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Complex Public Health Emergencies

Frederick M. Burkle Jr.

INTRODUCTION

Public Health Emergencies

The term “public health emergencies” denotes disasters that adversely impact the public health system and its protective infrastructure (water, sanitation, shelter, food, and health) thus resulting in both direct and indirect consequences to the health of a population. When this protective threshold is destroyed, overwhelmed, not recovered or maintained, or denied to popu- lations through political violence, war, conflict, or other disasters, classic consequences, all preventable, emerge. Outbreaks of com- municable disease, food shortages leading to undernutrition and eventual malnutrition inevitably result in worsening vulnerabil- ity and insecurity, population displacement, loss of livelihoods, and poverty.

Public health emergencies occur more often in developing countries where public health infrastructure, adequate numbers of health sector workers, and basic medications and equipment are lacking or nonexistent. An exception occurs in developed countries when urban environments become more populous and dense, commonly with migrants experiencing low socioeco- nomic status and increased vulnerability. Urban occupancy for the disadvantaged is often limited to unfavorable disaster-prone areas with poor or absent infrastructure. Such a combination of factors results in high risk for a major public health emer- gency to occur if additional essential infrastructure loss were to occur with an earthquake or tsunami. Similar public health emergencies happen whenever the protective public health cover is breached in large-scale disasters such as Hurricane Katrina and the Indian Ocean tsunami. Two years after Hurricane Katrina, a 47% increase in mortality was reported in New Orleans.1 This uncomfortable outcome of the public health impact of the disas- ter results from system resources and infrastructure deficiencies that are similar to the familiar and prolonged woes common to countries at war in Asia and Africa. Additionally, large-scale epi- demics, pandemics, and other biological, chemical, or radiation disasters have the potential to cause unprecedented public health catastrophes. By definition, public health emergencies result in dire health consequences and share similar health indices such

as increased mortality and morbidity, which remain the most sensitive indices of short- and long-term impact and outcome.

Complex Humanitarian Emergencies

The focus of this chapter is the prototypical public health emer- gency commonly referred to as complex humanitarian emer- gencies (CHEs). Descriptively, “complex” is added to define a worsening or absent, political, economic, governance, security, and social system that either catapults or accelerates a deteriorat- ing public health environment and severely curtails its recovery.2

The political violence and warfare commonly grows so severe that it requires international humanitarian assistance and UN peacekeeping or peace enforcement assets to protect the civil- ian population. CHEs have also been called “complex political emergencies” favored by some to emphasize the pervasive polit- ical violence that is at the core of these tragedies.3

Additional public health emergencies are covered elsewhere, but because they may differ in cause, all are conceptually linked by similar consequences brought about by the disruption in the protective cover that public health provides to a population. CHEs have been defined by the U.S. Centers for Disease Control and Prevention (CDC) as “situations affecting large civilian pop- ulations which usually involve a combination of factors including war or civil strife, food shortages, and population displacement, resulting in significant excess mortality.”4 The twentieth century is known for cross border wars such as WWI and II, the Korean War, and the 1991 Persian Gulf War, yet few understand that during that time more people were killed by war, conflict, and its consequences within their own country rather than from outside forces.

CHEs represent the most common human-generated disas- ters of the past three decades. Internal crises are often catalyzed by longstanding social and sex inequities, poverty, judicial injus- tices, cultural incompatibilities, ignorance, racism, oppression, tribalism, and religious fundamentalism, all of which adversely influence public health and access to it.2 In the past two decades, the agricultural and protective public health infrastructure has declined while hunger in the world (defined as without food

361 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-07 11:41:05.

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362 ■ FR E D E R I C K M. BU R K L E JR.

Figure 24.1.1. Refugee camp conditions in northern Iraq 1992. Camp demographics are critical in determining requirements and vulnerability. As Kurdish men were killed by Saddam’s Iraqi forces, or were fighting to keep their own territory safe, the fleeing Iraqi Kurds were primarily children (50%) women (30%) and the elderly (20%). Logistics and health care in the precarious camp tents placed on the side of mountains had to adapt to unique needs. (Burkle, 1992). See color plate. All photos were taken and are owned by me. I give permission for their use. Frederick M. Burkle, Jr., MD, MPH, DTM.

for basic health) has climbed 18% to 850 million people.5 The chronic, smoldering political violence adversely affects access to and availability of health facilities and services, leading to in- creasing mortality and morbidity rates among the most vulner- able populations (e.g., women, children, elderly, and disabled). Such data go uncounted, unnoticed, and without political atten- tion from the outside world. While the number of CHEs has declined over the last decade, the few that remain are more com- plex, longer lasting and more insecure. The number of crisis- affected countries and territories across four continents at risk for deadly conflict remains unchanged.5 Politically, these are com- monly referred to as “failed” or “fragile states.”

CURRENT STATE OF THE AR T

Measuring the Human Cost of CHEs

Characteristically, CHEs are initially confined within nation- state borders and result in massive numbers of internally dis- placed populations (IDPs). Political violence and its direct effects on individuals occur first, resulting in death and injury.3 In time, IDPs begin to experience the consequences of being separated from essential public health services and mortality and mor- bidity from indirect causes begin to escalate. Most CHEs risk effecting neighboring countries with escaping refugees and in spreading, over time, the political turmoil and the conflict itself across borders.

Without epidemiological studies the short- and long-term impact of various forms of political violence would remain elusive. Studies performed in the early 1990s highlighted the dominance of public health consequences and the preponder-

ance of civilian victims. Epidemiological studies detect and verify continued health problems, confirm whether victims are bene- fiting from aid operations, and often catalyze major alterations in the direction and strategies of the international relief commu- nity and governmental donors. The additional lack of local and nation-state capacities in governance, economics, public safety, communications, and transportation work against an efficient and effective recovery and normalization to predisaster health indices.

Data analysis suggests that CHEs have changed substantially over the last three decades, especially in the overall levels of insecurity.6 At the time of this writing, in Iraq, for example, security assessments and relief strategies have not yet evolved effectively to deal with worsening security, especially as it impacts civilians and the relief community.

The humanitarian community relies on use of specific direct and indirect indices to 1) assess consequences including severity of the conflict, 2) measure the impact or outcome of interventions in declining mortality and morbidity, and 3) identify the most vulnerable of populations requiring care. The most common baseline health indices followed are

■ Mortality or death rates ■ Morbidity rates ■ Nutritional status ■ Aid program indicators to ensure predicted impact and out-

come ■ Age and sex-specific mortality and morbidity rates critical to

determine population vulnerability ■ Attack rates and case fatality rates crucial during outbreaks

and epidemics

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-07 11:41:05.

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CO M P L E X PU B L I C HE A LT H EM E RG E N C I E S ■ 363

Figure 24.1.2. This Figure illustrates camp conditions that contributed to the 80% of childhood deaths resulting from diarrhea and dehydra- tion secondary to common waterborne bacteria and viruses. Water from melting snow that ran through the camp was polluted by makeshift toilet facility run off and the washing of soiled laundry. (Burkle, 1992) See color plate.

