UNCERTAINTIES AND RESEARCH IN PROVIDING MEDICAL AID IN COMPLEX DISASTERS

By Phillip Cullison Bonner

Published on June 2009

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During complex disasters such as wars, the collapse or disruption of states, or social rebellions where civil structure is threatened or removed, delicate health infrastructures seldom escape the stress placed upon their services, and thereby result in an increased rate of morbidity and mortality. Providing basic medical need during complex emergencies presents a multiplicity of challenges. These include scientific, logistical, political, moral, and ethical issues. Both the aid organizations and individual medical provider must be aware that every action taken has a consequence. The unique dynamics of populations in conflict and consequences of previous assistance programs demands that much research in emergency situations is required in order to afford better preparedness, efficiency, efficacy, and intervention strategies implemented by participating health organizations. This increase in preventable deaths commands the attention of the international community and elicits a humanitarian response, to combat infectious disease, as well as establish temporary, and at least minimal, public health protection.

Complex emergencies have become more frequent since the Cold War, where the patterns of conflict have changed historically from interstate to internal civil conflict, where 34 conflicts were active worldwide in 2007¹¹. Due to the lack of resources during conflict time, populations may suddenly be displaced and relocated to camps or settlements where the crude mortality rate may reach 60 times higher than the baseline¹. The international community’s response was to establish a large number of non-governmental organizations (NGOs) to become involved in delivering humanitarian aid and medical assistance. Since 1980, funds allocated to humanitarian organization programs have increased 10-fold to 3.5 billion USD in 1994 and grown to 9 billion in 2006².

Medical emergency care through aid on many accounts has drastically reduced mortality rates by targeting specific prevention and control measures such as measles vaccination, simple vector control practices, and malaria control in regions of risk³. However, in complex emergencies where immediate care is implemented, specific disease risks are frequently underestimated when establishing priorities for emergency and disaster health. In 1994, cholera killed 12,000 refugees in Goma, former Zaire in just three weeks due to disagreement and failure to implement control strategies by the intervening aid organizations⁴.

Immediate intervention and health services capabilities are limited by the preparedness of the NGO. Current trends in assessing the state of health and need in complex emergencies are limited by the lack of research, resources, and occasionally the experience of the contributing aid organizations. Initial responses in the field were understandably ad hoc, though after 20 years of established aid organizations, errors are still being made due to inadequate provisions and knowledge in the complex and uncertain environment in which crises produce⁵. A large number of these uncertainties can be alleviated through the application of applied and operational research. However, such initiatives have fallen critically short of what is needed to provide the successful and immediate health needs for emergencies.

A number of approaches to medical aid in complex disasters have been used to ensure measures for infectious disease outbreak control. There are numerous records of successful interventions by health agencies that have prevented or controlled infectious disease outbreaks in war-affected areas. Such success came by extensive training of available local staff and using established resources in the area. However, approaches such as these become problematic where total removal of an established health system has occurred, as they are based on Primary Health Care models and designed for stable areas. These fail when medical agencies use it as a substitute to mitigate the collapse of the public health services. In these situations mortality may be very high. As an example, an excess of 3 million deaths over a 32-month period from 1998 to 2001 was reported in the eastern part of the Democratic of the Congo. Of these, only 350,000 deaths were attributed to violence, while the remaining majority were related to disease and malnutrition⁶. Although several aid organizations were present, the limited health service information and inadequate preparation resulted in inadequate aid.

Existing strategies in assessing need and establishing emergency response are primarily based upon the single measurement of the crude mortality rate (CMR) of the region. CMR can be used in a comparative measure of relative risk of death during conflict compared with that in pre-conflict times. Rates measured as or above 1 death per 10,000 population per day is considered to be an emergency situation (CMRs have been reported as high as 60 in the case of the 1994 Rwanda incident)². The use of the CMR is also useful as a tool to indicate what type of intervention is to be sought during post-conflict reconstruction. For example, a population with peacetime CMR much lower than during conflict indicates that the excess mortality is probably due to factors such as violence, massacres, and battles associated with conflict. On the other hand, peacetime CMR that is high but not much different from that during conflict may indicative of generally poor health standards⁷. Intervention strategies can be loosely based by rates; though the CMR provides a clear and important definition of the state of need, it does not indicate or provide the required details to the aid organizations on how intervention for specific disease control measures should be approached.

