Public Health in Humanitarian Crises
Armed conflict is a leading public health issue with an estimated 181,795,000 deaths caused by war and civil conflict injury in 2008 alone.1 While global data on mortality and morbidity rates related to armed conflict is difficult to assess, particularly with regards to deaths indirectly caused by conflict, conflict-specific reports have provided a more complete view of mortality in recent years. The World Health Organization’s data on cause-specific mortality estimates include war and civil conflict as direct causes of injury-related death; they do not articulate the numbers of disease-related deaths indirectly caused by conflict. Violence as well as disease, both communicable and non-communicable, impact all those affected by armed conflict: military, civilians, combatants, humanitarian actors, and others.
The Sphere Project, which was established in 1997, aims to improve public health in humanitarian crises. Their handbook, Humanitarian Charter and Minimum Standards in Humanitarian Response, provides guidance on minimum standards in: water supply, sanitation and hygiene promotion; food security and nutrition; shelter, settlement and non-food items; and health action. Although not legally required to do so, several humanitarian organizations have adopted the Sphere standards, resulting in a common understanding of care among organizations engaged in a shared environment and valuable assessments of their impact.
Violence-related mortality and disability are often quickly recognized as a direct result of armed conflict: those wounded on the battlefield or maimed by unexploded ordinances and land mines after the cessation of hostilities. Violence extends beyond the battlefield, however, as rape and sexual assault are rampant during wartime chaos. Victims face the threat of unwanted pregnancy, sexually transmitted disease, depression, psychical disability, and death. Accurate estimates of sexual violence are hard to gather due to the silence of many survivors; however, sexual violence was used as a weapon of war in past conflicts. Responding to this, the UN Security Council passed Resolution 1888 in September 2009 to condemn the use of sexual violence as a war tactic.
Violence and injury are not the only causes of concern. Communicable diseases have the potential to eradicate entire communities and can thrive in close quarters. As civilians flee from the front lines, refugee camps become increasingly strained and chances of infectious outbreaks grow exponentially. Over-crowding, and limited availability of potable water and sanitation have contributed to some of the worst outbreaks in history. The last few years have seen cholera and other infectious diseases, such as meningitis and measles, flourish within refugee camps in Chad, Thailand, and Kenya. The UN High Commissioner for Refugees monitors refugee camps throughout the world and annually reports on whether the recognized camp standards for hygiene and health are met.
Conflicts are increasingly of a non-international character, as such, internally displaced persons (IDPs) have increased in number and the number of refugees has decreased. Additionally, there is a rise in those living in non-camp settings. Vaccination efforts coupled with the increased numbers opting out of camps, may aid in preventing violent outbreaks of disease; however, there remain other serious concerns with unique to non-international armed conflict. Access to vulnerable groups can be difficult, and the number of women, children, and older individuals affected by the conflict is high.
Non-communicable diseases tend to affect higher numbers of conflict survivors in prolonged conflict then in shorter bouts of conflict. These include mental health disorders, malnourishment, cancers, and other ailments. Prolonged malnutrition and starvation can lead to impaired brain development in children in addition to death in the general population. Depression and Post-traumatic Stress Disorder may lead to suicide or addictive behaviors (drug and alcohol abuse, smoking), which in turn lead to cancers and other imbalances in the body. It may take several years after the conflict for non-communicable diseases to take hold in the body; as such, the widespread impact of conflict in this way can be overlooked in most morbidity statistics.
Inaccessible facilities and lowered standards of care wreak havoc on populations, no matter the intensity of the violence. Untreated wounds risk infection, communicable diseases risk spreading, and non-communicable diseases worsen without treatment. Depending on the type of armed conflict and the availability of aid, the public health of an affected population may fluctuate at different rates.
The duration and location of the conflict, regardless of its status as international or non-international, also impacts the severity of the public health situation. Wealthy countries may have the ability to bounce back from short bouts of conflict in time; however, prolonged periods of armed conflict and violence have the potential to destabilize populations for generations in both wealthy and developing countries. Developing countries have the most difficult time in recovering from conflicts and even those of short duration can leave large disruptions in national health. Low-income areas with low life expectancies see infectious diseases and neonatal disorders as the largest cause of excess mortality.2
Humanitarian actors attempt to maintain or reduce the crude mortality rate and the younger than five mortality rates at the levels of, or less than, double the baseline rate prior to the crisis situation. This rate varies from country to country and may raise challenges for organizations and humanitarian actors. There is a need to balance the care required in a crisis situation with the care available in non-affected areas. For example, a dilemma arises when the standard of care in a refugee camp surpasses that provided in the local area not subjected to conflict. Care must be taken to support the local public health systems and to avoid rendering them obsolete. In prolonged aid operations, humanitarian actors may work to ensure stability of public health through community engagement and education of local doctors and staff.
Humanitarian organizations must balance the provision of care with an appreciation for the underlying causes of disease. At times, this may be a matter of providing proper vaccinations and adequate nutrition. Debate among humanitarian organizations arises, though, where the underlying causes rest with the ruling party. The UN and several NGOs support the adoption of a rights-based approach to humanitarian action. Opponents to this approach stress the value of neutrality and fear that any political leanings will interfere with their operations.
While the impact of armed conflict and disaster on public health is inevitable, measures can be taken to mitigate the severity. The adoption of minimum standards and the engagement with local public health actors are examples of the strategies that have been employed. As geopolitics and global climate conditions continue to evolve, so too will their impact and the subsequent response. It is essential for humanitarian agencies to stay abreast of such trends and devise agile and effective responses accordingly.
1WHO, Global Burden of Disease, 2008, available at: http://www.who.int/gho/mortality_burden_disease/causes_death_2008/en/ind....