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please read the following and answer the question* The Van Rooyen article lists emerging issues and future trends for the provision of humanitarian aid in complex humanitarian emergencies. Choose three of these and describe how they are being handled or have been handled at any complex humanitarian emergency outside the United States within the last 15 years. Again, choose a unique event from your classmates so that we can enrich ourselves with a greater degree of education rather than having everyone talk about the same two or three events.
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SPECIAL REPORT
Emerging Issues and Future Needs in
Humanitarian Assistance
Michael J. VanRooyen, MD, MPH; Steven Hansch, MPH; Donna Curtis, BS;
Gilbert Burnham, MD, PhD
The Johns Hopkins Center for International
Emergency, Disaster and Refugee Studies
The Johns Hopkins University School of Medicine
and Bloomberg School of Public Health
Baltimore, Maryland USA
Coirrespondence:
Michael VanRooyen, MD, MPH,
FACEP
The Johns Hopkins Center for
International Emergency, Disaster
and Refugee Studies
1830 E. Monument Street, Suite 6-100
Baltimore, MD 21305 USA
Email: mvanrooy@jhmi.edu
Keywords: aid; assistance, humaniarian; barriers; complex emergencies; dangers; data;
development; disaster; effects; efficiency;
evaluation; health system; managers; nongovernmental agencies; participation; policymaking; prevention; recipients; reform; volunteers; workers, field
Abbreviations:
CHART = Combined Humanitarian
Assistance Response Training
HELP = Health Emergencies in Large
Populations
ICRC = International Committee of the
Red Cross
NGO = non-governmental organization
OFDA = Office of Foreign Disaster
Assistance
PAHO = the Pan-American Health
Organization
WHO = World Health Organization
Prehospital and Disaster Medicine
Abstract
During the past two decades, there has been tremendous investment in the
ability to intervene in disaster settings, and significant barriers remain to
providing appropriate services to populations affected by natural and manmade calamities. Many of the barriers to providing effective assistance exist
within the NGO community, and illustrate emerging needs for international agencies. These emerging needs include improving methods of recipient
participation to promote the local health system, developing improved
methods for quality assurance, enhancing options for personnel development, and addressing long-term needs of reconstruction and rehabilitation.
Relief agencies face challenges on all levels to develop sound practices in
providing humanitarian assistance that can lead to long-term benefits to
populations affected by disaster.
VanRooyen MJ, Hansch S, Curtis D, Burnham G: Emerging issues and
future needs in humanitarian assistance. Prehosp Disast Med 2001;
16(4):216–222.
Introduction
Disasters are occurring with increasing frequency because of explosive
population growth, rapid urbanization, poor land use, and industrialization. In addition, modern warfare in
the post-cold-war era has caused profound effects on the health and productivity of entire populations.
During the past two decades, there
has been tremendous investment in
the ability to intervene in disaster settings. Unfortunately, many of these
efforts have been ineffective.1,2
While advances in telecommunications have improved our ability to
access and characterize a disaster, significant barriers remain to providing
appropriate services to people and
communities affected by natural and
man-made calamities.
Many of these barriers to aid are
due to the nature and complexity of
specific human emergencies, such as
multiethnic conflicts (Bosnia), new
frontiers in military intervention
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(Somalia, Kosovo), and those with
disregard for non-governmental
organization (NGO) neutrality
(Sierra Leone, Chechnya). However,
many of the barriers to providing
effective assistance also exist within
organizations; many lack the professional support or institutional memory to continually improve operations.
