Public Health

1
Public Health HUMAN SECURITY In Complex
Emergencies Pierre Perrin MD, MPH IMSP Fac.
Medecine University Geneva
2
Public Health
The aim of public health is to improve health and
the quality of life of the entire population
through the rational organisations of health
services.
Most disasters have a tremendous impact on health
and public health is a key component in the
response.
3
Overview
Part I Health emergencies and public health Part
II Public Health and Human Security Part III
Public health and  Political Affairs 
4
Part I Health Emergencies and Public
Health (Classical role of public health)
5
Health Emergencies Public Health
Population
Event
Systems
Population
Health Emergencies

Health Systems
6
Mortality rate in camps Darfur

• Crude mortality rates, expressed as deaths per
  10 000 per day, were
• 3.2 (95 confidence interval CI, 2.2-4.1) in
  Kass,
• 2.0 (95 CI, 1.3-2.7) in Kalma,
• 2.3 (95 CI, 1.2-3.4) in Muhajiria.
• Under 5-year mortality rates were
• 5.9 (95 CI, 3.8-8.0) in Kass,
• 3.5 (95 CI, 1.5-5.7) in Kalma,
• 1.0 (95 CI, 0.03-1.9) in Muhajiria.

Mortality and Malnutrition Among Populations
Living in South Darfur, Sudan Results of 3
Surveys, September 2004 Francesco Grandesso,
MSc Frances Sanderson, MD, PhD Jenneke Kruijt,
MPH Ton Koene, MSc Vincent Brown, MD, MPH
JAMA. 20052931490-1494.
7
Distribution of reported cause of death by age
group, in a sample of IDPs, Kalma Camp, South
Darfur, Sudan, 15 June 15 August 2004
Reported causes of death 0 to 4 years 5 to 14 years 15 to 49 years 50 years All ages
Fever 17 0 25 20 17
Respiratory disease 17 29 0 20 17
Diarrhoea 52 57 0 30 42
Injury or Violence 20 0 63 10 10
Other 12 14 13 20 14
Retrospective Mortality Survey Among the
Internally Displaced Population Greater darfur,
Sudan, August 2004 - WHO, 15 September
2004 Note The total number of deaths in the
table is 77 instead of 80 because cause of death
was not recorded for three deathsRetrospective
Mortality Survey, Darfur Sudan, August 2004
8
The health response in Darfur
Food Security
Water Environment
Medical Care
Psycho Social Support
Health Promotion and Prevention
9
Kashmir Relief operation for the wounded
First aid
Triage - Stabilisation
Evacuation
Surgical care
Rehabilitation
10
Kashmir Relief Operation for the Population
Food Security
Water Environment
Medical Care
Health Promotion and Prevention
11
Relief Operations A Public Health Framework
Water Environment
Medical Care
Psycho Social Support
Food Security
Health Promotion and Prevention
Outpatient Care
Availability of food resources
Water
Health Promotion
Social welfare
Hospital Care
Accessibilité aux ressources alimentaires
Habitat Shelter Hygien
Mental Health
CD Prevention
12
PHC HEI
Population
Potable water Nutrition food resources Mother
and Child Care Immunization (EPI) Prevention of
comunicable diseases Hygiene Promotion Treatment
of common diseases Essential drugs Reproductive
health Mental health
Community participation Cost !!! Immediat
efficacy Approproiate Technology
13
Part II Public Health and Human Security (An
wider role of public health)
14
Health Access to health care

• Willingness to limit/stop access to health
  services
• Insecurity in accessing health services

To deal with the immediat causes which prevent
affected people to have access to health services
Food Nutrition
Health Services
Water Shelter
15
Public Health Access to Health Services
By quantifying the impact on health of the lack
of access to health services, including food and
water, Public Health may play an important role
to regain access to those services. For instance,
negotiating for a cease-fire to carry on mass
immunization campaingns.
16
Health Human Rights

• Prohibiting, limiting access to health services
  is in itself a violation of the rights of people
• In armed conflicts violations of human rights
  may well extend to violations of the integrity of
  people

17
Individual Community Integrity
Torture
Disappearances
Sexual violences
Forced displacements
Splitting families
Ethnic cleansing
..
18
Health Human Security

• Forced displacements
• Ethnic cleansing
• Torture
• Disappearance
• Extra judicial killing
• ..

• Limiting access to health services
• Prohibiting access to health services
• Insecurity in accessing health services
• .

