Humanitarian Aid in Disaster and Conflict

Types of Humanitarian Emergencies

A humanitarian emergency, or humanitarian crisis, is “a critical threat to the health, safety, security, or wellbeing of a community or other large group of people, usually over a wide area.” Humanitarian crises can be natural disasters (floods, earthquakes, tsunamis), human-made disasters (armed conflict, industrial accidents), or complex emergencies. A complex emergency occurs “where there is total or considerable breakdown of authority resulting from internal or external conflict and which requires an international response.”

A key feature of humanitarian crises is the mass displacement of large numbers of people from their homes. Displaced populations are designated either as internally displaced persons (IDPs) or refugees. An IDP is someone who has been forced from his or her home but who remains within the country of origin. If an IDP crosses an international border to seek help in another country, she or he becomes a refugee. The distinction is important. While refugees enjoy protections and rights guaranteed by international treaty, IDPs must depend (in the absence of international aid) on their own government for help, even though the actions—or inaction—of their government often caused their displacement.

Many people assume that humanitarian clinicians spend most of their time treating serious injuries: fractures and crush injuries from earthquakes, infected flesh wounds in floods, or blast and penetrating injuries in conflict. While this is true in some emergencies, the reality is that most medical relief in humanitarian crises is spent reinforcing primary care and basic medical services that have been destroyed or bolstering public health programs to prevent diseases in displaced populations.

A significant portion of the disease burden in humanitarian emergencies is brought on by the displacement itself. Forced into crowded and often unsafe conditions and removed from their usual sources of medical care, displaced people suffer from the lack of access to basic health services. Chronic conditions such as hypertension and diabetes go untreated. Women and infants die from the lack of safe perinatal care. Children may not receive lifesaving vaccinations. Densely packed refugee camps promote outbreaks of measles and other infectious diseases. The breakdown in basic public health is another critical threat. Lack of clean water, latrines, washing facilities, proper shelter, and good nutrition are often the main causes of poor health among displaced people.

Mass urban migration in the 20th and 21st centuries has led to a dramatic increase in city populations worldwide. Crises in urban environments pose unique challenges to humanitarian response because security considerations, logistic and supply chain factors, and distribution systems are very different from those in rural settings. Increasingly, humanitarian response training includes a focus on urban humanitarian response methods and how to work within dense urban settings that require close coordination with municipal governments and city-based organizations.

Natural Disasters

Humanitarian crises are broadly described as either natural or human-made disasters. Natural disasters, often seen as random acts of nature, can attract media attention and public sympathy that spur a robust aid response. The effects of natural disasters, however, are generally predictable. The type of medical and public health response needed varies by the type and location of disaster ( Table e2.1 ) and is also affected by the preexisting vulnerabilities of the population. Damage to health facilities is common in most natural disasters, and medical relief is often focused on reestablishing primary care and basic health services.

Earthquakes cause uniquely high rates of complex injuries: fractures, crush injuries, burns, and even hypothermia. Search-and-rescue teams may need help with confined space medicine and field amputations. Surgical field hospitals are often needed in the first hours and days after an earthquake to provide lifesaving neurosurgical or orthopedic care. The need for inpatient postoperative wound care, rehabilitation services, and prosthesis care continues for months or even years.

In contrast to earthquakes, most natural disasters produce less severe, more easily survivable injuries. Medical care in these disasters usually focuses on restoring baseline health services. Surgical field hospitals, if needed, typically perform wound care and everyday emergency surgeries (cesarean section, appendectomy). In disasters that produce high death rates—earthquakes, tsunamis, landslides, and volcanic eruptions—postmortem services may be emergently needed. Psychological first aid and mental health care are also key to the health response to sudden-onset natural disasters.

Unlike sudden-onset natural disasters, droughts develop slowly over months and are characterized by crop shortages, skyrocketing food prices, and disruption of food markets. Poor or isolated populations can suffer a lack of access to food that, if unchecked, leads to famine. The acute medical needs in drought often stem from severe malnutrition (especially in young children) and subsequent infections.

Certain populations faced with an acute humanitarian crisis, such as those with widespread undernutrition at baseline, may be more vulnerable to acute malnutrition than others. Special training in therapeutic feeding programs and supplemental food distribution is needed for clinicians responding to famine, or to any emergency in which a population’s baseline rate of severe malnutrition is high.

Disease Epidemics/Pandemics

Despite two large-scale Ebola virus disease (EVD) epidemics in the 2010s (the 2014 West Africa outbreak and 2018 Democratic Republic of Congo outbreak), epidemics that cause humanitarian emergencies were still relatively uncommon until 2019 with the severe acute respiratory syndrome coronavirus-2 (COVID-19) pandemic (see Chapter 120 ). Nevertheless, the EVD outbreaks highlight the need for more international aid agencies to be able to respond to large global epidemics. Disease outbreaks, such as the cholera epidemic in Haiti, can further complicate humanitarian efforts, threaten vulnerable populations, and erode public trust in international responders. Future epidemics, especially those that spread to densely populated areas with an underdeveloped public health infrastructure, may require a specialized form of international response. Response to epidemics in urban areas will require a response coordinated with attention to special conditions created by an urban setting, such as crowded slums, general population density, and mass transport systems.