Humanitarian aid still is a young
science (and art). Significant needs
and deficits remain in the organization and provision of aid. In addition,
there are entrenched, vested interests
that prevent even the best aid organizations from objectively evaluating
their own work. Despite efforts to
standardize and coordinate humanitarian activities, the relief community
remains an intricate mosaic of people,
capabilities, and allegiances. As this
mosaic recreates itself with every new
major emergency, there are a number
of recurrent incongruities that
emerge. The goal of this paper is to
Vol.16, No.4
VanRooyen et al
217
Field Operations
Recipient participation
Promoting the local health system
Evaluation and Assurance
Improving field data collection and analysis
Using qualitative data and field measurements to
improve program quality
Human Resources
Enhancing training and professionalism in humanitarian
workers
Improving the effectiveness of field managers
Utilizing short term volunteers
Addressing psychological needs of field workers
Addressing danger to field workers and the need for
security training
Organizational Policy
Using health as a bridge to peace
Increasing focus on disaster prevention
Addressing post-crisis reconstruction of health services
Anticipating the harmful effects of aid
Prehospital and Disaster Medicine 2001 VanRooyen
Table 1—Emerging issues and future trends
explore emerging issues of importance in humanitarian
assistance, particularly in the health sector, and to discuss
future trends. In all cases, the intent of the authors is to
open a dialogue on how the variations in practice among
the organizations can be improved for the sake of excellence in humanitarian assistance.
Emerging Issues and Future Trends
In the context of this discussion, emerging issues are
defined, in general terms, as issues that are understood to
be of significance, but are not well-developed in the practice of humanitarian assistance. These key issues significantly impact the operation and performance of providers
of humanitarian assistance, particularly in the health sector.
These issues are divided into the topics listed in Table 1.
1. Field Operations
The need for improving field operations has increased as
NGOs function in conflict and post-conflict settings with
a number of competing and complicating factors. In these
situations, there is pressure to perform rapid evaluations,
respond to emergency needs, and simultaneously integrate
the mechanisms of transition from relief to development
operations. There have been many lessons learned from
past emergency activities. The most important include
involving the recipients and local health providers and promoting the local health system.
Recipient participation
Relief workers, disaster managers, and journalists alike often
forget that most of the life-saving action—whether search
and rescue or food acquisition—is performed by the communities themselves, with limited help from international
agencies.1 They are the survivors and often heroes, though
we rarely acknowledge or publicize their efforts. Even where
NGOs deploy in large numbers, the vast majority of NGO
staff doing the immunizations and feeding and building are
local hires—the emergency-affected populations.
The neglect to incorporate the recipients of aid into the
October – December 2001
selection and design of relief efforts has contributed to the
ineffectiveness of numerous field programs. Recipients are
not consulted routinely, and if they are, typically it is late in
the process. Early efforts using participatory methods for
program design have been encouraging, but it is not clear
how these methods may be translated into the acute disaster
setting. One attempt to address this issue is the Ombudsman
Project, which aims to provide an official avenue for recipients to participate in the management of relief efforts.2 This
type of “field friendly” method for ensuring recipient participation should be incorporated into the design of relief
efforts, so that NGOs can more easily and more reliably
work with the beneficiaries of assistance.
Promoting the local health system
Both military and civilian organizations have utilized
mobile clinics that can set-up on a site, draw large numbers
of patients, provide mass treatments, and then, pack-up at
sundown.3 Transient clinical programs rarely are sound
medically, and often may be dangerous; such mobile
health clinics and transient curative programs can quickly
undermine the local primary health care system. Thus,
individuals and communities are encouraged to bypass
local personnel in favor of expatriates, who may not necessarily be trained appropriately to handle the medical needs
of the affected population. Inappropriate health care is not
better than no health care—because of the risks involved in
spreading disease, community dissatisfaction, and risks
often incurred in traveling to and from distant medical
facilities.4
Transient health posts in refugee settings certainly serve
a purpose, but even in this setting, early investments in
training indigenous personnel and adaptation to a system
familiar to the constituents will yield long-term benefits in
the post-emergency phase. The promotion of primary and
community-based care by equipping and supporting local
health posts, can stabilize the health of the population,
provide essential community-based care, and form the
foundation for the next tentative steps toward rehabilitation, reconstruction, and long-term development.
2. Evaluation and Assurance
The principal way to ensure efficacy of humanitarian aid
programs is to study what has been successful in the past,
and to use this evidence to design future programs and create policies.4 In order to institute these ‘evidence-based
policies’, the international relief community must develop
and streamline systems for data collection and analysis, and
then, translate the information into implementing changes
to improve their programs.