Direct Indices Direct effects of political violence result in death, injury, and

disabilities, including psychological, as well as the direct conse- quences resulting from a lack of protection from, and respect for, international humanitarian law. Direct effects are quantitative in nature, subject to organized attempts to measure (i.e., population based cluster sampling), and easier than indirect effects to find and for which to hold people accountable.

Intervention from outside agencies and organizations is ini- tially driven by reports of battlefield and civilian deaths. Assess- ment teams use both direct observation and rapid assessment tools to measure the consequences of the conflict on essential public health parameters such as access to and availability of food, water, sanitation, shelter, health, and fuel. Initial assess- ments focus on measurements for crude mortality rates and “younger than age 5” mortality rates. As the humanitarian com- munity becomes more established, follow-on surveys include population-based cluster samplings and studies that further dis- aggregate the crude mortality rates to determine age and sex vulnerability (i.e., infant and maternal mortality and morbid- ity rates). Ongoing surveys and surveillance ensure that man- agement responses meet SPHERE (Humanitarian Charter and Minimum Standards in Disaster Response) and other essential public health standards.7

Figure 24.1.3. Mountain streams ended up as stagnant and polluted pools at the base of the camp where children played. Simple and easily corrected public health solutions must be sought to prevent outbreaks. (Burkle, 1992) See color plate.

The assumption is that low-cost humanitarian aid, if properly performed and managed, will reduce the direct indicator rates to pre-war/conflict levels or better within 4–6 months.6 As the direct effect mortality rates decline however, so does outside interest and relief aid from donor agencies and governments, often giving a false assurance of success.

Indirect Indicators It is the indirect collateral damage effects of conflict result-

ing from population displacement, disruption of food supplies, destroyed health facilities and public health infrastructure, and consequences, such as poverty and destroyed livelihoods that will ultimately account for 90% or more of overall mortality and morbidity. Women and children are the most common victims, as are the elderly and those with disabilities. No existing datasets, however, measure indirect death tolls, and except for a few coun- tries, the humanitarian community has no idea how to gauge the worldwide extent of indirect deaths.

In contrast to direct indices, indirect deaths are rarely mea- sured, are more functional and abstract in nature, frequently require qualitative or semiquantitative measures, and their accu- racy is difficult to confirm. In CHEs the health system and pub- lic health infrastructure is the first to be destroyed and last to recover or be rehabilitated. In the postconflict phase the risk of continuing death and disability from environmental, commu- nicable, and noncommunicable diseases related to the lack of this recovery may continue to decay up to 10 years postconflict and the effects may far exceed the immediate loses from the war itself.8,9 Similar consequences are found in countries contiguous to the conflict.

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364 ■ FR E D E R I C K M. BU R K L E JR.

Despite the cessation of hostilities, subtle and rarely counted mortality and morbidity result from those now out-of-work and despondent, demobilized soldiers, and IDPs who are more likely to suffer suicide, depression, and alcohol and drug abuse. A sensitive marker of the continued community decay and eco- nomic and physical insecurity is an increase in sex-based violence among intimate partners.10 In developing countries experienc- ing residual postconflict insecurity, families struggling to recover economically will frequently delay reenrollment of their children to school, usually females – a factor that subtly correlates with high child mortality rates. Over the past decade, humanitarian assistance has moved from insecure rural Africa and Asia to overcrowded urban areas.11

Urban aid is predominantly focused on protecting single or widowed mothers with young children seeking some sem- blance of security, education, and essential public health and social services once their rural economies are destroyed. Many have been forced to resort to prostitution to avoid abject poverty, only to succumb to the ravages of sexually transmitted diseases. The increased density of urban populations has rapidly out- stripped the fragile and poorly maintained public health infras- tructure. Few urban conclaves have safe water and sanitation. More than 2.6 billion people, almost one of every two people in the developing world, do not have adequate water and sanita- tion.11 In areas where the vector exists, outbreaks of dengue fever serve as a marker of economic decay and worsening governmen- tal services resulting from increased breeding of mosquitoes in the stagnant water of failed public rubbish collections.12

Achievement Indicators Achievement indicators refer to the completion of a certain

humanitarian-related missions, such as emergency delivery of military rations and rebuilding of clinics and hospitals. Coalition military and private contractors prefer to use achievement indi- cators rather than outcome indicators in measuring effectiveness of their interventions. Achievement indicators do not necessarily result in improved outcomes or guarantee the functional return of the health and public health infrastructure. Whereas these functions are critical to the relief process, claims of success in humanitarian aid and reconstruction must be viewed with cau- tion when achievement indicators alone are used.

Epidemiology of CHEs

CHEs can be divided into: developing; smoldering or chronic country; and developed models, all with differing data presenta- tions.2,4 Models are valuable in predicting priorities for imme- diate aid, even before confirming field level assessments. There are overlaps in these three models, especially when developed country conflicts persist with failed public health infrastructure resulting in failing indices similar to those seen in developing countries. Iraq once enjoyed stable health indices indicative of a developed country. In 2007, after 4 years of war and a worsening public health infrastructure, the infant mortality rate equaled that of Afghanistan and Sierra Leone.13 A common element of CHEs is that acts of genocide, ethnic cleansing, and torture have been universally reported in all models.

Developing Country Model Developing country CHEs primarily occur in central Asia

and Africa and are characterized by a health profile that exacer- bates preventable diseases, such as infectious diseases and mal-

Table 24.1: Developing Country Health Profile

■ 90% of deaths are preventable

■ Outbreaks of communicable diseases

■ Malnutrition and micronutrient diseases

■ Absent protective public health infrastructure

■ Major deficiencies in WHO childhood vaccine protection

■ Mental health consequences are most often unmeasured and untreated

■ Internally displaced and refugee populations

■ Weaponry, usually small arms and machetes, accounts for 4%–11% of deaths

■ High crude mortality rates range from 7–70 times normal baseline

■ Higher mortality rates in orphaned and unaccompanied children

■ High case fatality rates

nutrition, resulting from lack of protective levels of food, water, sanitation, shelter, and healthcare (Table 24.1).14 This results in high crude mortality rates, the majority coming from deaths from children younger than the age of 5 years. Seventy-five percent of the world’s epidemics occur during CHEs.2 Outbreaks only occur from unprotected endemic diseases. The major causes of mor- tality and morbidity are diarrhea and dehydration; malnutrition and micronutrient diseases such as vitamin A, C, and B6 deficiencies; complications from childhood vaccine-preventable diseases such as measles and tetanus; and complications from acute respiratory infections; and malaria.

CHEs result in people attempting to flee the war and con- flict. If they flee their homes but are unable or unwilling to cross the country’s border they are termed IDPs. With international law they remain under the authority of the host country, even though national forces may be attempting to find and kill them. This contradiction remains a dilemma for the international com- munity, a well-known illustration being the forced abandonment

Figure 24.1.4. Although considered a common and treatable problem in the western world, impetigo patients are triaged as urgent in refugee camps and among internally displaced pop- ulations, especially if the victims are malnourished. Impetigo can progress rapidly from a minor skin infection to septicemia when micronutrient deficient and severe malnutrition exist. (Burkle, 1990) See color plate.

