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EMERGENCY \ND HUMANITARIAN ACTION
DEPARTMENT BRIEF
September 2002
WHO: TESTED BY DISASTERS
WHO applies the public health approach and epidemiological methods to disaster reduction. WHO
defines disasters as 'any occurrence that causes damage, ecological disruption, loss of human life, or
deterioration ofhealth services, on a scale sufficient to warrant an extra-ordinary responsefrom outside
the affected community'. Disasters and emergencies are public health affairs. WHO sees health and
human survival as the cross-cutting objective and the measure ofeffectiveness ofhumanitarian assistance.
Therefore, WHO sets for itself the goal "To reduce avoidable loss of life, burden of disease and
disability in emergencies and post-crisis transitions". This is to be achieved by ensuring the presence
and operational capacity in the field to strengthen coordinated public health management for optimal
immediate impact, collective learning and health sector accountability.
Coordination is difficult, but essential; the number of health-related actors is constantly increasing,
and there is great demand for accountability and quality standards. WHO is especially challenged to
deliver under these circumstances. However, member countries, agencies and donors have the right to
expect that the Organization, as UN technical agency, to be the leader in coordination of health
response, as well as in building capacities for preparedness in the health sector.
Emergency and Humanitarian Action are central to WHO global functions. The permanent offices
that the Organization has in most, if not all the countries and territories that are most vulnerable to
disasters, give WHO a comparative advantage in this area of work (..." we are there before, during
and after a crisis"..) but also great responsibilities. Emergencies or "exceptional situations" cannot be
an excuse to accept the unacceptable: they just make it imperative that exceptional action is taken for
public health. Even in the direst circumstances, there are key measures that can save lives, and WHO
sees them as its core commitments.
WHO responsibilities provide clear terms of predictability and accountability, a precise list of what
the Organization and the health partners must be ready to deliver in crises and, therefore, a blueprint
for preparedness plans. Around these priorities, WHO promotes institutional capacities and linkages in
member states and partner agencies. This process needs continuous strengthening, especially at
country level, where each year one WHO office out of five faces a major crisis.
THE DEPARTMENT OF EMERGENCY AND HUMANITARIAN ACTION:
Emergency and Humanitarian Action is a horizontal function of WHO internal co-ordination, service
and support. As part of an international response system, the Department of EHA is the instrument that
assists WHO to perform in emergencies and humanitarian action.
The Office ofthe Director ensures overall coordination, mobilizes and administers EHA's core resources:
• formulating global policies and strategies in consultation with regional offices, other WHO
departments and international humanitarian partners
• ensuring regular and extra-budgetary funding for EHA core functions
• ensuring accountability and transparency vis-a-vis partners
• representing WHO in the Inter-Agency Standing Committee Working Group and other fora.
Managing crises: mobilising partnerships in support of local health systems
In Geneva, EHA staff are in daily contact with country and regional offices, trying to anticipate crises,
reacting to alerts and striving to provide response to the needs in the field with technical assistance,
supplies and financial resources.
A team for Emergency Health Partnership coordinates with the country and regional offices and a
network of focal points in other WHO departments, operational partners, collaborating centers, and
donor agencies. Activities include:
• Coordinating and conducting rapid health assessments.
• Mobilizing WHO's technical departments and external partners for the delivery of essential life
saving interventions
• Assisting in the mobilization of external resources for emergency in line with WHO's corporate
priorities
• Providing technical and logistic back-stopping
• Facilitating coordination between national and international humanitarian actors, so as to ensure that
field operations are in line with best public health practices.
• supporting special emergency programs, e.g. in occupied Palestinian territory and the Hom of Africa.
Disseminating health intelligence and knowledge
A team for Health Intelligence and Capacity Building produces, consolidates and disseminates
information on health-related issues, as well as standards and best public health practices relevant to
preparedness, response, rehabilitation and recovery. Activities include:
• Managing information and producing health intelligence
• Documenting lessons leamt, consolidating and communicating norms, best public health practices for
disaster reduction
• Disseminating best public health practices
• Building competencies for disaster reduction within WHO
• Collaborating with specialized centers and academic institutions for training and research in
emergency health management
YOU CAN COUNT ON US:
To identify experts for rapid assessments and assist you with defining priorities. The WHO handbook
for Emergency Field Operations will help you in this planning process.
To assist writing project proposals, including those for the Consolidated Appeal Process.
J To facilitate dialogue with international donors and UN agency partners.
J To mobilize WHO's technical departments for life-saving interventions in your country.
J To help with the logistics of emergency operations and mobilize supplies through the UN
Humanitarian Response Depot (UNHRD) in Brindisi.
J To facilitate coordination between national and international agencies and place humanitarian
concerns in a perspective of national capacity building.
J To identify disaster related training programs implemented by WHO technical departments, partner
agencies and academic institutions.
J An Emergency Health Library Kit can provide technical guidance to agencies operational in the field
and assist you in coordinating the response. The Virtual Health Libraryfor Disasters on a CD-ROM
containing over 300 publications supplements the kit.
Through the quarterly newsletter 'Health in Emergencies', you can inform a worldwide audience of
your activities in emergencies, www.who.int/disasters/newslettei7.
J On the EHA website, www.who.int/disasters, you will find situational information including baseline
statistics, health situation reports and epidemiological surveillance data. You can access all WHO
disaster-related guidelines for effective programme planning.
y We can help access the expertise of Collaborating Centers.
J We can assist in your evaluations or lessons leamt workshops.
HOW TO REACH US: You can contact our department on any issue related to disasters. Contact details
for the various projects can be found at www.who.int/disasters. Or send your e-mail to EHA@vvho.int,
and we will forward it to the best person to answer your question.
■I
ECOSOC 2002 Humanitarian Segment
WHO technical contribution to the Panel
Reaching the vulnerable in the context of complex humanitarian
emergencies and natural disasters
New York, 16 July 2002
I stress the need to protect health systems and ensure access to the basic necessities
for life - even when there are hostilities1
Just one year ago, in July 2001, the UN Secretary-General's call for Days of Tranquillity
allowed safe passage for polio vaccinators in synchronized National Immunisation Days
in the DR Congo and Angola.
In September 2001, even after the evacuation of international staff, the 1st round of the
National Immunisation Days (NID) could take place in Afghanistan, thanks to the
national staff of NGOs, UNICEF and WHO. A lull in the bombings allowed for a
second round in November. During the campaign, Vitamin A was administered to
children Under-5, thus improving their chances of survival through the winter.
Health and Humanitarian Access
"Humanitarian corridors" or "windows
of
tranquillity" are not new and they are deeply
rooted in the history of medicine and public
health. Already before Solferino, truces were
called, e.g. for the care of the wounded on the
battlefield. More recently, they have been
established to allow safe passage for
humanitarian
medical supplies and/or
immunisations. WHO was instrumental in the
growth of the modern concept of humanitarian
cease-fires. In the 1980's it was PAHO that
conceived an initiative of cross-line negotiation
on health priorities that allowed for an
immunisation campaign in El Salvador that saw
the collaboration of the Government, the rebel
movement, ICRC, UNICEF, the Catholic
Church, and others.
In Afghanistan itself,
cease fires for immunisations had already taken
place in 1988/9, in 1994, 1996,1997 and 2000.
Starting from 1986, WHO knows of at least 60
instances of Days of Tranquillity in 16 different
countries . Health can be a bridge for peace 9
and people's health needs peace, at least as
much as it needs clean water, food and
immunizations.
Any public health strategy is built on the
principle of equitable, unhindered access. Thus,
conflict management is integral to public health
in complex emergencies: in terms of primary
prevention as well as secondary prevention, if
one wants to provide life-saving care in a
context of violence: in Afghanistan like in
DRC, Sri Lanka, Indonesia or the West Bank.
That is why WHO works at training health professionals in humanitarian law, political
analysis, negotiation, etc, so to enhance their capacity to work in areas of conflict. Being
there in spite of the circumstances is a strong testimonial of the absolute value of
human life and humanity also in complex emergencies. WHO's stake in peace and
1 Gro H.Brundtland, World Health Assembly, Geneva, May 2002
2 WHO: Humanitarian Cease-fires Project, www.who.int/disasters/
3 see www.who.int/disasters/ ibid.
1
humanitarian access stems from its mandate. Furthermore, WHO represents also a
community of professional peers from all Member States in the World, that share
principles of medical ethics, public health concerns
Health as a Bridge for Peace
in Indonesia
and knowledge. This provides a useful platform
In Maluku, WHO commenced operations
for political dialogue at global level,.
in Ambon in March 2001, working on drug
supplies
and
management,
disease
At field level, the principle of equitable, surveillance, health manpower development
and trying to facilitate inter-community
unhindered access needs to be integrated by clear dialogue and collaboration around health
vision, shared values and common priorities for priorities. In June 2 the international staff
had to be evacuated due to deteriorating
action. It must be supported by sound logistics and security.
However, the main activities
operational coordination, complemented by long continued to be carried out by local health
term perspective of strategic planning. It needs authorities through the working groups set
up jointly thanks to WHO's brokerage.
good understanding of the potential synergies
between sectors and strong partnerships between local and international actors.
Reaching the vulnerable is always difficult. It may appear easier in the aftermath of
natural disasters. However, we know that there is no purely "natural" disaster: there are
natural hazards, which impact upon human
Vulnerability
The character of
extreme events is
vulnerabilities that are mostly due to human
determined not simply by some set of
causes, by commission or by omission. A degree
characteristics inherent in the physical
of political analysis and negotiation is always
phenomena (e.g., a hurricane, monsoon
rains), but by the interaction of those
necessary: the poor, the most vulnerable to an
characteristics with other systems (e.g.,
earthquake or a cyclone, often risk to be also left
impoverished communities living on denuded
mountains slopes in Nicaragua, or on huge
behind in the rehabilitation phase.
garbage dumps in the Philippines).
Thus, in the context of natural disasters, WHO
sees "reaching the vulnerable" mainly as
preventive action. Investigating the factors of
vulnerability, enhancing the resilience of people,
reducing their exposure, promoting equity and
healthy livelihoods - before and after an extreme event - are all major parts of WHO's
cooperation work with national and international partners at country level..
Understanding vulnerability must take into
account the context-specific nature of risks
and shocks, and the capacity of individuals,
households and communities to manage
such risks.
( Sarewitz and Pielke Jr, 2002)
The stakes are much higher in complex emergencies. In these contexts, reaching the
vulnerable means deploying humanitarian staff to dangerous and often isolated trouble
spots around the world, where they risk disease or injuries too. The UN and its partners
have faced many tragedies. The theme of the Consolidated Appeals for 2002, “Reaching
the Vulnerable”, highlighted both the need for access to civilians trapped by conflict, and
for improved security for relief personnel.
Securing access to the vulnerable in war-tom areas calls for exceptional arrangements
and procedures. Negotiating for humanitarian access is fraught with difficulties and
expensive: there is anecdotal evidence from Colombia that different process of
negotiations with armed groups can double the costs of delivering health care. This sort
of human and financial investment must be cost-effective: i.e. it must be sustainable and
make a true difference on the determinants of people's survival and health.
All efforts to reach the vulnerable must be backed up by the systems that can make the
access more sustainable and useful. In WHO's view, arrangements for forward control,
2
communications, security, warehousing and transport for food aid need to be integrated
at least by infrastructures for nutritional rehabilitation and health referral, not to mention
the cold chain: immunisations is a well known life-saving intervention in complex
emergencies.
This backstopping needs to take full advantage of
The vulnerability of national staff
the local systems. No matter how poor or
Already in 2001, WHO had alerted the
ECOSOC to the fact that supporting
disrupted, they are key to the humanitarian
national -or refugee- health workers is key
endeavours, and need to be supported. Synergies
to relief and to the preservation of local
capacities. WHO also called for more
must be found and fostered between the local and
attention to issues of local human
the global system of relief. We know that the first
resources management, for progress in
to respond to any crisis are the people affected: if
the practice and outcomes of humanitarian
programmes. Today, an Afghan doctor
they do not cope, there is nobody for the external
working for the new Ministry of Public
aid to assist. The capacities of local people and
Health earns 25 US$ per month, of which
20 USS are paid in food vouchers.
systems are key to humanitarian work, at least as
much as inter-sectoral collaboration. WHO sees this everyday, from Afghanistan to the
DRC: humanitarian assistance cannot do without the goodwill of its local partners.
Among those whom we have to reach, some are especially vulnerable. The children come
first to mind, and the women, particularly the poor. However, from a public health
perspective, one should be quick to add the elderly, the disabled and the chronically ill.
More in general, in situations of distress,
The disabled
especially vulnerable are all those who have WHO estimates that up to 10% of the world's
population has a disability, and the majority of them,
no means to cope with fast changes.
about 80%, live in developing, more disaster-prone
The vulnerability of individuals or groups is
not a pre-fixed, static condition. WHO tends
to agree with those who see vulnerability as
The elderly
Until recently, emergencies were largely confined to
countries with a young age-structure. Recent events
in regions with an older age structure changed this
and the numbers of older people affected is
increasing. Figures of refugees and IDRs can hide the
full extent of the problem. Often, the elderly and the
disabled are too frail to move away from affected
areas. Sometimes they have to be left behind while
the rest of the community flees. In most societies, old
age, disability, poverty and vulnerability are closely
intertwined. Another major distinctive factor in older
persons is that they seem to be equally - if not more vulnerable to natural as well as man-made disasters.
Traditionally emergency operations target other sub
groups such as children and women, Thus, lack of
awareness and focus on the aged and the disabled
may have contributed to a neglect of these groups.
countries. Furthermore, persons with chronic
diseases and disabilities have special vulnerabilities.
It is well known that Sub-Saharan Africa accounts
for almost 70%of the global burden of HIV infection.
Afghanistan and Angola show tragic figures of
landmine amputees, etc. However, also lack of
drugs and maintenance systems for chronic
cardiovascular, kidney and respiratory affections,
diabetes and mental patients, as seen during the
long crisis in the Balkans and recently in the West
Bank, can be cause of serious concern.
a process, a progressive "loss of well-being":
first psychological and economic insecurity,
then increasing physical suffering. All
along this process there are points where
humanitarian assistance, supported by public
health information and guidance, can
complement the individuals' and the
community's caring and coping strategies,
and
reduce
vulnerability.
Thus,
understanding the process of becoming
vulnerable can be as important as assessing the degree of vulnerability4.
4 D Sarewitz, R Pielke, Jr. Vulnerability and Risk: Some Thoughts From A Political and Policy Perspective
Discussion Paper prepared for Columbia-Wharton/Penn Roundtable on "Risk Management Strategies in
an Uncertain World", April 2002
3
Identifying beneficiaries according to specific risk factors makes managerial sense, as it
helps formulate policies and strategies, but it carries its risks. Defining vulnerability by
pre-existing assumptions may or may not suit a particular context. It may induce gaps
in the response, or hide some of the needs of a population.
Furthermore, it is one of the oldest lessons ever learnt by humanitarian assistance that
nobody should be seen simply as a burden on a community or a programme: thus, it may
be worth reminding that vulnerable is not synonymous with " helpless victim". We know
that every individual's skills and knowledge
Addressing vulnerability
constitute assets for a community. It is the
distinctive mark of good relief to integrate and to
in the post-crisis transition
build on these assets without losing sight of the
The challenge is to establish linkages
between the 'extraordinary emergency’ and
immediate goal of reducing mortality and suffering.
the ‘ordinary vulnerability’ of the weakest
groups. For instance, in FYR Macedonia, in
1997-2000, WHO produced a health policy
safeguarding equity, human rights and the
integration of vulnerable groups that was
supported by UNICEF and UNHCR: this
helped promoting changes through visible
field-level "demonstration programmes"
against the segregation and social exclusion
This approach required investing in capacity
building and rehabilitation of facilities.
It may seem naive to try and promote participation
and equity in situations of armed conflict, when the
warring factions actively pursue inequity.
However, emergencies can offer opportunities. It is
WHO's experience, shared by some of its partners,
that approaching immediate humanitarian needs in
a medium/long-term perspective, e.g. working
simultaneously for health relief and the reform of
local health systems with national and international actors, can reduce vulnerability and
facilitate the transition to a more equitable and sustainable recovery (see box).
Finally, another reminder: the most vulnerable are the unknown and the forgotten. We
see now in Angola the scale of the needs of the populations previously inaccessible and
unaccounted for. The experience in Afghanistan and DRC show that emergencies do
not disappear if the world's attention shifts. There are major disparities in international
emergency response. The “forgotten emergencies", those in low profile areas, suffer from
a lack of international agency presence, under-resourcing and minimal media coverage.
This is a major problem of the international aid system that needs to be urgently
addressed.
It is my belief that, all together, we have the know-how, the capacity and the
commitment to respond effectively to theseformidable challenges to our work in
humanitarian crises. But we need to continue to work together, and event intensify
our alliances, among ourselves as UN agencies, and with governments, NGOs,
collaborating centres, the media, communities, families, committed private partners.
We must keep in mind that in emergencies, lives are lost whether the TV cameras are
there to remind us about it or not ( G.H.Brundtland)
4
■■
. i
ECOSOC 2002 Humanitarian Segment
WHO technical contribution to the Panel
The transition from relief to development in the context of complex
humanitarian emergencies and natural disasters
New York, 16 July 2002
The approach to humanitarian needs must be medium to long term in its perspective1
The main lesson that WHO has learnt in the last ten years about transitions in the context
of complex humanitarian emergencies is that only peace reveals all the health needs. .
When inaccessible areas open up
Afghanistan
they release a "backlog” of public
health needs long left unattended, Afghanistan represents an "extreme" case of these challenges.
typically flagged by measles Natural disasters have coexisted there with a long complex
emergency, and military interventions are being carried out
epidemics. Demand for services simultaneously with relief and recovery activities. Aid has long
increases as the expectations of been politicised. The crisis of the health system must be
communities, local authorities and analysed against this complex background. The system has
dramatically fragmented. NGOs have their own networks,
external
partners
grow. which grew separate from the local, weak or absent
Furthermore, cease-fires need administration. More than 50% of the primary network may be
special health support: for owned and managed by NGOs.
demobilisation, de-mining and With no central nor local administration, no sector policy yet
return of refugees and internally and weak coordination mechanisms, deregulation prevailed:
national staff get different incentives, separate procurement
displaced persons.
Another lesson, that applies also
in the aftermath of natural
disasters, is that re-storing the
original health system is not
necessarily the right choice.
Caution is needed, as the systems
that were in place before the
conflict were part of its structural
causes and rehabilitation must not
recreate past vulnerabilities or,
worse, inequities. Likewise, a
hospital destroyed by an
earthquake or a cyclone clearly
needs to be re-built following
different standards. Thus, when
and supply systems coexist, different technical guidelines were
developed, training curricula proliferated. It is common to find
several NGOs supporting different wards of the same hospital.
This system does not allow for economies of scale, and
precious resources are wasted. To reconduct these networks
into a unified system, linked to an administrative division of the
territory, will require time, huge efforts and trade-offs. Without
funds to manage, the capacity of the government to influence
how resources are allocated, will grow slowly. In such an
environment, the flow of donor resources risks to be
unpredictable, undocumented, insensitive to context, driven by
fashions and imported models.
Afghanistan is a case in point of the old saying that extreme
situations require extreme remedies. However, choices made
in the initial phase of transition will influence heavily the
subsequent development of the sector. In post-conflict
countries, institutional weakness limits the ability of ministries
of health in influencing the formulation of an appropriate
rehabilitation policy; donors and international financial
institutions have wide space for manoeuvring.
(WHO, 2002)
1 Nigel Fisher, DSRSG, Pillar II, UNAMA, at the Afghanistan Support Group, Geneva 11 July 2002
2 During the first, short-lived cease fire in Angola, it was common saying among humanitarian workers
in Luanda that "1991 was a food emergency, but 1992 is a health emergency".
1
or •
I
the health sector is required to re-establish coverage, since access to care is rightly
perceived as a major factor of stabilisation, it also needs to re-think itself.
After conflicts, also capacity building can carry specific challenges: in Sri Lanka, for
instance, we see that the protracted segregation of the country in two parts means that the
younger generations know little of the culture, even the language of the "other side". This
means that the professional integration of new national cadres will need to be thought
in a new, cross-cultural learning frame.
All these burdens fall upon the national health ( and other) systems at the worst possible
moment: when, however fragile to start with, they are further de-capacitated by lost
assets and human resources, missed investments and collapsed cost-recovery.
Information is scanty, cash is short, health-related essentials ( e.g. food, clean water or
energy) are equally precarious, people's coping strategies are exhausted and external
assistance often bides its time.
During the acute phases of an emergency, basic needs are clear and there is usually a
consensus on what to do3. However, in the protracted crises or in post-conflict situations,
COllSUllSUS 1S lai less UUVIUUS. I^iieiiiiiiaa ui iCgitunaCy aim ouSiaiiiauiiiLy aiC iiiLiiiibiv iv
these environments. But they are compounded by the contradictions and limitations of
the prevailing aid instruments
Countries in post-conflict see a sudden flurry of pledges and strong pressures for quick
strategic planning and major structural reform, definitely justified by the will to sustain
peace. Actual disbursement of funds for
In Cambodia, having remained at very low
reconstruction is in fact often slow, and remains
levels until 1991, aid became a vital
source of support for the health sector
low when compared to the aid flowing into
once UNTAC came into force: by the
countries not affected by conflicts, but there is a
period 1992-1995, it accounted for 75% of
relative sudden expansion in spending, and the
the total health expenditure.
international actors often have disproportionate
Similarly in Ethiopia, despite the
power
on how it is spent and on what.
government using the peace dividend to
support the health sector, dependence on
aid to finance health increased: by 1992
aid accounted for 46% of total health
expenditure, compared with 29% in 1989.
Macrae, 2002
Power goes hands-in-hands with responsibility.
The reason why WHO feels the need to re
emphasise this (at least as far as the health sector
is concerned), is self-evident, but too often
ignored. The decisions taken in the transition have not only an immediate impact on
people's survival in a critical period, but they also influence their long term livelihoods:
ideally they should translate into sustainability and, in the long run, equity and social
stability. Irrespectively of who sets the post-conflict agenda, it will be the nationals who
will be called accountable at a certain point in time.
