Discussion Draft

PLANNING AHEAD

FOR

THE HEALTH IMPACT

OF COMPLEX EMERGENCIES

Introduction

Since the end of the Cold War, there has been a perception that the world has been engulfed in a series of violent armed conflicts and resulting mass population displacements. Iraq, Somalia, Bosnia, Rwanda, Chechnya, Sudan, Kosovo, and East Timor are some of the more publicised examples of conflicts whose roots have not (at least obviously) been based on political ideologies. These conflicts have largely been attributed to ethnic and religious tensions; however, many have arisen during a period of economic instability. Certainly, many appear to have evolved from “suppressed tensions” that have been released in the context of profound political change and uncertainty. The term “complex humanitarian crisis” has been coined to describe these events; however, some critics who prefer the term “complex political emergency” have recently challenged that phrase. It is the politics that are complex while the humanitarian effects remain as they always have been: population displacement, food scarcity, malnutrition, high morbidity and mortality, including violence intentionally directed at civilians, and severe mental stress.

In many countries affected by civil strife, tensions and violence between groups within the population have been intensified by anxiety related to economic uncertainty. In some instances, political leaders or parties have exploited this anxiety and therefore have heightened the perceived differences between these groups. This appears to have occurred in the republics of the former Yugoslavia, Chechnya, Georgia, and Azerbaijan. In other countries, a sudden economic downturn has contributed to overall political instability unleashing communal violence, such as in Ambon, Ternate, Kalimantan, and West Timor in Indonesia. In addition, latent secessionist movements have found new life, such as in East Timor, Aceh, and Irian Jaya in the same country.

As the leading global public health agency, WHO is grappling with these new complexities, and seeks to identify options for acting to mitigate the impact of evolving economic and political crises on the health of populations. These options need to be explored firmly within the context of the organization’s mandate, structure, and member state expectations. WHO does not have an international mandate to directly address the root political causes of conflict; however, it has an obligation to respond to identified risk factors for the deterioration of population health in any given setting. Briefly, this requires an early recognition of a vulnerable population, an analysis of the direct and indirect health consequences of economic and political instability, and the identification of critical health programs that need the support of the international community.

Like most international agencies during the past decade, WHO has focused on improving the response to humanitarian crises, with disaster reduction and mitigation largely confined to natural hazards, such as earthquakes, hurricanes, and tsunamis. The search for a strategic paradigm for country-level work in situations of transition and instability has become urgent and of the utmost relevance for WHO.

In 1997, with the support of the Australian Government, the WHO Department of Emergency and Humanitarian Action (EHA) organised a meeting on “Health Coordination in Emergencies: Options for the Role of WHO”. The meeting opened an important process of reflection on the Organization and EHA's priorities in response. This reflection was furthered by a second consultation on needs for Applied Health Research in Emergency Settings, held in October of the same year. This was followed by the establishment of an Advisory Group on Applied Health Research in Emergencies.

However, WHO's mission also covers disaster reduction and prevention; preparing for the response to emergencies; mitigating their health consequences; and creating a synergy between emergency action and sustainable development. EHA's mandate specifies that this has to be pursued through a concerted effort across the various departments and offices of WHO, and includes the ultimate goal of increasing the capacity and self-reliance of member countries.

Therefore, EHA, with the support of the Macfarlane Burnet Centre for Medical Research (Australia) and of the Scuola Superiore Sant'Anna/ International Training Programme for Conflict Management of Pisa, Italy, is organising a third consultation. This will aim to broaden the debate on WHO’s role in emergencies to include preparedness for, mitigation of, and recovery from the health effects of complex emergencies in vulnerable countries. Together, WHO and its operational partners should examine strategiesand programme options for strengthening the national and international capacity for contingency planning, risk analysis, prevention, mitigation, and response vis-à-vis the health and nutrition consequences of complex emergencies.

Key Issues

  1. Economic and political transition

The post-cold war era has seen a variety of tensions being released among and within nations. These tensions interact with swift economic transformations and result in political instability and violent conflicts in several areas of the world. Indonesia (and East Timor), the Balkans, and Caucasus region are only the most recent and most media-covered crises. Estimates based on data of May 1999 from the UN Office for the Coordination of Humanitarian Affairs (OCHA), suggest that as many as 73 countries, with a total population of almost 1800 million people are passing through differing degrees of instability.

Globalization demands high levels of economic and technological competitiveness. It risks marginalising entire regions - mainly but not only Africa - and exacts high social costs from countries undergoing economic and political transformation. This is illustrated by the steep reduction in life expectancy observed in Russia between 1992 and 1997, or by the case of the Democratic People's Republic of Korea, where the annual crude death rate increased from 6.8 per 1000 in the early '90s to 9.3 per1000 in 1998.

The rapid changes that have been occurring in the last 10 years include and interact with the redefinition of the role of the State. These include the crisis of the welfare system in industrialized countries, the collapse of states, and the explosion of violent conflicts in contexts of greater vulnerability, where changes can accelerate and precipitate long-dormant tensions. (see also World Bank Development Report, the State in a Changing World). Least developed countries see their capacity for health service delivery severely compromised or completely collapsed, such as in Somalia.