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CO M P L E X PU B L I C HE A LT H EM E RG E N C I E S ■ 365

Figure 24.1.5–7: Scurvy, or Vitamin C deficiency and other micro-nutrient deficiencies (especially A and B l) must be suspected in prolonged war where malnutrition exists. These cases, seen in Viet Nam in the 1960s presented as minor bruising, severe pain when the limbs were moved and fragile tongue lesions that easily bled. Similar cases were seen in East African camps in the 1990s when the waste diet given to refugees lacked micronutrient supplements. Vitamin C serves as a co-enzyme in the metabolic reaction of clotting. Once paraternal Vitamin C was administered, the pain from bleeding under the periosteum ceased rapidly. (Burkle, 1968) See color plate.

Table 24.2: Smoldering or Chronic Country Model Health Profile

■ Many years of chronic violence

■ Social and political unrest

■ Poor maintenance of basic public health infrastructure

■ Environmental degradation high

■ Little or no access and availability of health and education

■ Below-sustenance-level economy

■ Chronic malnutrition and stunted growth

■ Children grow up knowing only a culture of violence

■ Few indigenous healthcare providers

■ Lack of basic reproductive health services

■ Organized mental health services generally nonexistent

■ Incidents of violent surges, resulting in peaks in death rates from direct violence and sudden-onset consequences of chronic conditions (i.e., acute malnutrition and dehydration in children with chronic malnutrition)

■ Primarily small arms deaths and wounds, advanced weaponry increasing

■ Violent surges increase internally displaced and refugee populations

of fleeing Tutsi civilians by UN peacekeeping forces in Rwanda. Characteristically, IDP mortality and morbidity rates are among the highest and nongovernmental organizations (NGOs) strug- gle to gain access to them, often one dangerous step ahead of menacing national or rebel forces. Populations who cross bor- ders to flee death and prosecution are allowed refugee status under international law and the protective UN Agency benefits, both physical and political, that these provisions provide. Once international programs are in place in refugee camps the health indices begin to improve and in time may prove better than the neighboring country housing the camps. Crucially, similar aid programs must benefit the surrounding countryside to prevent resentment and new hostilities from erupting.

Required expatriate healthcare assets are those with primary care, public health and preventive medicine, and infectious dis- ease, obstetrical, and emergency medicine skills.15 Immediate international assistance comes in the form of World Health Orga- nization (WHO) Emergency Health Kits that provide basic health supplies for a population of 10,000 for 3 months. Additional sur- gical and safe birthing kits are available.

Smoldering or Chronic Country Model

Countries such as Sudan, Haiti, and Gaza have experienced high levels of conflict for many decades, resulting in a distress- ing health profile (Table 24.2) with characteristics of a country

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Figure 24.2.1-2. Examples of dehydration and malnutrition are common in complex emergencies, especially in Africa and Asia. Severely dehydrated children exhibiting extreme loss of skin turgor. (Burkle, 1968) See color plate.

suffering both developmental failure and ongoing requirements for all basic public health services (food, water, sanitation, shel- ter, health, and fuel) essential for survival. Absent or poorly maintained public health infrastructure results in chronic and untreated survivors of preventable diseases. Expatriate health workers and NGOs frequently serve as the rudimentary public

Figure 24.2.3. A Kurdish child with severe dehydration from diarrhea. The diagnos- tic “old man facies” occurs with severe loss of body water and electrolytes. Fur- ther examination was not allowed. Confir- matory laboratory tests are rarely available. These cases are usually field managed as isotonic losses with oral rehydration. With clinical improvement the family trusted the physician to complete the physical exami- nation. (Burkle 1992) See color plate.

health system for the country but are often prevented by insecu- rity from providing care to persecuted and minority groups. Communicable diseases within these countries, other than the ravages of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), are similar to those seen in the developed world in the early 1900s.

Because of chronic high vulnerability, these countries are more prone to adverse consequences of disasters. Haiti has suffered from increased deforestation and lack of tree–root

Figure 24.2.4. The majority of resupply in com- plex emergencies is through local logistical net- works such as these rehydration salts, from UNICEF, being trekked through jungle trails along the Burmese border to a refugee camp run by the International Rescue Committee. (Burkle, 1993) See color plate.

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CO M P L E X PU B L I C HE A LT H EM E RG E N C I E S ■ 367

Table 24.3: Developed Country Model Health Profile

■ Occur in baseline populations who are relatively healthy

■ Demographic and disease profiles similar to western industrialized countries

■ Excess trauma deaths from war-related advance weaponry and small arms

■ Excess age and gender related deaths increase during times of ethnic cleansing

■ Few epidemics

■ Excess mortality from untreated chronic diseases

■ Significant rates of elderly with undernutrition

■ Rape, abductions, and psychological traumatic exposures common

structures that normally protect other countries from worsening floodwaters. In recent years, uncontained floodwaters resulted in more than 3,000 preventable deaths from mudslides and drown- ing. A dilemma for the international community has been the frustration of responding to an emergency situation within a country that chronically suffers smoldering environmental decay. The environment suffers incrementally with each added conflict or environmental insult (e.g., drought, famine, posthurricane flooding). Do disaster terminology semantics accurately describe the problems that exist? As with Haiti and Sudan, is it appropri- ate to describe these events as emergencies or as developmental crises? Indeed, they fit a category that exposes the inability of the international community, mainly restricted by existing interna- tional sovereignty laws, to intervene on the behalf of innocent civilians who may never see a sustainable life style at any time in their life.

This model results in a chronic excess of “younger than age 5” death rates. Rebel force violent surges result in an increase in adult direct death rates that often represent ethnic cleansing. A return to the chronic epidemiological picture occurs when the fleeing refugees again suffer from the ravages of preventable deaths and morbidity in barren desert conclaves and hastily built refugee camps.

Required professional expatriate assets are similar to that fol- lowing an acute emergency in a developing country.15 Without emphasis placed on stable governance and long-term nation- state development, including education and training of indige- nous healthcare workers, these countries risk repeating similar emergency crises over and over again.

Developed Country Model

Prior to recent warfare, the former Yugoslavia, Chechnya, and Iraq enjoyed health profiles similar to that of Western industri- alized countries (Table 24.3). As with the previous two mod- els, worsening political violence results in internally displaced populations and also refugees seeking permanent asylum in will- ing countries. Characteristic of this model is the dominance of advanced-weapon-related deaths. When these weapons are fired in an indiscriminate manner, the resulting deaths by the age and sex epidemiology should reflect their representation within the baseline population demographics; however, epidemiologi- cal studies in Kosovo showed excess death rates in patriarchal males and young adult males of military age. This study became

Figure 24.3.1. Bubonic and septic plague and other endemic infec- tious diseases are common when the public health infrastructure is destroyed in war and conflict. This figure illustrates an auxillary bubo. Grain stained confirmed Gram negative bipolar rods. (Burkle, 1968) See color plate.

pivotal in Hague war crime trials as evidence of targeted ethnic cleansing.16

In the former Yugoslavia the elderly population resisted dis- placement and often showed rapid decline in health due to under- nutrition, stress-related mental health conditions, and exacer- bation of chronic diseases such as diabetes, hypertension, and cardiac disease as violence separated them from sources of their medication. Ethnic cleansing methods resulted in rape, abduc- tions, and assassinations. Interestingly, epidemics are uncom- mon in this model, in part because the educated population is aware, even in the worst of conditions, of the need for some semblance of basic hygiene including hand washing.