That is why the transition requires that the international community recognises a central
authority and work through it. However, as new regimes are often contentious, and their
administration and bi-lateral external relations always very weak, aid tends to be
channelled through relief-type interventions. These tend to play in favour of a project
3 ...Analogies in reliefpractices have been identified in countries as different as Bosnia and Angola,
leading to conclude that " relief operations are functionally blind to the specific conditions that
confront them ” ( Pavignani and Colombo, 2000)
2
based approach. NGOs tend to dominate service provision, and key considerations of
financing (e.g. fees for service) and supply systems (drugs, etc) are waived because of
the extraordinary conditions. Experience from around the world suggests that
rehabilitation in the health sector tend to concentrate on rebuilding the infrastructure and
on supplying free medicines. Planning and managerial capacities, human resources in
particular, their training and management tend to be downplayed. The most obvious and
contentious issue is the contractual
East Timor
and professional status of national
health workers, whose salaries are
In East Timor Early in 2000 the Interim Health Authority
often below subsistence level.
was created with national and UNTAET staff. Team visits
to all districts were carried out and a Joint Donor mission
resulted in the Health Sector Rehabilitation and
Development Programme, targeting the restoration of
basic services and the development of the health policy.
A Trust Fund was set up to channel aid, paving the way
to a sector-wide approach (SWAp).
Under the coordination of the Interim Health Authority,
NGOs prepared district health plans: emphasis went on
sustainability, limiting the number of facilities and staff.
The second health budget targeted the strengthening of
ongoing services and the development of policy,
regulation and administrative systems. Contracting out of
NGOs services was implemented through a competitive
process managed by the Ministry of Health.
(Tulloch, 2002)
We all agree that peace is a process
not an event. We know that making it
sustainable depends on reshaping the
relationship between societies, their
governments and the international
community. But we feel that it
depends also, more down-to-earth, on
having ex- (or potential) combatants
recognise their stake in it.
Rehabilitation of buildings and
increased provision of drugs can save
lives and are important. But post-crisis transitions need structural, not only infrastructural
interventions. And also the overall objective of international assistance needs to be
structural: beyond saving lives one must work at re-building livelihoods.
The common structure adopted by donor
agencies, split between development and
humanitarian desks does not help either.
As far as we know, only USAID4, Sida5
and DFID6, so far, have departments or
programmes addressing emergencies all
along their life-cycle.
WHO: main lessons learnt from the health
sector recovery in Kossovo
o
o
o
The fact is that whatever the channels of
aid, and whatever the doubts regarding
the new regimes, rehabilitation cannot
maintain the same pattern as relief, lest
it de-capacitates further the local
systems.
The experience of WHO in East Timor
and Kosovo, now enriched by the work
on-going with national public health
authorities and international partners in
o
The roles of various key actors should be
defined early in the process.
(An external technical agency) should take on a
direct governmental role as the lead policy
organisation only in the most exceptional
circumstances, when there is no existing
legitimate governmental authority.
The lead policy organisation should concentrate
on policy development and coordination and
should support the process of implementing
policy developed by national and local
authorities, if they exist.
In addition, this lead agency could serve as a
resource for implementing agencies in areas
such as developing workplans, indicators, and
monitoring and evaluation systems.
The lead policy organisation should develop
varied and multiple funding sources for this
function so that it can be and be seen to be an
honest broker in such situations. (from Shuey
at al, 2001)
4 Complex Emergency Response and Transition Initiative (CERTI) http://www.certi.org/
5 Humanitarian assistance & conflict management http://www.sida.se
6 Department of Conflict reduction and Humanitarian Assistance DFID http://www.dfid.gov.uk/
3
Afghanistan is that UN technical agencies have a primary role to play. In transitions, they
are the best placed to assist the new government as impartial brokers, in taking the lead
for policy development and sectoral coordination ( or to lead directly, where no
legitimate authority exists).
As far as health is concerned, WHO has learnt that a sector's policy framework with a
vision of the future can channel humanitarian assistance into activities that contribute to
development and reform of the health sector. Such policy framework is useful even
before the transition, as it can conciliate the short term emergency relief with the general
lines of rehabilitation and recovery. WHO’s experience shows that planning for
reconstruction should start as early as possible, in spite of the pressures of the "acute
phase". In the first weeks of its presence in Kossovo, in the summer of 1999, WHO
produced a two-pages policy outline that played and important role in directing
emergency aid towards what would be relevant also at longer term.
Emergencies - be they conflicts or major natural disasters offer unique opportunities to
reappraise systems and to set the basis for stronger development. Indeed, emergencies
are extreme "endurance-tests" for policies, strategies, programmes, practices,
partnerships and leadership. There is already a fair inter-agency consensus, conjured by
ALNAP that underlines the need to integrate this learning function in mechanisms for
operational coordination7. WHO subscribes to this vision.
By careful selection of the technical messages and the aid packages that it provides, the
international community can promote planning already in the early phases of a crisis,
and help bring about positive changes in the beneficiary countries. WHO experienced
this directly, for instance, when dealing with tuberculosis control in the former
Yugoslavia.
In its works for easier dialogue between national and international public health actors,
be it through technical information, workshops, seminars, or simply routine health
coordination meetings, WHO endeavours to give to local and international staff and
organizations in the field opportunities to discuss on technical priorities and work more
effectively together.
7 ALNAP (ActiveLearning Networkfor Accountability and Performance in Humanitarian Assistance)
is an internationalforum working to improve quality and accountability across the humanitarian
system. The ALNAP Secretariat is hosted by ODI in London, www.alnap.org
4
fel
World Health Organization
Cluster of Sustainable Development and Healthy Environments
Department of Emergency and Humanitarian Action
Emergency Preparedness at National and Sub-national Levels
Adapted from Claude De Ville, PAHO/PED1
1. A multi-hazard approach to disaster reduction
Most countries tend to focus preparedness efforts only on one type of disaster. The reality is that
any country faces a variety of hazards. Therefore, Emergency Preparedness and Response (EPR)
at country level calls for a multi-hazard approach: this means that there needs be a single
’’mechanism” to coordinate, define priorities, prepare and respond to all types of disasters.
The health sector and the ministries of health have the most challenging and visible
responsibilities in emergency response. Failure on the part of the health sector to be
institutionally prepared is particularly costly, not only in terms of lives lost, but also technically
and politically both for the ministry of health.
Also the health sector needs to adopt a multi-hazard approach. All MOHs recognise prevention,
preparedness and response against epidemics as their core responsibilities: they know that in an
outbreak they must take the lead. But all natural or man-made emergencies threaten human life
and health (see table). Therefore for all of them the MOH needs to be prepared and ensure that
inter-sectoral efforts are integrated (and optimised) by essential public health action2
2. MOH: specific responsibilities, interests and advantages
The role of MOH within Disaster Management stems from its specific responsibilities but also
its interests and advantages. The MOH has a leading role in
i. advocating for general reduction of vulnerability and working directly to mitigate the risk
of damages to health and water facilities.
ii. contingency plans for health response in case of emergency
iii. training all health actors for disaster reduction and emergency management
iv. ensuring health coordination of response
Other functions, e.g risk mapping or education for public awareness are equally important for
disaster reduction, but MOH/the health sector have no special advantage nor responsibility for
the. They must take place, but MOH should limit its role at central level to advocacy and
promotion of the health perspective.
Definitely, at all levels of MOH, specific resources - human and material- should be assigned to
the reduction of vulnerability of the health infrastructures. This is not a luxury: the more
vulnerable the country, the more important it is setting aside resources for mitigation and
preparedness.
1 Emergency Preparedness at National and State Levels- presentation given at the Inter-country meeting on disaster
preparedness, Bali, June 2001
2 See WHO Core Corporate Commitments: l.e. life-saving public health measures that must be immediately
implemented in any circumstance,
3. MOH/EPR programmes
EPR programmes are needed within the health sector to make a difference where disasters hit,
I.e. at the local level. Local EPR programmes must have a multi-hazard scope. They must
encompass, serve and lead the entire health sector: hospitals and public health institutions,
private, governmental or NGO. PAHO/PED experience in the Americas points to two
complementary approaches
i. training and awareness activities through workshops, courses, dissemination of
material at central and local levels
ii. the establishment and institutionalisation of an administrative structure for disaster
reduction within the health sector, generally sited in the MOH.
3.1. Health preparedness at community level is always an elusive goal and especially so in the
presence of poverty and structural instability. However, before contemplating any initiative at
community level it is necessary that the EPR programme be decentralised at sub-national3 level.
Always keeping in mind that poorly planned decentralization can cause additional difficulties,
at sub-national level, the EPR programme should work at
i. mobilizing the sector for disaster prevention, mitigation, preparedness, response and
early rehabilitation
ii. coordinating with other sectors
iii. coordinating and advocating for health vis-a-vis central authorities and donors
3.3.At national level, a strong programme for Health EPR is needed to provide overall support
and guidance. It must have dedicated staff and budget, and easy access to decision-makers.
4. WHO’s role
Disaster reduction needs to be seen as a core function of MOH. There is no quick-fix for disaster
reduction, which is a process of investment in people and institutions. Financial and political
investments are essential for a programme to have continuity and induce positive changes. This
continuity of investment and efforts must be sustained in the face of competing priorities. On the
part of WHO all this implies
i. Supporting the development ofHuman Resources. Training is an essential component of
capacity building. WHO can ensure that opportunities exist through workshops or short
courses that are current practice in all WHO regions, or through university training,
following the experience in the Americas and the Philippines. It is worth exploring ways
to introduce Emergency Management in the curriculum of faculties of Medicine and
Nursing and Public Health Schools.
Specific training activities can be defined for each element of'Capacity building4': in terms
of audiences (i.e. policy makers, managers or operators), formats, objectives and main
contents. Ideally, the training material should cover all that is relevant: from concepts such
as hazard and vulnerability to practical procedures such as occupational safety, passing
through coordination techniques and logistic management.
ii. Supporting the development of Institutions. WHO can do this by strengthening the
disaster office/program in the health ministry and/or supporting its decentralization at sub
national level.
3 district, province, region, state, A.L.
"Capacity", in the context of emergency management summarizes four major elements: a) information on the
problem to be tackled, b) authority to act, c) plans, resources, and procedures for their application, d) partnerships.
(WHO/EHA: TRAINING FOR EMERGENCY HEALTH MANAGEMENT- Preliminaries for a Consolidated Strategy, 1998)
Most of all, WHO can assist by promoting inter-agency collaboration. In order to bear
fruits, the MOH/EPR programme needs the support of the national institution responsible
for overall disaster management - be it the Prime Minister Office, the National Prevention
and Relief Agency, the Civil Protection - and other actors in the public and private sectors.
Making these partners aware of, and responsive to the meaning of Health and the role of
the health sector in disaster reduction is a precise responsibility of WHO5. On certain
issues, the health sector can be a catalyst for change, e.g. - as in the case of PAHO/PEDby promoting transparency and accountability by proper emergency supply management.6
iii. Structuring WHO's country technical cooperation. All disaster have a negative impact on
health as defined in WHO’s constitution and EPR needs to be integrated as a core function
of WHO country office7. The structure of any institution needs to reflect its core functions.
Therefore each WR should appoint one staff to act as focal point for all disaster reduction
related matters - from prevention to response. He/she will have coordinating functions:
technical liaison with MOH, other national and international partners in the health and other
sectors, institutional memory, stimulation of involvement of all WHO professionals in
disaster reduction, etc. Given the political dimensions of emergency management it is
advisable that this staff be international or otherwise have appropriate status within the
WHO Country Team. All other WHO staff members need to be aware that reducing the risk
of disasters is everyone's responsibility in his/her area of competence and not the reserved
domain of the ‘focal point’.
In highly vulnerable countries, assigning a full time officer to preparedness/ prevention is
essential. Equally essential is adopting adequate contingency provisions in WHO's country
cooperation strategy and budget, e.g by mutually agreeing in advance with MOH which
resources can be re-directed from regular programmes to respond in case of emergency. It
seems short-sighted for a government and a development agency to have to mobilize
millions of dollars for humanitarian response without committing themselves to improve
the local capacity of the health sector to prevent and prepare for disasters.
5 WHA 48.2. Emergency and Humanitarian Action
6 See SUMA
7 Emergency and Humanitarian Action-Disasters, Emergencies and WHO.paper presented at the 2nd GPMG
meeting, Geneva, March 2000 (Agenda Item 5)
Table: Multi-hazard . .Hproach: Rationale for Preparedness Planning
Type of
Emergency
Primary
Hazard
Primary
Causes of
Death & Illness
Main responsibility of the
Health Sector
Risk of
damage
for the
Health
Network
the Health Sector
Capacities needed
Technical
Support
personne
I and
infra
structure
s
Epidemics of
Infectious
Origin
Emergencies
by Other
Natural
causes
Known
Disease
Agent-specific
New
Emerging
Diseases
Agent-specific
Mass Food
Poisoning
by Natural
Causes
Drought
Agent-specific
Floods
Diarrhoea,
Malnutrition,
Any other
cause, by
decreased
access to Health
services and
higher
vulnerability
Drowning,
Trauma,
Diarrhoea, ARI,
vector-borne
diseases
Alert and Assessment
Surveillance
Case Management
Outbreak Control_______
Alert & Assessment
IDENTIFICATION OF
AGENT
Surveillance
Case Management
Outbreak Control_______
Assessment
Identification of Cause
Case Management
Information and education
Need assessment
Disease Control
Nutritional Surveillance
Therap./Supplem.feeding
Search & Rescue/triage
Need assessment
Disease control
Assistance in temporary
shelters
+
+++
+++
Epidemiology & DC
Medical/Nursing care
Environmental Health
As above, plus field
research, crash training of
personnel, new, specific
health education possibly
Cordon Sanitaire
Communications, Laboratory,
Facilities & Supplies
Inter-sectoral collaboration
Funds
As above, plus access to more
sophisticated Reference
Centres, greater capacity for
Isolation, special drugs or
vaccines
Epidemiology
Medical/Nursing care
Education
Communications, Laboratory
Facilities & Supplies
Inter-sectoral collaboration
Epidemiology
Disease control
Nutrition
Communications. Logistics &
Funds for Outreach. Supplies
Inter-sectoral collaboration and
coordination of relief
Mass casualty
Management
Env. Health/Vector Control
Health care in temporary
shelters
Special Training for staff and
volunteers
Inter-sectoral collaboration and
coordination of relief
Emergencies
from
Technologica
I causes
(contn)
Industrial
explosion,
fire, spill,
radiation
Collapse
of man
made
structure
Failure of
lifeline
systems
Mass Food
poisoning
by Human
causes
Complex,
Emergencies
Armed
Conflict
Mass
Labour
Unrest
Complex
Emergencies
(contn)
Blast, Trauma,
Burns, Acute
respiratory
distress,
suffocation,
Agent-specific
Trauma,
suffocation,
drowning, other
according to
type of structure
Any cause, by
lack of critical
support care
Trauma by
crowd panic
Agent-specific
Search & Fu^cue/Triage
Casualty Management
Trauma,
malnutrition,
ARI, Diarrhoea,
Measles,
Meningitis,
Vector-borne
diseases______
Trauma, any
cause by lack of
critical support
care__________
Blast, trauma,
Fire, suffocation,
etc other
specific, (eg.
Chems, Biol,
Nucl)
+
Mass Casualty
Management
Specific Medical/Nursing
care
Intensive care facilities
Hospital vulnerability
assessment and reduction
Search & Rescue/Triage
Casualty Management
Assistance in temporary
shelters
+++
Mass Casualty
Management
Intensive care facilities
Hospital vulnerability
assessment and reduction
Prompt back-up
Casualty Management
+++
Mass Casualty
Management
Hospital vulnerability
assessment and reduction
Back-up systems
Alert and assessment
Identification of Agent
Case Management
+
Epidemiology
Specific Medical/Nursing
care
Environmental health
Need assessment and
Advocacy
Disease Control
Nut. Surveillance & Select.
Feeding
Injury Management
+++
Epidemiology & Disease
Control
Nutrition
War Surgery
Health Care in temporary
shelters
Toxicology
Special Decontamination
facilities
Access to special Reference
Centres___________________
Special Agreements &
Procedures
War Surgery facilities/capacities
Safe Transfusion facilities
Coordination of International Aid
Mass Casualty
Management
+
Mass Casualty
Management
Special Agreements &
procedures
Mass Casualty
Management
Mass Casualty
Management
Intensive care facilities
Special care against
specific agents
CD Outbreak control
Specific Medical/Nursing
care for chemical and
radiation outcomes
Reference labs, experts, etc
Protective equipment and
specific isolation/ decon
tamination facilities
Special coordination with
security systems
Refugee/
Displaced
Influx
Major Public
Functions
State Visit
Pilgrimage
Mass
Entertainm
ent
Diarrhoea, ARI,
Malnutrition,
Measles,
Meningitis,
vector borne
diseases
Any: illness of
state guests
Illness among
spectators
Crowd incidents
(stampede etc.)
Epidemic
diseases
Illness among
spectators
Crowd incidents
(stampede etc.)
Illness among
spectators
Crowd incidents
(stampede etc.)
Disease Coi.uol
Nut. Surveillance & Select.
Feeding
Assistance in
Camps/Transit points
Epidemiology & Dis se
Control
Nutrition
Health Care in temporary
shelters
Recruitment of volunteers
Outreach and supervision
Coordination
Back-up for possible
special, high-profile medical
emergency Readiness for
crowd incidents
Medical/Nursing care
Intensive care facilities
Disease Control
Readiness for crowd
incidents
Back-up for increased
demand
Epidemiology & Disease
control
Environmental Health
Mass Casualty
Management
Intensive Care facilities
Temporary outreach facilities
Back-up for increased
demand
Readiness for crowd
incidents
Mass Casualty
Management
Intensive Care facilities
Special coordination with
security systems
EHA-Add.05.98
Emergencies
by Other
Natural
causes
(contn)
Cyclone
Tidal
surge &
Tsunami
Earthquak
e
Landslide
Volcanic
eruption
Bush Fire
Emergencies
from
Technologica
I Causes
Transport
Incident
(road,
railways,
air, sea
etc.)_____
Fire in
Human
Settlement
Trauma,
Drowning,
Diarrhoea, ARI,
Vector-borne
diseases_____
Drowning,
Trauma,
Diarrhoea, ARI,
vector-borne
diseases_____
Trauma,
suffocation,
Bums
Diarrhoeas, ARI,
Vector-borne
diseases_____
Trauma,
Suffocation;
Diarrhoeas, ARI,
Vector-borne
diseases_____
Trauma,
suffocation,
burns, Acute
Respiratory
distress______
Burns, Trauma,
suffocation
Trauma,
Drowning,
Burns,
suffocation
Same as above
++
Same as above
Same as above
Same as above
+
Same as above
Same as above
Search & Rescue/triage
Need assessment
Casualty Management
Assistance in temporary
shelters
+++
Mass Casualty
Management
Intensive care facilities
Hospital vulnerability
Assessment and reduction
Same as above
+
Same as above
Same as above
Need assessment
Casualty management
Assistance in temporary
shelters
+
Mass Casualty
Management
Intensive Respiratory Care Unit
Search & Rescue/Triage
Casualty Management
+
Mass Casualty
Management
Intensive care facilities
Burns, Trauma,
suffocation
Search & Rescue/Triage
Casualty Management
+++
Mass Casualty
Management
Intensive care unit
Burn care facilities
Hospital vulnerability
assessment and reduction
Health Care in Temporary
shelters
Health Care in Temporary
shelters______________
Same as above
Same as above
Burn care facilities
Statement of the World Health Organization
Economic and Social Council
Humanitarian Affairs Segment
11-13 July 2001
Over the past year again, for an unacceptable number of people, surviving through extreme events,
be they conflict, displacement, floods or earthquakes has become the predominant objective in daily
existence.
Following landmark resolution UNGA/46/182, the World Health Assembly passed resolution
WHA48.2 on Emergency Preparedness and Response, defining WHO's role as a founding member of
the Interagency Standing Committee. WHO's responsibility is to focus on reducing the avoidable death
and suffering that result from any natural or man-made disaster. As stated by many delegations, this
responsibility can be met only in partnership in as much as WHO ensures that all concerned work with
full awareness of risks and opportunities, on the basis of shared interests. and at the best of their
technical capacities.
The determinants of life and death in armed conflicts are well highlighted by different studies inter
alia, in D.R. Congo. Health problems account for the largest part of the suffering, and most people die
of preventable causes: malnutrition, linked to infectious diseases and simple childhood illness,
HIV/AIDS, tuberculosis, not to forget deaths linked to pregnancy and childbirth.
At the same time, global interests converging around health provide unique opportunities. HIV/AIDS
commands global attention as a global security threat and its transmission has been linked to the
epidemic of conflict and sexual/gender-based violence we see affecting several continents. The need
to eradicate polio from its last abodes provides resources for what is left of local health systems in
countries ravaged by long wars. For WHO, there is a challenge to capitalize on this commonality of
interests, between the international health and humanitarian communities.
As we know the relief efforts of one sector need synergy with the other sectors, we also know those
first called to respond to a crisis are the people affected: if they do not cope, there is nobody for
external aid to assist. Inter-sectoral collaboration and local systems capacity are key to all effective
relief efforts. WHO sees it as its responsibility that health concerns are addressed in Consolidated
Appeals, and that health sector contributions not only to relief, but also to preparedness and mitigation,
are well coordinated. WHO fully supports coherence, collaboration and solidarity within Humanitarian
Coordination and UN Country Team as well as IASC mechanisms.
WHO approaches human survival and health in a broad perspective that encompasses medical care,
water, sanitation, nutrition, disease control, immunization, family, reproductive, and mental health.
WHO aims to provide overall technical coordination and in addition assumes specific operational
responsibilities such as health assessment and surveillance, and coordination with local and national
health actors, particularly local and national health authorities. As an operational agency, we are
evaluating and building on what we have learnt in the UN Administered Territory of Kosovo, East
Timor, Democratic People's Republic of Korea, not to forget El Salvador and Gujarat.
1
Because nobody dies "ofa disaster''-, and people die of starvation, of measles, of obstructed labour, of
bullet wounds, or renal failure from crush injury; by analyzing the causes of death, WHO aims to
provide health information targeted to decision-making in the field. The value of this approach was
demonstrated last year in the crises in the Hom and West Africa. WHO will expand this capacity, bring
it closer to where the needs are, and thus make it more useful for humanitarian actors. An immediate
case in point will be the DRC and the efforts being made by the international community to face the
catastrophe largely determined in health terms.
WHO disseminates public health practices to ensure best technical performance from all working in
the field. In the least twenty years, sound and affordable interventions have been identified for most
health risks. In 2001, WHO worked with UNHCR, UNICEF, ICRC and the SPHERE Project to
produce Health Library for Disasters on CD-Rom, jointly with PAHO. It contains more than 250
technical publications, spanning the spectrum of relief to preparedness and mitigation, and thanks to
donor support, is being distributed free or at production cost.
Improved public health practice also facilitates dialogue between national and international actors.
Together with NGO partners, WHO is looking into practical arrangements that would allow field
workers to discuss local emergency health priorities on the basis of accepted technical knowledge and
thereby help them to co-ordinate more effectively.
