Disasters and Complex Humanitarian Emergencies
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DISASTERS AND COMPLEX HUMANITARIAN EMERGENCIES
Tennessee Psychological Association Carol Etherington, MSN, RN, FAAN November 2, 2012
Global Catastrophic EventsCrete/ Santorini Tsunami 1645 BC (100,000)Holland Sea Flood 1228 (100,000)Bubonic Plague 1346-52 (25 million)Calcutta EQ 1737 (300,00)Flu Epidemic 1918 (25 to 100 million)Chinese Flood 1931 (3.7 mil disease, drowning/ starvation)Peruvian Avalanche 1962 (3000 dead)Bhopal India Chemical Accident 19 84 (3000)SE Asia Tsunami 2004 (250,000)
High Profile U.S. Events
Johnstown, PA Flood 1889 (3000 dead)San Francisco Earthquake- 1906 (3000 dead)Nashville Train Wreck 1918 (101 dead)Pearl Harbor 1941; D-Day 1944Coconut Grove Fire Boston, MA. 1942 (491 dead)Vietnam War 1963 - 1975Three Mile Island 1979Hyatt Regency Walkway, Kansas City 1981 (113 dead)Oklahoma City Bombing 1995Hurricanes- Galveston/06, Camille, Andrew, Katrina, SandyTornados (Nashville Area) 1974, 1998, 2005; Flood 2010Persian Gulf War; Iraq War; Afghanistan Sept. 11
Disasters/Traumatic EventsNatural: usually have warnings; may or may not have preparation time
Man-Made Accidental: dependent on circumstances
Man Made Intentional: dependent on circumstances*
Anatomy of a DisasterPredromes: early warningsPre-ImpactImpactPost- Impact(Honeymoon, Disillusionment)Post Traumatic Stress Acceptance RecoveryorPost Traumatic StressDenial/Unremitting EmotionPTSD*
The Characteristics of Natural DisastersExtreme devastation, injuries, and deathNumber of natural disasters is increasing, affecting larger numbers of people and causing more economic losses, but proportionately fewer deathsBiggest relative impact is in developing countries and with the poorDisasters damage infrastructure, including health infrastructure (contrast impact of a hurricane in Haiti versus U.S.)
The Health Burden of Natural DisastersTens of thousands die each year from natural disastersDirect and indirect health effects vary by disasterEarthquakes: kill quickly and lead to many injuries with other long-term effectsVolcanoes: deaths due to mud and ashTsunamis: immediate drowning, few injuriesFloods: increase in diarrheal disease, respiratory infections, and skin diseases; Mud SlidesWildfires; Droughts, which can be deadly when combined w/conflict
What is a Complex Humanitarian Emergency (CHE)A major humanitarian crisis of a multi-causal nature that requires a system-wide approach.CHEs have been a major political, security and public health feature of the post-Cold War world. These man-made disasters account for more morbidity and mortality than all natural and technological disasters combined. To deliver effective aid during CHEs, international relief agencies must have a solid understanding of the political and social climates in which they are operating. They should base their health interventions on objective epidemiological data, especially standardized rates of morbidity and mortality.
