Health in Conflict Zones Dr.Dilshad Jaff Rotary Peace Fellow MPH Candidate,

The development of an armed conflict Peace Peace CrisisReconstruction ConflictResolution

Consequences of armed conflict: Population displacement Injuries Murder Harassment Famine Disappearance Torture Rape Hostage taking Separation from families Ethnic cleansing Genocide

Several categories of refugee must be distinguished: Refugees who have fled their own countries because of an armed conflict or a situation of internal violence “not because they are personally objects of persecution”. Refugees who fear personal persecution on account of their race, political opinions, or religion “defined by the 1951 convention on Refugees and the Protocol of 1976”. Individual cases – for example, during an int. armed conflict, nationals of a state who, in fleeing the fighting, enter the territory of adverse state.

Essential Services Needs

Imbalance between the needs and the available services during crisis Essential Services Needs

The problems in crisis Lack of access to food Lack of access to health care Lack of access to water Lack of access to shelter Poor sanitary conditions

The Health Care Pyramid Water and Environmental Health Food and Nutrition Public Health Medical Care

Planning process Initial assessment of the situation General objectives of the action Strategic orientations Specific objectives Activities and tasks Resources

Planning outline: Simplified version Initial Assessment Plan of Action Evaluation / Monitoring

Choice of a site

Choice of a site for a camp Access to water Security (little possibility of population being affected by hostilities, or coming into conflict with local residents). Access to food resources Sufficient space (30 square meter/person) Adequate drainage No major environmental health hazards (high winds, flooding) Fairly easy access to road and other communications Agreement with the local population

Risks associated with inadequate shelter Overcrowding Cold Heat Rain

Daily needs for 10'000 displaced people Food: 5’500 Kg Water: 200,000 Liters

Quantity of water supply recommended in emergencies: 20 liters per person per day

Estimating the number of potential patients in a displaced population who will require access to a health care facility 1% of the population require out-patient care 1% of patients seeking out-patient care require hospitalization 1/1000 the number of beds required for hospitalization is 1 per 1,000 people (except in epidemics)

Food supply Communicable diseases control Nutritional rehabilitation Sanitation Water supply Medical care Vector control Immunization Shelter Psychological support Control of epidemics Population's Health

The main communicable diseases in emergency situation: Measles Diarrheal diseases (including cholera) Malaria Hepatitis A Acute respiratory infections TB Meningococcal meningitis Intestinal parasites AIDS Skin infections (Scabies)

Cutaneous leishmaniasis (Baghdad Boil)

Classification of communicable diseases by their relation to water: Ingestion of polluted water:  Cholera  Amoebiasis  Hepatitis A Inadequate personal hygiene due to lack of water:  Scabies  Trachoma Presence in the water of an intermediate host carrying the pathogenic agent:  Schistosomiasis

Development of vectors of communicable disease in water:  Malaria  Yellow fever Combination of the causes above:  Amoebiasis: polluted water and inadequate personal hygiene

Main communicable disease vectors 1. Mosquitoes  Malaria Yellow fever 2. Flies  Diarrhoeal diseases Trachoma Trypanosomiasis (tsetse) 3. Lice  Typhus

4. Rats  Leptospirosis 5. Fleas  Plague 6. Ticks  Encephalitis

Factors contributing to increased incidence of communicable diseases in emergency situations: Presence of new pathogenic agents to a displaced population or a host population No immunity Overcrowding Large population of children No environmental measures Increase number of vectors No personal hygiene Insufficient water Unsafe water

High malnutrition rate No preventive health measures (e.g. immunization) Lack of basic health services Breakdown of the family structure

Women and children most vulnerable in emergencies: high proportion in refugee or IDP populations High mortality rates in children <5, highest in infants <1  1991 Kurdish Refugees at Turkey-Iraq border: 63% all deaths children <5  1996 DRC: 54%

Major causes of death in all ages, hospital And community of Pugnido Camp Western Ethiopia, 1989

Major causes of death in children < 5 years of age in refugee hosting areas in nine districts Malawi, July 1990

First aid !!!

Most health problems in large population emergencies can be prevented

Coordination between all the humanitarian agencies is needed. Types of relationships between the humanitarian agencies in the field: Confusion Consultation Conferring Concentration Cooperation Coordination Contribution Coercion Competition Confrontation Conflict

Effects of humanitarian aid POSITIVE EFFECTS Save lives Relieves suffering Contribute to the protection of victims Rehabilitates local systems

NEGATIVE EFFECTS Takes responsibility away from the victims Alters behaviors and habits Helps support political systems Contributes to the war efforts

Our safety and security is a priority

Thank you