Overview of Military Medical Humanitarian Emergencies

Learning GoalsKnow the terminology of HA opsAppreciate the variety of organizations involved in disaster relief & their specific capabilitiesKnow the health priorities in HA ops

Acute situation affecting a large population where either the population or its government is incapable of providing its basic needs

Many Types of DisastersHurricanesDroughtVolcanoTsunamiEarthquakeChernobylUnion Carbide SpillWarEmbargoGenocide

Number of Humanitarian Disasters Worldwide 1985-95

Not All Refugees are the SameRefugeeIDP(Internally Displaced Person) Cross Political Boundaries 15 million (1997) Entitled to UN and intl rights Stay within own country 20 million (1997) Harder to intervene, assist

ECOSOC, U.S. Mission to U.N.Estimated Number of Displaced Persons Worldwide 1984 - 1997

Civilian Deaths in Complex Humanitarian DisastersECOSOC, UN 1996

Country

Deaths

Time Period

Sudan

> 1 mill.

1983 Pres

Ethiopia

750k 2 mill

1984 1993

Rwanda

500k 1 mill

1994 Pres

Cambodia

> 1 mill

1975 1993

Somalia

500 k

1988 Pres

Bosnia-Herzegovina

200 k

1992 - 1996

How do you measure disaster severity?

Crude Mortality Rate (CMR)the number of deaths per 10,000 people per day

CMRs of Recent EmergenciesInfect. Dis Clinics NA Jun 95

The Vulnerable Suffer the Most(Kurdish Population, Northern Iraq 1991)

Other Vulnerable PopulationsUnaccompanied MinorsLactating MothersPregnant WomenWoman Head-of-Households

Type of Emergency Dictates Response

Phases of EmergenciesD --> D+30ChaosHigh CMRAssessmentD+30 --> D+60Relief TailoredCMR dropsContinuing AssessmentD+60 onwardMove towards self-sufficiencyCMR and quality of life returns to baseline0 - 3030 - 6060 -- ???

The Players in Humanitarian EmergenciesHostMilitaryWorld Food ProgramWorld Health Org.UNHCRHostGovernmentOFDANATONGOs

NGOsThousands out thereMost are small with an even smaller focusshoes for children, eyeglasses, irrigation trainingMost specialize in a type of emergency reliefCompete for aid money from private and government donorsmajority (~ $5 billion) from governments in 1995

International Committee of the Red CrossUnique among NGOs in that its mission is MANDATED by international law.Geneva Convention 1949 & Protocols of 1977Acts principally in civil disturbance and has RIGHT and DUTY to interfere in national and international conflictsBrokers relief assistance, assures legal protection for victims and POWsHas primary role in family reunification

International Committee of the Red CrossWill go to maximal lengths to maintain NEUTRALITYfully discloses activities to all parties in a conflictRefuses participation in any activity that may be perceived as partialconsequently, the ICRC is self-sustaining including airlift, logistics, and commNeutrality agreement refused in Iran-Iraq, Afghanistan; ignored in Chechnya

NGOsCooperative for American Relief EverywhereLogistics, Food Aid, Camp Management ($300 M)Doctors without Borders / MSFMedical Care ($ 150 M)Oxford Committee for Famine ReliefWater and Sanitation ($ 200 M)Catholic ReliefFood DistributionSave the Children FundFood Aid and DevelopmentIrish ConcernSupplemental Feeding

USAID U.S. Aid for International Development coordinates US govt programs for intl development and response to disasters Disaster response is job of Office of Foreign Disaster Assistance (OFDA) becomes involved when Asst Sec of State for that region declares a state of disaster

USAID contd In disaster, deploys a DART (Disaster Assistance Response Team) composed of expertsthey evaluate and prioritize overall relief needsrelease pre-positioned disaster relief commodities stockpiled in disaster-prone regions (plastic sheeting, water containers, chain saw kits, body bags, hard hats, gloves, water purification suppliesreview NGO / UN proposals and award funds for the hands-on work of relief

Other Governmental AgenciesEuropean Community Humanitarian Organization (ECHO)

Overseas Development Agency (UK)

Canada International Developmental Agency (CIDA)