Armed Conflict

Armed conflicts are a major cause of global humanitarian emergencies, leading to direct threats to and displacement of civilians, destruction of infrastructure, and deprivation of access to resources. Lack of access to basic services and appropriate health care due to insecurity creates a significant vulnerability that disproportionately targets women, children, and the elderly. The lack of access to medicines, providers, and the collapse of medical and public health services create major challenges for civilian populations in conflict settings. In addition, armed conflicts cause a prolonged breakdown in local security, access, and civil society structures, which can inhibit the restoration of health services. Responders in conflict settings must prepare for the complexity of operating in insecure environments and prolonged deployments.

Violent injuries are typically limited to civilians who are either trapped in active conflict zones or directly targeted by fighting forces. The number of civilians who suffer injuries is usually small in proportion to the total number of people affected by armed conflicts. Conflict is also often associated with high rates of interpersonal violence, abuse, and sexual assault. Survivors of these forms of trauma will require both appropriate medical care and culturally adapted mental health services.

Standards in Humanitarian Response

The international response community has developed practice guidelines that stem from international law, research, and expert consensus. Responders should be familiar with these international standards and laws to ensure that their response efforts fulfill the rights of the people affected by crisis.

International Law

Humanitarian aid is not simply a charitable act. Rather, it is intended to fulfill the rights to assistance that all civilians have during humanitarian crises. To fulfill these rights, responders must understand the genesis of human rights. Two bodies of international law set forth these rights: international humanitarian law (IHL) and international human rights law (IHRL).

IHL is often described as the law of war. Its core documents are the Geneva Conventions. IHL gives special protections to people not taking part in conflict (civilians and those soldiers rendered incapable of fighting due to injury, illness, surrender, or having been taken prisoner). It mandates that these non-combatants be treated humanely and provided food, water, shelter, and medical care. IHL not only ensures noncombatants the right to humanitarian assistance but also grants humanitarian aid workers the right to offer that assistance. This means that humanitarian responders must be allowed to provide lifesaving aid uninterrupted and must not become war targets as long as they remain neutral in the conflict.

Indeed, IHL is one of the primary tools used to ensure protection in conflict zones for aid workers, who, as neutral actors, do not carry weapons. Humanitarian aid agencies often use IHL to negotiate with conflict commanders for safe access to civilian populations, as these commanders can be individually prosecuted for legal violations or war crimes.

Although IHL applies only during conflict, human rights law applies at all times. The 1948 Universal Declaration of Human Rights, the core document of human rights law, states that “all human beings are born free and equal in dignity and rights,” and are entitled to life, liberty, security of person, and “a standard of living adequate for…health and well-being.” The Declaration and other human rights laws enshrine specific civil, political, economic, social, and cultural rights; prohibit torture, genocide, and racial discrimination; and provide special protections for women, children, refugees, and internally displaced persons.

IHL and human rights law govern the scope of activity of humanitarian response. More importantly, it is by virtue of these international laws that humanitarian responders legitimately can enter a country and intervene in the lives of its citizens.

Codes of Conduct

Nongovernmental organizations (NGOs) use codes of conduct to specify behavioral, professional, interpersonal, and ethical standards for their workers. Humanitarian response often requires long work hours in uncomfortable and insecure settings. Personnel must maintain appropriate conduct despite challenging circumstances and near-constant stress. Maladaptive coping behaviors such as drug and alcohol abuse, inappropriate relations with national staff or locals, and security protocol violations put individuals and organizations at risk. Codes of conduct help establish behaviors necessary to ensure an ethical and effective response.

Sphere Standards

The Sphere Handbook , a collaborative project of humanitarian response experts, sets international standards for the provision of humanitarian aid. It is widely considered to define the gold standard of global humanitarian response. The Sphere Handbook begins with the Humanitarian Charter, which distills international law, humanitarian principles, and the humanitarian code of conduct into a five-page document that establishes the legal and ethical essence of the humanitarian imperative.

The Sphere Handbook provides a single set of uniform standards for aid agencies to follow in humanitarian response. These standards are the measures by which aid agencies evaluate their responses, and as such are the basis of accountability for international response efforts. The Sphere Handbook provides minimum response standards for water and sanitation, food and nutrition, shelter and settlement, health care, and protection. It also sets forth a core humanitarian standard that applies to all sectors, such as partnering closely with beneficiaries in the response ( Fig. e2.1 ). These minimum standards are supplemented by specific indicators, numerical signposts that help responders know when they are on track to meet the standards. For example, the first Sphere standard for water supply is “People have equitable and affordable access to a sufficient quantity of safe water to meet their drinking and domestic needs.” But how much water is that? While the exact answer may vary depending on the context, the key indicator for this standard is at least 15 liters of clean water per person per day. Similar standards and indicators are given for other sectors of humanitarian aid. Box e2.1 lists a few of the key indicators from the Sphere Handbook .