In Complex Emergencies Public Health & HUMAN SECURITY In Complex Emergencies Pierre Perrin MD, MPH IMSP Fac. Medecine University Geneva

Public Health The aim of public health is to improve health and the quality of life of the entire population through the rational organisations of health services. Most disasters have a tremendous impact on health and public health is a key component in the response.

Overview Part I: Health emergencies and public health Part II: Public Health and Human Security Part III: Public health and « Political Affairs »

Part I: Health Emergencies and Public Health (Classical role of public health)

Health Emergencies & Public Health Population Public Health Event Systems Population Health Emergencies = Health Systems

Mortality rate in camps: Darfur Crude mortality rates, expressed as deaths per 10 000 per day, were : 3.2 (95% confidence interval [CI], 2.2-4.1) in Kass, 2.0 (95% CI, 1.3-2.7) in Kalma, 2.3 (95% CI, 1.2-3.4) in Muhajiria. Under 5-year mortality rates were: 5.9 (95% CI, 3.8-8.0) in Kass, 3.5 (95% CI, 1.5-5.7) in Kalma, 1.0 (95% CI, 0.03-1.9) in Muhajiria. Mortality and Malnutrition Among Populations Living in South Darfur, Sudan Results of 3 Surveys, September 2004 Francesco Grandesso, MSc; Frances Sanderson, MD, PhD; Jenneke Kruijt, MPH; Ton Koene, MSc; Vincent Brown, MD, MPH JAMA. 2005;293:1490-1494.

Distribution of reported cause of death by age group, in a sample of IDPs, Kalma Camp, South Darfur, Sudan, 15 June – 15 August 2004 Reported causes of death 0 to 4 years 5 to 14 years 15 to 49 years 50+ years All ages Fever 17% 0% 25% 20% Respiratory disease 29% Diarrhoea 52% 57% 30% 42% Injury or Violence 63% 10% Other 12% 14% 13% Retrospective Mortality Survey Among the Internally Displaced Population – Greater darfur, Sudan, August 2004 - WHO, 15 September 2004 Note: The total number of deaths in the table is 77 instead of 80 because cause of death was not recorded for three deaths Retrospective Mortality Survey, Darfur Sudan, August 2004

The health response in Darfur Psycho –Social Support Food Security Water & Environment Health Promotion and Prevention Medical Care Psycho –Social Support

Kashmir: Relief operation for the wounded Triage - Stabilisation First aid Triage - Stabilisation Evacuation Surgical care Rehabilitation

Kashmir: Relief Operation for the Population Food Security Water & Environment Health Promotion and Prevention Medical Care

Relief Operations: A Public Health Framework Food Security Water & Environment Health Promotion and Prevention Medical Care Psycho –Social Support Availability of food resources Water Health Promotion Outpatient Care Social welfare Accessibilité aux ressources alimentaires Habitat Shelter Hygien CD Prevention Hospital Care Mental Health

Health Emergency Interventions PHC & HEI Strategy Health Emergency Interventions Strategy Primary Health Care Population Potable water Nutrition food resources Mother and Child Care Immunization (EPI) Prevention of comunicable diseases Hygiene Promotion Treatment of common diseases Essential drugs Reproductive health Mental health …… Community participation Cost !!! Immediat efficacy Approproiate Technology

Part II: Public Health and Human Security (An wider role of public health)

Health & Access to health care To deal with the immediat causes which prevent affected people to have access to health services Willingness to limit/stop access to health services Insecurity in accessing health services Food & Nutrition Water & Shelter Health Services

Public Health & Access to Health Services By quantifying the impact on health of the lack of access to health services, including food and water, Public Health may play an important role to regain access to those services. For instance, negotiating for a cease-fire to carry on mass immunization campaingns.

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

Individual & Community Integrity Torture Disappearances Integrity . Individual - Physical - Psychological . Community - Family - Cultural - Etnic Sexual violences Forced displacements Splitting families Ethnic cleansing …..

