Complex Humanitarian Emergencies Clydette Powell, MD, MPH USAID

Objectives Define and discuss the causes and phases of CHEs Define and discuss the causes and phases of CHEs Understand the magnitude and measures of CHEs Understand the magnitude and measures of CHEs Use a case scenario to illustrate the reality and optimum approaches to addressing CHEs Use a case scenario to illustrate the reality and optimum approaches to addressing CHEs

Definition of CHE CHE: Human disaster that occurs during and follows war and civil strife CHE: Human disaster that occurs during and follows war and civil strife Inciting event: natural or man-made Inciting event: natural or man-made Characterized by displacement Characterized by displacement Loss of existing societal infrastructure Loss of existing societal infrastructure Concerns for personal security Concerns for personal security 90% of war related mortality among civilian non-combatants 90% of war related mortality among civilian non-combatants

Refugees and IDPs Flight across border (R) or within border (IDP) Flight across border (R) or within border (IDP) 14 million refugees 14 million refugees 15 – 20 million IDPs 15 – 20 million IDPs UN and international protections vary UN and international protections vary Degree of difficulty in assistance Degree of difficulty in assistance

Phases of CHEs Acute (early) emergency: 0 – 1 month Acute (early) emergency: 0 – 1 month Late or recovery : 1 -6 months Late or recovery : 1 -6 months Rehabilitation and development : 6 or more months Rehabilitation and development : 6 or more months Measure of severity: depends on magnitude and vulnerability of population Measure of severity: depends on magnitude and vulnerability of population CMR: number of deaths per 10,000 per day CMR: number of deaths per 10,000 per day

Scenario Recent political changes with ongoing instability Recent political changes with ongoing instability Drought and early famine Drought and early famine Aggressive land reform with massive displacement of people (IDPs) Aggressive land reform with massive displacement of people (IDPs) Excellent health care system on sharp decline, with drop in trust by public Excellent health care system on sharp decline, with drop in trust by public Public health services characterized by patchy coverage (eg., EPI) Public health services characterized by patchy coverage (eg., EPI)

Rapid inflation, increasing unemployment Rapid inflation, increasing unemployment Out-migration of health care professionals Out-migration of health care professionals Disease outbreaks Disease outbreaks HIV on rise (1 in 3 persons) and TB incidence increasing HIV on rise (1 in 3 persons) and TB incidence increasing Poor recognition of disease or means of treatment; poor coping skills Poor recognition of disease or means of treatment; poor coping skills Increasing urban migration Increasing urban migration

YOU in the scenario: You are a public health director of a rural health clinic with limited facilities You are a public health director of a rural health clinic with limited facilities Over the following two days, 10,000 exhausted IDPs arrive in your area Over the following two days, 10,000 exhausted IDPs arrive in your area Included in these are women and children and people of different ethnic groups (known to be at odds with one another) Included in these are women and children and people of different ethnic groups (known to be at odds with one another) District authorities have come asking for your help. District authorities have come asking for your help.

Question #1 What are your priorities, given the situation? What are your priorities, given the situation?

Lesson 1 - Coordination Before jumping to health solutions or any needs, build a team Before jumping to health solutions or any needs, build a team Have clear authority structure for delegation and coordination Have clear authority structure for delegation and coordination Communicate clearly and succinctly Communicate clearly and succinctly Have a camp manager Have a camp manager Designate a “reporter” Designate a “reporter”

Question # 2 Now that you have your team, what needs for this population must you consider – and in what sequence? Now that you have your team, what needs for this population must you consider – and in what sequence?

Priority needs Food Food Water and sanitation Water and sanitation Shelter Shelter Identification of vulnerable populations Identification of vulnerable populations Appropriate health interventions for these populations – for example: Appropriate health interventions for these populations – for example: Immunizations Immunizations Nutritional assessment (e.g., MUAC) Nutritional assessment (e.g., MUAC)

Lesson # 2 Keep first things first Keep first things first Keep the big picture in mind (“30,000 foot view”) Keep the big picture in mind (“30,000 foot view”) Collect only the data you need Collect only the data you need Be watchful for disease outbreaks for rapid response Be watchful for disease outbreaks for rapid response Maintain nutritional surveillance Maintain nutritional surveillance Monitor security and safety conditions Monitor security and safety conditions

Day 3 Government officials and politicians, along with UN agencies, World Food Program, arrive on the scene Government officials and politicians, along with UN agencies, World Food Program, arrive on the scene CNN as well as local news media are setting up cameras, and reporters are swarming the camp perimeter CNN as well as local news media are setting up cameras, and reporters are swarming the camp perimeter

Question # 3 How do you handle the “new arrivals”? How do you handle the “new arrivals”?

Lesson 3 - Communication One designated “camp reporter” One designated “camp reporter” Daily updates and sound bites Daily updates and sound bites Data driven, not sensationalistic or speculative Data driven, not sensationalistic or speculative No opinions offered No opinions offered Do not get drawn into criticisms Do not get drawn into criticisms If answer not known, offer to get back to person with question If answer not known, offer to get back to person with question Remember: journalists are never “off duty” Remember: journalists are never “off duty”

Communication (cont’d) Be aware of UN politics Be aware of UN politics Respect national politicians and the process Respect national politicians and the process Be aware of hidden agendas, confusing or overlapping mandates Be aware of hidden agendas, confusing or overlapping mandates Keep in mind historical context Keep in mind historical context Anticipate your comparative advantage and whether you will stay engaged in the process or withdraw at some point Anticipate your comparative advantage and whether you will stay engaged in the process or withdraw at some point

Two Weeks Later…. The army arrives to contain both the situation and the IDPs, who are regarded as a threat to local and national security. You are told that the army is there for your safety and security, but their presence limits your access to the camp and curfew is put in place. The army arrives to contain both the situation and the IDPs, who are regarded as a threat to local and national security. You are told that the army is there for your safety and security, but their presence limits your access to the camp and curfew is put in place.

Question # 4 How do you respond to this new development in the second week, especially in light of large and expanding health needs and ongoing health services? How do you respond to this new development in the second week, especially in light of large and expanding health needs and ongoing health services? Does the composition of your health staff modify, or mitigate, your approach ? Does the composition of your health staff modify, or mitigate, your approach ?

Lesson # 4 Use low tech interventions Use low tech interventions Recruit among the camp population Recruit among the camp population Anticipate from the start your exit plan, contingencies, potential scenarios different from the one at the beginning. Anticipate from the start your exit plan, contingencies, potential scenarios different from the one at the beginning. Attempt to promote ongoing dialogue between the camp and local population Attempt to promote ongoing dialogue between the camp and local population

Resources UN High Commissioner for Refugees; for Human Rights UN High Commissioner for Refugees; for Human Rights International Committee of the Red Cross International Committee of the Red Cross Medecins sans Frontieres Medecins sans Frontieres Office for Coordination of Humanitarian Affairs Office for Coordination of Humanitarian Affairs FEWSNET FEWSNET Universal Declaration of Human Rights Universal Declaration of Human Rights International Law of Human Rights International Law of Human Rights USAID - Office of Foreign Disaster Assistance and Office of Transition Initiatives USAID - Office of Foreign Disaster Assistance and Office of Transition Initiatives DOS - Population Refugees and Migration DOS - Population Refugees and Migration

Thank you!