With worsening security, attacks against civilian and military targets include increasingly lethal improvised explosive device attacks and landmine detonations. Victims exhibit unprece- dented multiorgan high-velocity blast effects. Fragile civilian health systems lack the capacity to manage complicated resus- citations for multiple organ failure, multiple limb loss, acute respiratory distress syndrome, and traumatic brain syndrome and the specialized care required for prolonged recovery and rehabilitation.

With the emphasis on traumatic casualties, the international requirements for aid include emergency medicine and surgical and anesthesia specialties.15 Such services and resources rarely arrive from outside the country before 3 days time. The best programs are those that use previously educated and trained indigenous healthcare providers. These local personnel assume augmented responsibilities for emergency healthcare and stabi- lization during and immediately after the traumatic event, with delayed surgery, intensive care, evacuation, and other interven- tions coming from the international community. It is essential that outside interventions include more skill training provided by the international resources so that the level of competency remains improved even though the international “experts” leave.

Communicable Diseases in CHEs

Connolly et al., found that communicable diseases, alone or in combination with malnutrition, account for most deaths in

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Figure 24.3.2. The humanitarian community must be sensitive to cul- tural beliefs that are not dismissed as modern medical care is added. In this toxic and comatose child, an inguinal bubo was surrounded with a lime substance believed to prevent spread. A paste material was placed over the umbilicus with “Chinese medical” writings as petitions to the “evil spirits” that caused disease. Onion flakes were placed in the hair for fever. The child had a febrile seizure immediately after this photo was taken. The mother, thinking that I had provoked an evil spirit within her child with the foreign instrument (camera) I held in my hand, fled with her child. The mother only agreed to return the child for treatment if I was removed as the health care provider. This being impossible, I managed the case from a distance through locally trained assistants. (Burkle, 1968) See color plate.

CHEs.17 Disease transmission is promoted by poor and dense population conditions common to refugee camps. Refugees flee- ing the slaughter from small arms and machetes in Rwanda rapidly crowded makeshift camps across nation-state borders. A camp at Goma, in the former Zaire, surged to a population of more than 300,000 in 5 days. Crowding contributed to outbreaks of dysentery and cholera that killed thousands more. Whereas effective interventions are often possible in camp settings, pop- ulations covering large and poorly accessed geographical areas or entire countries pose a greater challenge. Health workers, at a minimum, must have an operational understanding of communicable diseases and the management in austere envi- ronments of diarrheal disease (watery, bloody, and nonbloody) and dehydration, acute respiratory infections, measles, tetanus, malaria, meningitis, tuberculosis, HIV/AIDS, viral hemorrhagic

Figure 24.3.3. Flea bite over cervical bubo resulting in highly contagious plague. (Burkle, 1968) See color plate.

Figure 24.3.4. Vaccine preventable diseases are common. Tetanus aris- ing from a foot lesion caused severe “lockjaw” in this 10-year old male. Hyperventilation with nasal flaring resulted in secondary tetany. This child survived with parenteral penicillin and antitoxin. (Burkle, 1969) See color plate.

fevers, cholera and dysentery, and trypanosomiasis and leishma- niasis.

Standard case definitions for these diseases are critical to reduce variability in reporting. Epidemiological studies confirm, for example, that control of diarrheal diseases occurs through provision of clean water, simple hygiene practices, and sanita- tion systems, distribution of soap, training of clinical staff and indigenous health workers in aggressive rehydration therapies, and improved basic health services and disease detection. West- ern medical and nursing resources generally lack education and training in tropical disease diagnosis and management, and lack experience with the manner in which HIV/AIDS, tuberculo- sis, and malaria first present with advanced complications in a resource poor environment. Management of region-specific

Figure 24.3.5. Tuberculosis is commonly seen and may result in many secondary cases in crowded camps. This child exhibits both Pott’s disease and a scrofula lesion of the neck. (Burkle, 1969) See color plate.

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CO M P L E X PU B L I C HE A LT H EM E RG E N C I E S ■ 369

Figure 24.4.1. Makeshift tents for women on the left and infants on the right. Kurdish fathers objected to the resuscitative measures taken on their ill infants claiming that death was dictated by religious beliefs. The humanitarian community must recognize cultural, religious, and ethnic restrictions and develop a dialogue that both addresses and balances health requirements and local values. (Burkle, 1992) See color plate.

pharmaceutical resistance must be researched before deployment with special attention to malaria resistance, and to the less fre- quent clinical presentations of tropical diseases such as dengue fever and Japanese B Encephalitis (Southeast Asia), and leprosy (Sudanese refugees).

There are three key elements to humanitarian interventions in communicable disease.17

1) Prevention and control of communicable disease a) Adequate campsite planning and shelter b) Water and sanitation c) Immunization d) Vector control e) Epidemic preparedness and response

2) Case management a) Use of standard treatment protocols b) Simplified and efficient drug regimens c) Syndromic management protocols for acute respiratory

diseases and sexually transmitted diseases are often nec- essary where diagnostic facilities are lacking

3) Assessment, surveys, and surveillance a) Rapid health assessments and an initial overview of

immediate consequences and needs b) Surveys which consist of intermittent, focused assess-

ments that gather population-based health data c) Surveillance consisting of ongoing, systematic gathering,

analysis, and interpretation of health data

Trends and baseline epidemiological information are criti- cal for program and mission interpretation and as measures of long-term effectiveness and postconflict recovery and rehabilita- tion.

Malnutrition and Micronutrient Diseases in CHEs

Food shortages may be generalized across the entire popula- tion, limited to the most politically and economically vulnerable within certain ethnic, religious, or minority groups, or found only in IDPs and refugees. The most vulnerable in these popula- tions are children, especially infants and children younger than 5 years of age and those unaccompanied or orphaned, women both pregnant and lactating, the elderly, and the disabled. Mortality and morbidity are most often the result of communicable dis- eases and malnutrition or a combination of the two. Death due to measles is rare in a nonmalnourished population. In CHEs, deaths from the complications of a simple and preventable child- hood disease, such as measles, highlight the inherent threat to the immune system that results from malnutrition and micronutri- ent disease. Micronutrient diseases such as vitamin A deficiency, even without other manifestations of malnutrition, inhibit bio- chemical and cellular protective processes essential to infectivity and pathogenicity of an infectious agent.

