History and Hope: The International Humanitarian Reader

Evidence-Based Health Assessment Process in Complex Emergencies

288 Disaster assessment is defined as the “survey of a real or potential disaster to estimate the actual or expected damages and to make recommendations for preparedness , mitigation and relief action.”1 In natural disasters, such as rapid onset earthquakes and cyclones, the health consequences are usually the direct results of injury or death. Often, however, the greatest toll on humans comes from the unappreciated long-term secondary effects as seen with slow moving droughts and massive flooding. Zwi has defined complex emergencies as “situations in which the capacity to sustain livelihood and life are threatened primarily by political factors and, in particular , by high levels of violence.”2 The most common complex emergencies of the past two decades have involved famine and forced migration. Since the 1980s, few famines have occurred that were not human-induced, and many famines catalyzed the onset of complex emergencies. The most severe consequences of population displacement have occurred during the acute phase, when relief efforts have not yet begun or are in the early stages.3 Refugees (populations that cross internationally recognized borders) and internally displaced populations have experienced high mortality rates during the period immediately following their migration. Internally displaced populations, in contrast to refugees, do not enjoy the immediate protections under international law that are afforded to refugees by the UNHCR (United Nations High Commissioner for Refugees). They must fend for themselves without the benefit of basic healthcare services, food, water or sanitation that make up the protective infrastructure of refugee camps. Therefore, in complex emergencies, the health consequences are both directly and indirectly related to the conflict itself (Table 22.1).4 Historically, response activities in both natural and human-generated disasters have often been ineffective, both because of the poor quality of the information available as well as the manner in which an assessment was conducted. Disaster assessment and assistance activities are often hampered by organizational Evidence-Based Health Assessment Process in Complex Emergencies Frederick M. Burkle Jr., M.D. CH22_2012_016_FUP_Cahill_p287-302.indd 288 CH22_2012_016_FUP_Cahill_p287-302.indd 288 2/15/13 11:34 PM 2/15/13 11:34 PM HEALTH ASSESSMENT PROCESS IN COMPLEX EMERGENCIES 289 problems that ultimately diminish the effect of these efforts on the population they intended to help.5 Unfortunately, lack of personnel, medical records, and financial resources often hinder the assessment of the health situation in a complex emergency by conventional epidemiological methods practiced in traditional development programs. Epidemiological methods established for situations of restricted resources employ a simpler method of statistical analysis to be performed . The technique offered by these epidemiological methods became known as a “rapid assessment.”6 The outcome of an appropriately organized and directed assessment is an efficient and effective response. During the decade of the 1990s, both health and nutritional assessments in complex emergencies gained a reputation for quality. With critical advances in indicator identification, epidemiological analysis, data retrieval technologies, and in education and training of relief personnel , health and nutritional assessments have continued to improve as an art and science. The immediate priorities of assistance in complex emergencies are the protection of the affected populations and the reduction of mortality and morbidity.7 The effective response to complex emergencies requires timely, accurate public health information and data.8 The rationale for an assessment is to provide objective information for planning, prioritizing needs, implementing health programs, evaluating the relief process, and identifying health issues needing further investigation.9 The humanitarian community (international organizations, nongovernmental organizations, private governmental organizations, and peacekeeping militaries) has a professional obligation to base the assistance on the best evidence available.10 This assumption is the cornerstone of the concept of evidence-based healthcare. The need and demand for health care in complex emergencies are increasing at Table 22.1. Direct and indirect effects of complex emergencies Direct Effects Indirect Effects Injuries/Illnesses Population displacement: internally displaced and/or refugees Deaths Disruption of food Human rights abuses Destroyed health facilities International Humanitarian Law violations and abuses Destroyed public health infrastructure Psychological stresses Disabilities CH22_2012_016_FUP_Cahill_p287-302.indd 289 CH22_2012_016_FUP_Cahill_p287-302.indd 289 2/15/13 11:34 PM 2/15/13 11:34 PM FREDERICK M. BURKLE JR., M.D. 290 a rate determined, in part, by the rate at which public health infrastructure is destroyed and the moral integrity of governance disappears. Initially, healthcare needs may be greater than the rate at which resources are being made available.11 Use of an evidence...