The way in which institutions and societal systems respond to tensions and challenges varies and is difficult to predict. Thailand was able to resist the economic crisis that hit South East Asia in 1998, but Indonesia was severely affected. Albania was overwhelmed by the collapse of the pyramid schemes. The Caucasus and Balkan countries are struggling to stabilise their new institutional frameworks. Obviously, a country with marked social inequalities, food, job, economic, environmental and human-rights insecurity, and an inefficient or corrupt public sector is more vulnerable and more likely to see tensions - be they of economic, political, religious or ethnic nature - explode into violent conflict. Nevertheless, it is difficult to pinpoint a deterministic causality: not all inequalities necessary lead to violence, while in the former Yugoslavia the presence of a functioning state did not avoid the conflict.

The impact of economic crises is far from predictable. In the recent Asian financial crisis, the political, social, and health outcomes have varied among those countries affected. The crisis led to a change in political leadership in Thailand, the fall of a president in Indonesia, which led to greater democracy, but minimal political changes in other countries. The events that led to the independence of East Timor can be traced directly to the onset of the financial crisis in Indonesia. Negative economic growth occurred in Indonesia, Thailand, Korea, and the Philippines; however, the economy grew in Laos due to expansion of the agricultural sector. Health budgets decreased in most countries, except Indonesia; however, actual health expenditure decreased in Indonesia partly due to the effects of decentralisation and inadequate skilled manpower at the district level. In general, urban populations suffered greatly compared with rural dwellers.

On the other hand, various countries have passed through economic crises, political transition, and even armed conflicts without the same health consequences or serious changes in health and disease dynamics. Sri Lanka is one such example of a country experiencing prolonged armed conflict that has been able to maintain essentially free basic health services and to prevent deterioration in national health indicators, except - and this is the important exception - within the zone of conflict itself. Other cases may include Nigeria, which passed through a long constitutional and economic crisis punctuated by civil strife in the Ogoni minority area, or Mexico, that suffered a severe economic crisis without major political instability, but it is nevertheless affected by a "low-intensity" civil war in Chiapas. At the global level, many countries find themselves along a spectrum of increasing vulnerability and instability, as the high-risk situations of Indonesia and Myanmar illustrate, passing through Colombia, to the extreme case of Angola, now entering its 25th (some would say 40th) year of complex emergency.

Countries that have experienced pressures such as those cited above could be characterised as “disrupted states”. Whatever the primary cause of this disruption, it appears obvious that effective solutions to prevent further deterioration towards a “failed state” can only be within the political arena. Nonetheless, instability, crisis and complex emergencies have an undeniable impact upon public health. In Burundi, the annual under-5 mortality rate has increased from 108 per1000 in 1992 to 190 per1000 in 1998. And public health is also policies and politics. Public health professionals have the responsibility to contribute to wider efforts, exploring mechanisms to strengthen the resilience of health systems. In addition, efforts should focus on preparing for situations where the health status of vulnerable communities, namely the majority of the population in many settings, is made worse or when entire societies become vulnerable because of collapsing governance.

  1. Worst case outcomes

The term "Complex Emergencies" is widely used when referring to these conflicts. Some prefer the names "Complex Humanitarian Emergencies" or "Complex Political Emergencies", whether they want to highlight the humanitarian manifestations of the emergency or its causes, that are essentially political. One problem in using such terms is that they are often used to avoid confronting the real cause and features of the crisis. For instance, speaking of complex emergency for the events of 1994 in Rwanda seems inadequate. The international response was first unable to avoid the genocide and then ended up being blamed for supporting the perpetrators .

From an epidemiological point of view, one can recognise causal sequences linking economic crisis, political instability, and complex emergencies - with no other qualification- as defined by the US Centers for Disease Control in Atlanta as:"… situations featuring armed conflict, population displacement and food insecurity with increases in acute malnutrition prevalence and crude mortality rates ". Most emergency health workers agree that mortality is a sensitive and specific measure of the level of a public health emergency. WHO publications (RAP) indicate a daily crude mortality of 1/10,000 as the cut-off value for emergency warning. When previous rates are well known, a noticeable increase in mortality (doubling) is sometimes used.

Nevertheless, recent events in Kosovo qualified as a "complex emergency " in the minds of most people but did not feature increases in mortality rates. At this point, one could ask whether all complex emergencies are also immediately "Health Emergencies". Do health workers always need to be at the forefront of relief efforts? Wouldn't resources be better applied beforehand, to increase the resilience of health systems in vulnerable countries, enabling them to deliver health care in spite of violent conflict? The taxpayer assumes that funding for humanitarian agencies is related to the needs of the beneficiaries. With no clear criteria to evaluate efficiency and cost-effectiveness of emergency interventions, funding of agencies and thus their own survival largely depends on field visibility (i.e. coverage by the media) and the image this creates vis-à-vis potential donors.

In essence, this meeting should be focused on mitigation of the effects of a public health emergency that has its causal roots in political and economic turmoil and civil conflict.