In this respect, support to national -or refugee- health workers is key to the preservation of local
capacities, and we call for more attention to issues of local human resources management, for progress
in the practice and outcomes of humanitarian programmes. This goes hand-in-hand with our
interagency effort on the elderly in conflict and disasters, where we promote a vision of the elderly and
other vulnerable populations, not just as victims, but also as key assets, including for efforts of
humanitarian advocacy and to use health dynamics and interventions as bridges towards peace and
reconciliation, as well as rehabilitation.
In this humanitarian segment, it is good to emphasize the reactions of people caught in disasters are
normal reactions to extra-ordinary situations, but they may cause new instability and new hazards. The
psychosocial aspects of disasters cannot be reduced to a matter of mental health, but there is a need
to better understand them and at the same time respond to the best of our ability. WHO sees action in
this area as a necessary contribution by public health to humanitarian assistance. WHO convened in
October 2000 in Geneva with UNHCHR and UNHCR as well as RSG/IDP, an 'International
‘ Consultation on mental health of refugees, displaced and other populations affected by conflict and
post-conflict situations". This Consultation endorsed the 'Declaration of Cooperation on mental health
of refugees, displaced and other populations affected by conflict and post-conflict situations', hereby
referred to ECOSOC.
In closing, WHO congratulates the Emergency Relief Coordinator for his intervention at the
beginning of the segment, and thanks the other agencies and NGO partners, members of the IASC,
as well as ISDR for their effective collaboration, in testimony to the tenth anniversary of UNGA
46/182.
2
World Health Organization
Cluster for Sustainable Development and Health Environments (SDE)
Department of emergency and Humanitarian Action
Emergency Health Intelligence and Capacity Building
Public Health Learning
for Emergency Coordination
Program brief, January 2002
One of WHO’s strategic goals is to facilitate the dialogue between national and
international actors on the basis of internationally accepted guidelines.
Three projects have been developed to improve best public health practices for
humanitarian assistance and disaster reduction, which are included in this document.
1. The Emergency Health Library Kit
2. The Health Library for Disasters, a virtual library
3. Learning for Coordination - survey and a programme for the field
World Health Organization
Cluster for Sustainable Development and Healthy Environments (SDE)
Department of Emergency and Humanitarian Action
Emergency Health Intelligence and Capacity Building
EMERGENCY HEALTH LIBRARY KIT
Health data and public health guidelines are the best lubricants for coordination
With the goal of reducing avoidable death and suffering caused by
disasters, one of WHO's strategic objectives is to facilitate the dialogue
between national and international actors on the basis of WHO and/or
internationally accepted guidelines.
The Department of Emergency and Humanitarian Action (EHA) has
selected a number of key guidelines on best public health practices for
humanitarian assistance and disaster reduction, composing the Emergency Health
Library Kit (EHLK).
Upon request the EHLK can be provided to agencies working in the field
during emergencies. The Kit contains essential documents related to Public
Health in Emergencies and it is intended to provide technical guidance to
agencies operating in the field. The EHLK follows the model of the Blue Trunk
Library, a WHO library project, providing basic health and medical information
to district health teams in developing countries.
Each EHLK comes in a metal trunk, which can be used as a bookshelf.
It contains 150 documents: guidelines and reference manuals produced by WHO,
other UN organizations, and external publishers. Summaries of the contents of
EHLK with detailed information can be accessed at the web address:
http.7/www.who.int/cha then click under Publications to look for Bibliography.
The cost of each Kit amounts to US$ 2300, transportation costs excluded.
So far, the Kits have been distributed through various WHO offices, and
Universities, including East Timor, Indonesia, Kosovo, Mozambique, North
Caucasus, Ethiopia and South Sudan. EHA has a number of kits ready for
shipment on request. The contents of the Kit is regularly updated.
For further details please contact WHO/EHA at: eha@who.ch.
World Health Organization
Cluster for Sustainable Development and Health Environments (SDE)
Department of emergency and Humanitarian Action
Emergency Health Intelligence and Capacity Building
Health Library for Disasters
The Global Virtual Library of Essential Information Resources on
Public Health for Disasters and Complex Emergencies
Health data and public health guidelines are the best lubricants for coordinaton.
One of WHO's strategic goals is to facilitate the dialogue between national and international
actors on the basis of internationally accepted guidelines.
The Department of Emergency and Humanitarian Action (EHA) and the Disaster Programme of
the Pan American Health Organization (PAHO/PED) have produced a CD-ROM on best public
health practices for humanitarian assistance and disaster reduction, with grant assistance from
DFID.
In 1999 PAHO/PED produced a similar CD-ROM. EHA had selected a Bibliography of Public
Health guidelines for Humanitarian Assistance, part of which are already available to member
countries and international agencies through WHO's Emergency Health Library Kits. Now, these
two experiences are merged into a new CD-ROM, that contains more than 250 technical
publications dealing with disaster reduction and best public health practices that are relevant to
humanitarian assistance.
The contents of the CD-ROM were selected through a consultation that brought together with
EHA and PAHO/PED all WHO technical departments at HQ and regional levels, as well as other
UN agencies-UNHCR, HCHR, UNICEF, ICRC, the SPHERE project, Non-governmental
organizations such as OXFAM, WHO collaborating centers such as the Center for Disease
Control and Prevention (CDC-Atlanta), the Center for Research in the Epidemiology of Disasters
(CRED- Bruxelles) and academic institutions like Tulane University.
Web publishing is substantial to this process. This electronic library composed of technical and
scientific disaster information sources and resources which is selected for its technical value and
quality, is also accessible on the Internet. Thus, initiative will be transferred and made available
to the millions of end-users free of charge without any limit on time and space.
Summaries of the contents of CD-ROM can be accessed at the web
Addresses: http://www.who.int/eha and at http://www.paho.org/english/ped/pedhome.htm
The complete collection can be viewed at http://www.helid.desastres.net
The CD-ROM will be distributed by WHO and partners agencies, partly free of charge, partly
at recovery cost.
The world of disaster reduction is constantly changing and expanding. To confront this reality,
we are using state-of-the art electronic information technology to contribute to make available
the most complete and up-to-date material possible. This first CD-Rom opens a process which
will be evaluated, replicated and updated in the future.
For further details please contact WHO/EHA at: eha@who.ch. or PAHO/PED at disasterpublications@paho.org
w
World Health Organization
Cluster for Sustainable Development and Health Environments (SDE)
Department of emergency and Humanitarian Action
Emergency Health Intelligence and Capacity Building
Learning for Coordination
Public Health Guidelines in Emergencies
Joseph Mailman School of Public Health/Columbia University
World Education
The Challenge
In emergencies, national authorities have the prime responsibility to respond to the needs
of the affected population. However, especially in protracted crises and/or complex
emergencies, the situation can often deteriorate to a degree that undermines fatally the
capacity of the Ministry of Health or local authorities to meet the urgent public health
needs. National efforts must then be supported by international relief workers.
A rapidly changing environment, weak coordinating mechanisms, unclear roles and
responsibilities among the aid agencies, and little understanding of the affected country
or region's overall problems and priorities characterize almost all the emergencies
particularly in the early stage. Supplies may arrive in a haphazard manner and they may
not be appropriate to the situation. Issues of security, sovereignty, language, culture, and
differing ways of understanding the problem are compounded by a sense of urgency and
the need to “do something quickly” to respond to the emergency.
In these situations, coordinating public health program^ that respond to the real needs is
difficult at best. Creating an environment in which field staff agree on technical priorities
and work as a team, and organizations co-ordinate effectively together is a critical
challenge. Tired, stressed relief workers, little time to think and plan, inaccurate and
incomplete information, language and cultural barriers; all these need to be overcome for
effective co-ordination to take place.
It is as a first step in this direction that in 1999 WHO started producing an Emergency
Health Library Kit (EHLK) containing essential documents related to Public Health
Management in Emergencies and intended to provide technical guidance to humanitarian
field workers. So far, the EHLK has been distributed through various WHO offices,
including East Timor, Indonesia, Kosovo, Mozambique, North Caucasus, Ethiopia and
South Sudan. Also some international NGOs and institutions requested and received
Emergency Health Library Kit to use as the reference material for their field staff.
However, experience shows that, in order to be more widely and resourcefully used by
the relief workers, the Kit needs complementing with a training component that must fit
in the difficult circumstances described above.
The Response
World Health Organization, Columbia University School of Public Health and World
Education feel that the response should consist, at least for protracted crisis and complex
emergency such as Kosovo or West Africa, in a flexible programme, that would act as
a laboratory for relief workers to come together in structured learning settings to discuss
principles and best practices, and thus contribute to health emergency coordination. This
"Laboratory" would provide with the opportunity to identify resources and priorities,
define roles and responsibilities, and give practical, hands-on experience in planning and
coordination. A prime source of technical references would be the WHO Emergency
Health Library Kit.
The personnel to participate in this program will be mostly national district level health
workers who have good knowledge of the local epidemiology, state of health services
and evolution of the emergency, and the international aid workers who arrive with more
up-to-date knowledge and experience of other emergencies .
The major challenge is how to make of this learning activity a welcome tool that
facilitates coordination, rather than an additional task for overburdened workers.
Research; data collection and analysis
The team from Columbia University School of Public Health and World Education have
gathered information about current practices in public health coordination in
emergencies. The main purpose was to identify whether the ideas expressed above could
be developed into a field mechanism for co-ordination and support to best public health
practices.
The data collected assisted the Columbia/World Education team to design a highly
flexible program adjusted to the particular needs of relief workers in an emergency
situation. They will also help assess the capability of relief workers to select and use
WHO's and other guidelines and to apply them in different situations.
Designing the syllabus and the delivery system
On the basis of the results of this research, Columbia/World Education has prepared a
syllabus for training of local and international health workers at the field level in complex
emergencies and/or protracted crises. The syllabus explicitly aims at promoting dialogue
in the aid community and at improving users' knowledge and skills in co-ordination and
utilization of reference resources.
Columbia/World Education will also design a flexible, motivating delivery system that
can fit to the circumstances at hand, respond to the needs of the participants. The design
of the delivery system will include a set of indicators for the evaluation of the program.
Proposal for developing the training resources
The syllabus with the basic contents of the training modules and the proposed delivery
system is being discussed between Columbia/World Education, WHO, the Active
Learning Network for Accountability and Performance (ALNAP) members and partners
at field level both in and outside WHO.. Once there is agreement, the team will prepare
a proposal for programme implementation that will cover the costs of
1. developing the training modules and the materials for both the training of trainers
course to prepare a core group of facilitators and training at the field / country level.
2. Conducting the trainer's training course
3. Advertising and marketing the programme
4. Organizing at least two pilot courses at field
We expect that by the end of the program, participants will be able to:
■ be familiar enough with the contents of the Emergency Health Library Kit to be able
to use it quickly as a resource reference and training/briefing materials.
■ effectively utilize the available reference resources, EHLK and others for better
management in emergency relief operations
■ improve the co-ordination of health relief activities among the actors at the field /
country level
I
WR/CLO global meeting 2001 EHA.working paper
DEFINITIONS
For reference only.
Disaster:
* an occurrence disrupting the normal conditions of existence
and causing a level of suffering that exceeds the capacity of
adjustment of the affected community. < UNDMTp’ 1992)
. a serious disruption of the functioning society, causing
widespread human, material or environmental losses which
exceed the ability of affected society to cope using only its own
resources. Disasters are often classified according to their
natural cause (natural or man-made), (dha, 1992)
Emergency:
• a state in which normal procedures are suspended and extra
ordinary measures are taken in order to avert a disaster, (who,
1992)
• sudden state of danger, etc. requiring immediate action. (Oxford
Pocket Dictionary, 1992)
Complex Emergency:
. situations featuring armed conflict, population displacement
and food insecurity with increases in acute malnutrition
prevalence and crude mortality rates. (coc-Atianta)
• a humanitarian crisis in a country, region or society where
there is total or considerable breakdown of authority resulting
from internal or external conflict and which requires an
international response that goes beyond the mandate or
capacity of any single agency and/ or the ongoing United
Nations country program, (iasc, December 1994)
World Health Organization
Cluster for Sustainable Development and Healthy Environments (SDE)
Department of Emergency and Humanitarian Action
Emergency Health Intelligence and Capacity Building
Programme Brief, October 2000:
Developing WHO’s evaluation function in emergencies
Monitoring and evaluation ensure feedback to management systems. Evaluation contributes to
transparency and accountability. It has a positive impact on the entire management cycle: the
evaluation approach has implications for needs assessment and planning, as well as for
monitoring and reporting. Evaluation also provides technical insights for best practices and
informed decision making. Furthermore, evaluation is an important tool for institutional learning:
sharing evaluation findings benefits the entire humanitarian community and can improve
outcomes for affected populations. Developing evaluation methods that are tailored to public
health in emergencies will directly and indirectly benefit all WHO’s partners.
Therefore, with the overall goal of improving the health sector performance in disaster reduction
and humanitarian assistance, WHO wants to develop its evaluation function as an integral part
of its responsibilities in emergencies.
The Organisation wants to improve its own performance for the benefit of the affected
populations, provide additional tools for public health management and increase its accountability
vis-a-vis member countries and international partners.
For the above, WHO Department of Emergency and Humanitarian Action (EHA) will develop
an evaluation framework in collaboration will all concerned parties and then pilot test it in 2-3
countries. Opportunities for training will be facilitated for staff from WHO and member
countries, so to develop their evaluation capacity. Furthermore, WHO will strengthen its support
to global efforts in the area of quality assurance, learning and accountability for humanitarian
action.
Activities will be implemented by a dedicated officer posted in EHA/HQ, in collaboration with
other WHO technical departments, regional and selected country offices. Links will be ensured
with EHA advisory bodies like the Advisory Group on Research in Emergencies (AGRE), the
Inter-agency Medical/Health Task Force (IMTF) and networks like the Active Learning Network
on Accountability and Performance (ALNAP). The activities are expected to produce:
• A policy paper outlining WHO’s specific evaluation needs in emergencies
• A framework and procedures for evaluating public health programmes in
emergencies
• Training materials targeted at public health staff in emergencies
• Technical recommendations to improve planning, monitoring and reporting
• Health professionals, from WHO and other bodies trained in evaluation methods
Costs are tentatively estimated around 370,000 US$/year. Start-up activities are planned over two
years. The annual plan of work and quarterly progress reports will be available on request from
EHA. A programme evaluation is foreseen at the end of the first year.
For further details please contact WHO/EHA at: eha@who.ch.
I
0
Internally Displaced Persons, Health
and WHO
Paper presented at the Humanitarian Affairs Segment of ECOSOC 2000
New York, 19-20 July 2000
EXECUTIVE SUMMARY
Estimating the number of internally displaced persons (IDPs) is difficult, but global figures are
enormous: over 20 million at the end of 19991. World wide, the number of IDPs surpasses the number
of refugees.
Displacement exposes IDPs to new hazards and accrued vulnerability. These dynamics result in
greater risk of illness and death. Often, access of IDPs to health care and humanitarian assistance is
deliberately excluded by conflicting parties. Furthermore, the arrival of IDPs can strain local health
systems and the host population ends up sharing the sufferings of the internally displaced. Health
outcomes are dismaying. A recent survey in eastern D.R.Congo2 found that the fighting there resulted
in at least 1.7 million excess deaths between January 1999 and May 2000 and concluded that, in such
context, "war means disease'. In other cases, dramatic increases in mortality rates for children U- 5
and maternal mortality have been documented. Polio eradication and malaria control face daunting
challenges in countries undergoing complex emergencies, and HIV/AIDS is of paramount concern.
From a health perspective, the best option is to avoid human displacement. WHO contributes to the
prevention of displacement by working for sustainable development. Placing health high on the
political agenda helps maintain stability and thereby reduce the likelihood of displacement.
Primary responsibility for assisting IDPs, irrespective of the cause, rests with the national government.
Nonetheless, the conditions under which assistance can be delivered in the case of a drought, for
example, are far different from those prevailing in case of armed conflict. In any situation, though,
only dialogue between national and international actors can improve the understanding of the health
issues concerning the IDPs. All primary humanitarian concerns are based essentially on survival and
health issues, and health can provide the best "lubricant" for inter-sectoral co-ordination: standards,
guidelines and measures of effectiveness.
There is consensus among WHO's partners that, in emergencies, the Organization must:
> Take the lead in rapid health assessment, epidemiological and nutritional surveillance, epidemic
preparedness, essential drugs management, control of tuberculosis, HIV/AIDS and sexually
transmitted diseases, physical & psychosocial rehabilitation;
> Provide guidelines and advice on nutritional requirements and rehabilitation, immunisation,
medical relief items, reproductive health3.
If the vital health needs of IDPs, i.e. security, food, water, shelter and sanitation, soap and household
items are not satisfied, health services alone cannot save lives. Health care, though, is another vital
' At the request of the Inter-agency Standing Committee, the Norwegian Refugee Council is developing a database of
information to track the numbers and needs of internally displaced populations.
2 IRC: Mortality in Eastern DRC-Results from Five Mortality Studies. Prepared by Les Roberts, IRC Health Unit, 2000.
3 EHA consultation with donors and collaborating agencies on the role of WHO in complex emergencies, Geneva, March 1997
intemaffy-Displaced'Pedons; Health and WHO
need. HIV/AIDS and tuberculosis are common to any IDP context and, together with malaria, are
difficult to tackle. Reproductive health has become a primary concern, the same as mental health.
However, IDP situations occur mostly in developing countries and major causes of mortality can be
prevented by low-cost public health priority interventions such as measles immunisation4.
Community participation is essential and implies bolstering the assets and capacities of the
beneficiaries. Under the principle of "doing the most for the most", WHO advises first addressing
vulnerability by area and only subsequently targeting specific groups.
As long as IDPs remain inaccessible and therefore not identified, nothing can be done to safeguard
their health. In such contexts, WHO sees advocating and negotiating for secure humanitarian access as
integral parts of public health promotion. Protection, access and informed response are critical for the
survival of IDPs. Country expertise, human rights principles and best public health practices must
provide the basis for humanitarian action. Parties to the conflict must be integrated in these processes.
WHO sees IDPs’ predicament as a dynamic, progressive loss of health: first psychological and
economic insecurity, then increasing physical suffering that forces them to flee in order to survive.
Along this process, health relief can and must complement the IDPs' own coping strategies, while
looking for durable solutions. Public health principles provide the basis for WHO co-operation with
the member countries and its partners in the Inter-Agency Standing Committee to mitigate the plight
of IDPs.
4 M. Toole Twelve lessons for public health in emergencies, paper presented at FICOSSER, Paris 1999.
2
Intemalfy DiSp^ced'Persons, Hteltrran&WHO1
'Protecting [internally displaced] persons.... is one of the most daunting challenges of our time.
Whether the victims are forced into camps, choose to hide or merge into communities, they tend to be
among the most desperate ofpopulations at risk. Internal displacement.... denies innocent persons
access to food, shelter and medicine and exposes them to all manner of violence. ,s
I. Context
"Internally displaced persons (IDPs) are persons or groups of persons who have been forced or
obliged to leave their homes or places of habitual residence, in particular as a result of or in order to
avoid the effects of armed conflict, situations of generalized violence, violations of human rights, or
other natural or human-made disasters' and who have not crossed an internationally recognized state
border" 6. Hard data on the numbers of IDPs do not exist, and estimates are difficult to make.
Depending on the reasons that force people to flee, figures can seem amazingly high, e.g. in most
natural disasters, or amazingly low, e.g. in displacement due to civil strife. In the latter case,
governments may be unable or even unwilling to acknowledge the existence and real numbers of
IDPs. Sometimes the IDPs themselves do not wish to be identified for fear of persecution.
Nonetheless, global figures are enormous; the US Committee for Refugees estimated that there were
over 20 million IDEs at the end of 1999^. Over 10 million of these were in Sub-Saharan Africa, and
1.9 million were in South America, mainly in Colombia. Other countries with large internally
displaced populations include Iraq (almost 1 million people), Afghanistan (estimated 750,000-1
million) and the Russian Federation (1 million)8. Other persons are in an even more tenuous situation;
they are not included in the figures above but they are sometimes mentioned as internally displaced,
e.g. in the Middle East, the Philippines and South Africa9. Worldwide, the number of IDPs surpasses
the number of refugees.
Contrary to refugees, IDPs enjoy no special status nor does any specific legally binding instrument
guarantee them protection and assistance. For example, a recent study found that US legislation only
"provides a minimal but not sufficient statutory basis" for Government action on behalf of IDPs10.
Thus, of the forced migrants, IDPs are among the most vulnerable. Furthermore, in most
circumstances it is the poorest and most vulnerable people who are forced to leave their homes or
places of habitual residence by a natural or human-induced crisis.
As persons and citizens, though, IDPs are covered by the laws of their own country. International
human rights law also remains applicable in cases of displacement. When the displacement occurs in
the context of armed conflict, protection under international humanitarian law applies. Specifically,
Article 3 and Additional Protocol II of the Geneva Conventions spell out essential principles of
treatment of civilians fleeing an internal armed conflict, including protection and care for the wounded
and sick. Special protection is set out for women and children11. The ‘Guiding Principles on Internal
Displacement’12 set out the specific rights of protection and humanitarian assistance of IDPs and the
obligations of governments in all phases of displacement. While not legally binding, these Principles,
along with humanitarian and human rights laws, provide a framework for action.
5 OCHA, Handbook for Applying the Guiding Principles on Internal Displacement, (pg i).
6OCHA, ibid (pg 6).
7IFRC, World Disasters Report, 2000.
8 Norwegian Refugee Council Internally Displaced Persons Database. At the request of the Inter-agency Standing Committee,
the Norwegian Refugee Council is developing a database of information to track the numbers and needs of internally displaced
populations (http://www.idpproject.org/).
9 Save the Children, War Brought Us Here, 2000.
10 James Kunder: The U.S. Government and Internally Displaced Persons: Present but Not Accounted For. US Committee for
Refugees, The Brookings Institution Project on Internal Displacement, November 1999.
11 Lavoyer, Jean Philippe: Refugees and internally displaced persons: International humanitarian law and the role of ICRC,
ICRC, 1 March 1995.
12 OCHA, ibid.
3
?
intem^iy Dfspfscecf Persons,
Especially tragic is the plight of those who remain
inaccessible and are therefore not identified as
IDPs; because of the location or the nature of the
crisis, they get no public or institutional attention.
This scenario is typical of complex emergencies,
where there is little or no information on large areas
and populations due to inaccessibility. It is a
frequent finding - from Mozambique in the 1980s'
to contemporary D.R.Congo14 - that before victims
of war flee the most insecure areas, and thus get
recognised as IDPs, they first try to cope by
shuttling between their fields and houses during the
day and hiding in the bush at night. Recent
evidence suggests that this is a period of maximum
risk 15.