Improving field data collection and analysis
In the past several years, there has been concern voiced
about the quality of health information systems in emergency situations. Often, the individuals or organizations
that provide initial statistics, such as mortality rates and
infant death rates, are wrong. The net death totals spoken
about and published for various disasters often are quite
inaccurate. Reasons for this imprecision range from incompetence to deliberate political fudging. Because there is no
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Prehospital and Disaster Medicine
218
Issues and Needs in Humanitarian Assistance
central credible and honest authority to gather epidemiological data, there often is room for insertion of bias by
news agencies or governments that may report erroneous
numbers to justify their intervention.
The essential task of reliable data collection in emergencies must lie with international aid agencies working
with the affected population. When governmental statistics
fail and military estimates are biased, NGO statistics are
one of the most reliable sources of information. Accurate
statistics require compliance among the major players on
the ground and a standardized method of data collection.
It is an unfortunate myth that statistical analysis is too time
consuming to perform during a humanitarian crisis. On the
contrary, because of time constraints, lead agencies can’t
afford NOT to perform accurate and statistically sound
assessments. Without doing so, organizations will risk misplacing much-needed assistance.
Using qualitative data measurements to improve program
quality
Steps have been taken to ensure that most humanitarian
organizations use a standard information system, with very
basic indicators, that begins during the emergency phase.
Appropriate emphasis has been placed on crude mortality
rates as an overall health status indicator. Surveillance
using case sentinel events has been used successfully to
characterize the health status of affected populations. In a
recent study of 45 refugee camps, Spiegel et al found that
although there was extensive variation, the health information system broadly represented the health events in the
refugee community.5
How relevant is this information for future planning? It
is likely that during the post-emergency phase, a different
type of information is needed for program design and monitoring than is provided through use of standard disease
tally sheets. For example, in the post-emergency phase,
crude mortality rates lose much of their value as indicators.
Bolton describes a qualitative assessment methodology that
can be applied in order to understand how a community
perceives its health needs.6 Using this approach in refugee
populations, health services may be redesigned to better
meet community needs. Since emergencies are lasting
longer, there is a major need to improve qualitative measures
and strengthen the monitoring so that these programs can
transition more efficiently into development. It is time to
look beyond the simple outputs of numbers of reported
cases, and to begin to measure the outcomes and impacts of
health programs for displaced populations.
Collection and analysis of data not only are important
for future planning, but they also can be used to evaluate
the effectiveness of an intervention, and to compare it to
other interventions in order to set priorities on the basis of
relative effectiveness, efficiency, costs, and benefits that
result. Large amounts of money often are donated to disaster relief operations, yet little has been done to study the
cost-effectiveness of various relief activities.4 Cost-effectiveness may not be the only element used in planning and
prioritizing relief activities, but cost-effective analysis will
provide another tool for comparing and evaluating relief
activities. Loevinsohn et al used cost-effective analysis to
Prehospital and Disaster Medicine
evaluate whether vitamin A supplementation should be
targeted to high-risk populations. They found that targeting was not cost-effective, and that vitamin A supplementation should be administered to all of the pre-schoolers in
the developing countries.7
Such studies use evidence collected from the field to
determine the effectiveness of a program, and can be used by
other organizations to improve their programs. Griekspoor
et al also conducted a study on cost-effective analysis of
treating visceral leishmaniasis in the Sudan as an example of
using the Disability Adjusted Life Years (DALY) to evaluate health interventions.8 In this particular situation, treatment of visceral leishmaniasis proved to be a very good value.
The development of these types of evaluation tools for field
operations could prove extremely helpful in comparing, evaluating, and prioritizing health interventions.8,9
3. Human Resources
The success of a humanitarian intervention hinges on the
personnel in the field. Therefore, training and support of
field personnel is crucial to the implementation of any
organization’s programs.
