, 2011-13
Libyan refugees in TunisiaSyrian refugees in Turkey
Malian refugees in Mauritania, 2013
Source: Armed Conflict and Intervention Project, Center for Systemic Peace, 2012
Globally, in December 2012 there were:
15.4 million refugees
and 937,000 asylum
seekers
Sources: UNHCR and Internal Displacement Monitoring Centre, 2012
28.8 million internally displaced
persons
At the end of 2012
• Pakistan was host to the largest number of refugees
worldwide (1.6 million), followed by the Islamic Republic
of Iran (868,200), Germany (589,700) and Kenya (565,000)
• More than half (55%) of all refugees worldwide came from
five countries: Afghanistan, Somalia, Iraq, Syria, and Sudan
Syrian refugees and IDPs – September 2013
• Syrians in Lebanon 718,000
• Syrians in Jordan 518,000
• Syrians in Turkey 464,000
• Syrians in Iraq 210,000
• Syrians in Egypt 110,000
Total Registered Refugees: 1,994,000
• The U.N. estimates that 4.25 million people are internally displaced inside Syria (population = 21 million)
• Overall, almost 30% of Syrians have left their homes
World’s largest populations of
internally displaced persons, end of 2012
• Colombia 4.9 – 5.5 million
• Syria 3 million
• DR Congo 2.7 million
• Sudan 2.2 million
• Iraq 2.1 million
• Somalia 1.2 million
Source: Internal Displacement Monitoring Centre, 2013
0 5 10 15 20 25 30
Darfur
West Timor
Albania
Zaire
Nepal
Kenya
Iraqi border
Ethiopia Somalis, 1991
Kurds, 1991
Somalis, 1992
Bhutanese, 1992 Rwandans, 1994
Kosovars, May 1999
East Timorese, Nov 1999
Mean daily deaths per 10,000
Crude Mortality Rates for selected refugee &
displaced populations (1991-2004)
2004
Causes of mortality and morbidity in refugee
and internally displaced populations
• Direct
– Trauma
– Sexual violence
• Indirect
– Communicable diseases
– Malnutrition
1. Indirect
• Due to forced displacement into camps lacking basic facilities
and
• Food scarcity related to armed conflict
and
• Disruption to health services
Prevalence of acute malnutrition, children <5 yearsSelected refugee and displaced populations
Percentage
Major causes of death among refugees and
displaced persons in developing countries
• Measles was a major cause, with more than 3,000 deaths
in one camp (Eastern Sudan, 1985)
• Diarrhoea almost always among top three causes
– Cholera outbreaks very common, with case-fatality rates up to
25% in Central Africa
– Shigella dysentery outbreaks common in Africa and South Asia
(increased antibiotic resistance)
Major causes of death (continued)
• Malaria often associated with movement from high to low altitudes (Ethiopians in Sudan, Rwandans in Zaire)
• Acute Respiratory Infections usually among top three causes of death
• Meningococcal meningitis outbreaks relatively common
• Hepatitis E outbreaks common in East Africa (including a large outbreak in Sudan)
The major causes of mortality in refugee populations in developing countries
may be prevented through the prompt use of proven, low-cost public health
interventions
Essential elements of an emergency humanitarian program
• Address basic needs:
– Adequate food (>2100 kilocalories
per person per day plus all
essential micronutrients)
– Adequate clean water (15-20 litres
per person per day)
• Water containers
– Sanitation (one latrine per 15
persons) and waste disposal
– Shelter, warmth, ventilation, and
vector control
– A secure environment
• Rapid needs assessment and public
health surveillance
Basic health services
• Primary health care approach
– Community health workers
– Health posts
– OPD and small “ICU”
– Referral hospital
– Essential drugs list and rational drug use
• Communicable disease control and epidemic preparedness
– Diarrhoeal diseases and hepatitis E (+ polio in Somalia, Pakistan,
Afghanistan, Chad, and DRC)
– Measles, Malaria, ARI
– Meningitis, and other endemic diseases
• TB control, once the emergency is over
Remaining reservoirs of polio transmission are
all in conflict-affected areas
• Selective feeding programs
– Supplementary – selective or blanket
– Therapeutic – facility- or community-
based
• Sexual and reproductive health
care
– Basic minimum package
– HIV prevention, treatment, and care
– Prevention of sexual violence
• Appropriate mental health
programs
International humanitarian aid standards
2. Direct
• Injuries due to conflict
• Sexual violence
Role of surgery, anaesthesia, and emergency care
• Almost always in areas of ongoing conflict, such as currently:
– Syria
– Somalia
– Afghanistan
– NW Pakistan
– Darfur region of Sudan
– Colombia
– DR Congo
• The two largest international humanitarian agencies providing
these services are the International Committee of the Red Cross
and Médecins sans Frontières (either directly or indirectly)
Mirwais Hospital in Kandahar (ICRC)
Serves 5 million people, 300 beds, 40 international staff
Mullaitivu Hospital in Sri Lanka (MSF)
MSF provided services in northern Sri Lanka for more than 20 years
MSF supports six hospitals in Syria as well as
hospitals (with international staff) in Lebanon and
Jordan
All medical staff in Syria are nationals
Comprehensive management of the effects of
sexual violence: DR Congo
Surgical complex in Kalonge District run my
International Medical Corps
Summary
• Every emergency is different and responses should be guided by
a rapid needs assessment
• In most emergencies, the provision of safety, shelter, water, food,
and sanitation are the priorities
• Medical programs need to be based on the most common
causes of morbidity and mortality, including malnutrition, with
an emphasis on prevention
• Surgical and emergency care services are priorities in areas of
ongoing conflict