Integrity
Food Nutrition
Health Services
Water Shelter
19
Global Approach
Integrity
Food Nutrition
Public Health
Health Services
Water Shelter
20
Congo - MSF
Basankusu Impact of violence on population from
1998 to 2001
Type of violence (n771) Nb. C.I.
Theft 596 77.3 65.8 88.8
Destruction Houses/field 362 47.0 33.0 60.9
Physical assault 160 20.8 10.2 31.3
Imprisonment 85 11.0 5.7 16.4
Torture 118 15.3 8.5 22.1
Sexual abuses 103 13.4 5.8 20.9
Mines 3 0.4 0 0-8
Bullet wounds 41 5.3 0.4 10.2
Knife/machete wounds 34 4.4 0.2 8.6
Forced recruitment 82 10.6 2.1 19.2
Sexual abuses
Of the 912 households questionned, 771, or 84.9
stated that at least one member had experienced
violence from 1998 to 2001
Source MSF, Access to health and violence in
Congo (RDC) Results of five epidemiological
sureys Dec 2001
21
A Framework for Complex Emergencies
22
Health Professional the management of the
 Political Affairs 
23
Political Field
The Framework of Complex Emergencies
Humanitarian Field
PPR - 2000
24
Crisis Management and Health Interventions
Affected Population
Crisis Armed Conflict Transition
25
Study in DRC Study in Iraq
26
Mortality in the Democratic Republic of Congo a
nationwide survey The lancet Vol 367 January 7,
2006
CMR Under 5 Mortality rate
Health Zones reporting violence 3.0 (2.6 3.4) 6.4 (5.7 7.2)
Health zones not reporting violence 1.7 (1.5 1.9) 3.1 (2.7 3.5)
Mortality rates expressed as deaths per 1000 per
month (95 CI) Comparison of east health zones
with and without violence
27
Mortality in the Democratic Republic of Congo a
nationwide survey The lancet Vol 367 January 7,
2006
Example of statistical analysis "A Poisson
regression analysis of all eastern health zones
suggested that the CMR would be 1.7 peer 1000
population per month (95 CI 1.6 1.9) in the
absence of all violence"
28
Stating the Issue
"These findings show that the DRC remains in the
grip of a major humanitarian crisis that
continues to be most severe in the eastern
provinces."
Mortality in the Democratic Republic of Congo a
nationwide survey The lancet Vol 367 January 7,
2006
29
Stating the Cause
"the reductions in crude mortality are closely
associated with reductions in violence and by,
extension, improvements in security"
Mortality in the Democratic Republic of Congo a
nationwide survey The lancet Vol 367 January 7,
2006
30
Giving proposals
"another key finding of the survey was that most
deaths were due to preventable causes such as
malnutrition and infectious diseases.Moreover
young children are disproportionately affected by
theses illnesses. Improving food security and
increasing access to to essential health
services, such as immunisations, clean water,
insecticide-treated bednets and case management
of common diseases, have the potential to
contribute greatly to reductions in excess
mortality."
Mortality in the Democratic Republic of Congo a
nationwide survey The lancet Vol 367 January 7,
2006
31
Giving proposals
"more robust peacekeeping force than the current
MONUC contingent of 16,700 is urgently needed to
effectively address the security concernss and
associated humanitarian needs in DRC"
Mortality in the Democratic Republic of Congo a
nationwide survey The lancet Vol 367 January 7,
2006
32
Mortality Study in Iraq
Mortality after the 2003 invasion of Iraq A
cross-sectional cluster sample survey The lancet
Published on line October 11, 2006
33
Mortality Study in Iraq
 We estimate that as of July 2006, there have
been 654965 (392979-942636) excess Iraqi deaths
as a consequence of the war, which corresponds to
2.5 of the populaiton of the study area. Of
post-invasion death, 601027 (426369-793663) were
due to violence, the most common cause being
gunfire 
Mortality after the 2003 invasion of Iraq A
cross-sectional cluster sample survey The lancet
Published on line October 11, 2006
34
Mortality Study in Iraq
Mortality after the 2003 invasion of Iraq A
cross-sectional cluster sample survey The lancet
Published on line October 11, 2006
35
Mortality Study in Iraq
Mortality after the 2003 invasion of Iraq A
cross-sectional cluster sample survey The lancet
Published on line October 11, 2006
36
Mortality Study in Iraq
Mortality after the 2003 invasion of Iraq A
cross-sectional cluster sample survey The lancet
Published on line October 11, 2006
37
Mortality Study in Iraq
Mortality after the 2003 invasion of Iraq A
cross-sectional cluster sample survey The lancet
Published on line October 11, 2006
38
Mortality Study in Iraq Response from the
Political Actors
39
Mortality Study in Iraq Response from the
Political Actors
40
Human Security of Affected Population
41
Armed Conflicts
Political Humanitarian
Belligerants States UN General Assembly UN
Security Council PK Forces, NATO Private
companies USAID ECHO Medias Human rights
organisations National Societies of
RC/RC UNHCR UNICEF WHO NGOs ICRC
Coercitive diplomaty
Conduct of Hostilities
Organizing the Police
Peacekeeping operations
Human Right Promotion
Embargo on weapons
Maintain Protect Human Security
Democratization
Economic embargo
Conflict Prevention
Peace enforcement with military means
Organization and monitoring of elections
Preventive diplomacy
Conflict resolution
Education
Assessing violations of IHL
Early Warning
Providing health services
Adapting National Law
Supporting social services
Dissemination IHL
Providing economic support
Looking for the missing
Tracing family members
Protection of the POW
Demobilization of soldiers
Humanitarian Diplomacy
Advocacy
42
Normative Framework Values, Law, Principles,
Policies, Guidelines
Human Security of Affected Population
Providing health services
Providing food support
Providing economic support
Providing shelter
Providing water
Immunization
Promoting HR Law
Psychosocial support
Time frame Stability Crisis
Armed Conflict Transition
Stability
43
Playing with the Framework
44
The example of AP Landmines
PPR plapretoria 11 - 1999
45
Normative Framework Values, Law, Principles,
Policies, Guidelines
Belligerants
Armed forces / groups
UN Security Council
Use of antipersonel landmines
PK forces
Human Security of Affected Population
States
.
NGOs
WHO
National RC/RC societies
Providing health services
IOM
UNHCR
ICRC