Malnutrition is best appreciated as a combined threat of protein, energy, and micronutrient deficiencies referred to as protein-energy malnutrition. It is characterized by four thera- peutic elements, all of which must be addressed in every mal- nourished victim.

1) Malnutrition itself is rapidly assessed first by mid-upper arm circumference in both children and adults, followed by surveys using more specific weight-for-height measures, and are continued long term through surveillance-based Z- scores.

2) Micronutrient deficiencies, especially vitamins A, C, and B6, are common and assumed to be present in severe malnutri- tion, but additional deficiencies should be assessed based on

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370 ■ FR E D E R I C K M. BU R K L E JR.

Figure 24.4.2. “Collateral damage” goes beyond injury and death. The fragile and superficially placed piping seen in the foreground was the main water artery to this village in Iraq. Public health infrastructure may be different than the normal standard for civilian contractors, the military, and aid workers. Public health “indirect” deaths are more prevalent than direct deaths from weaponry and violence. (Burkle, 1992) See color plate.

known regional and geographical deficiencies such as iron and iodine. Prevalence in the population of disorders such as scurvy, beriberi, pellagra, and xerophthalmia give cause to assume that all those with severe malnutrition suffer these deficits until proven otherwise.

3) Assume all those who are malnourished are either harbor- ing an infectious disease or are susceptible to one and its complications. Severely malnourished are often unable to rally fever, positive skin tests (TB), or leukocytosis as indi-

Figure 24.4.3. This child soldier was a self- designated “general” in the rebellion against the Taylor regime in Liberia. Threatening and unpredictable, he also demonstrated childlike behaviors and needs. Originally from Sierra Leone, he was abducted at the age of eight and knew nothing but war and killing. (Burkle, 2003) See color plate.

cations of an occult infectious disease. Even when skin tests are positive, it is unclear whether this is the result of prior Bacille Calmette-Guérin (BCG) immunization rather than acute tuberculosis infection. This is especially challenging since WHO recommends BCG vaccine be given at birth to patients in the developing world.

4) Assume all malnourished children to be dehydrated. Hydra- tion must be addressed immediately with determination of whether dietary supplementation alone or hospital-based therapies are required. Rarely does the international commu- nity provide parenteral rehydration, even in cases of cholera. Studies suggest and clinical experience confirms that oral rehydration is as effective or better than parenteral rehydra- tion even in the most severe cases.18 International workers must gain experience and confidence in oral rehydration techniques and rehydration salts designed for austere envi- ronments.

Children entering a camp setting are assumed to be vitamin A deficient with no immunity to measles. Progress in humanitar- ian assistance requires immediate measles immunization, vita- min A supplementation, and possible prophylactic antibiotic coverage. Humanitarian relief efforts in developing countries are directed toward support of breast-feeding with extra rations and micronutrient supplementation to mothers, identifying those infants and children requiring wet nurse supplementation, and supplementary and therapeutic feedings (with hospitalization) for those most severely ill and malnourished. Women in devel- oped countries at war (e.g., former Yugoslavia) more often than not have adopted many developed country habits such as bottle- feeding while working outside the home. Rates of breast milk substitute use of 60% or more provoke a crisis when outside supplies cease as the war escalates. The humanitarian commu- nity in the former Yugoslavia and other developed countries in

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crisis had no option but to reorganize rapidly the logistics sys- tem to supply and distribute breast milk substitute and weaning foods.

Psychosocial and Mental Health Problems

Assessment instruments and interventions developed in west- ern countries are medically focused (emphasizing diagnosis and treatment of selected individuals) and rarely assess their cross- cultural impact or accuracy. Individuals suffering from psychoso- cial and mental health problems often present differently in dif- ferent environments and require interventions adapted to their situation and culture. Many interventions promoted over the last three decades are not based on sound scientific evidence or best practices, and they have not been evaluated for their feasibility or effectiveness in the contexts in which they are being used, especially among multicultural populations.19

Current thinking recommends interventions that pro- mote unity of psychosocial, mental health, and public health approaches while equally emphasizing community and medi- cally based programs along with traditional multicultural and family-centered structures. This approach helps in clarifying that extreme human rights abuses, so prevalent in humanitarian crises, will no longer be simply medicalized. It forces an appre- ciation that a broader psychosocial, mental health, and public health services approach is necessary to address the variety of cultural, religious, and political factors that threaten well-being among these populations.

Culture can be considered, in part, to be a collection of coping mechanisms or behaviors shared by a group of people. These behaviors are learned ways of navigating the world safely, and having been developed and refined over centuries, these behaviors are often recognized as defining a culture and its strengths. CHEs, especially those resulting in displacement, involve upheaval to the extent that many of these behaviors are no longer appropriate or possible. Psychosocial programming in the immediate period after a crisis should include approaches aimed at making as many of these behaviors as possible appro- priate and possible once more.20,21 This consists of reestablishing many of the physical and social structures that existed prior to the disaster.

■ Reconnecting families ■ Reconnecting communities ■ Reestablishing security

Risk Factors CHEs produce risk factors that increase both individual and

population risk for developing psychosocial and mental health problems and compound the problems for persons with existing psychological conditions.21–23 Behavior of neglected and abused mentally ill in a refugee camp setting can lead to an erosive impact on the fragile social fabric of displaced communities. Additional factors include, but are not limited to

■ Poor health and nutrition ■ Separation from family and caregivers ■ Suboptimum perinatal care, neglect, and understimulation

of children ■ Exposure to chronic communicable diseases that affect the

brain

■ Risk of traumatic epilepsy ■ Exposure to extreme and repeated stress and sleep depri-

vation

War, conflict, and camp conditions often place those with existing problems at greater risk for

■ Abuse, including gross dereliction, stigma, ostracism, sexual violence

■ Child abduction, youth violence/death ■ Family separation and displacement ■ Neglect or abandonment by family and caretakers ■ Exploitation ■ Destruction of supportive institutions and services, including

psychiatric facilities and medications ■ Life-threatening physical illnesses and suicide ■ Conditions that foment hatred and revenge ■ Unremitting conditions that lead to worsening disability and

premature death, especially among the elderly

Interventions Common guiding principles and strategies for the human-

itarian community in developing interventions for populations exposed to extreme stressors include21–24

■ Contingency planning before the acute emergency ■ Assessment before intervention ■ Inclusion of long-term development perspectives ■ Collaboration between agencies ■ Provision of treatment in primary care and community set-

tings ■ Access to services for all in need ■ Training and supervision ■ Monitoring indicators, including project impact

Immediate psychosocial interventions should focus on sup- porting public health activities aimed at reducing mortality and morbidity, mitigating the burden on the community of managing the seriously mentally ill who need specialized psychiatric care, and mobilizing community-based resiliency and adaptation to new circumstances affecting people during the emergency. These immediate interventions may mitigate more serious mental ill- ness in a large portion of the affected population.