In these situations of collective distress, some are
especially vulnerable: the elderly, the very young,
the pregnant women, the disabled, the chronically
ill and, more in general, all those who are more
recently displaced and haven’t yet found ways to
cope with their new condition.
Country Undergoing a Complex
Emergency
Total Population
Inaccessible
Accessible
Displaced:
Urban
Rural
Residents:
Affected
Non-affected
Refugees/Returnees
<-
“commuters
I
Combatants
Demobilised
Soldiers \
Issues of protection, vulnerability and access are intimately linked. Additionally, for health and WHO,
vulnerability is not a static condition but a complex process - in the case of IDPs, a very dynamic and
rapid one. To approach and intervene in these dynamics, WHO suggests taking the IDPs’ point of
view on entitlement to protection and access to health.
IL
Internally displaced persons and public health concerns
Public health for refugees, internally displaced persons and other conflict-affected populations has
evolved as a specialised field with its own policies, procedures, manuals, indicators and reference
materials ,6. Displacement of a population always affects health status and health care. In the
epidemiological triad of host, agent and environment interaction, displacement exposes IDPs to new
hazard dynamics:
> Infectious agents and vectors might be present in the new environment, to which IDPs may lack
immunity and or coping skills;
> In general, poor quality of water and sanitation and overcrowding, as in temporary settlements,
modify interaction with existing infectious agents;
> Absolute and relative food shortages occur due to disruptions in the production and supply
systems;
> Psychosocial balance is disrupted by being uprooted, insecurity, lacking meaningful employment,
etc;
> Displacement can also lead to an increase in hazardous behaviours (e.g. promiscuity and sexual
and/or intra-household violence);
> Weather vagaries and other natural hazards may be present in the new environment.
These new hazards are compounded by accrued vulnerability due to:
> Loss of assets and entitlements;
13 Personal observation, Mozambique 1988. Also in R.Geffray 1990 and K.Wilson, 1991.
14 IRC: Mortality in Eastern DRC-Results from Five Mortality Studies. Prepared by Les Roberts, IRC Health Unit, 2000.
15 IRC, ibid.
.
16 M.Toole Twelve lessons for public health in emergencies paper presented at FICOSSER, Pans 1999.
4
internally Dtspl^^d Persons, Health and' WHO'
> Loss of social networks and caring capacities, often disruption of households. This has a
particularly profound impact on women, children and the elderly;
> Lack of knowledge and information on the new environment;
> Decreased food security and dependence on external aid;
> Often inadequate shelter, sanitation and access to safe water;
> Reduced access to health care facilities and health care services: IDPs lose access to the health
services they knew and are at a disadvantage, in cultural, financial, and functional terms in
accessing health services in areas of relocation.
Exposure to new hazards and greater vulnerability result in greater risk of illness and death for these
populations. Graph 1 compares crude mortality rates (CMRs) of IDPs with baseline rates. In most
places rates for the IDPs are significantly higher than the baseline rates; in the most extreme case,
Somalia, CMRs for internally displaced were 50 times the baseline.
Graph 1: Crude Monthly Mortality Rates Internally Displaced Persons
60
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□ Baseline CMR 0IDP CMR
Sources Public Hea«ti Consequences d Disaster, Nojl. 1997
MortlaKy in Essrlen ORC. IRC. May 2000
In April, 1999 Angola suffered the largest polio epidemic ever recorded in Africa. After 30 years of
war and destruction of health infrastructure and services, massive population displacement - and the
consequent over-crowding, poor sanitation and inadequate water supply - created an ideal environment
for the spread of poliovirus.17
In Colombia, almost 2 million people have been obliged to move away from their places of origin to
protect their lives. The situation is made more difficult by the fact that much displacement occurs
"silently", and people simple merge unnoticed in the host population 18. Only 22.1% of them are
reported to have access to medical care19.
Access can be made difficult simply by the fact that IDPs lack information on the availability of health
services, their location or costs, etc. It can be argued that the high mortality rates often seen
immediately after displacement (e.g. in Malawi in 1998) are also due to the time it takes for new
17 Taken from: Outbreak of Poliomyelitis - Angola 1999, MMWR, April 30, 1999/ 48(16);327-9.
18 Fabio Rivas Munoz, personal communication, June 2000.
19 Basic Country Health Profiles for the Americas, Summaries, 1999, PAHO.
5
internally Displaced Persons, Health and' WHO
arrivals to find out where the services are located and how to access them20. But often, access of IDPs
to health care and assistance in general - and of humanitarian workers to the IDPs - is deliberately
excluded by parties in armed conflict.
Even in a best-case scenario, functional access is difficult and the host population shares the sufferings
of the internally displaced. The arrival of a large number of people can strain local health systems that
are not sufficiently resilient. If the new arrivals are unexpected, or if information is uncertain and
slow, as it is often the case, personnel, supplies and facilities rapidly become inadequate. This
translates into reduced access to health care and poor health outcomes for all. Internally displaced
persons and host communities may also end up competing for access to food, infrastructures and
environmental resources. In addition, IDPs may introduce diseases not normally seen in the host
population. The hosts can perceive the IDPs themselves as a hazard.
In countries where armed conflicts are more prevalent and IDPs more numerous, health outcomes are
dismaying. An International Rescue Committee (IRC) survey in eastern D.R.Congo states that the
fighting there resulted in at least 1.7 million excess deaths between January 1999 and May 2000 and
concluded that, in such context, "war means disease" and that "violent deaths and non-violent deaths
are inseparable". IRC elaborates that the majority of deaths are the result of a combination of
violence, lack of services, extreme vulnerability and "common" diseases, including trauma: the total
number civilian deaths documented by the survey is "directly attributable to the warring parties and
their backers", although in only 13% of the cases "the mechanism of death was a man with a weapon
21
In Burundi, the under-5 mortality rate increased from 108 x 1000 in 1992 to 190 x 1000 in 1998; in
Afghanistan and Sierra Leone, maternal mortality rates are as high as 1,700 or 1,800 x 100,000 live
births, respectively22. Polio eradication faces daunting challenges in all countries affected by conflicts
or severe crises. Malaria is endemic in 80% of countries undergoing complex emergencies in Africa,
Asia and Latin America23. The interactions between social instability, violent conflicts, human
displacement and HIV/AIDS are of paramount concern. Sub-Saharan Africa, the region with the most
IDPs is also the most severely affected by the HIV/AIDS pandemic, accounting for almost 70 percent
of HIV-positive people and 83 percent of cumulative AIDS deaths24.
III.
WHO and Internal Displacement
Health is a key factor in the growth of human capital, in disaster reduction and social stability. As part
of its fundamental mission, WHO contributes to the prevention of human displacement through
advocacy and technical co-operation for sustainable health development. Equity of access to health
services and preventive care are essential to the reduction in hazards and factors of vulnerability.
WHO also assists national authorities in designing health systems more resilient to crises and in
building capacities for preparedness, so that local health systems can better adapt to the arrival of IDPs
if displacement occurs.
This form of “health preparedness” can and should contribute to the prevention of human induced
crises. Placing social services high on the political agenda can help maintain societal cohesion,
national unity and stability. WHO's co-operation with member countries includes assessing the
capacities and vulnerability of the health sector and facilitating consensus on priority public health
interventions which must be ensured for everyone, even or more particularly in a case of emergency .
“M.foo/e. ibid.
22 WHO/FCH: A health sector strategy for reducing maternal and perinatal morbidity and mortality by WHO and partners.
January 2000.
23 WHO/CDS: presentation at Partnership Meeting on Roll Back Malaria in Complex Emergencies, Geneva, June 2000
24 Inter Agency Standing Committee-Sub-working group on HIV/AIDS in Complex Emergencies. Controlling the Spread of
HIV/AIDS in Complex Emergencies in Africa. Geneva, May 2000
25 ‘Planning Ahead for the Health Impact of Complex Emergencies, Draft Discussion Paper' WHO (EHA), 8 Dec 1999.
6
Internally Df^placed'PGrsons, Heaittrand WHO
Whatever these priorities, they have to take into
account the possibility of internal displacement
and to be flexible enough to be readjusted
according to its dynamics.
Primary responsibility for assisting IDPs,
irrespective of the cause of the displacement,
rests
with
the
national
government.
Unfortunately, while the core needs of IDPs
may be similar, the conditions under which
assistance can be delivered during e.g. a drought
are far from those prevailing during a war or a
violent conflict.
Disaster ana
Sustainable Development
HUMANITARIAN ASSISTANCE
Response
Disaster
■
;/
Relict
u )
Preparedness
\
Even in the case of natural disasters, especially
in developing countries, IDPs are the ones to
M^^Reha b i li tation
suffer most. Most of the government's resources
are absorbed by the emergency phase, leaving
RECONSTRUCTION
DEVELOPMENT
huge gaps when it comes to rehabilitation.
Durable solutions for those displaced by the
disaster may remain long unattended. In situations of natural disasters, WHO is well placed to
facilitate and support health co-ordination because of its long-term presence in the country.
Particularly building on health sector and programme preparedness, WHO uses evidence-based public
health advice to facilitate understanding between the country and its international partners, co
ordinating and complementing interventions for health relief, recovery, health development and
preparedness26.
Most massive population movements, though, are connected with armed conflicts, and there, the
authorities generally have very little capacity - and sometimes very little interest - to assist IDPs. They
are considered a burden or an embarrassment, during and after a conflict. Worse, they can become
pawns in the tactics of combat or even "means of production" in the economy of war .
In complex emergencies, WHO, as a UN specialised agency and an Inter-Governmental Organization,
needs to reconcile its unique responsibilities in the health sector, the humanitarian imperative and the
mandate to assist its primary constituent, the member state. As a government feels undermined in its
capacities and legitimacy, co-operation with ministries of health and local health actors can come
under strain. Work with national counterparts in general becomes more difficult, while access to
national/local knowledge and capacities remains essential for effective action.
When governments are unable or unwilling to provide necessary aid to the IDPs, some of the needs are
met by NGOs (local and international) and others by UN Agencies. UN co-ordination is assured by the
Inter-Agency Standing Committee (IASC) through the system of humanitarian co-ordination. WHO
participates and has been a full member of the IASC since its beginning in the early 1990’s. Through
the country offices of the various IASC participants, co-ordination is also assured within countries.
There is still much room for improvement. A recent WFP review28 identified three main gaps in
humanitarian assistance to IDPs:
> Protection gaps: in the absence of one agency with overall responsibility for the protection of
IDPs, this remains an outstanding issue;
> Resource gaps: non-food sectors are often under-funded;
26 WHO/EHA: Emergency and Humanitarian Action -Disasters, Emergencies and WHO; paper presented at the Second Meeting
of the Global Programme Management Group, Geneva, 17 March 2000.
27 J-C.Rufin: Les economies de guerre dans les conflits de faible intensite, Defense nationale 1993.
28 WFP IDP Review: Experiences with Internal Displacement, WFP, 16 March 2000.
7
intemalfy Dispfacecf' Persons; MealWantf WH&
> Coordination gaps: there is a need to ensure a collaborative, coordinated approach to assistance to
displaced persons.
Arguably, the first two gaps depend on variables that escape the direct control of those more closely
involved. The "co-ordination gap", though, can and must be filled by national and international actors
working together. All the experiences from the late 1980s onwards indicate that also in situation of
displacement, highly effective outcomes may be achieved through active involvement of host
government, utilisation of local skills and the insistence on accountability by relief agencies29.
In WHO’s mandate, it assists its member countries to attain and maintain the highest possible level of
health for all their citizens, and displacement is not a qualifying variable in this respect. It is important
to remember that in a specific country or situation the World Health Organization also represents the
collective presence of all the other WHO member countries, and particularly the views and capacities
of those countries’ health sector. A privileged relationship with the ministry of health is central to
WHO’s presence, continuity and its function of global health exchange. In practice, though, the
Organization recognises that the ministry of health is not necessarily the only or the most appropriate
partner for its technical co-operation, particularly during emergencies. New partnerships are forged
with other ministries, local or international NGOs, UN agencies and the military during emergencies.
WHO’s contribution is based on its technical and moral authority and its special relationship with its
member countries. Within the context of the IASC, this gives the Organization a specific advantage to
advocate for and work toward having:
> The existence and the health rights and needs of IDPs acknowledged;
> IDPs identified and counted;
> Humanitarian access ensured;
> External resources mobilised for health;
> Local health capacities identified and strengthened- be they institutional or community based;
> Public health best practices adopted.
For WHO, the most important and urgent need is for dialogue between national/local actors and
international partners in order to improve the understanding of health issues in IDP situations. As all
primary humanitarian concerns are based essentially on survival and health issues, for WHO health
concerns provide the best "lubricant" for inter-sectoral co-ordination.
IV. Principles for WHO Action on Health of Internally Displaced Persons
Population figures are key for planning and monitoring any relief operation and are the essence of
public health, which is a population-based discipline. IDPs must be recognised and counted; this is not
easy, particularly when IDPs are integrated with host families. However, for instance, health records
(e.g. a sudden increase in vaccination coverage) can help identify "silent displacements". Simply by
providing national data on figures and structure of population and by applying vital statistics and
epidemiological tools, WHO can facilitate the definition of the beneficiaries, estimating their numbers
and needs, and establishing monitoring systems.
The health of the IDPs is best preserved through a community-based, preventive approach, which
is dependent on the satisfaction of the following vital health needs:
> Security;
> Water;
> Food;
> Shelter and sanitation;
> Clothes, blankets and essential domestic items; and
> Preventive and curative health care.
29 M. Toole, ibid.
8
fntemalfy Dispfacea Persons, Health and'WHO'
There is consensus among WHO's partners that, in emergencies, the Organization must:
> Take the lead in rapid health assessment, epidemiological and nutritional surveillance, epidemic
preparedness, essential drugs management, control of tuberculosis, HIV/AIDS and sexually
transmitted diseases, physical & psychosocial rehabilitation;
> Provide guidelines and advice on nutritional requirements and rehabilitation, immunisation,
medical relief items, reproductive health30.
For other vital needs, WHO is not primarily responsible. Nonetheless, as the UN technical agency
responsible for health, WHO needs to advocate that they be met by other agencies, lest preventable
deaths occur. The Organization can also provide the guidelines and information that can assist its
partners in planning or measuring the effectiveness of their relief interventions. In all these instances,
WHO’s action is consistent with its core corporate functions31.
i.) Security - from violence as well as from hunger and disease - is the IDPs' paramount need.
Violence is a major cause of illness and death, directly and indirectly. WHO needs to ensure that
war and other violence-related injuries are included in epidemiological surveillance - and
advocates for proper care of the victims. For certain vulnerable groups like children and the
elderly, security has more basic requirements, e.g. family reunification, which in turn impinges on
programmes for mental health. Health education can include segments on violence, first aid
training and injury prevention. Programmes for mine awareness and clearance, disarmament and
demobilisation contribute to security. All need a health component to be co-ordinated with
national counterparts, and WHO can provide support. Lastly, WHO has growing experience with
programmes such as ‘Health Bridge for Peace’(HBP)32 in support of conflict resolution, peace
building and secure environments.
ii.) Water is vital. In emergencies, ensuring at least 20 litres of water per person/day is central to
any strategy. Water supply programmes need to ensure adequate number and distribution of water
points - the more users of a source, the easier the contamination - and that the community be
empowered to maintain the sources and the quality of the water, e.g. by education and provision of
user-friendly pumps, spare parts, buckets and chlorine. Besides providing guidelines on water
safety and in some instance being directly involved in improving water supply, WHO also has its
scientific authority to bring to bear, so that health data, e.g. number of cases of diarrhoea and skin
infections, are used to monitor the effectiveness of assistance.
iii.) Minimum food requirements exist (2100 kcals/person/day) below which no "health" is
possible. Internally displaced persons require the same quantity and the same range of nutrients
required by all human beings. Supply-driven aid is ineffective and unethical33. Food aid
programmes must ensure adequate quality and quantity of food is available to the entire affected
population (as well as pots and fuel to prepare it). Food is either procured by the IDPs (i.e. by
foraging, trading or market purchase), distributed through food aid or, most commonly, through a
combination of both. Selective feeding provides only supplementary food to specific vulnerable
groups and special food for those in need of nutritional rehabilitation; it cannot compensate for
inadequate general rations. Ensuring that nutritional surveillance is in place, and that its
EHA consultation with donors and collaborating agencies on the role of WHO in complex emergencies, Geneva, March 1997
WHO core functions have been outlined as:
> Articulating consistent, ethical and evidence-based policy and advocacy positions;
> Managing information to assess trends and compare performance, along with setting the agenda for and stimulating
research and development;
> Catalysing change through technical and policy support;
> Negotiating and sustaining national and global partnerships;
> Setting, validating monitoring and pursuing the proper implementation of norms and standards (best practise);
> Stimulating and testing of new technologies and tools and guidelines for disease control, risk reduction, health care
management and service delivery.
(On ‘Policy framework for programme budget 2002-3’, WHO)
The main purpose of the HBP programme is to identify and develop actions and strategies that can maximise the peace
building effects of health programmes before, during and after conflicts.
33M. Toole, ibid.
30
31
9
Internafly^Drspfaced Persons', Health’
information is used to monitor food distribution is universally accepted as WHO’s responsibility34.
Guidelines for therapeutic feeding are another of WHO's responsibilities. Furthermore, disease
consumes nutrients^ only proper preventative and curative health care can optimise food aid.
iv. ) Shelter, sanitation and the environment are primary determinants of health. Exposure can be
a fatal hazard, especially for weakened persons; IDPs must have shelter, blankets and clothes.
Shelter has also direct implications on the use of impregnated bed nets against malaria, while
hygiene and good environmental management are generally needed to control vectors of disease.
As with water, there are minimum standards for sanitation that are essential for people's health and
dignity35. Good programmes need the full support of the beneficiary community that should be
given responsibility and the means to fulfil it according to local norms and cultural acceptability.
Again, WHO will provide the technical guidelines and measures of effectiveness for activities that
are responsibility of sectors other-than-health but that have impact on the people’s health status.
v. ) If the other vital needs are not satisfied, health services alone cannot save lives. However
adequate health care is another primary concern; IDPs are at increased risk of illness and death.
WHO must ensure the public health component of assistance is technically sound. Some
overarching principles apply36:
>
The absolute priority is to keep, or bring the daily crude mortality rate below 1 per 10,000
population and the daily under-five daily mortality rate below 2 per 10,000 children loss than
five years old.
> Appropriate decision-making for health and nutrition in IDPs situations depends on reliable
information and a focus on disease prevention and health promotion37. Rapid health
assessment and epidemiological surveillance in such situations are responsibilities of WHO .
Establishing surveillance systems in IDP camps is fairly easy. It is much more difficult when
IDPs are hosted by friends, families, volunteers etc - and often not properly registered. WHO
sees its responsibility as facilitating integration between the national health information
system, those set in place by external partners, e.g. international NGOs, and local structures,
e.g. the national Red Cross/Red Crescent society.
> In the early 1990s, experience showed the most prevalent diseases in IDPs situations affect
mainly children and are readily preventable or treatable39. The events in the Balkans and the
patterns of illness prevailing among IDPs in Europe and elsewhere have triggered more
thinking, especially in terms of public health measures for victims of violence, chronic
conditions and equitable referral systems. HIV/AIDS and tuberculosis are infectious hazards
common to any context and, together with malaria, the most difficult to tackle. Reproductive
health is gaining more and more ground as a primary need, as is mental health. Nonetheless,
the fact remains that IDPs situations occur mostly in developing countries and that major
causes of mortality can be prevented by proven, low-cost public health interventions. Measles
immunisation is one of these priority interventions40.
>
Community participation in a co-ordinated health programme is always an advantage in the
provision of health and nutritional support services, and has a value in itself, particularly in
terms of mental health. Community participation implies identifying and bolstering the assets
and capacities of the beneficiaries. IDPs carry along their personal skills, and their coping
strategies must be encouraged and supported. As a minimum practical step, WHO can and will
34 EHA consultation, ibid.
35 The Sphere Project-Humanitarian Charter and Minimum Standards in Disaster Response. First final edition 2000.
36 ‘First International Emergency Settlement Conference: New Approaches to New Realities, Emergency Settlements’ ApriH996,
University of Wisconsin - Disaster Management Center.
37 M. Toole, ibid.
38 EHA consultation, ibid.
39 ‘First International Emergency Settlement Conference, ibid.
40 M. Toole, ibid.
10
k
•
Intemalfy Displaced Persons, Heaitti and WHO
insist with national authorities and international partners that any health worker among the
IDPs has her/his qualifications recognised and made use of, including proper remuneration.
—; are also impoverished, in poor health and lacking food,
> Where those hosting the 'IDPs
assistance should reach all, both the displaced and the surrounding community. Under the
disaster reduction principle of "doing the most for the most , it seems advisable to first address
vulnerabilities by area and only subsequently target specific groups. Since the early 1990s, on
the basis of experience gained in Central America and Southern Africa, WHO has been
promoting community-based approaches that aim at empowering the host communities to
assist IDPs41.
V. Operationalising the principles in WHO
‘Public health... can be effective only in as much as the security of victims of armed conflicts is
guaranteed. Security embraces the sustainable satisfaction of needs and respects basic rights of
human beings.,42
As long as IDPs remain inaccessible and therefore not identified, nothing can be done to safeguard
their health. In such contexts, and in IDP situations in general, WHO sees advocating and negotiating
for secure humanitarian access as integral parts of public health promotion. Possibly the most
important task for WHO is to support local NGOs on the basis of humanitarian principles, because
they are generally the ones that have the best access to IDPs. WHO’s moral authority prompts it to act
as an interface between the ministry of health and the local NGOs dealing with IDPs, minorities and
special vulnerable groups.
A key element of preparedness planning and a priority for inter-sector/agency co-ordination is to
identify trends, flows of displacement, points of passage, and most suitable (or likely) areas of shelter.
This will allow assistance to IDPs en-route and preparation of local health systems to assist the
newcomers. Furthermore, all plans should make contingency provisions for sudden increases
originating from inaccessible areas, i.e. new IDPs carrying along a "public health backlog of missed
opportunities for ante-natal care, immunisations, etc.
Humanitarian co-ordination must bring UN agencies, national authorities and the military together
with the Red Cross (ICRC, IFRC and national societies) and NGOs working in or near the conflict
zones. It is at this stage that protection, access and informed response become critical elements for the
survival of IDPs. Country expertise, situation analysis, human rights, vital health needs and best public
health practices must be combined to provide the basis for planning, humanitarian diplomacy and for
operational arrangements. Parties to the conflict - if that is the cause of displacement - must be
integrated in these processes. WHO can contribute to humanitarian intelligence, negotiations, planning
and monitoring with data from the country’s health profile, public health standards, need assessment,
epidemiological surveillance and direct technical assistance.