Japan International Cooperation Agency (JICA)

United NationsLimited ability to provide unless invited by a host governmentUN Chapter VII provides for forceful intervention only if international security is threatened

UN Agencies UN High Commissioner for Refugeescoordinates a material responseadvocacy for displaced people rather than on camp management

World Food Program coordinates delivery of food stuffs

More UN AgenciesUNICEF a fund, not an agency can provide assistance without permission of host government focuses on social programs for kids, pregnant and lactating womenWorld Health Organization Consultation and policy in preventive and curative health care

Still More UN AgenciesUN Development Program coordinates pre-disaster UN programs

Off. for Coord. of Humanitarian Affairs Created 1992 to coordinate all UN agencies and liaison with NGOs, militaries

U.S. Military Increasingly drawn into HA operations

Why the U.S. Military?Speed: no other organization can mount as large a logistical operation as rapidly

Security: arrives fully prepared to secure people and material

Why the U.S. Military?Transportation: Possess array of assets to deliver anything, anywhere, anytime

Why the U.S. Military? Logistics: Can maintain supply lines in austere environmentsCommand and Control: well-defined structureSelf-sufficiencySpecialty Units: Engineers, Medical

Drawbacks of U.S. Military ParticipationMedical Care: Oriented to combat casualty care, not civilian disaster victimsFocus: Short term objective driven; not aimed at re-developmentPolitical RamificationsExpense ...

Humanitarian Operations are ExpensiveDifficult to provide cost-effective assistanceSomalia: $ 100 M per monthEthiopia: coalition airlift for famine of 1980s was cost-inefficient and provided no medium or long-term benefit (good publicity, though)Cost of 1 C-130 flight with 15 tons of grainCost of purchasing a 30 ton capacity grain truckand fueling it for 6 months=

Root Causes of MortalityDisruption of food sourcesDisruption of Health Services Loss of ShelterDisrupted SanitationLoss of IncomeCrowdingLack of Water

Leading Causes of Death in Humanitarian Disasters in the Developing World Diarrhea / Dehydration Measles Malaria Respiratory Infections Malnutrition

Causes of Death, by %Wad Kowli Camp, Sudan, 1985MeaslesDiarrheaResp. InfectionMalariaMMWR 41:RR-13

Causes of Death,by %Malawi, 1990MeaslesMalariaResp. InfectionDiarrheaMalnutritionOtherMMWR 41:RR-13

Causes of Death, by %Lisungwe Camp, Malawi, 1990MMWR 41:RR-13DiarrheaMalnutritionMalariaMeaslesRespOther

CMR by Malnutrition Prevalence

Ten Essential Emergency Relief Measures# 1Rapid Assessmentof magnitude, environment, needs, local response capacityAssess the Standard of Care and stick to it!

# 2Provide Shelter and Clothing

exposure to elements increases vulnerabilityas well as caloric requirements

minimum of 2000 kcal / person / dayequitable distribution systemtargeted feeding programs for the most vulnerableLow-value foods work best

#3 Provide Adequate Food

# 4Sanitation and Clean Water

minimum of 3-5 L / person / day(~ 20 is comfortable)

# 5

Diarrhea Control Program

personal hygiene, improved sanitation, proper medical management of dehydration

# 6Prophylax Against Measles

Vaccine to most susceptible, quarantine, Vitamin A supplementation

# 7Primary Care Algorithms

Based on prevalent diseases, resources, and local standards of care

# 8Disease Surveillance

Necessary to monitor interventions and re-align priorities

# 9Organize Human Resources

Most under-recognized asset -- disaster victims themselves

# 10Coordinate Activities

Establish liaison with local government, local military, intl groups, NGOs

Change your frame of reference. You are there to provide the local standard of care, not the American standard of care.

USAIDPL 480 (Food for Peace) supports emergency HA in form of agricultural comodities. Jointly operated by DOA and USAID. Title II managed by Food for Peace office. FY 97 budget was $387 million. Also gives to NGOs and World Food Program (1/3 of budget). With approx. 26 million starving, it takes 3.5 million tons of food at a cost of $2 billion to give basic sustenance.Title III. more long-tewrm food development to countries.