Overview of Military Medical Humanitarian Emergencies

Learning Goals u u Know the terminology of HA ops u u Appreciate the variety of organizations involved in disaster relief & their specific capabilities u u Know 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 Disasters Hurricanes Drought Volcano Tsunami Earthquake Chernobyl Union Carbide Spill War Embargo Genocide

Number of Humanitarian Disasters Worldwide

Not All Refugees are the Same Refugee IDP (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

Civilian Deaths in Complex Humanitarian Disasters ECOSOC, UN 1996

How do you measure disaster severity?

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

CMRs of Recent Emergencies Infect. Dis Clinics NA Jun 95

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

Other Vulnerable Populations u u Unaccompanied Minors u u Lactating Mothers u u Pregnant Women u u Woman Head-of-Households

Type of Emergency Dictates Response

Phases of Emergencies u u D --> D+30 – –Chaos – –High CMR – –Assessment u D+30 --> D+60 –Relief Tailored –CMR drops –Continuing Assessment u D+60 onward –Move towards self- sufficiency –CMR and quality of life returns to baseline ???

The Players in Humanitarian Emergencies Host Military World Food Program World Health Org. UNHCR Host Government OFDA NATO NGO s

u u Thousands out there u u Most are small with an even smaller focus – –shoes for children, eyeglasses, irrigation training u u Most specialize in a type of emergency relief u u Compete for aid money from private and government donors – –majority (~ $5 billion) from governments in 1995

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

u u Will go to maximal lengths to maintain NEUTRALITY – –fully discloses activities to all parties in a conflict – –Refuses participation in any activity that may be perceived as partial F F consequently, the ICRC is self-sustaining including airlift, logistics, and comm – –Neutrality agreement refused in Iran-Iraq, Afghanistan; ignored in Chechnya International Committee of the Red Cross

NGOs Cooperative for American Relief Everywhere Logistics, Food Aid, Camp Management ($300 M) Doctors without Borders / MSF Medical Care ($ 150 M) Oxford Committee for Famine Relief Water and Sanitation ($ 200 M) Catholic Relief Food Distribution Save the Children Fund Food Aid and Development Irish Concern Supplemental 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 u u In disaster, deploys a DART (Disaster Assistance Response Team) composed of experts – –they evaluate and prioritize overall relief needs – –release pre-positioned disaster relief commodities stockpiled in disaster-prone regions (plastic sheeting, water containers, chain saw kits, body bags, hard hats, gloves, water purification supplies – –review NGO / UN proposals and award funds for the hands-on work of relief

Other Governmental Agencies European Community Humanitarian Organization (ECHO) Overseas Development Agency (UK) Canada International Developmental Agency (CIDA) Japan International Cooperation Agency (JICA)

United Nations u u Limited ability to provide unless invited by a host government u u UN Chapter VII provides for forceful intervention only if international security is threatened

UN Agencies UN High Commissioner for Refugees coordinates a material response advocacy for displaced people rather than on camp management World Food Program coordinates delivery of food stuffs

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

Still More UN Agencies u u UN Development Program – – coordinates pre-disaster UN programs u u Off. for Coord. of Humanitarian Affairs – – Created 1992 to coordinate all UN agencies and liaison with NGOs, militaries

U.S. Military u u Increasingly drawn into HA operations

Why the U.S. Military? u u Speed: no other organization can mount as large a logistical operation as rapidly u u Security: arrives fully prepared to secure people and material

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

Why the U.S. Military? u u Logistics: Can maintain supply lines in austere environments u u Command and Control: well-defined structure u u Self-sufficiency u u Specialty Units: Engineers, Medical

Drawbacks of U.S. Military Participation u u Medical Care: Oriented to combat casualty care, not civilian disaster victims u u Focus: Short term objective driven; not aimed at re-development u u Political Ramifications u u Expense...

Humanitarian Operations are Expensive u u Difficult to provide cost-effective assistance u u Somalia: $ 100 M per month u u Ethiopia: 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 grain Cost of purchasing a 30 ton capacity grain truck and fueling it for 6 months =

Root Causes of Mortality u u Disruption of food sources u u Disruption of Health Services u u Loss of Shelter u u Disrupted Sanitation u u Loss of Income u u Crowding u u Lack 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, 1985 Measles Diarrhea Resp. Infection Malaria MMWR 41:RR-13

Causes of Death,by % Malawi, 1990 Measles Malaria Resp. Infection Diarrhea Malnutrition Other MMWR 41:RR-13

Causes of Death, by % Lisungwe Camp, Malawi, 1990 MMWR 41:RR-13 Diarrhea Malnutrition Malaria Measles Resp Other

CMR by Malnutrition Prevalence

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

# 2 Provide Shelter and Clothing exposure to elements increases vulnerability as well as caloric requirements

minimum of 2000 kcal / person / day equitable distribution system targeted feeding programs for the most vulnerable Low-value foods work best #3 Provide Adequate Food

# 4 Sanitation 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

# 6 Prophylax Against Measles Vaccine to most susceptible, quarantine, Vitamin A supplementation

# 7 Primary Care Algorithms Based on prevalent diseases, resources, and local standards of care

# 8 Disease Surveillance Necessary to monitor interventions and re-align priorities

# 9 Organize Human Resources Most under-recognized asset -- disaster victims themselves

# 10 Coordinate 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.