Health & Human Security Forced displacements Ethnic cleansing Torture Disappearance Extra judicial killing ….. Limiting access to health services Prohibiting access to health services Insecurity in accessing health services …. Integrity Food & Nutrition Water & Shelter Health Services

Public Health Global Approach Integrity Food & Nutrition Public Health Global Approach Water & Shelter Health Services

Congo - MSF Sexual abuses Basankusu: Impact of violence on population from 1998 to 2001 Type of violence (n=771) Nb. % C.I. Theft 596 77.3% 65.8 – 88.8 Destruction Houses/field 362 47.0% 33.0 – 60.9 Physical assault 160 20.8% 10.2 – 31.3 Imprisonment 85 11.0% 5.7 – 16.4 Torture 118 15.3% 8.5 – 22.1 Sexual abuses 103 13.4% 5.8 – 20.9 Mines 3 0.4% 0 – 0-8 Bullet wounds 41 5.3% 0.4 – 10.2 Knife/machete wounds 34 4.4% 0.2 – 8.6 Forced recruitment 82 10.6% 2.1 – 19.2 Sexual abuses Note pour le planning Of the 912 households questionned, 771, or 84.9% stated that at least one member had experienced violence from 1998 to 2001 Source: MSF, Access to health and violence in Congo (RDC) – Results of five epidemiological sureys – Dec 2001

A Framework for Complex Emergencies Integrity Food & Nutrition Health Services Water & Shelter Providing health services Providing water Psychosocial support Immunization Providing food support Providing economic support Providing shelter Dissemination IHL Dealing with sexual violences Monitoring HR Preventing HR violations Assessing conduct of hostilities Humanitarian Diplomacy Promoting HR Law Note pour le planning

Health Professional & the management of the « Political Affairs » Note pour le planning

The Framework of Complex Emergencies Political Field The Framework of Complex Emergencies Humanitarian Field Note pour le planning PPR - 2000

Crisis Management and Health Interventions Preventive diplomacy Coercitive diplomaty Demobilization of soldiers Peacekeeping operations Embargo on weapons Economic embargo Peace enforcement with military means Organization and monitoring of elections Conduct of hostilities Democratization Conflict resolution Organizing the Police Affected Population Crisis Armed Conflict Transition Note pour le planning

Study in DRC Study in Iraq Note pour le planning

Health Zones reporting violence 3.0 (2.6 – 3.4) 6.4 (5.7 – 7.2) Mortality in the Democratic Republic of Congo: a nationwide survey The lancet Vol 367 January 7, 2006 CMR Under 5 Mortality rate Health Zones reporting violence 3.0 (2.6 – 3.4) 6.4 (5.7 – 7.2) Health zones not reporting violence 1.7 (1.5 – 1.9) 3.1 (2.7 – 3.5) Note pour le planning Mortality rates expressed as deaths per 1000 per month (95% CI) Comparison of east health zones with and without violence

Example of statistical analysis Mortality in the Democratic Republic of Congo: a nationwide survey The lancet Vol 367 January 7, 2006 Example of statistical analysis "A Poisson regression analysis of all eastern health zones suggested that the CMR would be 1.7 peer 1000 population per month (95% CI 1.6 – 1.9) in the absence of all violence" Note pour le planning

Mortality in the Democratic Republic of Congo: a nationwide survey Stating the Issue "These findings show that the DRC remains in the grip of a major humanitarian crisis that continues to be most severe in the eastern provinces." Mortality in the Democratic Republic of Congo: a nationwide survey The lancet Vol 367 January 7, 2006

Mortality in the Democratic Republic of Congo: a nationwide survey Stating the Cause "the reductions in crude mortality are closely associated with reductions in violence and by, extension, improvements in security" Mortality in the Democratic Republic of Congo: a nationwide survey The lancet Vol 367 January 7, 2006

Mortality in the Democratic Republic of Congo: a nationwide survey Giving proposals "…another key finding of the survey was that most deaths were due to preventable causes such as malnutrition and infectious diseases….Moreover young children are disproportionately affected by theses illnesses. Improving food security and increasing access to to essential health services, such as immunisations, clean water, insecticide-treated bednets and case management of common diseases, have the potential to contribute greatly to reductions in excess mortality." Mortality in the Democratic Republic of Congo: a nationwide survey The lancet Vol 367 January 7, 2006

Mortality in the Democratic Republic of Congo: a nationwide survey Giving proposals "more robust peacekeeping force than the current MONUC contingent of 16,700 is urgently needed to effectively address the security concernss and associated humanitarian needs in DRC" Mortality in the Democratic Republic of Congo: a nationwide survey The lancet Vol 367 January 7, 2006

