1. COMPLEX EMERGENCIES: What do we measure and why? Frederick M. Burkle, Jr., MD, MPH Deputy Assistant Administrator Bureau for Global Health/USAID Senior Scholar, Scientist & Visiting Professor The Center for International Emergency, Disaster & Refugee Studies Schools of Public Health & Medicine The Johns Hopkins University Medical Institutions

3. Natural and Technological Disasters: Defines the public health Exposes its vulnerabilities Direct effects dominate Easy to define

4. Complex Emergencies: “…situations in which the capacity to sustain livelihood and life is threatened primarily by political factors, and, in particular, by high levels of violence.” A. ZWI: London Sch of HTM

5. Complex Emergencies: Lethal Mix of ………... Inequities Poverty Injustice Cultural incompatibilities Ignorance Racism Oppression Religious fundamentalism

6. Complex Emergencies: ….... DIRECT EFFECTS Injuries/Illness Deaths Human rights abuses International Humanitarian Law abuses Psychological stress Disabilities INDIRECT EFFECTS Population displacement Disruption of food Destroyed health facilities Destroyed public health infrastructure

7. In Complex Emergencies: a similar requirement to: evidence based indicators develop evidence based indicators….. conflict that characterize and define the public health consequences of conflict…… populations on populations affected….. effectiveness and accountability of humanitarian response and to ensure the effectiveness and accountability of humanitarian response……..

8. Measuring process in complex emergencies: Many layers of data (both quantitative and qualitative) building on one another…... Constantly characterizing and clarifying what complex emergencies seem to represent……... From this emerge dominate indicators (criteria) that both define and measure……...

9. Evolution…... Hostile environment “dirtied” the data Significant inconsistencies in data gathering and reporting; frequently self- serving * * JAMA: 1994;272:371-376

10. Evolution…... Crude mortality rate (CMR) emerged as a unifying indicator CMR, cause specific mortality rates, and nutritional indicators in under age 5 (U5MR) emerged to ‘characterize’ complex emergencies in developing countries

11. Evolution…... New and more sensitive indicators required in developed country emergencies (advanced weaponry, elderly, raped, mental health)*….and…. In each phase of a disaster…..prevention, preparedness, emergency response, recovery, rehabilitation, transition, sustainable development….. Spiegel PB, Salama P: War & mortality in Kosovo, Lancet, 2000

12. Evolution…... Indicators used to drive delivery of aid led to decreases in mortality and morbidity Led to numerous sources of indicators…NGOs, IOs, Donors, Military, etc…….

13. Evolution…... Attempts to collaborate to provide standards in water/sanitation, nutrition, food aid, shelter/site planning,health services…. And controversies in their implementation…..proved to be insensitive to the phases and politics of relief…...

14. Future...... By measuring complex emergencies we chose to intervene…bring order to chaos….reduce suffering….and become more effective and efficient…. will continue to evolve Standards and professionalism of response to complex emergencies will continue to evolve……

15. Future...... Research: Evidence based * across all phases of disasters …… direct and indirect, quantitative and qualitative, health and non-health, political, economic, social indicators to ensure measurable outcomes, appropriate decision-making, leading to sustainable development……… * Spiegel P: PDM 2002;16 (4):281-285