The challenge for the humanitarian community is to support the population in the displacement camp. Humanitarian agen- cies and UN agency organizations usually have limited resources and are faced with displaced populations with overwhelming needs. Experience has shown that projects imported to deal with behavioral and mental health problems frequently are lacking in cross-cultural sensitivities or benefits and may prove detrimen- tal. Such programs and their inexperienced personnel have no place in these critical situations. Indigenous and expatriate men- tal health professionals with specific skills should be properly identified and vetted to provide the best value-added expertise to a community-based approach. In doing so, they will provide care where most needed. Psychiatric, psychological, and social work practitioners trained in developed countries may play a critical role in training, providing consultation, supervision, and specialized care to the most seriously mentally ill, and in pro- viding assessments and evidence-based investigations, preferably through a culturally sensitive partnership with the local popula- tion, indigenous healers, and caregivers. Limited resources must

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Figures 24.5.1. The picture of mental health problems brought about by war depicts an elderly and overtly psychotic woman aban- doned by her family to US military forces believ- ing that the US held magical powers to cure her mental illness. (Burkle, 1992) See color plate.

be directed to improve capacity of family basic survival needs through a community-oriented approach.

Psychosocial and mental health services need to be provided through both primary healthcare and community settings. Pre- sentations tend to fall into three categories24

1. Severe psychological reactions to trauma

Figure 24.5.2. The last remaining survivor of her families’ bunker destroyed in an air raid, this child was mute and refused to be held or receive care within the hospital wards. (Burkle, 1968) See color plate.

Figure 24.5.3. A preadolescent male who built a mine to kill “occu- pying forces” accidentally triggered the device sustaining these severe injuries. More visible hemorrhage was prevented by massive vaso- constriction physiologically available as a last measure before death in children. With anesthesia this hormonal protection ceased and he rapidly lost what remained of his meager blood volume. In this case, the surgical team was aware of this risk and instituted protective blood, fluids and venous access before anesthesia was begun. Decod- ing of vital signs looking for fragile stroke volume losses are a required skill when Western monitoring technologies are unavailable. (Burkle, 1968) See color plate.

2. Significant problems in individuals who may be able to cope and adapt once peace and order are restored (this subgroup generally represents the majority of the population)

3. Disabling psychiatric illnesses (new or exacerbation of exist- ing illness)

THOSE SUFFERING FROM SEVERE PSYCHOLOGICAL

REACTIONS TO TRAUMA

Displacement from home and familiar cultural and religious surroundings may cause cognitive and emotional disorganiza- tion in the displaced population. This is often catalyzed by some degree of “experienced brutality” (e.g., rape, physical and men- tal torture, witnessing of killings of family and friends), which because of fear of possible reprisal and stigma may not be eas- ily or readily revealed to healthcare workers. Beyond the phys- ical suffering that occurs, displaced people are often deprived of their livelihoods and suffer a loss of identity, purpose, and community. Displacement camps are frequently crowded, poorly designed, and inadequately serviced. When war and conflict damage traditional ways of life, cultural bereavement, along with individual bereavement, can be key determinants of psy- chological distress. It is not uncommon that once the displaced population witnesses success in the ethnically relevant commu- nity programs for the severely mentally ill the same programs may see increased numbers presenting with acute trauma-related symptoms. This suggests that the initial barriers of stigma and suspicion tend to decrease with time.

Options for programing include both population-based interventions and conventional, “western-oriented,” one-on- one therapies. Mental health problems common to displaced populations without a history of mental illness but with history of trauma exposure (including problems of children and adoles- cents), include several of the psychiatric diagnoses defined in the Diagnostic and Statistical Manual of Mental Disorders IV.

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Figure 24.5.4. All resources are scarce and must be efficiently used without wastefulness. In this Figure multiple burn patients received care using the contents of a single surgical pack. This pack was also aged and contained WW II era sulfa powder. (Burkle, 1968)

■ Situational depression and major depressive disorder ■ Drug and alcohol abuse ■ Somatization ■ Anxiety ■ Posttraumatic stress disorder (PTSD) ■ Comorbidity of depression and PTSD

Claims of large populations experiencing PTSD have limited evidence; research suggests that only a minority of those exposed to mass violence suffer from this disorder, with numbers varying from 4% to 20%22–24 A purely medical model of intervention that focuses on PTSD to the exclusion of other diagnoses is problematic in that it may fail to address other problems that present in the population; however, epidemiological evidence indicates that symptoms commonly associated with both PTSD and depression are identified in most cultures. Ethnographic assessments that recognize culturally determined language for relevant symptoms may help identify individuals suffering from these disorders.

THOSE PRESENTING W ITH SIGNIFICANT PSYCHOSOCIAL

AND/OR BEHAV IORAL PROBLEMS WHO MAY BE ABLE TO

ADAPT AND COPE ONCE STABILITY IS RESTORED

Complaints presenting in this group generally differ in degree and these persons often demonstrate a greater ability to cope and adapt. Culture and community cohesiveness determines, to a large extent, how war, trauma, and displacement are experienced and what coping mechanisms are used. Programatic empha- sis can be placed on community-based programs that focus on strengthening family and kinship ties, promoting indigenous healing methods, facilitating community participation in deci- sion making, fostering leadership structures, and reestablishing spiritual, religious, social, and cultural institutions and prac- tices that restore a framework of cohesion and purpose for the whole community. The goal is to encourage and strengthen pre- event coping and adaptive capacities of the population. Program strategies are developed to reduce stress and encourage normal

activities and active participation of those displaced.24 Examples are

■ Establishing cultural and religious events, including funeral ceremonies and grieving rituals involving spiritual and reli- gious practitioners

■ Restarting formal or informal schooling and recreational activities

■ Promoting adult and adolescent participation in relief activ- ities, especially those that facilitate the inclusion of social networks of people without families

■ Organizing community-based self-help support groups, especially focused on problem-sharing, brainstorming for solutions and effective ways of coping, and mutual emotional support and community-level initiatives

■ Economic redevelopment initiatives such as microcredit or income-generating activities

The psychosocial and mental health response in the immedi- ate post disaster period often emphasizes this type of approach. In addition, a program commonly called Psychological First Aid can be introduced.25 It is an assessment strategy and an interven- tion that entails basic, nonintrusive pragmatic care with a focus on listening but not forcing talk, assessing needs and ensur- ing that basic needs are met, encouraging but not forcing com- pany from significant others, and protecting people from further harm. With this approach many of the “symptoms” of mental health disorders may resolve, increasing the likelihood that those who continue to have symptoms have specific disorders requiring specific treatment.

THOSE SUFFERING FROM DISABLING

PSYCHIATRIC ILLNESSES

Psychoses and severe mood disorders (including Diagnostic and Statistical Manual of Mental Disorders IV–defined diagnoses of major depression and bipolar disease) cause considerable disability in every culture worldwide. How these disorders are

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conceptualized, recognized, and managed across cultures and in a conflict or postconflict situation may differ considerably. Although it may be possible to diagnose psychotic disorders that were present prior to the event after a crisis occurs, providing sustained and effective treatment may be difficult. This places considerable stress on the families of those with severe illness and may exacerbate the ongoing stress to the camp population especially if their behaviors are disruptive. For anxiety and mood disorders that existed before the disaster, it is often impossible to distinguish the symptoms of these disorders from normal responses to an overwhelming crisis event.