At a certain point IDPs become accessible and "visible". In some cases, IDPs are brought to a first
reception/transit centre by soldiers, such as after a military operation. Another scenario is that IDPs
gather spontaneously, for example by a source of water, a road or a city, and are met there by
humanitarian workers. More often, individuals or small groups seek shelter with relatives or friends in
a safer area; there they can be identified and assisted by volunteers, e.g. of the national Red Cross
society. In most cases, they will at least be registered by local authorities for security purposes.
WHO must engage actively with the actors who are most likely to be the first to meet the IDPs,
because it is they who can provide immediate, life-saving assistance. Preparedness is essential. Village
41 HEDIP-Health and Development for Displaced Populations, WHO/Emergency Relief Operations, 1993.
42 P. Perrin ‘War and Public Health: Extending the Concept of Public Health for the Victims of Armed Conflict’, from Health in
Emergencies, Issue 3, EHA/WHO, 1998.
11
•i •
Irrtemalty Dispi^ed Persons, Heattfrand WHO
health workers, Red Cross volunteers, local administrators, even party cadres can help pre-position
assistance close to inaccessible areas; at a bare minimum they can inform IDPs about which health
services are available where and how to access them. Agencies such as UNHCR, NGOs and the
military are the best placed to assist the IDPs in transit/reception centres. IDPs in spontaneous
settlements can receive a degree of first, immediate health assistance, e.g. rescue teams can administer
measles immunisation to all the displaced children they encounter. As health workers are often on the
front line of assistance to IDPs, WHO advocates that they have the knowledge and skills needed to
ensure that IDPs’ health encompasses their right to security and protection. Therefore, in countries
undergoing or at high risk of complex emergencies, WHO's programme Health as a Bridge for Peace
focuses on training health workers in humanitarian law, political analysis, negotiation, etc.
This is health co-ordination in practice: working with national or local authorities, from health and
from other sectors, with UN agencies and NGOs to ensure that all accessible areas can offer first
health relief; monitoring that relief fits the IDPs' needs; ensuring that relief has adequate systemic
follow-up and operational support; working for the IDPs to meet the security that comes from the
sustainable satisfaction of needs and the respect of the basic rights of human beings.
IDPs concentrated in camps or in shanties around safe towns bring dramatic challenges to public
health. As soon as possible, conditions of life must be improved by expanding and extending the
existing health systems. Improved water supply, food security, sanitation, housing and health care
delivery are essential. Keeping in mind the burden that the newcomers can represent for the host
community, WHO needs to advocate for an integrated, area-based approach, rather than a vertical,
vulnerable-group approach.
Also, in the Organization’s experience, historical evidence provides a warning that only cases of
extreme emergency justify parallel structures. Even if very strongly represented at local level, all
external interventions rely on national capacities - no matter how weak - for back-up and support, e.g.
hospitals, cold-chain systems or reference laboratories. For WHO, it is clear that international aid can
be detrimental by hiring away local workers, duplicating services and creating a two-tier health
system. In order to be immediately effective and then sustainable, external assistance needs to be co
ordinated, include local capacity-building and be carefully planned, so as to fit in the national systems.
Finally, if the medium-term perspective is to integrate IDPs in the host community, investment must
include education and the creation of economic opportunities. If this cannot be done where the IDPs
are concentrated, then public health concerns justify that they are moved elsewhere. Whether the crisis
at the origin of the displacement is solved or not, decisions must be taken, lest the IDPs' plight is
maintained indefinitely and, for instance, they become political hostages in peace negotiations. The
choice is between the IDPs returning home, which will often require rehabilitation in the area of
origin, or resettlement, which will necessitate investment in a new area. These are politically-loaded
decisions. Again, WHO has a degree of responsibility to see that they are taken and wants to
contribute on the basis of public health principles and its technical authority.
In rehabilitation and reintegration, caution is needed. Restoring the original health system is not
necessarily the right choice; arguably, what that was in place before the crisis - be it armed conflict or
natural disaster - was part of the structural cause of the displacement itself. Rehabilitation must not
recreate those conditions. For instance, rehabilitation must take into proper account the needs of
previously under-served, minority groups and ensure more equitable and appropriate access to health
services. Furthermore, all major crises bring change; this is particularly true for violent conflicts. Even
if damage to the infrastructure is limited, demographic patterns change, new social structures emerge
and new economic options are needed. Even the natural environment may be permanently changed
(e.g. by landmines). People will have new needs and, often, greater expectations. For some rural
communities, the move into IDPs camps can represent an experience of forced fast urbanisation, for
some of them, the first contact with health services.
12
if..'
Internally Displaced Persons, Heaiffi and WHCf
VI. Conclusion
All institutions risk reducing reality to what is covered by their mandate, or to what they are able to
deal with43. In WHO's view, its mandate gives it a comparative advantage in looking at internally
displaced persons: health is for all, not only for vulnerable groups. The fact that it is easier to assist
IDPs once - and as long as - they are concentrated in a camp should not overshadow their dynamic
predicament: a progressive "loss of health", first as psychological and economic insecurity then as
increasing physical suffering that forces the person to flee. IDPs are individuals who must move to
find new coping mechanisms and survive. All along this process there are points where health relief
can be provided to complement the IDPs' coping strategies, while action is taken to find the durable
solutions to which they are entitled.
No matter how dramatic or outright tragic, internal displacement is only a symptom of a wider public
crisis. The challenges that instability pose to humanitarian and developmental work are many: the loss
of legitimacy of national institutions, the difficulty of identifying critical stakeholders and negotiating
between them, the contradictions that may occur between transparency and neutrality, differing
agendas of the international community, e.g. economic sanctions imposed upon societies already
affected by structural crisis, to mention just a few44.
In addition to international health information exchange and liaison, WHO's mandate at country level
is to increase the resilience of iocai/nationai public health systems through technical co-operation.
During crises, the WHO country office must remain functional and be ready to advise on and adopt the
most suitable strategies. Arguably, a key indicator of WHO’s corporate performance is the way its
country programmes withstand the impact of crises and international relief efforts and are able to
accommodate new realities, such as IDPs.
Whatever the circumstances, WHO has the public health tools to ensure that the IDPs' vital needs are
met, thus preventing further deterioration of their health status. The challenge for the Organization is
to ensure that its country offices structure these instruments in strategies that are appropriate to the
context at hand. Regional and country experiences provide some hints45. They point to the need for
early intelligence and networking with a vast range of partners, for involving NGOs and civil society
at large in dialogue with health authorities and making IDPs active stakeholders of health assistance.
Another calls for the re-gearing of country technical co-operation, having all programmes remain
active and collaborating to meet the needs of the IDPs and to ensure that once a crisis is over there will
be no gap on the road to recovery. WHO offices can and must make their role in health co-ordination
tangible by providing partners with the "learning functions", i.e. documentation and health intelligence
that some indicate as essential46,47 for informed response in emergency operations.
If it is true that, as the technical reference for health, WHO can facilitate co-ordination of all aspects of
assistance to IDPs, then the Organization's mandate must be supported by presence and proximity.
Predictability, health intelligence, proactive networking and services to its partners and constituents
are at the core of how the World Health Organization exercises its responsibilities.
43 James Kunder, ibid.
44 EHA Inter-Regional Retreat, Neemrana Fort Palace, 28 February-2 March 2000.WHQ/EHA , April 2000
45 EHA Inter-Regional Retreat, ibid.
46 M.Bhatt, M.Reddick Retrospective Model for Orissa Learning Office-Issues Raised and Lessons Learnt. Draft report for
discussion at ALNAP meeting, London 6-7 April 2000
47 E.Pavignani, S.Colombo June 2000 "Health as a Bridge for Peace. National Health Systems and Protracted Humanitarian
Emergencies. Preliminary Findings from a Comparative Study on Angola and Mozambique. WHO/EHA, Geneva, June 2000
13
Internally Disp^ced Person^ Health'and' WHOX
What worked in Colombia?
A case study from PAHO
There are approximately 2 million Colombians deprived of normal access to health care due
to continued displacement with the country. Overcrowded conditions mean basic water and
sanitation facilities are inadequate.
AMRO/PAHO spearheads efforts to improve the quality of coverage of basic health care
and sanitation for the internally displaced. PAHO is promoting new partnerships between
NGOs, local authorities, local emergency committees and other health professionals so that
all are working together to:
♦ Facilitate access to health care for the internally displaced by disseminating information
on rights of IDPs;
♦ Develop standardised technical guidelines for local health personnel to ensure
consistency, co-ordination and professionalism;
♦ Strengthen local health delivery mechanisms to improve the quality of emergency health
response.
These activities illustrate how the humanitarian principles outlined in Section IV of this paper
can be implemented. Access of the IDP to assistance, which has been highlighted as a
major issue, is addressed by this project. Standardised guidelines, widely distributed to local
partners improve activities designed to meet the vital needs of the affected population.
Planning programmes that build human capacity through training and improve access to
health care facilities protect the health of the displaced population and of the host
communities.
(Source: ‘Health Project for the Internally Displaced Population in Colombia: Emergency
Preparedness and Disaster Relief Coordination Program, PAHO, Jan. 2000)
14
World Health Organization
Department of Emergency and Humanitarian Action
Presence and Surge Capacity for Public Health in Emergencies
Programme Brief, August 2001
Human survival and health are the cross-cutting objectives and the measures of success of all
humanitarian endeavour. WHO's goal " to reduce avoidable loss of life, burden of disease and
disability in emergencies and post-crisis transitions" is core to the humanitarian agenda.
WHO's Department of Emergency and Humanitarian Action (EHA) contributes to the
Organization's goal by ensuring that at field, regional and HQ level the Organization has the
presence and operational capacity needed to strengthen coordinated Public Health
management for optimal immediate impact, collective learning and health sector
accountability in the situations mentioned above.
Today, through its Representatives, Country Liaison Officers and Heads of Humanitarian Offices,
WHO is present in 148 countries and territories worldwide. In addition, WHO sub-offices are
becoming more frequent and expand the Organization's operational capacity in special situations:
from Somalia to Afghanistan, from the Caucasus to Africa's Hom and Great Lakes regions, from
Indonesia to Colombia, from Iraq to Angola. There is growing consensus across WHO that
"wherever we feel that something is bound to happen", the Country office needs to be
strengthened. In coordination between Country, Region and HQ, dedicated officers are appointed
as"EHA focal points" at country level. The strategic objective is to support the Host Country's
preparedness programme and ensure that whenever an emergency takes place, a public health
specialist is there to provide the first, life-saving action and advice (see WHO's Core Corporate
Commitments). Furthermore, following the example of PAHO, some strategically-sited WHO
offices are being given sub-regional functions for emergency preparedness and response, e.g. to
support and monitor cross-border humanitarian operations and capacity building. Similar
experiences are underway also in AFRO and are considered in WPRO. They are not yet
institutionalised, but represent a positive trend that deserves supporting and replicating.
Whatever WHO's presence at field level, though, an emergency- by definition- calls for extra
ordinary measures and resources. Therefore, WHO needs to have surge capacity to ensure that
its public health expertise is translated in concrete life-saving actions. The strategic objective is
to provide prompt additional public health resources as needed, when and where needed.
PAHO's experience is that much can be done by mobilising regional and sub-regional solidarity
and expertise. AFRO is consolidating regional rapid response health teams and was quite
successfill in Mozambique's floods of 2000. However, especially for complex emergencies,
external, international assistance remains critical. Donor countries, are increasingly
demonstrating their capacities and goodwill in this area, e.g. in Kosovo and Mozambique. Thus,
EHA is exploring the feasibility for WHO to enter arrangements with major donors, by which
human and material resources would be made available to the Organization for deployment "at
24 hours notice", with procedures similar to those adopted for the WHO Emergency Revolving
Fund. By appropriate induction briefing and technical monitoring, EHA would ensure that these
additional resources are in line with WHO's corporate strategy, technical views and standard
procedures. By coordinating a prompter and more focused health response in disasters, WHO
would greatly contribute to improving the global humanitarian relief scene.
For more detail, see www.who.int/disasters or contact eha@who.int
Getting your information out
a Take public information seriously You don't need to be at the media's beck and
call all day to be media-friendly, but you do need to be accessible if you are going
to get make the most of the inevitable media attention. Try and set a time for
media queries each day, especially if the situation is changing fast. Be prepared to
do one-on-one interviews with important media. If you have an information
officer, or a staff member with good communication skills ad a strong ability to
tract the situation as it progresses, consider giving them the authority to deal with
media queries directly and to manage access to you.
□ Face to face: press briefings Holding a daily (or even twice-daily) 15-30
minutes briefing - run by your spokesperson - either first thing in the morning or
later in the afternoon is the most efficient way to update media en masse in fast
moving situations. Face to face briefing is more efficient both for you and the
media than written materials. Sometimes in emergencies, one organization will
have responsibility for overall press briefing across the sectors. If so it's very
important to be physically present, to contribute, and to field queries on health
subjects. The aim is not only to have stories written directly about health issues,
but to ensure that health is present in broader reporting of the crisis.
□ Face to face: press conferences Hold a formal press conference when you have
something specific to say - an important issue to raise, action to urge, an appeal,
an impactful activity to announce - or bad news. Call the press conference
immediately you hear important news - bad news does not improve with age. Try
to have other partners/players there to add their comment.
□ On paper: situation updates Situation updates should be brief paragraphs
outlining what new information or issues have come to WHO that day (or later in
a crisis, that week). Look for new information or a new angle, don't simply
repeat. But also make sure you follow "running stories", for example, the number
of cases in an outbreak, the movement of people, the progress of sample
investigation. Be ready for requests for interviews or filming in the field
situations, which are opportunities to add emphasis and detail.
□ On paper: press releases Use press releases when you want to get a specific
piece of information or an issue to media outside the immediate crisis area. Say
clearly what your message is in the first paragraph - don't preamble. Then cover:
who, what, where, when and, very importantly, why what you are announcing is
important. Try to include a quote from the WR and, where appropriate, other
partners such as the Ministry, NGOs or agencies. Fax or email the release to local
and international media and news agencies, websites such as Relief Web and
WHO's emergency and humanitarian action sites, and "interested parties" such as
donors or NGOs.
□ On air; public service announcements If you want to get public health
messages across rapidly in an emergency, think sound. Radio is often the most
accessible, sometimes the only method of communicating with scattered and
scared populations.
For more information please contact Melanie Zipperer, Communication and Media
Relations Officer, Department of Emergency and Humanitarian Action, WHO, email:
ZIPPERERM@WHO.INT, mobile tel. (+41) 79 477 1722;
DISASTERS OCCcR WHEN HAZARDS MEE I VULNERABILITY
The Progression of Vulnerability
^2
1
ROOT CAUSES
DYNAMIC
PRESSURES
UNSAFE
CONDITIONS
DISASTER
HAZARDS
Lack of:
locations
• Training
Limited access to:
• Local markets
• Power
• Structures
• Resources
public life
Ideologies:
Macro-forces:
RISK=
Hazard+
Vulnerability
(R=H+V)
bacteria and
• Political systems
• Economic
systems
growth
risk
schedules
• Deforestation
• Decline in soil
productivity
.Adapted l‘roin:Fig 2.1 ‘Pressures that result in disasters: the progression of vulnerability’
At Risk Natural Hazards, people's vulnerability, and disasters by Piers Blaikie, Terry C annon. Ian Davis, and Ben Wisner
DISASTERS AND HEALTH
Vulnerability
Disaster
Hazard
Direct
morbidity and
mortality
Indirect
morbidity and
mortality
Impact on Environment
Health
Response
s c
AND
R O
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In September 2002, a World Summit on Sustainable Development (WSSD) will take place in Johannesburg, South Africa
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But asthma doesn’t discriminate, not between sexes, at
least. She could just as well be a boy. The medical fraternity is
sure though, asthma does prefer the affluent and the children
of affluence, more so. It is the curse of modernity. A morbid
attendant at the door to the new world, waiting to catch the
entrant unawares. A murderer that chokes 180,000 people to
death each year. And the lists of its victims only grow longer
each year with humans increasingly embracing a lifestyle that
is too cushioned to resist the onslaught of allergen.
Doctors try to fathom the method to the madness, predict a
trend. But trends emerge as chaotic as the life of an asthmatic.
January 15, 2002 Down To Earth
If you are not an asthma patient here’s how you can expe
rience the misery of one: take a deep breath. No, do not exhale.
Not just now. Hold it for 20 seconds. Now exhale. But only for
two seconds. Inhale again, holding it this time for 15 seconds.
Repeat this for intervals by holding your breath for 10-15
seconds more. Never before did oxygen feel this precious. To
slip from the precipice into an abyss, just about. To be pulled
back, finding your feet grounded again, only to fall back once
more. Repeatedly. Millions of people, often children, regularly
endure this near death experience. Attacks occur suddenly,
without any provocation. Today in India, about 15-20 million
asthmatics daily live this encumbering reality. One out of 10
children in the country are asthmatic. In Delhi alone 700,000
people live under the spectre of asthma.
Asthma is more prevalent in Australia, the UK and New
Zealand. In the us, asthma cases have shot up by 75 per cent
between 1980 and 1994. The disease kills 5,000 us citizens each
year. The rates of affliction are much lower in Asia — about
PREETI SINGH/CSE
eight per cent on an average, compared to the global average of
14 per cent. Across countries in Asia, and within each country,
significant variations exist.
But experts are unanimous that in case of India the disease
is one of the most underreported ones. In fact, nine out of 10
cases of asthma in children go undetected say some guessti
mate. And while children may be the primary targets, asthma
in adults too seems to be on the rise. The British Medical
Journal reports on a Scotland-based study that showed asthma
in adults to have doubled in the past two decades.
Baffled by figures
And the rate of those inflicted with the debilitating disease
increases by 12 per cent every decade. This is the world average
and it is a conservative figure. Real figures, however, may
never emerge. Diagnosing asthma is never easy.
A plethora of triggers bring the disease into play. Just as
the number of those afflicted rises, so does the list of triggers.
Environmental triggers like diesel, lifestyle-related ones like
junk food consumption — the range is maddening and frus
trating for the patient, the doctor and the researcher.
In India, data on asthmatics is not collected officially. The
data bank created could help find patterns — trends that help
focus medical and pharmacological research. So a comprehen
sive picture of the disease continues to elude experts.
Elsewhere, there is a great wealth of research on asthma, but
with little consensus. Some report that smoking, exposure to
allergen, dust mite or cockroaches cause asthma. Others
report that there is a genetic link. While one section of the
research looks for reasons behind asthma’s spread, the other
tries to find cures and disease mitigating drugs.
An asthmatic, trying to figure out just what triggers the
spasmodic dance of the devil inside, cannot wait for
a medical breakthrough or a cure. The asthmatic learns to
live with whatever drug regime is affordable, whatever pro
vides some solace. This moment.
Down To Earth January 15, 2002
ANALYSIS
Trigger happy
Asthma is easily caused. Innumerous allergen, from pollen grains to dust mite, play havoc, exacerbating the
disease. While experts are unable to reach a consensus, one thing's clear: modern lifestyle contributes to this disease
a
sthma affects people of all ages, runs in families and
can be severely debilitating, even fatal. It picks on the
/ % vulnerable children. Recent research suggests that
-A. ^-genetic, lifestyle, medical and environmental factors
combine together, often inextricably, to cause asthma. This is
undisputed. Researchers are now investigating other triggers
and risk factors such as family size, exertion, housing, socioe
conomic status and allergen in air and food that contribute to
its onset and severity.
Genetic causes
ATOPY: The propensity, usually genetic, for developing
immunoglobin E (igE) mediated responses to allergen is prob
ably the strongest identifiable risk factor for asthma develop
ment. A review of clinical evidence by Adnan Custovic of
Wythenshawe hospital in the UK in 1998 showed most asthma
patients to be atopic — they are prone to producing abnormal
amounts of IgE when exposed to allergen like domestic mite,
animal proteins, pollen and fungi. Atopy occurs in 30-50 per
cent of the population, but overall asthma prevalence is
usually much lower. In other words, most asthmatics are
atopic but only some with atopy will develop asthma. Yet,
when expressed in the lower airways, atopy remains among
the strongest predisposing factors for developing asthma. J K
Suri, head of respiratory medicine at Safdarjung Hospital,
Delhi, says, “While environmental factors aggravate asthma,
they cannot be supported without a strong genetic base.”
ETHNICITY: Asthma occurs among all races. Yet marked ethnic
differences have been observed. Minority groups are not only
asthma-prone, they also are more likely to die. African
Americans are 2.5 times more likely to die of asthma than
whites. Puerto Ricans have asthma rates 2-3 times more than
whites while, paradoxically, Mexican Americans have rates
significantly lower than whites, says Malcolm Blumenthal, a
professor of medicine at the University of Minnesota-Twin
Cities. Another study observed that in the group aged 5-34
years, asthma mortality rates were 0.5 per 100,000 in Chinese,
1.3 per 100,000 in Indians, and 2.5 per 100,000 in Malay sub
jects. Similar variations were seen for other age groups. In the
1960s, there was a rise in death rates in New Zealand, Australia
and the UK, and a decade later a second epidemic of deaths was
observed in New Zealand disproportionately affecting Maoris.
Scientists suggest western lifestyle may partly explain such dif
ferences, but exact reasons remain unknown.
AGE AND GENDER: That children are becoming increasingly
vulnerable to asthma is now confirmed. But the reasons are
poorly understood. Childhood asthma is more prevalent in
boys than in girls. However, this increased risk seems more
related to narrower airways and increased airway tones in
boys, which predispose them to enhanced airflow limitation.
growth OF THE CHILD: Asthma evolution depends on the age
of onset and possibly on the etiology of the disease.
Disproportionate foetal growth (large head and small trunk),
that is often associated with a birth weight of less than 2,500
gramme may carry an increased risk of developing asthma
during childhood or adolescence. Poor nutrition in under
weight babies may also impair basic immunological mecha
nisms. There is a correlation of early wheeze with reduced lung
function before the development of symptoms suggesting that
small lungs may be responsible for some infant wheezing that
resolves with the child’s growth. Asthma may disappear in 3050 per cent of children at puberty, but often reappears in adult
AIR ATTACK
A ir Pollution aggravates asthma.
/*\lndustrial smog (sulphur diox
El
ide particulate complex) and photo
chemical smog (ozone and nitrogen
oxides) are known to be triggers of
mass asthma attacks. Yet the causal
relationship is complex.
Asthmatics are the most sensi
tive group in a community, that is,
they suffer the most at lower levels.
Long-term exposure to even low
concentrations of particulate matter in air results in increased
rates of bronchitis and reduced lung function. Ozone reduces
lung function in a continuum, that is, higher the concentration,
longer the duration of exposure, greater the effect. Though sci
entific studies have found a wide range of sensitivity to sulphur
dioxide among both healthy people and those with asthma, says
World Health Organisation (WHO), even concentrations as low as
January 15, 2002 Down To Earth
Asthma incidences can be reduced
one part per million (ppm) can trigger an attack. These studies
also show that sulphur dioxide has continuous exposure
response relationships without any clear safe level, it points out.