Mortality Study in Iraq The lancet Published on line October 11, 2006 Mortality after the 2003 invasion of Iraq: A cross-sectional cluster sample survey The lancet Published on line October 11, 2006

Mortality Study in Iraq The lancet Published on line October 11, 2006 « We estimate that as of July 2006, there have been 654965 (392979-942636) excess Iraqi deaths as a consequence of the war, which corresponds to 2.5% of the populaiton of the study area. Of post-invasion death, 601027 (426369-793663) were due to violence, the most common cause being gunfire » Mortality after the 2003 invasion of Iraq: A cross-sectional cluster sample survey The lancet Published on line October 11, 2006

Mortality Study in Iraq The lancet Published on line October 11, 2006 Mortality after the 2003 invasion of Iraq: A cross-sectional cluster sample survey The lancet Published on line October 11, 2006

Mortality Study in Iraq The lancet Published on line October 11, 2006 Mortality after the 2003 invasion of Iraq: A cross-sectional cluster sample survey The lancet Published on line October 11, 2006

Mortality Study in Iraq The lancet Published on line October 11, 2006 Mortality after the 2003 invasion of Iraq: A cross-sectional cluster sample survey The lancet Published on line October 11, 2006

Mortality Study in Iraq The lancet Published on line October 11, 2006 Mortality after the 2003 invasion of Iraq: A cross-sectional cluster sample survey The lancet Published on line October 11, 2006

Mortality Study in Iraq: Response from the Political Actors

Mortality Study in Iraq: Response from the Political Actors

Human Security of Affected Population Preventive diplomacy Coercitive diplomaty Demobilization of soldiers Peacekeeping operations Embargo on weapons Economic embargo Peace enforcement with military means Organization and monitoring of elections Conduct of hostilities Democratization Conflict resolution Organizing the Police Human Security of Affected Population Providing health services Providing water Psychosocial support Immunization Providing food support Providing economic support Providing shelter Dissemination IHL Dealing with sexual violences Monitoring HR Preventing HR violations Assessing conduct of hostilities Humanitarian Diplomacy Promoting HR Law Note pour le planning

Armed Conflicts Political Humanitarian Maintain Protect Human Security Belligerants States UN General Assembly UN Security Council PK Forces, NATO Private companies USAID ECHO Medias Human rights organisations National Societies of RC/RC UNHCR UNICEF WHO NGOs ICRC Coercitive diplomaty Conduct of Hostilities Organizing the Police Peacekeeping operations Human Right Promotion Embargo on weapons Maintain Protect Human Security Democratization Economic embargo Conflict Prevention Peace enforcement with military means Organization and monitoring of elections Preventive diplomacy Conflict resolution Education Assessing violations of IHL Early Warning Providing health services Adapting National Law Supporting social services Note pour le planning Dissemination IHL Providing economic support Looking for the missing Tracing family members Protection of the POW Demobilization of soldiers Humanitarian Diplomacy Advocacy

Normative Framework: Values, Law, Principles, Policies, Guidelines Armed forces / groups UN: Security Council PK forces, NATO States Belligerants ………. Preventive diplomacy Coercitive diplomaty Demobilization of soldiers Peacekeeping operations Embargo on weapons Economic embargo Peace enforcement with military means Organization and monitoring of elections Conduct of hostilities Democratization Conflict resolution Organizing the Police Human Security of Affected Population Providing health services ICRC National RC/RC societies IOM UNHCR NGOs WHO ……… Dissemination IHL Dealing with sexual violences Monitoring HR Preventing HR violations Assessing conduct of hostilities Humanitarian Diplomacy Providing food support Providing economic support Note pour le planning Providing shelter Providing water Immunization Promoting HR Law Psychosocial support Time frame: Stability Crisis Armed Conflict Transition Stability

Playing with the Framework Impact sur les besoins, WW, accès à la nourriture……priorités différentes dans l'expression des besoins securité avant santé ou vice versa ?