Public health can be effective only in as much as the security of victims or armed conflict is guaranteed (Perrin, 1998). But, in practical terms, the objective of health workers is to prevent excess morbidity and mortality, and in order to achieve this in the acute emergency phase, they must often grant priority to non-medical action. Security, protection and the provision of shelter, food, water, sanitation may be of more immediate benefit than providing health care. This does not imply that health workers should take on those tasks themselves. Their role lies in triggering action from other sectors, based on the priority needs identified through the first rapid assessment and subsequent surveillance and monitoring. If the need for medical care is less prominent, priority should go to the real requirements of the population. In many instances, inter-sectoral coordination may be more important than stockpiles for epidemic control, and the timing of interventions is of crucial importance

  1. Detection

Nonetheless, effective early warning systems, namely those that assist in decision-making, remain largely inadequate. The quest for advanced humanitarian intelligence has stimulated a variety of initiatives: from the sets of indicators elaborated by DHA in the early '90s, passing through the UNICEF experience with vulnerability analysis, to the various frameworks promoted by OCHA/IASC. Nonetheless, the memory of the announced tragedy of Rwanda was still with most of us when it was revived by the events in East Timor. There has been much reflection on the value of health information in this direction, last but not least by EHA through HINAP and Health as a Bridge for Peace, and by USAID/CERTI. Still, one week of intense media coverage appears to carry much more weight than years of careful recording of worsening infant mortality rates. Moreover, the question remains regarding the control of those services that generate the health data (and their analysis and dissemination) in a politically tense situation.

Humanitarian agencies should be unbiased advocates of the health and human rights of the population they serve. But UN agencies face a difficult plight. At country level, they have the national government as their counterpart. If the government becomes involved in a conflict, it becomes difficult for one country office to distance itself enough to provide impartial assistance to those in need. Special arrangements have to be set in place, and this takes precious time. At the same time, donors may be demanding a swift response in line with their own political interests and/or with the expectations of their taxpayers.

These reflections are especially important for WHO. As a UN Specialised Agency accountable to its Governing Bodies, i.e. ultimately its member countries, WHO has to reconcile its unique responsibility in the Health sector, the Humanitarian Imperative and the mandate to develop the capacities and enhance or preserve the self-reliance of its primary constituents.

  1. Governance

There is a self-evident relationship between the responses to public health emergencies and the strengths and weaknesses of societal and government structures and their capacity to guarantee continued basic services. From this perspective, it seems important to link health interventions to principles of good governance:

  • Improvingeconomic management to maximise and fairly distribute the benefits of economic productivity;
  • Strengthening public sector management for more effective, equitable, and efficient delivery of health and related services;
  • Promoting effective and equitable legal systems and strengthening the rule of law; and
  • Strengthening civil representation and participation to enable better scrutiny of policies and practices.

(Partly based on “Governance”, Bruce Davis, in Focus, Australian Agency for International Development, July 1999)

Given the relationship between social tensions, increased civil violence, and the evolution of complex emergencies, health initiatives also need to be viewed along a spectrum defining their possible contribution to peace and/or conflict from:

  • simply not contributing to the conflict (“.. all health initiatives in … existing or likely armed conflict should be scrutinised … to assess the chances that they will cause or intensify conflict.” (Anderson, The project Do No Harm)

to:

  • actively promoting peace building through dialogue and collaboration on non-controversial issues(Zagaria and Arcadu, Health as a Bridge for Peace, the Angola case study, WHO/EHA 1998)

From a public health point of view, these two sets of concerns can be reconciled by (a) recognising that any continuum of care requires physical, economic and functional access to health services - inter-alia, stability; and (b) accepting that health professionals have a responsibility to contribute to equity and justice within a society. In the 19th century, it was realised that better housing and living conditions could improve the health and, therefore, the productivity of factory workers. Economic and humanitarian arguments were used to convince industrialists to implement the recommendations of health professionals, and a more equitable society brought about an improvement in general health indicators. On merely technical grounds, only public health programmes that consider the inequalities present in a society can address the needs of the entire population. Governments have duties and responsibilities toward all, not just a majority –or, worse, a minority- of its citizens.

  1. Health system adaptability

In most developing countries, even in non-emergency contexts, external assistance represents a large share of health expenditures. Major programmes, such as polio eradication and the expanded programme on immunisation, control of malaria, tuberculosis and AIDS, and the integrated management of childhood illness, simply would not be possible without this support. Additionally, social insurance programs, if they exist at all, have often achieved very low coverage. The difficulty of raising taxes has led to a search for alternative sources of funding; namely, community financing and patient charges. In an economic or political crisis, the barriers may become further complicated. In Indonesia, the response in the health sector of the government and major donors to the 1997 financial crisis was to broaden the social safety net, including the distribution of free health care cards. However, in 1998, health service utilisation actually decreased due to management problems in district health services, slow disbursement of funds, shortages of essential medical supplies, and civil strife and insecurity in a number of provinces. If political instability develops further into open conflict, militarization tends to compete with social expenditure and issues of funding – from government or private sources – can be at the very root of the political crisis. External assistance to the health sector is usually maintained, but it may also end up being constrained by political considerations, or simply by the difficulty of coordinating a suddenly swollen number of external partners.