Though research on asthma is yet to reach a consensus on the
exact mechanism and the quantum of effect of these pollutants
at different levels of concentration, most studies acknowledge
that air pollution triggers violent asthma attacks in pre-sensitised
atopic and normal individuals.
Although asthma prevalence is higher in industrialised countries, the direct role of air pollution has been questioned by some
studies. While a study of two German cities showed that asthma
and allergy were significantly more prevalent in the western city
of Munich with its heavy automobile traffic, as compared to
Leipzig in the east, which has heavy industrial pollution, a study
by the Centers for Disease Control and Prevention (CDC) shows
that lesser use of automobiles in Atlanta during the 1996 Summer
Olympics led to improved air quality and a large decrease in child
hood emergency room visits and hospitalisations for asthma.
ANALYSIS
THE ANATOMY OF AN ASTHMA ATTACK
The thin inner layer of
epithelial cells gets
eroded by the consant
mucous formation
causing the diffusion
of the more vascular
fluid. To compensate,
the epithelial cells
develop a thin layer of
basement membrane,
causing the basememt
membrane to thicken
which causes wheezing
»— inflammation
Mast cell
Cytokines
IgE
Eosinophil
When an allergen
interacts with a
T- cell (immune cells
produced by the
thymus) it
produces cytokines
contraction of
— the smooth
muscles
mucous
formation in
the airways
and brochioles
Membrane swells
and tightens muscle
Cytokines interact
with mast cells, the
immunoglobulin
E and eosinophils
Reduced airway
opening with
excess mucous
Muscle layer
contracts
-—IS?
Contracted and inflammed
bronchus of asthma patients
life and up to two-thirds of children with asthma continue to
suffer through puberty and adulthood.
Lifestyle factors
affluence: The prevalence of childhood asthma and atopy
varies widely between countries. Alistair Stewart doing a study
for the International Study on Asthma and Allergy in
Childhood (isaac) studied the correlation between gross
national product (gnp) and the symptoms of asthma and
other allergies in children from across 56 countries. A moder
ately strong correlation was established between gnp per capi
ta and the prevalence of asthma. This means the more the
income per capita, the greater the prevalence of asthma.
High-income countries like the us, Canada, New Zealand,
u
Normal
bronchus
Australia and the UK have an asthma prevalence rate of
between 20-30 per cent in these age groups. Many Latin
American countries like Brazil, Costa Rica and Peru have
an unusually high prevalence rate of around 20 per cent.
Though India and China have a lower prevalence rate
(between 4.2-6 per cent), the total number of asthmatics is
very high. Also asthma cases are underreported and poorly
diagnosed in India and China because of the stigma attached
to the disease.
Writing in Thorax, a medical journal published from the
UK, Adeola Olusola Faniran compared the prevalence of symp
toms in Australian and Nigerian children and found that
wheeze and persistent cough were less prevalent in Nigeria
(10.2 per cent and 5.1 per cent respectively) than in Australia
I
Telling difference
Jay controlling air pollution
Asthma prevalence rates in high-income countries
A study done in 1986-92 in Barcelona, Helsinki, Paris and London
like the US and Canada are higher than in
during 1982-92 showed a significant increase in the number of
low-income countries such as India
the reported cases of asthma with the rise in the air pollutant
■ Country estimates
< Centre estimates
0.4
leyels. Cases for adult asthma increased with the increase in the
nitrogen dioxide levels whereas the sulphur dioxide levels affected
'n
m
children.
2 0.3
§
Another study confirms that air pollution levels affect the chil
dren more than it does adults. The prevalence of asthma in school-
< children has been increasing gradually in Taiwan. High levels of
nitrogen dioxide, ozone, carbon monoxide, air-borne dust particles
and total suspended particulate were significantly related to 8-29 per
JU
g.o 0.2
s
€
cent increase in the asthma risk. A World Bank study states that in
a.
Delhi, one out of 10 children aged 5-16 suffers from bronchial asth
tT
ma, which is caused in part by air pollution.
Thus, even though there persists an uncertainty on whether air
pollution causes asthma, there is a wide consensus that it aggravates
the disease. Reason enough to operate on the precautionary princi
ple and reduce levels of air pollutants and exposure to them.
r
1
■ ?
•t _1 • ■
0.0
r
0
i
* i
• :
0.1
5,000
10,000
I(
15,000 20,000
25,000
30,000
35,000
GNP per capita (in US $)
source: Alistair W Stewart et al, The Relationship of per capita gross national product to
the prevalence of symptoms of asthma and other atopic diseases in children (ISAAC),
International Journal of Epidemiology 2001; No 30, pl 73-179
Down To Earth January 15, 2002
£3
ANALYSIS
(21.9 per cent and 9.6 per cent, respectively). Though there
was no significant difference in the overall prevalence of atopy
between the two countries (Australia 32.5 per cent, Nigeria
28.2 per cent), atopy was a strong risk for wheeze in both
countries. Despite this, Australian children had a higher
prevalence of asthma symptoms. This could be related to
various environmental factors, allergen exposure or to differ
ent racial susceptibility, genetic predisposition and environ
mental factors.
But the story is not as simple as it sounds. Hospital records
suggest that people of low socioeconomic status (ses) experi
ence higher mortality and morbidity in comparison with
people belonging to higher ses. A study done in London found
the severity of asthma cases being more prevalent in the
poorer sections. The poor seek treatment and admission only
when there is a crisis. They rarely follow a planned treatment
procedure and are under-users of primary healthcare facilities.
The attendance rate in casualty departments by the poor
during acute asthma attacks is four times more than other user
groups. Evidently, while the poor may suffer lower incidence
of asthma, when the disease does strike, it leaves them in a
worse situation than the rich.
Another study shows how the prevalence of severe asth
matic crisis increases inversely with the declining ses of the
patients. In Korea, mortality avoidable by medical interven
tion, defined as ‘mortality wholly or substantially avoidable by
adequate medical care’ decreases with the growth in socioeco
nomic conditions and health services. These studies show that
inequalities in health do exist. Are the poor more susceptible
and more exposed to trigger agents? If so, is it possible to mod-
Risk index
What gives rise to asthma in children?
Respiratory infections I
77
Spring and fall pollens I
53 ;
Weather changes
48
Exercise
'
42
Tobacco smoke I
12 J
■ r:
40
Cold air |
32
Animals |
28
28
Damp musty areas I
19
House dust I
14
Emotional factors I
14
Chemicals I 6.
Foods
87
20%
40%
■ Frequently/always
El
60%
■ Occasionally
80%
100%
Never
Source: Scott T Weiss et al. The prevalence of environmental exposure to perceived asthma
triggers in children with mild-to-moderate asthma. Data from the childhood asthma
management program (CAMP), Journal of Allergy and Clinical Immunology, Vol 107,
No 4, April, 2000
January 15, 2002 Down To Earth
Mighty mite
The dust mite too poses an exacerbate asthma
It lives in your pillow and if you
I have asthma it could be your worst
enemy. It is the dust mite.
The house dust mite are tiny (up
to 0.3 mm) arthopods, which revel in
the dust. Their numbers in a house
depend not on cleanliness, but on
the amount of moisture in the house. They eat the dust,
which comes from our skin all the time. They leave drop
pings everywhere they go. Their droppings contain left
over enzymes, which the mite use to digest the skin dust.
It is these enzymes that cause asthma and other allergic
diseases.
In fact, house dust mite and their droppings are the
most prominent cause of asthma worldwide. There is
ample proof that minimising mite leads to a decrease in
allergic symptoms. But, in practice it is proving to be
almost prohibitively difficult for most people to beat this
little pest.
One way found out of the vexing problem has been
the new patented bedsheet which prevents the mite from
breeding in the bed or the pillow or peircing through the
thickly knit fabric of the sheet.
ify some of these determinants of disease severity? But how
does this conform to the findings of the Isaac study on the
inverse correlation between income (gnp terms) and asthma
prevalence? It is time to design our health policies based on
epidemiological studies and demographic distribution.
SMOKING: There is now proof that while passive smoking
causes increased incidence of wheezing illnesses in the first few
years, it does not increase the risk of sensitisation to common
aeroallergens, an important risk factor for asthma that onsets
later. Surveys show that wheeze and asthmatic attacks are
more prevalent in children whose parents smoke.
DIET: The role of dietary factors is under scrutiny, but no clear
results have emerged. A recent paper in Thorax by Nariman
Hijazi investigated dietary and other factors for asthma in
Saudi Arabia where major lifestyle differences are found in dif
ferent communities. It found that family history, atopy and
eating fast food were significant risk factors for wheezy illness,
as were the lowest intakes of milk and vegetables and of fibre,
vitamin e, calcium, magnesium, sodium and potassium.
Studies show that low intake of fish may weaken asthma resis
tance and evidence suggests that intake of omega-3, a fatty
acid found in fish oil, may help keep the disease away.
It is also widely believed that food allergies are common
asthma triggers, though evidence is rare. Some food and addi
tives, including salicylates, food preservatives, monosodium
glutamate and some food-colouring agents, cause asthma
symptoms in some patients.
obesity: Obesity is associated with asthma symptoms regard
less of ethnicity. The association is consistent with the basal
metabolic rate because obese children are more advanced in
their maturation than other children. There is some evidence
that this association is stronger in girls than in boys.
>
ANALYSIS
Environmental triggers
ALLERGIES: The most important allergen are probably inhaled
allergen, like mite, fur of animals, fungi and pollens. Allergen
sensitise atopic persons by stimulating the development
of specific t lymphocyte cell clones and the production of
specific igE antibodies. Once a person is sensitised (that is, has
developed memory T lymphocytes and specific IgE), they are
likely to develop allergic inflammation upon re-exposure to
the same allergen.
The introduction of mite, the presence of large numbers of
insects and cockroaches in tropical countries are some impor
tant episodes in the history of asthma. Climate is important
because it is directly related to the amount of allergen present
in the environment. For example, a damp and warm climate is
favourable to mite and mould growth. Sensitisation to allergen
by exposure to sources like house-dust mite, cats, dogs, cock
roaches and smoke is strongly established, while other factors
are less strongly correlated.
Breathing easy
A hundred medicines, a dozen therapies but no cure,
that is the story of asthma treatment world wide.
Complementary medicine fill the vacuum
Chaotic trends
Every survey throws up different trends. But they are
all in agreement: asthma is on the rise globally
100
10
<u
I>
<u
i
o.i —
1950
S
m
1960
1970
1980
1990
In
2000
Year of survey
Source: D Jarvis, P Burney, 1998, ABC of allergies — the epidemiology of allergic diseases,
British Medical Journal; 316: 607-610
According to S K Kabra, an asthma specialist with the All
India Institute of Medical Sciences in Delhi, in the general
population of India, 60 per cent of the patients suffer from
asthma due to viral infections and 40 per cent of the cases are
due to allergen, pollens or seasonal variations.
urbanisation: Universally, levels of asthma in urban commu
nities seem to be higher than in rural ones. Yet, urbanisation
involves so many changes in environment and lifestyle that a
definitive explanation for this has so far been elusive.
Urbanisation with accompanying pollution appears to
be more directly related to increase in allergy. For example,
in polluted Swedish and Chilean cities, asthma has increased
drastically in the last two decades. In Japan, the increased
allergy to Cryptomeria japonica, soft wood pine, has been
attributed to sensitisation to urban diesel exhausts.
The trigger happy asthma needs just as many treatments
to catch it before it hits hard and to limit its effects. It is,
one must remember, controllable, even if not completely
comprehensible.
tn
:m
-w- * -yiTH increasing patients and many of them in
%
/ industrialised nations the market for asthma
%/ %/ drugs is growing rapidly. It is the eighth largest
▼
▼ selling drug market and possibly the most
profitable venture for pharmaceutical companies, at par with
profits made from cancer and heart diseases related drugs.
In the absence of evidence of the global growth of asthma,
sales of drug and medicines to treat asthma are a good indica
tor of how fast the disease is actually growing. According to the
us-based Asthma and Allergy Foundation, usa, spends us $2
billion annually seeking asthma and allergy relief and globally
the market is estimated to be at us $4.8 billion. Singulair,
Merck’s once-a-day leukotriene-antagonist medicine, alone
grosses worldwide sales worth us $860 million.
But compare this to the budget spent on research and devel
opment of drugs for asthma and one comes to know why the dis
ease is not finding any adequate response in the thousands of
prescriptions being handed out daily. The Pharmaceutical
Research and Manufacturers of America (pIirma) estimates the
total budget of asthma research is only us $1 billion of the total
us $80 billion industry. The revenues from asthma drugs
comprise about a healthy nine per cent of the total sales in
Down To Earth January 15, 2002
El
ANALYSIS
western markets according the World Pharmaceutical Outlook
2000. Just 15 years ago, in 1985, asthma drugs commanded only
1.5 per cent of the total global revenue. Against this backdrop,
one can evaluate the drugs, therapies and treatments present
today in the market for asthmatics.
Medication for asthma
Asthma is not yet curable and neither does any convincing
evidence exist yet to prove that it could be prevented.
It can, however, be treated and controlled. Good care and
a regimen of some expensive drugs can convert asthma from a
major handicap to a minor nuisance.
Treatment for asthma is based on the severity of the prob
lem faced by the particular patient. Three main types of treat
ments are usually recommended. The first set of medicinal
treatments is called bronchodilators. These make the muscles
around the airways relax. As this happens, air tubes open up,
making it easier for the patient to breathe. The other group of
medicines reduce swelling and irritation in the airways
and are collectively called anti-inflammatory drugs.
Corticosteroids are an example of such anti-inflammatory
steroids and are used very frequently. Anti-inflammatory
medicines help to control the inflammation of airways and
prevent the onset of asthma attacks. They work to reduce the
swelling in air tubes and keep them open for passage of air.
Consequently they also decrease the mucus.
Inhaled corticosteroids, which help relax the muscles
around the airways, are the most favoured these days. They
dominate the asthma market, accounting for one-third of
major-market sales of asthma medication. They are the most
effective long-term preventive medications since a greater
percentage of the dose is able to target the inflamed lungs.
Doctors also commonly prescribe other anti-inflammatory
medicines like cromolyn sodium and nedocromil.
Interestingly, sensitising to low doses of trigger antigens
can also be helpful in preventing asthma attacks. But this treat
ment is rarely done in India as it is too expensive and requires
a long treatment time with no assured relief. The risk also exists
of the patient suffering adverse reactions to the allergen.
resolve inflammation. On breaking the performance of med
ications into subcategories of response, differences can be
observed.
There does exist another kind of treatment that may be
helpful if asthma attacks are triggered by allergies. This treat
ment is called hyposensitisation therapy or allergy shots. In
India however, Kabra says, hyposensitisation therapy is prac
tised very rarely as patients are rarely subjected to allergy tests.
Quite often, patients through their own experiences are able to
identify the allergen.
Advances in medicine
A host of new medicines are also under development. Some
of them seek to better the node of delivery, while others seek to
optimise the chemical balances. Of all the therapies and
medicines under development, omalizumab, an anti
immunoglobulin E (igE) monoclonal antibody from
Genentech/Novartis, holds the greatest promise, believe
experts. The medicine is currently awaiting marketing
Asthma control regime
Step 1: Symptoms occuring less than once a week
Clinical features before treatment
•
•
•
•
Occurs less than once a week
Mild symptoms
Asthma symptoms during night
Normal lung function between
attacks
Daily medication required to
maintain control
• Medicines to be taken as needed,
orally
• Intensity of treatment depends on
severity of attacks
Step 2: Mildly persistent symptoms
Clinical features before treatment
• Symptoms more than once a week
but not more than once a day
• Attack may affect activity and
sleep
• Asthma symptoms during night
more than twice a month
Daily medication required to
maintain control
• Daily medications to control
symptoms and an anti
inflammatory along with
bronchodilator for night time
symptoms
Four steps to well being
E3
Based upon a set of symptoms, a stepwise approach is advised
for deciding the medication regime. A predetermined set of
symptoms is used to grade the severity of asthma attack. The
number of drugs used, type of drugs, dosage levels and the fre
quency of medication, all depend upon where the patient stands
on these four ‘steps’ (see box: Asthma control regime).
As in other medicines, the drugs are sold under brand names
and not generic names. They come in different forms, including
sprays, pills, powders, liquids and shots. When corticosteroids
are inhaled as in a spray, the risk of serious side effects is min
imised if not done away with completely. The chance of suffering
side effects increases when these medicines are taken in the form
of pills or as a liquid and that too over a long period. In case of
pills or liquids the patient needs to go for regular check-ups by a
doctor to make sure that the medicine works the best way. The
medicines ease the asthmatic condition but demand that a lot of
attention be paid to the usage and after care.
Although most medications aim to improve the lung func
tion when administered regularly, they differ in their mechanisms of action, in their offset of effect and how they actually
January 15, 2002 Down To Earth
Step 3: Moderately persistent symptoms
Clinical features before treatment
• Daily symptoms
• Attacks affect activity and sleep
• Night time asthma symptoms
more than once a week
• Need to use inhaled medicines
daily
Daily medication required to
maintain control
• Daily medications for control and
inhaled corticosteroid and
bronchodilator especially for
night time symptoms
Step 4: Severely persistent symptoms
Clinical features before treatment
• Continuous symptoms
• Frequent attacks and night time
symptoms
• Physical activities limited by
asthma symptoms
Daily medication required to
maintain control
• Multiple daily control medications
• High doses of inhaled and oral
corticosteroid along with
bronchodilator
Note: The presence of one of the features of severity is sufficient to place a patient in that category.
Source: Anon 2001, Asthma in America, asthmainamerica/slides/slideO.htm,
December 4, 2001
ANALYSIS
The cost of asthma
Best treatment is reserved only for the rich. The poor have to make do with ineffective substitutes
I Inder a global strategy for asthma management and
U prevention, the World Health Organisation has
prescribed international guidelines. These guidelines rec
ommend the regular use of prophylactic inhaled medication
along with inhaled bronchodilators. But do asthma patients
in poor countries receive proper treatment?
A survey conducted in 24 African and Asian countries
found that the treatment prescribed to most of the patients
in these countries fell far short of international guidelines.
Easy availability of oral drugs that are also cheap (98 per
cent of the centres had oral medicines) forced many doctors
to prescribe oral therapy rather than the recommend
approval. Dr Reddy’s Laboratories’ zafirlukast, a non-steroidal
leukotriene modifier launched recently in India, too holds
some potential. Leukotrienes are pro-inflammatory sub
stances released during pathogenesis of asthma resulting in
bronchoconstriction, oedema and inflammation. By selec
tively and competitively blocking leukotriene receptors, zafir
lukast helps in effectively controlling a range of asthma symp
toms and improves lung function. Available in oral pill form,
just two doses a day of the drug could provide 24-hour protec
tion from asthma attacks, claims the company. It remains to
be seen how effective this new oral dosage treatment will be,
given the physician’s existing preference for inhalers to treat
chronic patients.
Industry observers believe that the long-acting beta2 agonist-corticosteroid combination agents (which ease muscles
around the airways) will become the most popular choice,
replacing the single-agent inhaled corticosteroids and longacting beta2 agonists. Both combination agents offer more
convenient treatment regimens.
Therapeutically speaking, managing the disease has
improved enormously over the past 20 years due to advances
in both drugs and in the way these drugs are delivered.
Pharmacological treatment for asthma relies heavily on B-agonists and corticosteroids. The development of both classes of
drug combined with a general improvement in management
means that most patients with mild or moderate asthma can
have a relatively symptom-free life. Nasal sprays that treat
allergies have been improving. Older versions of the nose
sprays frequently caused allergic reactions because they were
essentially allergen in a water solution. Using a spray, patients
would endure allergy symptoms until their bodies built up a
tolerance to the allergen at hand. But researchers have learned
that giving patients a spray of cromolyn sodium first can stifle
a nasal spray’s allergy-inducing response, while still providing
protection against the allergen.
Other areas of developments involve the hunt for novel
allergy targets. Some also see room for improvement in existing
therapies. Innovating upon the allergy-shot method, a hi-tech
us-based lab recently cloned the genes for allergen contained in
cat dander and ragweed pollen. With genes in hand, they iso
lated the most potent portions of the allergen and then used
just those portions to create refined allergy shots. In theory,
these shots will deliver more therapeutic punch-over the
course of just a few weeks and with fewer side effects.
inhaled therapy. The cost of the beclomethasone 50mg
inhaler was 20 per cent of average local monthly income of
many of these poor people in these countries.
In comparison, the cost of oral drugs (90 salbutamol
4 mg tablets) was only 3.8 per cent of the average local
monthly income. A survey of general practitioners in Punjab
revealed overuse of ephedrine and an under-use of the
inhaled drugs because steroids are cheaper and provide
almost immediate relief.
The challenge of fighting asthma remains. It is time the
pharmaceutical industry makes effective inhaled medica
tion available at prices that are affordable.
Many experts believe that for a complex disease like
asthma such an approach would work only for a few allergen.
While the researchers practicing allopathic medicine
experiment with a handful of chemicals, trying to develop
the best possible mix for a drug that will be more effective
and have less or no side reactions, asthmatics have survived
the agony of a million gasps by trusting other schools of medi
cine. These complementary and alternative medicine systems
work out to be cheaper and more accessible, especially in
India’s case.
Alternative medicine
Complementary and alternative medicine (cam) systems may
not be a part of the mainstream and conventional therapy but
their popularity has only increased over time. Homeopathy,
yoga, herbal medicine and nutritional therapies — all are find
ing an increasing number of asthma patients converting to the
Future stock
Asthma drugs still in the pipeline
Generic name
Company
Age group targeted
Xopenex
Sepracor
4-11 years
Xolair
Tanox biosystems
6 years and older
Flovent
Glaxo SmithKline
4-11 years
Azmacort
Aventis
Not known
Ventolin
Glaxo SmithKline
4-11 years
Seretide
Glaxo SmithKline
Paediatric patients
Advair
Glaxo SmithKline
Not known
Asmanex
Schering-Plough
2-12 years
Aerobid
Forest laboratories
6 years and older
Xopenex
Sepracor
Newborn - 6 years
Pediavent
Ascent pediatrics
2 years and older
Foradil
Novartis
5 years and older
Asmanex twisthaler
Schering-plough
4-12 years
Oxsodrol recombinant
human superoxide
dismutase
Bio-technology
general
Premature infants
Cictesonide
Aventis
Not known
Source: Pharmaceutical Research and Manufacturers of America (PhRMA) website:
www.phrma.org\asthma\asthma-cures.htm (as of Dec 23, 2001)
Down To Earth January 15, 2002
EO
ANALYSIS
Faith fry
A family in Hyderabad uses a unique therapy
to treat thousands of patients
FJatients from across the country come to Hyderabad for
an unusual therapy using a live fish every year in the
summer on the Mrigashirakarthi day. The other three
doses are given on the following three nakshatras (con
stellation moons) in the next 45 days. About 156 years
ago, it is believed that a holy man blessed a well in a place
called Doodhbowli in Hyderabad. The water of this well
was used to make the mixture and passed on as a secret to
one Veerrana Gowd. It has been passed down three gen
erations to the current guardian, Shanker Gowd.