Although emergency health services are usually void of men- tal health personnel, including psychiatrists, some promise has been found among programs that utilize local psychiatric nurses and community volunteers to provide services. Whenever pos- sible, psychiatric interventions should be included as part of the established primary healthcare system, but even these resources may be severely lacking.

For the severely mentally ill, the impact of treatment is fre- quently dramatic with reintroduction of antipsychotic medi- cations and supportive community follow-up that can include rehabilitation in traditional family structures. In camps, commu- nity volunteers can provide outreach services, family education and support, and links to other agencies that can assist with rehabilitation. Basic needs of patients in custodial psychiatric hospitals must be addressed if the crisis becomes protracted.

Newer psychotropic medications, often those familiar to for- eign aid workers with experience in psychiatric treatment, are both scarce and prohibitively expensive. Aid workers must advo- cate for what is best for the populations they are attempting to serve and coordinate these requirements with the ability of local healthcare workers to sustain any medications from out- side resources.20

Measuring and Monitoring Effectiveness In general, the key psychological and psychiatric func-

tional indicators based on SPHERE standards for interventions are7

■ Individuals experiencing acute mental health distress after exposure to traumatic stressors have access to psychological first aid at health services facilities and in the community

■ Care for urgent psychiatric complaints is available through the primary healthcare system

■ Individuals with known psychiatric disorders continue to receive relevant treatment, and harmful, sudden discontinu- ation of medications is avoided

The International Response to CHEs

The UN Charter was launched at the end of WWII in 1945 to deal with cross border wars. Charter language does not ade- quately address internal conflict and the genocidal actions that dominate modern day emergencies. Sovereignty of individual nation states is steadfastly protected under the present Charter and severely limits the UN from entering any sovereign coun- try to protect a minority population from ethnic cleansing and outright genocidal acts. The Charter Article II, Part 7 right of sovereignty reads26

Nothing contained in the present Charter shall autho- rize the United Nations to intervene in matters which

are essentially within the domestic jurisdiction of any state.

Only the UN Security Council has legal authority to respond militarily. The peacekeeping and peace enforcement actions allowed under Security Council Resolutions to cease internal nation-state conflicts are often too little and too late in protecting these populations. Operational successes occurred in the Kurdish crisis of Northern Iraq, the Balkans, and East Timor, but little changed the overall course of conflicts in the poverty stricken, remote, and austere environments of Rwanda, the Democratic Republic of the Congo, and the prolonged debacle in the Sudan and Somalia.

The UN-led humanitarian response community, made up of NGOs, the Red Cross Movement (resources from both the International Committee of the Red Cross and the Federation of Red Cross and Red Crescent National Societies), UN agen- cies such as UNICEF, WHO, and UN High Commissioner for Refugees, and others, has worked to protect civilian popula- tions both within conflicted countries and on their borders. Over the last three decades, however, this traditional UN-led multi- national response system has been criticized for being ad hoc, unprepared, underresourced, and overwhelmed by legal restric- tions of an ill-equipped UN system. Without a major reform of the UN Charter that would favor human rights over exclusive sovereignty and include a standing UN Task Force of their own, the role of the UN in addressing any internal conflicts will remain limited in the future.

With increasing insecurity in places such as Iraq and Afghanistan, the political preference by western-led coalitions has been to bypass the UN-led system and traditional human- itarian community in favor of a non-UN military force. The humanitarian relief and reconstruction operations have been led by military resources and private contractors. Claims that these partnerships have succeeded when the UN-led humanitarian community has failed are in doubt.

Globalization has strengthened many Asian countries that have become economically interdependent with western indus- trialized countries. When the Indian Ocean tsunami occurred, a western-led consortium of military assets (from the U.S., India, Australia, Japan, Canada, and others), the World Bank, like- minded NGOs, and private contractors stepped in with the goal of ensuring rapid economic recovery. The consortium referred to the tsunami disaster as a CHE because two affected coun- tries, Aceh Province in Indonesia and Sri Lanka, have ongo- ing rebel insurgencies. Less economically developed areas of the world remain dependent on the conventional, underfunded, and underresourced UN-led humanitarian community that is driven by rights-based humanitarianism. Whether either of these mod- els will persist in the midst of donor country and international organization political change remains to be seen.27,28

Judt suggests that future coalitions of the willing will be pow- erless to respond appropriately to large-scale “natural disasters, famine, droughts, floods, resource wars, population movements, economic crises, and regional pandemics . . . ” and “will have to act through others in collaboration, cooperation, and with lit- tle reference to separate national interests or boundaries . . . ” The UN and its Agencies, such as WHO, UNICEF, and UN High Commission for Refugees have mature and tested “inter- national early-warning, assessment, response, and coordination mechanisms for when states fray and collapse.” The UN works

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best in handling crises “when everyone acknowledges the legiti- macy of its role.”29 Major power political interference and influ- ence currently impedes the opportunity for the UN to fulfill leadership in a consistent and predictable manner. In the mean- time, it is not known how the world will manage future complex humanitarian and other large-scale public health emergencies.

RECOMMENDATIONS FOR FURTHER RESEARCH

As stated, even though the absolute number of CHEs has declined, the list of countries in crisis has remained long with little information on the impact of these crises being available for monitoring and evaluation. The world community must find new ways to prevent instability in fragile countries and apply resources that emphasize political and economic sustainability. Furthermore, a professional civil–military approach is desirable to many of these crises, but political competition, relevant educa- tion and training, funding, and lack of a modern day UN Charter, among many other factors, have stopped these good intentions in their tracks.

Research critical to conflict studies remains unattended, especially in topic areas concerned with: vulnerable popula- tions, advances in international law that address access and protection, public health priorities, and sustainability. Aware- ness driven by globalization, especially Internet access to infor- mation, has led the world’s population to expect equity, trans- parency, and accountability in global health and humanitarian assistance. Populations have little tolerance for responses that are imperfect, ad hoc, and politically motivated. There are con- cerns that disaster management issues, especially those resulting from public health emergencies, if not fully addressed will fur- ther complicate the widening rift between the world’s haves and the have-nots. Recent events suggest that disasters occurring in countries economically interdependent with economic powers will receive robust relief that is directed at rapidly recovering the economy. In contrast, disasters in economically poor coun- tries will be left to depend on fragile UN-, UN agencies–, and Red Cross/Red Crescent Movement–led responses that have lim- ited funding and resources. Such inequities are apt to foment additional political unrest. Furthermore, a previously unrecog- nized public health overlap between conventional disasters and CHEs has been described. Conventional disasters and CHEs can occur during or following either event and epidemics commonly occur during CHEs. Unlike the findings in CHEs, the data do not support the often-repeated assertion that “epidemics, espe- cially large-scale epidemics, commonly occur following large- scale conventional disasters.” This emphasizes that training and tools are needed to help bridge the gap between the different types of organizations and professionals who respond to conventional disasters and CHEs to ensure an integrated and coordinated response.30

