Complex Emergencies and Public Health

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Complex Emergenciesand Public Health

• Jean-Luc Poncelet, MD, MPH
• Area on Emergency Preparedness and Disaster Relief

The National Academies Washington, D.C. 22 June
2004
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Contents

• Public health context
• PAHOs response
• Countries in complex crisis Haiti and Colombia
• Example of public health impact mental health
• Three main conclusions

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Contents

• Severe public health consequences documented
  after armed conflicts, mostly by non-nationals
• Since 1980, approx. 130 armed conflicts reported
• 32 of them produced more then 1,000 deaths
  (Toole/Wideman)
• Civilian population increasingly the target
• UNICEF estimates 1.5 million children killed
  since 1980.

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Direct Impact

• Increased mortality and morbidity rates
• Zenica Hospital in Bosnia reported
• 22 trauma cases in April 1992
• 78 in November 1992
• Even health services are the target
• Killing in hospitals
• Selecting who receives treatment

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Indirect Impact

• Longer-term interruption of health services
• Access
• Security
• Inappropriate provisional housing
• General insecurity and psychological impact
• Interruption of water, electricity, transport,
• Limited access to food (income, storage, crops,
  )

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Public Health Needs

• Humanitarian (short-term) survival assistance
• water, medicines, sanitation, shelter, food,
  epidemiological surveillance, logistics, etc.
• Development (long-term) functioning health
  programs with local resources
• Integration of NGOs, military, foreign assistance

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Challenges

• Complex emergencies are long-lasting events.
• Humanitarian experts must stick to their field of
  responsibility. They are the most visible, but
  have only part of the overall view.
• Long-term specialists must be present as soon as
  possible and integrated into the work of
  humanitarian specialists.

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PAHO/WHO

• To face natural disasters and complex
  emergencies, PAHO/WHO established a disaster
  program in 1976 at the request of its board of
  directorsthe Ministers of Health of Latin
  America and the Caribbean.

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PAHO/WHO Objectives
Work with local authorities primarily before
disasters in - Prevention - Mitigation -
Preparedness But also in response, based on
local capacity
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PAHO/WHO Response

• Coordinate international health assistance
• Provide technical cooperation in health to local
  and international entities
• Independent rapid needs assessment
• Mobilize international resources to complement
  national response

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Why the Needfor Coordination?
MSF
PAHO/WHO
France
USA
DHA/UNDP
OXFAM
UNHCR
Red Cross National Societies
Canada
ConvenioHipólito Unánue (CHU)
IFRCS
WFP
Japan
UNFPA
OAS
Nordic countries
European Union/ECHO
Netherlands
WHO/PAHO
ICRC
UNICEF
CARE
United Kingdom
CRS
SICA/CEPREDENAC
CDERA
PADF
Local NGO
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PAHO/WHO Preparedness

• Set up and continuous strengthening of national
  disaster programs
• Training of health sector personnel
• Inter-institutional coordination mechanisms
• Inter-sectoral coordination mechanisms
• The quality of the response depends first of the
  local response, and to a lesser extent, on
  international response.

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Risks of International Assistance

• May weaken the national/local system
• May not respond to local needs mass vaccination
• May become a burden on the national system
  expensive field hospitals arriving late and
  remaining in the country
• Common sense abandoned in the rush for visible
  action to satisfy international public
• Ex sending 300 health staff for one week

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Two Different ComplexEmergencies in the Americas

• Haiti
• Colombia

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Haitian Political Crisis

• Weak Ministry of Health (continuous political
  instability)
• Lack of staff in public hospitals
• Lack of budget (same GNP per inhabitant since
  1990)
• Damage to cold chain and water systems
• Essential programs interrupted
• Security problems, including in health facilities
• All public hospitals closed completely for two
  weeks and malfunctioning for months

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Short-term Needs
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Haiti short-term needs

• Re-establish security
• Restore minimum access to health care and water
  supply
• Establish disaster response capacity
• Restore other emergency public health programs
• Mass casualty management, epidemiological
  surveillance, etc.