Conflict-affected areas are potential zones of emerging or remerging infectious diseases such as Ebola in Uganda, or Lassa Fever in Sierra Leone. An influx of refugees from Liberia in 2002 to eastern Sierra Leone has settled in what is known as the Lassa belt, a region of the Lassa Fever Virus endemicity. In the case of Liberian Refugees, detection of Lassa Fever was delayed by inadequate detection systems and vector control strategies in settlement areas, resulting in rapid spread of the disease throughout the camps⁸. Similarly, an outbreak of Ebola Hemorrhagic Fever occurred between the region of Congo Brazzaville and the Gabon from December 2001 to April 2002. The epidemic was not detected until January 2002⁸ resulting in excessive deaths. Rapid detection and surveillance tools need to be developed to avoid the exacerbation of an already existing emergency situation.

Furthermore, the financial restraints of participating NGOs frequently limit the variety and availability of drugs, such as anti-malarials or antibiotics, and consequently negatively affect the organization and its purpose. Overuse, misuse, and lack of regulation of antibiotics can fuel the emergence of drug resistance in conflict-affected areas. Many aid organizations have access to only chloroquine based anti-malaria drugs and are frequently used in areas of known resistance, rendering treatment and prophylaxis inadequate. Research into effective drug combinations and use is required if mass treatment is required in emergency situations were individual patient care will be limited or unlikely. Access to first-line drugs is also needed to ensure effective diagnosis and treatment.

The above are a few examples of the research goals needed to create more effective and successful interventions in complex emergencies. Though seemingly trivial, research approaches in complex emergencies are difficult, both logistically and operationally, as scientists are faced with demanding humanitarian and ethical constraints and limited access to resources in the field. Research regarding complex emergencies and humanitarianism are also vitally important in the field of policy development and implementation, as there are relatively few non-humanitarian studies which suggest policy recommendations to NGOs, the UN or national governments. These multiple imperatives place considerable pressure on the researcher to ensure that the humanitarian research is academically sound as well as politically relevant⁹.

A renewed emphasis on research into complex emergencies and the importance of infectious diseases is needed to establish better intervention strategies of aid organizations to reduce excess mortality. Though plagued with obstacles, this international research commitment is crucial to develop systems that will rapidly detect and control epidemics, ensure effective, relevant, and responsible drug use, as well as systems to provide quick and thorough assessment of the emergency situation.

Finally, our individual responsibility as physicians in the era of evidence-based medicine is to alleviate suffering in all forms, either through direct medical care or through preventative medicine. In a stable political environment the provision of sound, ethical research provides the foundational bricks in which we lay all our clinical acumen that guide our hands and minds--to the best outcome--we can provide our patients. In the case for providing care in complex disasters, we must provide care no less differently. Should we then look at war as a social disease? Ultimately, for health care workers who do not have access to providing service in the field, the simplest public health measure is the promotion of peace.

Phillip Cullison Bonner is a 4th year medical student at the Medical School for International Health, a collaboration between Ben-Gurion University of the Negev in Israel and Columbia University. He has received a Masters Degree in Control of Infectious Diseases from the London School of Hygiene and Tropical Medicine and has worked in several conflict-affected areas such as Sierra Leone, Democratic Republic of Congo, and others. He can be contacted for questions or comments at pmcullison@yahoo.com.

References:

² Sondorp, E., T. Kaiser, et al. (2001). "Beyond emergency care: challenges to health planning in complex emergencies." Trop Med Int Health 6(12): 965-70.

³ Medicins Sans Frontieres, (1997). Refugee Health: An Approach to emergency situations. London, Macmillan Education Ltd.

⁴ Connolly, M. A. and D. L. Heymann (2002). "Deadly comrades: war and infectious diseases." Lancet 360 Suppl: s23-4

⁵ Burkle, F. M. (1999). "Lessons learnt and future expectations of complex emergencies." BMJ 319(7207): 422-6.

⁶ Roberts, L. (2001). Mortality in Easter Democratic Republic of Congo, results of 11 Mortality Surveys. IRC report, Final Draft 2001.

⁷ Guha-Sapir, D. and W. G. van Panhuis (2003). "The importance of conflict-related mortality in civilian populations." Lancet 361(9375): 2126-8.

⁸ Gayer, M. G., R; Salter, M (2003). Lassa Fever and Communicable Disease Surveillance and Control in Sierra Leone. Report and Recommendations of WHO/UNHCR mission to Sierra Leone. June 23 to July 7, 2003, World Health Organization.

⁹ ECHO, (2003). Ebola virus and conflict in Congo Brazzaville: Commission grants EURO 2 million in humanitarian aid.

¹⁰ Jacobsen, K. and L. B. Landau (2003). "The dual imperative in refugee research: some methodological and ethical considerations in social science research on forced migration." Disasters 27(3): 185-206.

¹¹ Harbom, L. Melander, E., et al. (2008). “Dyadic Dimensions of Armed Conflict, 1946—2007.” J Peace Research, 45(5): 697-71.

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