46
Public Health and Law
47
The example of Economic Embargo
PPR plapretoria 11 - 1999
48
Normative Framework Values, Law, Principles,
Policies, Guidelines
Political management of the crisis
Belligerants
Political Dilemma
Armed forces / groups
UN Security Council
Economic embargo
Peace enforcement with military means
PK forces
Human Security of Affected Population
States
.
NGOs
ICRC
National RC/RC societies
IOM
UNICEF
WHO

PPR - 2000
49
Normative Framework Values, Law, Principles,
Policies, Guidelines
Political management of the crisis
Belligerants
Armed forces / groups
UN Security Council
Economic embargo
PK forces
Human Security of Affected Population
States
.
Humanitarian consequences of economic embargo
NGOs
Monitoring the impact of economic embargo
ICRC
Providing health services
National RC/RC societies
Providing economic support
IOM
UNICEF
WHO

PPR - 2000
50
Normative Framework Values, Law, Principles,
Policies, Guidelines
Sexual Violences
Providing health services
Providing food support
Providing economic support
Providing shelter
Providing water
Immunization
Promoting HR Law
Psychosocial support
51
Health Management of Sexual Violences
Infections
Pregnancy
Sexual Violences
Health Consequences
Injuries
Health Management
Psychological Impact
Social Impact
52
Epidemiological Management of Sexual Violences
Sexual Violences
Health Consequences
Epidemiological approach As part of health
responsibilities, look for
Descriptive Time, Place, Persons
Protection
Analytic Circumstances, Environment
Prevention
53
Legal Management of Sexual Violences
Legal approach
Sexual Violences
Health Consequences
Epidemiological approach
Protection
Prevention
54
Public Health at three levels
Legal approach
Justice
Health Informations
Epi. Informations
Sexual Violences
Infections
Health Consequences
Pregnancy
Health Management
Psychological Impact
Social Impact
Injuries
Epidemiological approach
Descriptive Time, Place, Persons
Prevention Protection
Analytic Circumstances, Environment
55
Normative Framework Values, Law, Principles,
Policies, Guidelines
Forced Displacements
Providing health services
Providing food support
Providing economic support
Providing shelter
Providing water
Immunization
Promoting HR Law
Psychosocial support
56
Forced displacements a root cause of insecurity
57
Normative Framework Values, Law, Principles,
Policies, Guidelines
Forced Displacements
Providing health services
NGOs
Providing food support
ICRC
Providing economic support
National RC/RC societies
Providing shelter
IOM
Providing water
UNHCR
Immunization
WHO
Promoting HR Law
Psychosocial support

Helping stakeholders to define their activities
and their relationship with other stakeholders
58
Summary

• From health to HR issues
• Mutidisciplinary approach
• Linkage between activities
• Interaction between stakeholders

PPR - 2000