Characteristics of CHEsCEs have had greater impact on health in the last decade than natural disastersOccur over prolonged periods of timeCombatants often target civiliansOften systematic abuse of human rightsLarge numbers of people are displacedDisruption of society leading to shortages of food and water; corruption, lessening civil interactionMigration may lead to additional problems
Health EffectsEarly in CHE, most deaths from diarrheal diseases, respiratory infections, measles or malariaDiarrheal diseases in refugee situationsMeasles in campsNutritional deficienciesViolence against women often rampant; rape is used as a strategy of war, survival sex sometimes neessary
Addressing HealthOrganize camps with safety and security in mindDevelop contingency plans for areas of probable conflictHave materials and human resources staged to address displacement and health problems
Carry out an assessment of the displaced population; establish disease surveillance systemStrive for crude mortality rate below 1 death per 10,000 persons
Health EffectsEnsure that environmental and personal hygiene are maintained in camps Provide 15 liters of water per person per dayPeople should not have to walk more than 500 meters to a water sourcePeople should not have to wait more than 15 minutes for their waterProvide appropriate sanitationDistribute food rations by family
Other General InterventionsNeed to address diarrhea, measles, malaria, and pneumoniaMalnutrition is of exceptional importanceContinuing assessment of the health situation; critical in both natural disasters and CHEsPractice prevention as soon as possible to prevent/curtail: outbreaks of disease, rising tensions; stay apprised of illness and unrest in surrounding areas of camps with local community as well as DPs
In 225 conflicts that occurred during the 20th century, 72 million deaths were conflict related; nearly half were civilians. They accounted for 35-65% of war related deaths and injuries *
Evolving Role of Humanitarian ResponseDistant HistoryInternational Red Cross (Henri Dunant)American Red Cross (Clara Barton)United Nations UNICEFNGOS/PVOs/VOLAGs proliferated in the 90sFaith Based Groups More NGOS, GOs, GONGOS and UNIVERSITIES proliferated even more in the 00s*
Evolving Mental Health
WWI - shell shockWWI - Combat fatigueVietnam PTSDCrime Victims Crisis Intervention; rape trauma syndrome, battered wife syndromeRescue Personnel CISD
*Primary victims direct injury, witness to injury and death; witness to terrible scenesSecondary loss of loved ones/friends, social structure, home, work, place of worshipTertiary rescue personnel or other caregivers
In war and civil conflict, there is an abundance of all as well as many categories that we probably have not even thought of.
Individual Risk Factors Loss of loved ones or friendsLife threatening danger or physical harmExposure to gruesome death, or bodily injuryExtreme environmental or human violence or destructionLoss of home and possessionsLack of social support Intense emotional demandsExtreme fatigue, weather exposure, hunger, or sleep deprivationExtended exposure to danger, loss, emotional/physical strainExposure to toxic contaminationProximity to the disaster*
Population Risk Factors
SecurityInternal /civil society conflictIll trained/too few caregiversCulturally inappropriate interventionsPoor knowledge base of actual needPoor assessment > poor programNo long term planFalse hopes and promises
Vulnerable GroupsChildrenFragile Elderly/Disabled Serious and Persistent Mentally IllChronic illness/injuryEconomically DisadvantagedEthnic Minorities/Marginalized GroupsVeteransRefugees/IDPs e.g. non native speakers*
CDC: GUIDING PRINCIPLES FOR MENTAL HEALTH No one who experiences a disaster is untouched by itMost people pull together and function during and after a disaster, but their effectiveness is diminishedMental health concerns exist in most aspects of preparedness, response and recoveryDisaster stress and grief reactions are normal responses to an abnormal situation. ; Survivors respond to active, genuine interest and concern.Disaster mental health assistance is often more practical than psychological in nature (offering a phone, distributing coffee, listening, encouraging, reassuring, comforting).Disaster relief assistance may be confusing to disaster survivors. They may reject disaster assistance of all types.
CDC: Survivor Needs & Reactions (Responses differ, but there are common needs) CDC Concern for basic survivalGrief over losses: loved ones; valued/meaningful possessions; Fear and anxiety about personal safety and physical safety of loved onesSleep disturbances, including nightmares and imagery from the disasterConcerns about relocation and the related isolation or crowded living conditionsA need to talk, often repeatedly, about events and feelings associated with the disasterA need to feel one is a part of the community and its recovery efforts
Reactions that Signal Possible Need for Mental Health Referral (Many responses to trauma can be expected, but some are cause for extra attention/concern.)CDC
Disorientation: dazed, memory loss, unable to give date/time or recall recent eventsDepression: pervasive feeling of hopelessness & despair, withdrawal from othersAnxiety: constantly on edge, restless, obsessive fear of another disasterAcute psychosis: hearing voices, seeing visions, delusional thinkingInability to care for self: not eating, bathing, changing clothing or handling daily lifeSuicidal or homicidal thoughts or plansProblematic use of alcohol or drugsDomestic violence, child abuse or elder abuse
Longer-Term Effects Checklist (Potential down-stream consequences of exposure to a natural or human-caused disaster .. for victims and responders)
NightmaresIntrusive thoughtsUncontrolled affectRelationship problemsJob/school related problemsDecreased libidoAppetite changeBlame assignation
CDC: Sources of Stress for Responders Role ambiguity; Lack of clear tasks; Mismatching skills with tasksLack of team cohesion; Ineffective communication Discomfort with level of danger or hazardous environmentLack of/ too much autonomyIntense local need for information ; getting accurate information out Database/technology issuesLaboratory specimen tracking, reporting; resources/equipment shortagesCommand and control ambiguitiesRe-integration barriers; coworkers have to pick up your workLack of understanding or appreciation for what you have been through; lack of interest in the role you have had
DISPLACED PERSON CATEGORIESRefugeesAnyone who, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, or membership of a particular social group or political opinion, is outside the country of his nationality and is unable, or, owing to such fear, is unwilling to avail himself to the protection of that country.
