The complex humanitarian emergency:

an update on priorities

Mike Toole

IEC Symposium

5 September 2013

Complex Humanitarian Emergencies

“Situations affecting large

civilian populations

which usually involve a

combination of factors

including war or civil strife,

food shortages, and

population displacement,

resulting in significant

excess mortality”

Burkholder BH, Toole MJ (1995)

The Lancet, Volume 346, Issue 8981,

Pages 1012 - 1015, 14 October 1995

Rwandan refugees flee into Zaire, 1994

More than one million fled to Goma within one week

Democratic Republic of Congo, November 2008

More than 200,000 people displaced in eastern DRC

Internally displaced Tamils, Sri Lanka 2009

More than 400,000 displaced

North West Frontier Province, Pakistan, 2009

An estimated 2.8 million people were internally displaced

by conflict

Refugees from conflicts in the Arab world, 2011-13

Libyan refugees in TunisiaSyrian refugees in Turkey

Malian refugees in Mauritania, 2013

Source: Armed Conflict and Intervention Project, Center for Systemic Peace, 2012

Globally, in December 2012 there were:

15.4 million refugees

and 937,000 asylum

seekers

Sources: UNHCR and Internal Displacement Monitoring Centre, 2012

28.8 million internally displaced

persons

At the end of 2012

• Pakistan was host to the largest number of refugees

worldwide (1.6 million), followed by the Islamic Republic

of Iran (868,200), Germany (589,700) and Kenya (565,000)

• More than half (55%) of all refugees worldwide came from

five countries: Afghanistan, Somalia, Iraq, Syria, and Sudan

Syrian refugees and IDPs – September 2013

• Syrians in Lebanon 718,000

• Syrians in Jordan 518,000

• Syrians in Turkey 464,000

• Syrians in Iraq 210,000

• Syrians in Egypt 110,000

Total Registered Refugees: 1,994,000

• The U.N. estimates that 4.25 million people are internally displaced inside Syria (population = 21 million)

• Overall, almost 30% of Syrians have left their homes

World’s largest populations of

internally displaced persons, end of 2012

• Colombia 4.9 – 5.5 million

• Syria 3 million

• DR Congo 2.7 million

• Sudan 2.2 million

• Iraq 2.1 million

• Somalia 1.2 million

Source: Internal Displacement Monitoring Centre, 2013

0 5 10 15 20 25 30

Darfur

West Timor

Albania

Zaire

Nepal

Kenya

Iraqi border

Ethiopia Somalis, 1991

Kurds, 1991

Somalis, 1992

Bhutanese, 1992 Rwandans, 1994

Kosovars, May 1999

East Timorese, Nov 1999

Mean daily deaths per 10,000

Crude Mortality Rates for selected refugee &

displaced populations (1991-2004)

2004

Causes of mortality and morbidity in refugee

and internally displaced populations

• Direct

– Trauma

– Sexual violence

• Indirect

– Communicable diseases

– Malnutrition

1. Indirect

• Due to forced displacement into camps lacking basic facilities

and

• Food scarcity related to armed conflict

and

• Disruption to health services

Prevalence of acute malnutrition, children <5 yearsSelected refugee and displaced populations

Percentage

Major causes of death among refugees and

displaced persons in developing countries

• Measles was a major cause, with more than 3,000 deaths

in one camp (Eastern Sudan, 1985)

• Diarrhoea almost always among top three causes

– Cholera outbreaks very common, with case-fatality rates up to

25% in Central Africa

– Shigella dysentery outbreaks common in Africa and South Asia

(increased antibiotic resistance)

Major causes of death (continued)

• Malaria often associated with movement from high to low altitudes (Ethiopians in Sudan, Rwandans in Zaire)

• Acute Respiratory Infections usually among top three causes of death

• Meningococcal meningitis outbreaks relatively common

• Hepatitis E outbreaks common in East Africa (including a large outbreak in Sudan)

The major causes of mortality in refugee populations in developing countries

may be prevented through the prompt use of proven, low-cost public health

interventions

Essential elements of an emergency humanitarian program

• Address basic needs:

– Adequate food (>2100 kilocalories

per person per day plus all

essential micronutrients)

– Adequate clean water (15-20 litres

per person per day)

• Water containers

– Sanitation (one latrine per 15

persons) and waste disposal

– Shelter, warmth, ventilation, and

vector control

– A secure environment

• Rapid needs assessment and public

health surveillance

Basic health services

• Primary health care approach

– Community health workers

– Health posts

– OPD and small “ICU”

– Referral hospital

– Essential drugs list and rational drug use

• Communicable disease control and epidemic preparedness

– Diarrhoeal diseases and hepatitis E (+ polio in Somalia, Pakistan,

Afghanistan, Chad, and DRC)

– Measles, Malaria, ARI

– Meningitis, and other endemic diseases

• TB control, once the emergency is over

Remaining reservoirs of polio transmission are

all in conflict-affected areas

• Selective feeding programs

– Supplementary – selective or blanket

– Therapeutic – facility- or community-

based

• Sexual and reproductive health

care

– Basic minimum package

– HIV prevention, treatment, and care

– Prevention of sexual violence

• Appropriate mental health

programs

International humanitarian aid standards

2. Direct

• Injuries due to conflict

• Sexual violence

Role of surgery, anaesthesia, and emergency care

• Almost always in areas of ongoing conflict, such as currently:

– Syria

– Somalia

– Afghanistan

– NW Pakistan

– Darfur region of Sudan

– Colombia

– DR Congo

• The two largest international humanitarian agencies providing

these services are the International Committee of the Red Cross

and Médecins sans Frontières (either directly or indirectly)

Mirwais Hospital in Kandahar (ICRC)

Serves 5 million people, 300 beds, 40 international staff

Mullaitivu Hospital in Sri Lanka (MSF)

MSF provided services in northern Sri Lanka for more than 20 years

MSF supports six hospitals in Syria as well as

hospitals (with international staff) in Lebanon and

Jordan

All medical staff in Syria are nationals

Comprehensive management of the effects of

sexual violence: DR Congo

Surgical complex in Kalonge District run my

International Medical Corps

Summary

• Every emergency is different and responses should be guided by

a rapid needs assessment

• In most emergencies, the provision of safety, shelter, water, food,

and sanitation are the priorities

• Medical programs need to be based on the most common

causes of morbidity and mortality, including malnutrition, with

an emphasis on prevention

• Surgical and emergency care services are priorities in areas of

ongoing conflict