Public health is no longer relegated only to issues of health- care and prevention. Rather, public health is being redefined to include transportation, communications, public safety, judi- ciary, good governance, and many other critical entities that are necessary for a village, a nation, and the global community to function. Public health and health indices have and will always be one of the most sensitive measures of the recovery process and its ultimate success or failure. Indeed, despite all the atten- tion and resources that CHEs have received over the last three decades, the state of health of women and children, especially in

disaster prone areas, has declined. Public health and agricultural infrastructure in both developing and developed countries have not expanded with population and maintenance demands. CHEs which were first considered “water wars” in some resource areas of the world must now be seen as public health (infrastructure and system) wars in deprived areas that lack the buffer capacity to respond to the insults that disasters provoke. Public health must take precedence over politics and must not be driven by political motives. Disasters keep nation states and the global community honest by revealing vulnerabilities in the public health system and infrastructure. Through immediate recognition that pub- lic health systems and infrastructure play a monumental role in the consequences and recovery of large-scale disasters, pub- lic health will be seen in a new light. This involves focusing on strategic and security issues that deserve heightened attention including an international monitoring system and international law protections. If this does not become a priority, public health emergencies will continue to increase as a pivotal challenge for future disaster managers and the global community.

REFERENCES

1. Stephens KU, Grew D, Chin K, et al. Excess mortality in the aftermath of Hurricane Katrina: A preliminary report. Disaster Med Public Health Prepare. 2007;1(1):16–20.

2. Burkle FM. Complex humanitarian emergencies: A review of epidemiological and response models. J Postgrad Med. 2006; 52(2):109–114.

3. Zwi A, Ugalde A. Towards an epidemiology of political violence in the Third World. Soc Sci Med. 1989;28(7):633–642.

4. Burkholder BT, Toole MJ. Evolution of complex disasters. Lancet. 1995;346:1012–1015.

5. Crisis Group. Brussels, Belgium. International Crisis Group. Available at: www.crisisgroup.org/home/index.cfm?id=3541 &1=1. Accessed November 20, 2008.

6. Human Security Report 2005: War and Peace in the 21st Cen- tury. Human Security Centre, University of British Columbia, Canada. Oxford, UK: Oxford University Press; 2005: 123–144.

7. Humanitarian Charter and Minimum Standards in Disaster Response. Geneva, Switzerland: The Sphere Project/Oxfam, UK; 2004 (Revised).

8. Ghobarth H, Huth P, Russett B. The long-term consequences of civil war on public health. Soc Sci Med. 2004;59:869–884.

9. Ghobarth H, Huth P, Russett B. Civil wars kill and maim people long after the shooting stops. Am Pol Sci Rev. 2003;97(2):189– 202.

10. UN Office for the Coordinator of Humanitarian Affairs.: Gender-based violence: a silent, vicious epidemic. IRIN In-Depth. Available at: www.irinnews.org/IndepthMain.aspx? IndepthId=20&ReportId=62814. Accessed November 20, 2008.

11. World Health Organization. Coping with Water Scarcity (2007). International Decade for Action: Water for Life. Available at: www.un.org/waterforlifedecade. Accessed November 20, 2008.

12. Dengue fever, a man-made disease. The Economist. 1998; May 2:21(U.S. print edition).

13. Save the Children. State of the world’s mothers: 2006. Saving the lives of mothers and newborns. http://www.savethechildren.org/ publications/mothers/2006/SOWM 2006 final.pdf. Accessed November 20, 2008.

14. Roberts L, Hoffman CA. Assessing the impact of humanitar- ian assistance in the health sector. Emerg. Themes Epidemiol. 2004;1:3 doi:10.1186/1742–7622-1–3.

C op

yr ig

ht ©

2 00

9. C

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ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

376 ■ FR E D E R I C K M. BU R K L E JR.

15. VanRooyen MJ, Eliades MJ, Grabowski JG, et al. Medical relief personnel in complex emergencies: Perceptions of effectiveness in the former Yugoslavia. Prehosp Disaster Med. 2001;16(3):145– 149.

16. Spiegel PB, Salama P. War and mortality in Kosovo,1998–99: an epidemiological testimony. Lancet. 2000;355(9222):2204–2209.

17. Connolly MA, Gayer M, Ryan MJ, et al. Communicable dis- eases in complex emergencies : Impact and challenges. Lancet. 2004;364(9449):1974–1983.

18. Curioso WH, Miranda JJ, Kimball AM. Learning from low income countries: What are the lessons? Community oral rehydration units can contain cholera epidemics. Br Med J. 2004; 329(7475):1183–1184.

19. Van Ommeren M, Saxena S, Saraceno B. Mental and social health during and after acute emergencies: emerging consensus? Bulle World Health Organ. 2005;83:71–76.

20. Silove D, Ekblad S, Mollica R. The rights of the severely mentally ill in post-conflict societies. Lancet. 2000;355:1548–1549.

21. Silove D. The psychological effects of torture, mass human rights violations, and refugee trauma: Toward an integrated conceptual framework. J Nerv Mental Dis. 1999;187:200–207.

22. Mollica RF, Lopes-Cardoza B, Osofsky HJ, et al. Mental health in complex emergencies. Lancet. 2004;364:2058–2067.

23. Mental health in emergencies: Psychological and social aspects of health of populations exposed to extreme stressors. Geneva:

World Health Organization. 2003. Available at: www.who.int/ mental health/media/en/640.pdf. Accessed November 20, 2008.

24. Burkle FM, Chatterjee P, Bass J, Bolton P. Guidelines for the psycho-social and mental health assessment and management of displaced populations in humanitarian crises. In: Public Health Guide for Emergencies. International Federation of Red Cross and Red Crescent Societies, and Johns Hopkins University Medical Institutions, Geneva and Baltimore. 2008.

25. United States Department of Veterans Affairs. Psycho- logical First Aid: Field Operations Guide. Available at: www.medicalreservecorps.gov/file/mrc resources/mrc pfa.doc, Accessed December 2, 2008.

26. Charter of the United Nations. Available at: www.un.org/ aboutun/charter/unflag.htm. Accessed November 20, 2008.

27. Burkle FM. Globalization and disaster management: public health, state capacity and political action. J Intl Affairs. 2006; 59(2):241–265.

28. Bello W. The rise of the relief-and-reconstruction complex. J Intl Affairs. 2006;59(2):281–297.

29. Judt T. Is the UN Doomed? The New York Review of Books. Feb- ruary 15, 2007;54(2). Available at: www.nybooks.com/articles/ article-preview?article id=19876. Accessed November 20, 2008.

30. Spiegel PB, Le P, Ververs MT, Salama P. Occurrence and overlap of natural disasters, complex emergencies and epidemics during the past decade (1995–2004). Confl Health. 2007;1:1:2.

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