The example of AP Landmines Note pour le planning PPR plapretoria 11 - 1999

Normative Framework: Values, Law, Principles, Policies, Guidelines Belligerants Armed forces / groups UN: Security Council Use of antipersonel landmines PK forces Human Security of Affected Population States ………. NGOs WHO National RC/RC societies Providing health services IOM Note pour le planning UNHCR ICRC ………

Prohibition of Antipersonal landmines Public Health and Law Prohibition of Antipersonal landmines Political step The treaty of Ottawa Lessons HEALTH LAW Legal Step: CCW 80 Institutional step Epidemiological step Note pour le planning Use of Antipersonal landmines Surgical step

The example of Economic Embargo Note pour le planning PPR plapretoria 11 - 1999

Normative Framework: Values, Law, Principles, Policies, Guidelines Belligerants Political management of the crisis Political Dilemma Armed forces / groups UN: Security Council Economic embargo Peace enforcement with military means PK forces Human Security of Affected Population States ………. NGOs ICRC National RC/RC societies IOM Note pour le planning UNICEF WHO ……… PPR - 2000

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

Normative Framework: Values, Law, Principles, Policies, Guidelines Armed forces / groups UN: Security Council PK forces, NATO States Belligerants ………. Preventive diplomacy Coercitive diplomaty Demobilization of soldiers Peacekeeping operations Embargo on weapons Economic embargo Peace enforcement with military means Organization and monitoring of elections Conduct of hostilities Democratization Conflict resolution Organizing the Police Sexual Violences Providing health services ICRC National RC/RC societies IOM UNHCR NGOs WHO ……… Dissemination IHL Dealing with sexual violences Monitoring HR Preventing HR violations Assessing conduct of hostilities Humanitarian Diplomacy Providing food support Providing economic support Note pour le planning Providing shelter Providing water Immunization Promoting HR Law Psychosocial support

Health Management of Sexual Violences Infections Pregnancy Sexual Violences Health Consequences Injuries Health Management Psychological Impact Social Impact

Epidemiological Management of Sexual Violences Health Consequences Epidemiological approach As part of health responsibilities, look for: Descriptive: Time, Place, Persons Protection Analytic: Circumstances, Environment Prevention

Legal Management of Sexual Violences Legal approach Justice Health Informations Epi. Informations Sexual Violences Health Consequences Epidemiological approach Protection Prevention

Public Health at three levels Legal approach Justice Health Informations Epi. Informations Sexual Violences Infections Health Consequences Pregnancy Health Management Psychological Impact Social Impact Injuries Epidemiological approach Descriptive: Time, Place, Persons Prevention Protection Analytic: Circumstances, Environment

Normative Framework: Values, Law, Principles, Policies, Guidelines Armed forces / groups UN: Security Council PK forces, NATO States Belligerants ………. Preventive diplomacy Coercitive diplomaty Demobilization of soldiers Peacekeeping operations Embargo on weapons Economic embargo Peace enforcement with military means Organization and monitoring of elections Conduct of hostilities Democratization Conflict resolution Organizing the Police Forced Displacements Providing health services ICRC National RC/RC societies IOM UNHCR NGOs WHO ……… Dissemination IHL Dealing with sexual violences Monitoring HR Preventing HR violations Assessing conduct of hostilities Humanitarian Diplomacy Providing food support Providing economic support Note pour le planning Providing shelter Providing water Immunization Promoting HR Law Psychosocial support

Forced displacements: a root cause of insecurity

Normative Framework: Values, Law, Principles, Policies, Guidelines Armed forces / groups UN: Security Council PK forces, NATO States Belligerants ………. Preventive diplomacy Coercitive diplomaty Demobilization of soldiers Peacekeeping operations Embargo on weapons Economic embargo Peace enforcement with military means Organization and monitoring of elections Conduct of hostilities Democratization Conflict resolution Organizing the Police Forced Displacements Providing health services NGOs Dissemination IHL Dealing with sexual violences Monitoring HR Preventing HR violations Assessing conduct of hostilities Humanitarian Diplomacy Providing food support ICRC Providing economic support National RC/RC societies Providing shelter IOM Note pour le planning Providing water UNHCR WHO Immunization ……… Promoting HR Law Psychosocial support Helping stakeholders to define their activities and their relationship with other stakeholders

Summary From health to HR issues Mutidisciplinary approach Linkage between activities Interaction between stakeholders Note pour le planning PPR - 2000