A secret herbal recipe is put into the mouth of a 2-2.5
inch river fish called murrel (Channa spp). The fish delivers
the medicine to the congested parts and in the process of
passing down the throat, its slithering tail and fins clear
the throat of phlegm. In case of vegetarians, banana could
be used as the carrier for the medicine. The patients are
told to follow a strict diet. The family provides the therapy
free of cost.
Last year a record 800,000 people gathered at the exhi
bition grounds in Hyderabad for the treatment. "Till now,
there haven't been any cases of side-effects," claims the
Gowd family. So every year patients suffering with this
disease come with the hope of getting cured forever,
whether they do is also a secret.
SIPRA DAS/INDIA TODAY
if
SIPRA DAS / INDIA TODAY
January 15, 2002 Down To Earth
fold, looking for long-term and cheaper solutions.
And there are innumerable such options for the suffering
to explore. Take for instance the ayurvedic herb, Coleus
forskholii, which has a bronchodilating effect or the Chinese
wonder herb Ginkgo biloba and Tylophora asthmatica, which
improve pulmonary function.
While allopathic practitioners continue to doubt the effi
cacy of herbal drugs, two drugs have already been launched in
the previous year —Resipicare (developed by Bafco) and
Asmon (developed by the Indian Institute of Chemical
Biology, Kolkata). Both manufacturers claim that their medi
cines effectively control asthma without any side effects.
Doctors assert that herbal drugs cannot replace steroids and at
best can be used along with an allopathic drug.
While these doubts may persist, a comparative study of cam
approaches done by George Lewith in Thorax finds that yoga
breathing exercises — pranayama in a particular modification
(called the Pink City lung exercise) is an effective therapy.
“Homeopathy too helps in improving the immunity of the
patient,” contends Chanda Shah, a practising homeopath in
Mumbai and an asthma patient herself. She, however, recom
mends the usage of injections or a nebuliser in case of severe
asthma attack.
Awareness, the ultimate tool
But the most important weapon in the fight against asthma,
believe doctors, is education. “Education should be our top
priority” says S K Chhabra. “Asthma guidelines are given to
general physicians abroad by associations like the British
Thoracic Society or global protocols like the World Health
Organisation. These should be observed here too and taught
in the medical curriculum. This would go a long way in the
correct diagnosis of the disease.”
And it is not only about educating the asthmatics but about
the doctors and medical researchers also learning more about
the disease. Government agencies and research institutions in
India need to wake up. The us government has specialised agen
cies like the National Allergy and Infectious Diseases, which spe
cialises in research and creating awareness in public. Even the
Environment Protection Agency educates about allergen like
pollution due critical periods. Australia and New Zealand have
special helplines and warning centres during the ‘allergy sea
sons’. The least that the Indian government can do is enforce
protocols like asthma management and create a platform for
educating patients. This is true for the entire world also.
Building a global research protocol on the epidemiology of the
disease remains an imperative that is yet not paid attention to.
Meanwhile, scientists continue to seek a cure, attacking
asthma from new directions, using a variety of disciplines —
genetics, physiology, cell biology, epidemiology and immunol
ogy — to converge on the problem. That’s a big change from
years ago, when only allergists and lung experts studied the
disease. The real challenge lies in comprehending the con
founding number of triggers that push the millions of asth
matics into a paroxysm of gasps. It seems that there is no silver
bullet despite so many triggers. Till one is found the sufferer
will need to wait, with bated breath. ■
With inputs from Sarita, D B Manisha, Chandrachur Ghosh,
Apurva Narain, Jennifer O’Riley, Rachita Jha (in Delhi) and
Pujita Krishna (in Hyderabad)
I
World Health Organization
Cluster of Sustainable Development and Healthy Environments
Department of Emergency and Humanitarian Action
CRITERIA FOR WHO’s INTERVENTION IN EMERGENCIES
WHO intervenes to ensure integrated response to public health concerns in
three typical emergency situations:
a) Emergencies where humanitarian concerns affect all areas. These are
situations usually managed through the Inter-Agency Standing Committee
with the support of the UN Office for the Coordination of Humanitarian
Affairs (OCHA) and are covered by the UN consolidated appeals for
complete emergencies (CAP). The UN appeals for natural disasters follow a
similar pattern inter-agency consultations, but is the affected Government
which has to launch its appeal for international assistance (which can then
receive, if needed, coordination support from the UN).
b) Health emergencies with an international dimension (e.g. Rift Valley fever
in Yemen) where WHO leads or co-leads the intervention and uses the IASC
mechanism to address the health hazards.
c) Situations where the health security of the affected populations or
humanitarian workers is at stake. Various areas of collaboration with OCHA
are developed in these cases (e.g., recently, on depleted uranium).
To clarify when the UN declares emergencies and on the role of the IASC, here are
relevant excerpts from the UN resolution 46/182:
“An Inter-Agency Standing Committee serviced by a strengthened Office of the United
Nations Disaster Relief Coordinator [to day OCHA] should be established under the
chairmanship of the high-level official with the participation of all operational
organizations and with a standing invitation to the International Committee of the Red
Cross, the League of Red Cross and Red Crescent Societies, and the International
Organization for Migration. Relevant non-governmental organizations can be invited to
participate on an ad hoc basis. The Committee should meet as soon as possible in
response to emergencies”.
... and from the Consolidated Appeal Process Guidelines endorsed by the IASC on 13
April 1994:
“The use of the CAP is principally to meet the demands of ‘major’ as well as ‘complex
emergencies’. Both major and complex emergencies are generally acknowledged to be
those which exceed the mandate and/or capacity of any agency and are deemed to
1
require a system-wide approach. The determination of a complex or major Emergency
will be made by the Inter-Agency Standing Committee (IASC), led by the Emergency
Relief Coordinator. It is assumed that, as is the case for most international responses to
disasters and emergencies, the initial request for assistance of a complex or major
emergency will come from the Government of the affected country”.
2
\~ i
World Health Organization
Cluster of Sustainable Development and Healthy Environments
Department of Emergency and Humanitarian Action
July 2002
WHO RESPONSIBILITIES IN EMERGENCIES
Human survival and health are the cross-cutting objectives and the measures ofsuccess ofall
humanitarian endeavour. Therefore, WHO's goal is '"to reduce avoidable loss oflife, burden of
disease and disability in emergencies and post-crisis transitions”.
This is achieved by ensuring presence and operational capacity in the field to strengthen
coordinated public health management for optimal immediate impact, collective learning and
health sector accountability.
Identifying priority health and nutrition-related issues and ensuring that these are properly
addressed in an integrated primary health care approach that preserves and strengthens local
health system.
J Strengthening health and nutrition surveillance systems to enable monitoring of any changes,
early warning of deterioration, and immediate life-saving action through outbreak response and
technically sound nutrition interventions.
J Ensuring control of preventable ill health particularly communicable and vaccine-preventable
diseases.
Ensuring that risks related to the environment are recognized and properly managed.
J Ensuring access to basic, good quality, preventive ^and curative care including essential drugs
and vaccines for all, with special focus on the especially vulnerable - the elderly, the very
young, pregnant women, the disabled and the chronically ill.
J Ensuring that Humanitarian Health Assistance is in line with international standards and local
priorities and does not compromise future health development.
J Advocating and negotiating for secure humanitarian access, and neutrality and protection of
health workers, and the operation of services and structures as integral parts of public health
provision.
J Ensuring that the lessons learnt in a crisis are used to improve health sector preparedness for
future crises and disaster reduction.
J Defining an integrated health policy for preparedness, emergency response and post
conflict, for a coherent health sector development resilient to emergencies, to link relief
efforts with national capacities and initiate future health system reform.
1
' i x-
I
Economic and Social Council
Humanitarian Affairs Segment
New York, 15-17 July 2002
Statement of the World Health Organization
WHO will continue to be active in conflicts and crises, taking exceptional action to
sustain health systems, to ensure continued delivery ofhealth services and to protect
the health of the population1.
The past year may go down in most people's memory as the "Year of September 11".
New players and new concerns entered the humanitarian arena. This offers opportunities
but adds in complexity to our work. It brings new responsibilities to the international
community.
More complex emergencies turned chronic; twelve months ago we were responding to
the unacceptable levels of mortality prevailing in the Democratic Republic of Congo2.
We saw the conflict subside in Sierra Leone but engender a spill-over in Guinee; and
now tensions flare-up again in Liberia. The poorest and most disease-ridden
communities continue to need, and often fail to receive, substantial relief and, while
polio is being eradicated, people continue to die of measles, pneumonia, diarrhea and
malaria. The cessation of hostilities in Angola shows us the magnitude of the
humanitarian needs of the newly accessible populations.
The escalation of violence in the West Bank brings forward pressing needs for
humanitarian relief. It runs in parallel with the ambitious challenge of assisting
Afghanistan on the way to national recovery while responding to the Afghan people's
persisting, large needs for survival and dignity in the face of man-made and natural
hazards.
Poverty continues as a major factor of vulnerability. As more people live in vulnerable
areas, hazardous materials and rapid urbanization contribute to tragedies such as the
series of explosions in Nigeria, the landslide in the garbage dump in Manila and the
recent railway disaster in Tanzania. Well-known seasonal hazards return: floods are
today's news in India and China like almost every year. Food shortages are re-occurring
in Southern Africa : they interact with structural poverty, political instability and high
prevalence of HIV/AIDS in a new humanitarian crisis that threatens at least 60 Million
people with an estimated excess daily mortality of 8,000.
1 Gro H.Brundtlan d, Pre-WHA Meeting of Commonwealth Health Ministers, Geneva, 12 May, 2002
2 International Rescue Committee. Mortality in Eastern Republic of Congo. New York, 8 May 2001
1
The fear inspired by bacteriological weapons calls the biomedical sciences and WHO on
the frontline of preparedness and response. However, all crises, whether man-made or
natural, are public health affairs, and the health sector is always on the frontline.
Therefore, humanitarian and emergency action is central to WHO mandate, especially
at country level, where each year one Member State out of five faces a major crisis. In
Dr Brundtland's words, we know from experience of responding to emergencies that
prompt attention to health issues - through the provision ofeffective interventions - saves
many lives."3
Emergencies are about people's survival and demand that we take exceptional action. For
too many people, today, continuing to exist in spite of drought, floods or war is a daily
challenge, and health needs are a major part of it. Factors of vulnerability and risk are
more complex than lack of food, shelter or protection: people die of preventable causes:
measles, malaria, diarrhoeas, tuberculosis, maternal deaths. 65% of epidemics occur in
complex emergencies, that also see the highest risk for HIV/AIDS, the highest rates of
child and maternal mortality by preventable causes, the greatest burden of disabilities,
the greatest challenges to the control of malaria and TB. Survival is the priority.
Ill-health is a major threat to survival and security. A prompt response is a political
imperative, of which public health is an essential component. Timely health intelligence
is a critical resource. Member countries, agencies and donors expect WHO, as UN
technical agency, to be the leader in evidence-based coordination of the international
health preparedness and response. Furthermore, the developing countries rightly expect
that WHO work for humanitarian action contributes to the recovery and further
development of local and national capacities in the health sector.
WHO is up to this challenge. Dr Brundtland clearly stated how emergency and
humanitarian action are central to WHO global functions. She went further, stressing the
need to protect health systems, to ensure access to the basic necessities for life even when
there are hostilities and to resist the modem military trend to target the vital infrastructure
of whole societies4. Emergencies or "exceptional situations" cannot be an excuse to
accept the unacceptable: they just make it imperative that exceptional public health action
is taken to ensure continued delivery of services and protect the population.
There are critical public health measures that are essential to save lives. The most
reliable indicators of emergency needs are health indicators, and human survival is the
ultimate measure of success or failure of humanitarian operations. WHO identifies
those life-saving practices, adjust them to the epidemiological and operational context
and ensures that they are applied in a coordinated effort by all humanitarian partners.
WHO has defined a set of "core commitments” in emergency for which it can be held
to account. This represents a priority list of what the health partners must ensure for the
survival of people in a crisis and, therefore, a model for preparedness plans. Around
these priorities, WHO promotes institutional capacities and linkages in member states
and partner agencies.
3 Gro Harlem Brundtland, Speech from CAP 2002: Reaching the Vulnerable, 27 November 2001.
4 Gro Harlem Brundtland, statement at World Health Assembly, Geneva May 2002.
2
Coordination is essential even if difficult, and there is great demand for quality standards
and accountability. WHO is ready to offer these for all. Sound and affordable
interventions are known for most risks. Translating knowledge into practice is difficult,
though, when interventions are mainly based on the values of the providers. Effective
action demands needs analysis, inter-sectoral understanding, an articulated view of all
factors of risk and of the synergies that exist between the different humanitarian inputs5.
A life-saving package from DRC
WHO responsibilities
Mid-2001, a joint UNICEF/WHO mission travelled across
the Democratic Republic of Congo to assess the health
crisis. Following this, the two agencies brought together
in a technical meeting health officials from four rebelcontrolled areas and from Kinshasa.
The meeting reached consensus around a minimum
package of health services, flexible enough to be applied
both in acute and chronic emergencies. Even in DRC,
life-saving activities can realistically be implemented at
community and at health unit levels against seven major
killers: malaria, measles, diarrhoeas, acute respiratory
infections, malnutrition, maternal risk and HIV/AIDS.
For this life-saving package to be implemented
effectively, security, safe water, shelter, sanitation and
appropriate general food rations are needed, together
with immunizations, vitamin A and curative health care.
These essential public health goods, in turn, require
cross-cutting support: epidemiological and nutritional
surveillance, functioning local health systems,
coordination of all partners, e.g. for the right treatment
against malaria, but also for water and food to be in
place, and as close to the needs as possible. This, in
turn, requires logistics and, of course, resources, that
need to be mobilised, while access and security have to
be negotiated.
All this starts by the rapid assessment: of the needs that
must be addressed, of what is already in place, of how
much else is required and of the constraints that must be
overcome.
✓
Identifying priority health and nutrition-related issues
and ensuring that these are properly addressed in an
integrated primary health care approach that
preserves and strengthens local health system.
Strengthening health and nutrition surveillance
systems to enable monitoring changes, early warning
of deterioration, and immediate life-saving action
through outbreak response and technically sound
nutrition interventions.
z
Ensuring control of preventable ill health particularly
communicable and vaccine-preventable diseases.
z
Ensuring that risks related to the environment are
recognised and properly managed.
z
Ensuring good quality and access to basic preventive
and curative care including essential drugs and
vaccines for all, with special focus on the especially
vulnerable - the elderly, the very young, pregnant
women, the disabled and the chronically ill.
z
Ensuring that Humanitarian Health Assistance is in
line with international standards and local priorities
and does not compromise future health development.
z
Advocating and negotiating for secure humanitarian
access, and neutrality and protection of health
workers, services and structures as integral parts of
public health promotion.
z
Ensuring that the lessons learnt in a crisis are used
to improve health sector preparedness for future
crises and disaster reduction.
System-wide accountability is hinged on the z Defining an integrated health policy for
preparedness, emergency response and post
Humanitarian Coordinators and at country
conflict, for a coherent health sector development
level WHO contributes through its
resilient to emergencies, to link relief efforts with
commitments to public health. We still have
national capacities and initiate future health system
reform.
much work to do in this respect.
Accountability is also predictability and long
term commitment. WHO agrees that the approach to humanitarian needs must be
medium to long-term in its perspective. At no time this principle becomes so valid as in
the transition from relief to recovery, when crises run the highest risk of turning chronic.
5 ...In the recent response to drought in the Horn ofAfrica, lack offunding to improve sanitation, water
supply, health and the agricultural sector reduced the effectiveness of all reliefprogrammes...' WFP.
Annual report of the Executive Director: 2001. Rome, May 2002
3
But prevention remains better than cure: greater resources need to be put into longer term
programmes that promote sustainable healthy livelihoods, and not only mere survival.
In the past months, the reception that decision-makers and the public awarded to WHO
Report on Macroeconomics and Health confirmed that the real health needs of the
people need more attention. The Report carries explicit benchmarks for financial
investment in the health sector, below which people cannot be expected to have enough
health to contribute to economic prosperity. These benchmarks provided useful
background at the Donors’ Conference on Afghanistan in Tokyo.
Public health is also evidence-based political action for equitable and effective allocation
of resources, and WHO has a responsibility in advocating for public health in all
domains. Thus, unfortunately, WHO must once again bring to the attention of the
Council the fact that the Health section of the UN Consolidated Appeals remains under
funded. Humanitarian accountability means also that all actors are given the resources
to perform at their best according to their mandate.
WHO work in the area of Emergency Preparedness and Response is guided by its
Governing Bodies and follows-up on ECOSOC Conclusions, on UNGA Resolutions
46/182, 47/168 and 48/57 and the ensuing processes of reform and inter-agency co
ordination. Following landmark resolution UNGA/46/182, the World Health Assembly
passed resolution WHA48.2 that defined WHO’s role as a founding member of the
Interagency Standing Committee, and WHO is an active member of the IASC/WG.
WHO approaches human survival and health in a broad perspective that encompasses
security, medical care, water, sanitation, nutrition, disease control, immunization, family,
reproductive, and mental health. WHO's goal is to reduce the avoidable death and
suffering that result from any natural or man-made disaster. This goal can be attained
only if all the determinants, factors and processes of vulnerability are acted upon, and by
taking a life-cycle approach to crises and extreme events: from primary prevention,
through mitigation, preparedness response and recovery.
Besides providing technical guidance to all whose work contributes to people’s survival,
WHO assumes specific operational responsibilities_such as health assessment and
surveillance, advocacy and coordination with health actors, particularly local and national
authorities. WHO vision in this area is one of resilient healthy communities that are
prepared to deal with the unexpected and ready to maximise the opportunities coming
from external assistance for better relief and prompter recovery.
Causes and features of crises, as well as humanitarian policies and practice evolve
continuously: the same as the theory and practice of public health. WHO’s work to
generate new knowledge in this area and to assist member countries and international
partners has to grow accordingly, and this process can only be open-ended.
In closing, WHO congratulates the Emergency Relief Coordinator for his intervention
at the beginning of the Segment, and thanks the other agencies and NGO partners,
members of the IASC, as well as ISDR for their effective collaboration, in testimony to
the tenth anniversary of UNGA 46/182.
4
As published on Prehospital and Disaster Medicine, May/June 2002
RELEVANTIN TIMES OF TURMOIL
WHO and Public Health in Unstable Situations
Alessandro Loretti, Xavier Leus, Bart Holstein
Challenges
The first principle of Health is life, and natural and man made disasters threaten life and health. For
millions of people world-wide, surviving the pressure of extreme events, be they drought, floods or
war is the predominant objective in daily existence.
One sees countries undergo periodical disasters along apparently immutable patterns. Economic
downturns combine with natural or technological hazards and trigger off emergencies wherever or
whenever the capacity is lacking to cope with them. The distinction between natural and humaninduced disasters is becoming more and more blurred: the consensus is growing that there are no
"Natural" Disasters. Natural or man-made hazards impact upon human vulnerabilities that are mostly
determined by human causes. Thus, all emergencies can be said to have political causes: either by
commission or by omission.
Complex emergencies are but the most blatant instances of this. Some countries have known only
armed conflict for the last 25 years and their number is increasing. And the 1990s, with the end of the
Cold War and Globalisation, have seen the redefinition of the role of states, sometimes their collapse
and the explosion of wars in contexts of extreme vulnerability. Mid-1999, humanitarian sources
reported 24 ongoing emergencies, each of them involving at least 300,000 people "requiring
international assistance to avoid malnutrition or death"A. All together, including the countries still only
at risk and those emerging from armed conflicts, 73 countries, l.e. almost 1800 million people, were
undergoing differing degrees of instability at that time2.______________________________________
"...This compounding of extreme climatic events with rapid economic and institutional transition - or
collapse - presents a complex profile for future disasters. The poor, forced to live on marginal
"Relief- -Develop
land in urban and coastal areas where jobs are concentrated will suffer most as the planet
ment Continuum
warms up and disaster strikes - 96 per cent of all deaths from natural disasters already happen
" seems to have
in developing countries [.....] The deadly combination of environmental change, economic
dropped out of
inequity and political inaction will dominate the future of the humanitarian scene.".
- IFRC, World Disaster Report 1999
the language of
the international
community. However, the issues underpinning that paradigm remain. Disasters and development are
closely intertwined. Development is about change in human and environmental systems. In a
context of fast increasing population and fast economic, technological and social transitions, changes
reach deeper and further. They become more radical and less predictable. They can engender
crises that are more likely to catch people and societies unprepared, outstrip their coping capacities
and lead to disasters.
Change is inherent to human reality and one can define as especially vulnerable those individuals,
communities and societies that have least means to influence and cope with the pace and shape of
change. The greater the pace and rate of change,
"When it comes to living in an environment of deteriorating
the greater the instability and the risk.
social service delivery systems which ultimately result in
Defining Instability
Instability can be envisaged along a spectrum
(Table 1). At one end, "Utopia" represents an
ideal all-stable, all-equitable, well resourced
society fully integrated and at ease in global geo-
catastrophes, people's tolerance levels tend to increase to
accept more episodes and interpret them as normal. The
longer the situation continues the higher the tolerance
level and the less likely another incident or event will be
interpreted as dangerous enough to trigger a response"
- De Rooy C, Shiawl T: Vulnerability analysis, Equipping
country offices to beter forecast emergencies in West and
Central Afria Region, a study financed by UNICEFEmergency Operations. Abidjan . Novermber 1996
*We use the term instability with a degree of liberty : a system that is unstable is not necessarily bad. Likewise, Chaos
refers to a system that lacks evident structure and where prediction is difficult.. Only In public parlance, it means "horrible,
fast-changing, high-risk situation and it is used here in this sense. For argument's sake, we use here "Chaos" and/or
"extreme instability" to identify situations of high-mortality-risk, where there are more negative health outcomes, or the
"likelihood of 300% plus increases in morbidity and mortality."
Page 1
I
As published on Prehospital and Disaster Medicine, May/June 2002
politics and economy . At the opposite end, in "Chaos", the society is shattered and societal factors
lie at the root of the crisis, e.g. because the State itself applies and promotes violence against its
own citizenry.The spectrum can be defined by the varying presence and interplay of natural and man
made factors of risk.