Asylum-seekersPersons who have applied for asylum or refugee status, but who have not yet received a final decision on their application.
Internally Displaced Persons (IDPs)People forced to leave their homes or places of habitual residence as a result of, or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or situations of natural or human-made disasters, and who have not crossed an international border.
ImmigrantsIn popular usage, generally understood to be a person who migrates to another country, usually for permanent residence and admitted to the U.S. as a lawful permanent resident.
Undocumented Previously referred to as "undocumented or illegal aliens; in a country without legal papers or (in the case of the U.S.) without a current non-immigrant visa such as H-1B.
Trafficked Persons The term "trafficking" is used by international agencies to describe activities violence for certain exploitative purposes including prostitution. Trafficking in human beings is probably the fastest-growing business of organized crime. Although trafficking afflicts men and women equally, rough estimates by the UN suggest that between 700,000 to 2 million persons trafficked across international borders annually are women and girls. (http://www.unfpa.org/gender/trafficking.htm)
RefugeesThe 1951 UN Convention defines a refugee as anyone who, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, or membership of a particular social group or political opinion, is outside the country of his nationality and is unable, or, owing to such fear, is unwilling to avail himself to the protection of that country.
Voluntary repatriationReturning to ones home country, considered the most desirable solutionLocal integration Establishing roots in the host or asylum country, may be an option if returning home is not feasible due to ongoing instability or conflictResettlement to a third country For individuals not sufficiently protected in the original host country and/or who are considered particularly vulnerable (e.g. disabled/injured, women-at-risk, mixed ethnicity)
Durable Solutions for Refugees
Refugees in the U.S.
Competition for scarce resources plays an increasingly important role in provoking conflicts and human displacement
The result: more displaced persons around the world, including refugees and others to the U.S. and other developed countries. UNHCR Global Report 2009
**All can have devastating resultsOnset may be rapid or slow some simultaneously both/ Cite Poland, 1997 and Grand Rapids Idaho, 1997Some communities have a lot of expereince dealing with disasters but still leave psychological wounds; some indiviauls have a lot of expereince dealing with abouse, but it still leaves psychological scars*Recognition long ago that disaster response wa important due to disruption of life as it has been known: death rates, collapsed infrastructures, collapsed social structuresdevasting impact on economy dislocation/relocation of large groups migrations death ratesLong term illness/injuryIrreversible damge*More than 40 definitions of disaster in the literatureIt is an event that greatly exceeds the coping capacity of a communityDifferentiate epidemic, endemic, pandemic*Due to human malevelonce, crime, war, civil conflictTerrorism adds new dimensionRecogntion of evil in individuals or groups (difference between a passion murder and a methodical killer (Dahmer or Ted Bundy); group (soldiers vs. Nazi SS); targeting combatants vs. non-combatants Move from Child soldiers *DISCUSS LIMITATIONS OF RESEARCH
Prolonged TV viewing refers to the numbers of hours spent viewing not necessarily the content viewed.
Intense emotional demands REFERS TO THOSE FACED BY RESCUE PERSONNEL OR CAREGIVERS.
Low levels of social support
Toxic Contamination refers to GAS, FUMES, CHEMICALS, RADIOACTIVITY
The closer you are to the disaster area, the higher the risk
2. within team, w/ non-team members, w/hdq.
, (Conveying information to families about missing or killed, ce)
linkage between epidemiology, laboratory, and environmental sampling
*INTRODUCING STAKEHOLDERSMost of you are aware-36 million refugees, IDPs (internally displaced persons) and UNHCR persons of concern in the world today (2009)Can be confusion/misuse of terms: immigrants, illegal immigrants, refugees (i.e., Haiti)*The U.S. accepts more than double the number of refugees than all other official resettlement countries combined.*