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Long-term Needs
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Haiti long-term needs

• Restore functioning public health system,
  integrating NGOs
• Aid focused on outcomes and covering needs rather
  than on what agencies do best

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Colombia

• A 50-year-old conflict with continuous sudden
  displacement (more then 250,000 persons a year)
• Strong Ministry of Health
• Protracted complicated conflict in a large part
  of territory
• Legal status and health benefits of IDPs unclear
  
• cumbersome administrative process and little
  interest on the part of the displaced to be
  officially recognized (security)
• majority of unofficial/unregistered IDPs

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Short-term Needs
Photo ANPA
Refugees in Zulia
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Colombia short-term needs

• Mental health (depression, anxiety, )
• Expand regular programs to areas not controlled
  by the government (vaccination, )
• Reproductive health, because of sharp increase in
  pregnant adolescents

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Long-term needs
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Colombia long-term needs

• Clarify situation of unofficial IDPs,
  unregistered because of fear (forced return,
  retaliation, ...)
• Improve public health information on IDPs
• Review existing health system to integrate
  existing population

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Mental HealthAn area of public health that has
been impacted
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Mental Health in Complex Emergencies

• Scientific evidence has revealed that the
  psychological consequences of complex
  humanitarian emergencies are substantial.
• Much higher rates of mental disorders among
  affected population
• Depression and post-traumatic stress disorder
  (PTSD)
• Lower social functioning than populations that
  has not been affected by war and conflict. (i
  Mollica RF. Invisible Wounds. Scientific
  American 2000 June 282(6) 54-7.)

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Mental Health in Wars

• During World War II, 33 of all medical
  casualties were due to psychiatric causes.
• Research on U.S. Vietnam era veterans has
  revealed that ten years after the war, 15 were
  still affected by PTSD.

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Mental Health Issues (cont.)

• Environmental risk such as ongoing violence,
  destruction and degradation of community support
  (e.g. loss of family and neighbors)
• Resiliency factors (e.g. lack of schools and job
  opportunities)

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Prevalence of PTSD and Depression Among Refugee
Populations and Civilian Survivors of War
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Prevalence of Mental Health Disorders in Children
and Adolescentsaffected by CEs
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Colombia Mental health issuesamong IDPs

• A study by PAHO/WHO in 2002 compared the
  displaced population with the population stratum
  one (poorest population) in four cities in
  Colombia
• Several instruments were used including
  depression scale, scale of impact of events and
  index of quality of life.

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Median values in mental health measurements
according to displacement condition
Significant difference of medians (test of
rank sum)
Study of epidemiological patterns of displaced
population and population in stratum one in four
cities in Colombia. Pan American Health
Organization/National Institutes of Health. 2002
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Mental Health in fourColombian cities Cali,
Medellín, Montería y Soacha

• Distribution according to presence of depressive
  symptoms or levels of trauma in displaced and
  stratum 1 Consolidated EPEPV 2002

Study of epidemiological patterns of displaced
population and population in stratum one in four
cities inf Colombia. Pan American Health
Organization/National Institutes of Health. 2002
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Conclusion (1)Information

• Impact of complex emergencies on health is poorly
  known
• Bias notification
• Special funding
• Political interests or -
• Arrival of foreign specialists (criteria and
  number)
• Studies should be made with local resources and
  scientific interpretation (experienced local
  institutions)

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Conclusion (2)Protection of health services

• High risk of intrusive misbalanced external
  assistance
• Solution promote external assistance from
  experts of closely related systems/Institutions
• Health services/personnel in complex situations
  must be considered as if they are in open war
  situations

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Conclusion (3)

• Appropriateness of expertise
• Humanitarian needs in complex emergencies must be
  entrusted to disaster/ emergency specialists
• Emergency specialists must integrate their
  activities into and ensure a link with the
  countrys overall development plans.

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Thank you!