Enhancing training and professionalization of humanitarian workers
Improving the performance and effectiveness of humanitarian workers has been a goal of many graduate-degree
and short-course programs.10 The International
Committee of the Red Cross (ICRC) course Health
Emergencies in Large Populations (HELP), the Combined
Humanitarian Assistance Response Training (CHART)
course, and the Office of Foreign Disaster Assistance
(OFDA) funded courses, and others have attempted to
address this issue. In addition, management of health programs in humanitarian emergencies is now well-established in the curriculum of some schools of public
health.10,11 It seems intuitive that health managers trained
in basic principles will make more appropriate decisions
and avoid costly mistakes. However, with the rapid
turnover of personnel and the trends of using more professional staff from developing countries, there still is a long
way to go in order to create a stable cadre of readily available, skilled, health managers.
Experience in other areas shows that the lack of needed
skills is a major cause of poor employee morale. Inadequate
skills and lack of technical support may be a major reason
for the high turnover of health workers, and the large number of health workers in some organizations who leave
before the end of their contracts.12 Waldman et al discuss
new conditions that public health workers must face when
working in disaster relief.10 Today’s disasters often are
complex emergencies precipitated by conflict between
states; they commonly involve large populations and
human rights abuses.10 These new disaster scenarios
should be addressed by NGOs as they prepare their leaders
for work in the field.
Improving the effectiveness of field managers
Much of the immediate responsibility for any relief operation lies in the hands of the NGO field manager.
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Vol.16, No.4
VanRooyen et al
219
Improving field operations starts with improving the leadership and administrative capacity of field managers. Field
program leadership requires management skills in project
assessment and planning, finance, personnel and human
resources, and quality assurance and reporting. Field managers from most NGOs have little experience in program
management, and typically arrive in this position from a
technical background, with sector-specific skills in food
and nutrition, water and sanitation, or health. In order to
improve field operations, the NGOs must identify and
train field personnel in basic management principles.
While larger NGOs may provide such training, there are
no management courses available for the greater NGO
community.
Utilizing short-term volunteers
There have been numerous criticisms of NGOs for being
insufficiently professional, but bureaucrats and pundits
neglect the soul of NGOs — that the best work done by
many NGOs is by intelligent, motivated, specialist volunteers
who are not able to commit decades or careers to working
abroad. Very often, they just are willing to take off from their
jobs for a few months in order to help out during the worst
crisis periods. ‘Burnout’ (spiritual fatigue) is not the only reason that field staff stay only for short periods. It also is due
to the fact that the best aid workers have high opportunity
costs; that is, better-paying positions waiting for them at
home. Indeed, the NGOs have a difficult, perhaps impossible, job retaining intelligent, educated, creative individuals
on whom there is enormous pressure to relocate to the commercial world of stability, safety, and job security.10
There is no perfect balance for recruiting the right people for long-term commitments, and the most qualified or
skilled individuals often are the least able to stay for long
periods. The NGOs provide value precisely in creating
opportunities for top-talent volunteers to jump in for those
periods that their schedules allow. The answer then, lies in
the ability of NGOs to manage short-term personnel, and
to provide innovative, educational options for field staff.
Addressing the psychological needs of field workers
As health personnel are caught-up in conflict situations,
and are confronted by unspeakable atrocities, the emotional toll on these health workers is likely to be high.13 But
how high, of what kind, and of what duration? What measures are effective in ameliorating the consequences? Are
the emotions experienced by national relief workers different from those of expatriate workers? We know few
answers for any of these questions.
Although some organizations provide active psychological support, many relief organizations continue to recruit
and debrief employees by telephone. In the USA, a legal
precedent has been set for providing psychological support
to fire and police personnel who have been emotionally
traumatized in their work. Relief organizations have the
same responsibility to their staff traumatized in the course
of duties in Bosnia, East Timor, or the Congo. One example of such a program is the Caribbean Stress Management
in Disasters Program, created in 1998 by PAHO/WHO to
address the psychological needs of disaster workers. An
October – December 2001
added benefit to such a program is that it can be modified
to address the psychological needs of local employees and
the aid recipients.5 Evaluation of the success of the program and its applicability to other countries and situations
will yield import …
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