Natural and/or man -made hazards are absent or effectively managed in
"Utopia", while they are left unchecked and free to interact with each other until they "materialise as
disasters" in "Chaos".
pectrum
Table 1: The Instability Spectrum
CATEGORIES
Geography
"UTOPIA” «
------Easy access, good environmental
resource base
------------------ ►
CHAOS”
Poor access, e.g. landlocked
Environmental degradation
Climate
Absence of extreme phenomena
Drought, floods, storms
Geology
No major geological hazard
Earthquakes, landslides, volcanic
eruptions
Biota
Good balance between human
systems and potential pathogens
Epidemics, epizoonosis, pests
Human
Historically homogeneous; "normal"
demographic distribution
Unchecked Growth Rate;
"Demographic entrapment"; major
distortions in sex/age distribution;
ethnic diversity and strife
Economic Infra-structure
Sustainable and equitable availability of
natural resources
Stable and even distribution of
population
Violent conflict for vital re
sources: "infrastructural" violence
Forced human displacement
Regional Politics
Good relations
countries
Economy
Sustainable and equitable growth
Economic crisis
Society
Social cohesiveness and trust
Social disintegration; civil strife
Culture
Integrated, open to internal
external factors of change
Governance
Good governance
Structural & repressive violence
International Relations
Good integration in global economy
Marginalisation; sanctions;
"criminal" economy
State Policies
"Rule of Law"
Structural & repressive violence
Development Policies
Equity, participation, safety
Inequality; exclusion and violence,
technological disasters
Service Policies
Equitable, effective, sustainable
Collapse of services & lifelines
Capacities for
Emergency Management
In place, updated and sustained
Absent: total dependence on external
assistance
with
neighbouring
and
Armed conflict
countries
with
bordering
Strife among/against minorities
Cultural and political isolation
> +++
0 <
Instability Spectrum
At the "Utopia" end of the spectrum, as all surrounding systems are assumed to be in perfect
functioning, vulnerability is essentially individual and determined by biological factors. At the "Chaos"
end, vulnerability is primarily defined by socio-economic factors and largely collective. Conceptually
at least, there is a strong rationale for different public health approaches.
Page 2
As published on Prehospital and Disaster Medicine, May/June 2002
WHO and emergencies
All reality has implications for health, whether direct or indirect, and WHO's responsibility for health
does not cease in emergencies. On the contrary: as emergencies bring forward extreme challenges
to human life, medical and public health ethics make it imperative for the Organisation to be involved.
While working at how to optimise its comparative advantages, WHO cannot selectively shed elements
of its global responsibilities simply because they are complex or uncertain. Disasters, emergencies
and instability are public health concerns: dealing with them so to reduce their impact in terms of
illness and death is a fundamental responsibility of public health practitioners. WHO has to enhance
its presence and effectiveness in these situations in its capacity of universally accepted advocate for
public health.
The plight of people affected by any disaster is incompatible with WHO’s definition of Health: Article 2
of WHO's constitution specifies the Organization's mandate to assist governments and special groups
in emergency situations. At the same time, human survival and health are obvious cross-cutting
objectives of all humanitarian endeavour.
Furthermore as crises become more enmeshed with the crisis of legitimacy of the State and armed
conflicts become more directed against countries' social capital, they impinge more on WHO's work.
As a UN Specialised Agency accountable to its member countries, WHO has to reconcile its unique
responsibility in the health sector, the humanitarian imperative and the mandate to assist its primary
constituents.
WHO is not new to disaster reduction, nor to humanitarian action. Already in the 1960s WHO was
part of the UN operations in the newly independent Congo3. On the strength of that experience and of
that of Skopjie's earthquake, compounded by the need to meet the health needs of Palestine's
Occupied Territories4, around 1969-70 the Organization established a unit for Emergency Relief
Operations in the office of the Director General. In the 1970s, PAHO's Preparedness Program started
translating the epidemiological method into a regional program for disaster reduction. Since, the
Organization has never ceased to contribute to this area.
Also in "complex emergencies", well before the term was coined and before UNGA Resolution
46/1825, WHO had found ways to be effective in, and in spite of armed conflict. In the 1980s, PAHO
was a key player in the preservation and restoration of the health sector in Central America, an
experience that was to develop concepts of health as a bridge to peace and of integrated PHC for
refugee and host populations6. In 1988-92 in Mozambique7 and Afghanistan, WHO played a central
role in the first attempts at UN humanitarian coordination. The recurrent crises in the North and
Southern Balkans had WHO's Regional Office for Europe develop new approaches - the two most
significant, perhaps, the opening of sub-offices to get closer to the affected populations and a
declared "political" engagement to "Peace through Health.8 These experiences fed into various World
Health Assembly resolutions and a growing, although uneven, WHO's presence in large humanitarian
operations: from The Balkans to Africa's Great Lakes, from Indonesia, Iraq and East Timor, to West
Africa and Colombia.
In Somalia, WHO makes a difference in saving both lives and national capacities. In the recent
earthquake in Gujarat, it was WHO that ensured the first de-centralized humanitarian coordination in
the affected area. WHO's experience of integrated assistance to displaced and host communities as
a measure for post-crisis stabilization, in Central America, Mozambique, Sri Lanka and Bosnia
Herzegovina9, is still far from being mainstreamed in the field practice of operational agencies facing
"The Gap". WHO's cross-border health programs in the Horn of Africa, between the USA and
Mexico and between Thai and Myanmar have scarce equivalents in the international scene, at least
as far as inter-governmental cooperation is concerned. Major WHO's initiatives such as Roll Back
Malaria, Polio Eradication and Making Pregnancy Safer, include specific strategies for operating in
complex emergencies. In the most troubled continent, Africa, it is WHO that had its member states
adopt regional resolutions on peace as pre-condition for health10 and on the need for preparedness
against all emergencies, natural as well as man-made11. WHO presence in the Balkans and in
Central Asia strives at combining health policy development with emergency preparedness and
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stabilization. In Indonesia, WHO plays an important role in risk monitoring and is strongly committed
to capacity building in and programme promotion to foster health as a bridge for peace.
The Organization has specifically recognised that disasters, whether natural or resulting from human
activities12 can and do affect the achievement of health and health system objectives.
Within WHO, the Department of Emergency and Humanitarian Action (EHA) is the instrument for
intervention in such situations. Interestingly enough, EHA's predecessor, the unit of Emergency Relief
Operations, had been established for WHO to deal with the health aspects of a political crisis: the
one in the Palestine Occupied Territories. Resolutions 46.6 and 48.2 of the World Health Assembly
define the scope of EHA in terms of humanitarian action, emergency preparedness, national capacity
building and advocacy for humanitarian principles. Since 1997, a consultative process on WHO's
role in emergencies and unstable settings has been going on around EHA. After a consultation on
what the operational partners expected from the Organization in acute emergencies13, the process
accompanied the global debate in the public health and the humanitarian communities. This debate,
that recognises public health as a cornerstone of humanitarian action, is shifting its focus from acute
crisis management to mitigation, preparedness, and post-crisis transitions. The question of how to
preserve and restore people's health in a vast range of situations of instability is increasingly coming
into the limelight.
This process allowed to define WHO’s nine Core Corporate Commitments in emergencies (see Box
page 6), that is the technical public health priorities that WHO must ensure regardless of the
circumstances because key to reducing avoidable mortality and morbidity. On the institutional level,
when developing the agenda of their 2nd Global Meeting in March 2001, WHO Country
Representatives from all over the World requested that Disaster Preparedness and Response be
included as a separate item: in Geneva, they reviewed together the lessons learnt at country level
and made important recommendations as to how WHO's responsibilities can be translated into
practical activities in context of instability and emergency14.
Table 2: The instability spectrum and WHO's roles
Mode
------------
Emergency Mode
Development Mode
Scope
Technical
Partners
MOH
Concern
Individual
Focus
Care
Level
Country/Region
Responsibilities
(WHO
program or
department)
Programme/Strategy/Policy
"Political"
International Partners
IASC/WG
Collective
Management
Regional/Global
Global/UN
Emergency &
Humanitarian
Action (EHA)
e.g.
Injury Prevention
Mental Health
+++ "Chaos"
0 "Utopia"
◄
"unacceptable
numbers"
Coordination
Instability Spectrum
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Role of WHO in unstable situations
Looking at the " Instability spectrum" WHO's role changes (Table 2): from ensuring a two-way flow of
information on new scientific developments in public health in the ideal all-stable, all-equitable, well
resourced country, to dealing with sheer survival where the state is shattered or part of the problem.
National authorities are WHO's natural partners in "Utopia", while being able to work with/through
the "International Relief Community" and a variety of other partners under the umbrella of the
IASC/WG* is the condition for effectiveness in "Chaos". In such settings key priorities include
coordination of action and contributing to field relief activities, possibly collecting evidence that can
help mobilize international political solutions. The greater the instability of the environment, the less
health practitioners- the same as those from other disciplines - can do alone, and the wider the vision
and the capacity to understand and work in a multi-sectoral complex frame of reality.
Role and responsibilities are clear: how to satisfy them ?
WHO poses itself the explicit goals " to reduce avoidable loss of life, burden of disease and
disability in emergencies and post-crisis transitions" and "to ensure that the Humanitarian Health
Assistance is in line with international standards and local priorities and does not compromise
future health development'.
The planning tree depicted in Table 3 was
produced by WHO staff during a workshop on
Logical Framework Planning applied to
complex emergencies15. Given the overall
goal of reducing avoidable mortality and
morbidity (top in the figure), three specific
objectives were identified as critical: reducing
the risk from diarrhoeas, from acute
respiratory infection, malaria, epidemics- first
of all measles, and from acute malnutrition**.
Proceeding further upstream, for these risks
to be reduced a number of outputs are
needed.
Safe
water,
shelter and
environmental sanitation need to be in place,
together with immunization and distribution of
vitamin A, curative health care and
appropriate general food rations.
Always
proceeding from top to bottom, these five sets
of essential public health "products" in turn,
require to be sustained by precise activities:
epidemiological and nutritional surveillance,
preserving and strengthening local health
capacities,
coordinating
all
operational
partners, e.g. for water, sanitation and food to
be ensured. This is a good summary of what
is expected by health field workers in an
emergency
Table 3: Humanitarian response: health
goal, objectives, outputs and activities
MORTALITY REDUCED
______L
Safe
water
made
available
f
=
_____
Risk from
diarrhoeas
reduced
Risk from A.R.I.
malaria, measles &
other epidemics
reduced
I
Sanitation
made
available
LZ
=--- 1~--I
Measles
immunization
& VitA
made available
I
= I
Disease
surveillance
established
Local capacities
preserved and
enhanced
---- 1_______
Risk from acute
malnutrition
reduced
I
Curative
care
made
available
I
_]_____
General
ration
made
available
ZJ
Coordination
of all partners
established
I
Resources deployed to the field
I
RESOURCES, LOGISTICS & ACCESS SECURED
I
Partners
mobilized
I
I
Suppliesmobilized
Special Agreements
negotiated
ZZJ
FUNDING SECURED
I
For these activities to take place, resources
__________
I
must reach as close to the needs as possible.
| Needs, capacities & constraints assessed |
This, in turn, requires access, logistic
capacities and, of course, the resources
themselves. Human and material resources and, partially, logistics, depend essentially on
availability of funds that need to be mobilised,
* Inter Agency Standing Committee Working Group
** the case studies discussed at the workshop focused essentially on Africa: in the context of The Balkans, for instance,
greater attention should have gone to the risk for intentional injuries.
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Access - and thus, to an extent, logistic options - require that special agreements and procedures
are negotiated. This aspect is especially relevant in complex emergencies. However, in different
ways, e.g. as standing operating procedures, pre-defined legal provisions, by-laws and
it constitutes a important element of all emergency management
delegation of authority,
systems.
The planning tree "is rooted" in the rapid
assessment: of the health needs that must be
addressed, of the capacities already in place and
of how much else is required so that the needs
can be met, and of the constraints that must be
overcome -e.g. by negotiating humanitarian
access and the assumptions that must be
monitored for the project to be successful.
WHO Core Corporate Commitments
✓
Strengthening health and nutrition surveillance
systems to enable monitoring of any changes,
early warning of deterioration, and immediate
life-saving action through outbreak response
and technically sound nutrition interventions.
The planning tree reflects with fair accuracy the
list of WHO's Core Corporate Commitments. In
practice, reducing avoidable mortality and
morbidity in emergencies requires that the
Organization has the operational capacity in the
field and the credibility needed to ensure
coordinated Public Health management for
optimal immediate impact.
By deploying public health emergency experts,
or other specialists according to the needs, WHO
can identify priority health and nutrition needs
and ensure that these are properly addressed.
As long as the rapid health assessment is
properly connected with the institutional memory
of the WHO country office, the Organisation can
also immediately prepare to bridge the gap
between relief and recovery, by having life
saving priorities addressed in an integrated
primary health care approach, thus preserving
and strengthening local health systems. Besides
fulfilling the priority humanitarian responsibility,
this will also satisfy WHO's mandate in
contributing to collective public health learning
and health sector accountability.
Identifying priority health and nutrition-related
issues and ensuring that these are properly
addressed in an integrated primary health care
approach that preserves and strengthens local
health system.
Ensuring control of preventable ill health
particularly communicable and
vaccinepreventable diseases.
Ensuring that risks related to the environment
are recognised and properly managed.
Ensuring good quality and access to basic
preventive and curative care including essential
drugs and vaccines for all, with special focus
on the especially vulnerable - the elderly, the
very young, pregnant women, the disabled and
the chronically ill.
✓
Ensuring that Humanitarian Health Assistance
is in line with international standards and local
priorities and does not compromise future
health development.
✓
Advocating and negotiating for secure
humanitarian access, and neutrality and
protection of health workers, services and
structures as integral parts of public health
promotion.
Ensuring that the lessons learnt in a crisis are
used to improve health sector preparedness for
future crises and disaster reduction.
✓
Defining an integrated health policy for
preparedness, emergency response and post
Whereas it is true that, WHO's main role is
conflict, for a coherent health sector
supporting the Ministry of Health through national
development resilient to emergencies, to link
relief efforts with national capacities and initiate
officers, there is growing awareness that in
future health system reform.
emergencies this is not always the only nor the
- WHO/EHA, 2000
best avenue for action. Supporting the Ministries
of Health is essential, important and effective in
many instances. However, WHO is increasingly recognising the need to take a wider view of the
health sector and often to adopt different strategies as well as seek new health-relevant partners.
Adopting a precise operational approach, WHO has learnt to decentralize its country activities
during a crisis in order to ensure effective coordination of health relief where it is more needed
and to improve accountability and credibility14.
This has been proven by experiences in countries where war, conflict and displacement are
combined with a deteriorating health situation, epidemics and a sudden increase of relief
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assistance, by donors and NGOs. These experiences formed the basis of the consensus that
developed at the 2nd Global meeting of the WHO Country Representatives mentioned above.
Looking at the health challenges posed by the current global context , the "role of WHO in
emergencies" does not call for further debate. Neither do WHO's responsibilities: among member
countries and partners there is fair consensus that only WHO, as the UN Technical Agency for
Health, is in the position to meet them unchallenged, Across WHO, high level political
commitment is growing. In strategic terms, the next step is now for WHO to achieve deeper
institutional understanding and define the modus operand! that is more suited to fulfil this role and
responsibilities in practice.
Moving ahead: making a difference and building a reputation
WHO needs to improve its own performance for the benefit of the populations affected by all
disasters, as well as in order to fulfil its normative role with additional tools for public health
management and to increase its accountability vis-a-vis member countries and international
partners. This requires three key pre-conditions: presence, surge capacity and institutional
support, knowledge and competencies.
Today, through its Representatives, Country Liaison Officers and Heads of Humanitarian Offices,
WHO is present in 148 countries and territories worldwide. In addition, WHO sub-offices are
becoming more frequent and expand the Organization's operational capacity in special situations:
from Somalia to Afghanistan, from the Caucasus to Africa's Horn and Great Lakes regions, from
Indonesia to Colombia, from Iraq to Angola. There is growing consensus across WHO that
"wherever we feel that something is bound to happen", the Country office needs to be
strengthened.
In coordination between Country, Region and HQ, dedicated officers are
appointed as"EHA focal points" at country level. The strategic objectives are to support national
preparedness in the health sector, so that all member countries achieve readiness and selfreliance in the face of disasters, and to ensure that whenever an emergency takes place, a
public health specialist is there to provide the first, life-saving action and advice. Furthermore,
following the example of PAHO, some strategically-sited WHO offices are being given sub
regional functions for emergency preparedness and response, e.g. to support and monitor crossborder humanitarian operations and capacity building. Similar experiences are underway also in
AFRO and are considered in WPRO. They are not yet institutionalised, but represent a positive
trend that deserves supporting and replicating.
Whatever WHO's presence at field level, though, an emergency- by definition- calls for extra
ordinary measures and resources. Therefore, WHO needs to have surge capacity , to ensure
that its public health expertise is translated in concrete life-saving actions. The strategic objective
is to provide prompt additional, appropriate public health resources as needed, when and where
needed. PAHO's experience is that much can be done by^nobilising regional and sub-regional
solidarity and expertise. AFRO is in fact consolidating regional rapid response health teams and
was quite successful in Mozambique's floods of 2000. However, the reality is that, especially for
complex emergencies, the capacity to deploy international reputedly neutral experts through
external assistance remains critical. Donor countries, are increasingly demonstrating their
capacities and goodwill in this area, e.g. in for the crisis in Kosovo, the earthquake in Turkey and
the floods in Mozambique. Thus, EHA is exploring the feasibility for WHO to enter memoranda of
understanding with major donors, by which human and material resources would be made
available to the Organization for deployment "at 24 hours notice", under arrangements similar to
those adopted by OCHA for the UNDAC Team and within WHO for the Emergency Revolving
Fund. By appropriate induction briefing and technical monitoring, EHA would ensure that these
additional resources are in line with the Organization's corporate strategy, technical views and
standard procedures. As a matter of fact, by guaranteeing a prompter and more focused health
response in natural and man-made disasters, WHO would also contribute greatly to improving the
global humanitarian relief scene.
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The tension between the
"The humanitarian imperative ( the idea that human suffering demands a
response) fundamentally differs from the concept of development
humanitarian imperative
co.operation....When alleviating poverty through development, the
and developmental work
sustainability of the benefits of a given intervention is often the overriding
is considerable ( see,, box
indicator of success or failure while the alleviation of human suffering is usually
in this page) But public
an indirect impact of the development process. In humanitarian action, the
immediate imperative is concerned with saving lives and alleviating human
health professionals go
suffering....Development is widely recognised as a politicised process
back a long way in
whereas, historically, humanitariasm was perceived to be independent or
reconciling the apparent
neutral... However, most humanitarian agencies today acknowledge that
dualities of Health versus
humanitarian aid is rarely non-political and neutral( Greenway, 1999)....
Starting with the Hippocratic Oath ( whereby "The health and life of the patient
Disease, and Prevention
will be the first consideration"), justifications for provision of health services
versus
Cure.
And,
have always been intrinsically anchored in the humanitarian imperative. The
however, WHO is more
Hippocratic Oath makes no reference to sustainability of poverty alleviation.
than a humanitarian relief
Gro Harlem Brundtland has stated that "Health is the cornerstone of
humanitarian assistance, its ultimate objective, and the true yardstick against
agency. It is also a UN
which
one can evaluate needs for, and the overall performance of
Technical
Agency,
a
humanitarian assistance"
"Learning
Organization"
that is primarily geared to,
- Diskett P, Christoplos I: A forward looking study of health contributions in
humanitarian assistance Stockholm. Swedish International Development
and genuinely reflects its
Cooperation Agency, 2000
Member States' priorities
for sustainable
public
health. The Organization's work in emergencies cannot go divorced from this wider responsibility.
Under the pressure of emergencies, it is too easy for external actors to ignore, if not trample over
national and local health systems, and bring immediate - and valuable - relief at the expenses of
sustainable long-term health outcomes. Aspects of WHO's modus operandi may need to change
in order to accommodate the "extraordinary measures" imposed by emergencies, but the
Organization's views and concerns remain key for sound public health practice also in
emergencies. It is thanks to its so often discussed "special relation" with the national health
sector that WHO can ensure that best public health practice in emergencies stem also from the
experience and the needs of the beneficiaries and not only from the capacities( or mandate) of
external actors. Thus, in order to be effective, WHO's presence and surge capacity in
emergencies need to integrate the institutional knowledge, the competencies and the managerial
set up of the Organization.
This means that the additional human and material resources deployed to ensure WHO's
presence and/or surge capacity are predictably in line with the Organization's corporate strategy,
technical views and standard procedures. Meanwhile, WHO country and regional offices need
permanent access to technical expertise. Furthermore, their views represent the reality check of
this expertise in emergencies, and they must be fed into the Organization's resource-allocation
processes and institutional memory, as well as into global action for humanitarian assistance and
development.
References
1 National Intelligence Council, August 1999.
2 WHO: Planning Ahead for the Health Impact of Complex Emergencies, Geneva: World Health
Organization, discussion draft, December 1999
3 Personal communications from Mr. C. de Ville de Goyet
4 Personal communications from Mr. S.W.A. Gunn
5 UN: Resolution A/RES/46/182 Strengthening of the coordination of humanitarian emergency assistance of
the United Nations, New York: United Nations, December 1991
6 Guerra de Macedo C: Health for peace in Central America. Bulletin of the Pan American Health
Organization 1986; 20(1 ):62-66
7 Pavignani E, Colombo A: Providing health services in countries disrupted by civil wars. A comparative
analysis of Mozambigue and Angola, 1975-2000 Geneva: World Health Organization / Emergency and
Humanitarian Action, February 2001
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8 Hess G: The WHO/DfID Peace Through Health Programme Geneva: World Health Organization,
September 1998
9 Weiss Fagen P: Evaluation of Health and Development for Displaced Persons (HEDIP) Geneva: War-torn
Societies Project, UNRISD, April 1995.
10 WHO: Resolution AFR/RC46/R4 , Health and Peace Brazzaville: Africa Regional Office, September 1996
11 WHO: Resolution AFR/RC42/R11 Emergency preparedness and response, and humanitarian assistance
in the African Region Brazzaville: Africa Regional Office, September 1993
12 WHO: Resolution WHA 46.6, Emergency and humanitarian relief operations Geneva: World Health
Organization, May 1993
13 Toole MJ: Health Coordination in Emergencies: Options for the Role of WHO Geneva, World Health
Organization, concept paper, 1997
14 WHO, Report from the second Global Meeting of WHO Country Represantatives and Liaison Officers
Geneva: World Health Organization, unpublished draft, March 2001
15 WHO, Internal WHO/EHA workshop: Planning by Logical Framework Approach, Addis Ababa: September
1997
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