Emergency care in a humanitarian crisis

Introduction

Increasingly over recent years, Australian health professionals, including emergency medicine clinicians, have responded to humanitarian crises due to conflict or natural disasters within our region. Caring for displaced persons is not a new problem. Since World War II up to 100 million civilians have been forced to flee their homes due to unrest. The major factors that cause people to flee their country include conflict, political repression and persecution, and are as old as humanity. In 1573, the term ‘refugee’ was first used for Calvinists fleeing political repression in the Spanish-controlled Netherlands.

Until the end of the World War I, the response to refugees was from philanthropic sections of the community. In 1921, a High Commission for Refugees was established with a mandate to look after refugees fleeing the Russian and Armenian wars. Its first commissioner was Fridtjof Nansen, who established a special identity document, the ‘Nansen Passport’, as refugees frequently had no means of identification.

In the wake of World War II, the United Nations (UN) established the International Refugee Organization (IRO) to assist the millions of displaced persons in Europe. Between 1947 and 1951, it helped 1.6 million people, mainly Germans and Austrians.

The United Nations High Commissioner for Refugees (UNHCR) replaced the IRO in 1951 and the Convention Relating to the Status of Refugees came into being. This key legal document defines who is a refugee, what rights they can expect and what the legal obligations of the host nations are. It has been widely ratified to date and, notably, was signed by the President of Nauru, Marcus Stephen, on 17 June 2011. With some fine-tuning over the years it remains the cornerstone of International Refugee Law. It defines a refugee as:

A person who owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it…

The UNHCR encourages countries to receive refugees and to provide them with assistance and protection. One of the major protections provided for in the Convention is the principle of ‘non-refoulement’, which means refugees cannot be forcibly returned to their countries of origin, if to do so would threaten their life or freedom.

Unlike refugees, and because of the element of sovereignty, governments of countries where IDPs reside are responsible for their protection because these people have not crossed an international border. IDPs are commonly fleeing situations such as internal armed conflict, communal violence and other human rights violations. In many instances, state authorities may not only be the cause of displacement but may lack the will or capacity to address issues and the needs of the IDPs. This includes not only humanitarian relief assistance, but also protection. Where a state lacks capacity, it can request humanitarian relief assistance from UNHCR and other agencies. Since 1992, UNHCR has been focusing more efforts toward the protection of IDPs and, since 2007, has taken the lead in complex emergencies.

In 2017, according to UNHCR, there were 65.6 million people displaced worldwide (up by ∼23 million in 6 years). Of these, 22.5 million were refugees and 43 million were internally displaced persons (IDPs). Turkey is hosting 2.9 million and Pakistan 1.4 million refugees. Up to 93% of all refugees were being hosted within the region of the country they had fled. The major sources of refugees in 2017 were Syria (5.5 million), Afghanistan (2.5 million), and South Sudan (1.4 million). Of all these refugees, 46% are less than 18 years of age.

In 2017, China, the Philippines, Syria, the Democratic Republic of the Congo (DRC), Cuba, the United States, India, Iraq, Somalia and Ethiopia had more than one million new displacements each. At the height of the crises in 2010, the floods in Pakistan saw 20 million people displaced. The worldwide problem is clearly significant.

Sadly many nations are restricting border access and assistance to refugees fleeing crises.

The solution to any displacement problem is ultimately nonmedical because the underlying issue is commonly based on political instability. Even in the acute phases of refugee movement, the most urgent needs are food, shelter and clean water. Access to health care is important. Emergency physicians should have an understanding of the issues at hand and possible solutions including links to appropriate information and organizations where necessary. Of particular importance is that at all stages of relief assistance, the displaced population, sometimes referred to as ‘the beneficiaries’, must be actively involved in planning and delivery of aid. Affected communities themselves know what they need, who their leaders are, what the cultural norms are and they speak the local language.

Coordination in a humanitarian crisis

A number of reforms have been introduced in recent times to address problems of poor planning and coordination. After the Great Lakes Disaster in the early 1990s, it was agreed in 1997 to establish a set of minimum standards and rights to which refugees were entitled. The collaborative project, called Sphere, was initiated in 1997 by a group of humanitarian nongovernment organizations (NGOs) and the International Red Cross and Red Crescent Movement with the overall aim of improving the quality of their actions and accountability during disaster response. The Sphere Project produced a manual that is available free from the website www.sphereproject.org . The Sphere Handbook is widely known and sets out common principles and universal minimum standards for humanitarian response. The Sphere Handbook was first published in 2000 and the newest edition was published in November 2018. Other organizations, such as Médecins Sans Frontières (MSF), UNHCR and the World Health Organization (WHO), also have several excellent manuals describing in detail the approach to humanitarian emergencies.

In partnership with national and international actors, the Office for the Coordination of Humanitarian Affairs (OCHA) is the UN agency responsible for mobilizing and coordinating effective and principled humanitarian action. In 2005, OCHA initiated a review of its coordination processes. This resulted in the introduction of the UN clusters with the aim of building sufficient response capacity, improving humanitarian coordination and leadership and building effective partnerships. Table 29.5.1 shows the current clusters and their lead agencies.

Global cluster leads develop partnerships, humanitarian preparedness and set standards and policy. At a field level, the cluster lead, together with the affected country’s government representatives, ensures collaboration and coordination and are accountable to the senior UN representative, the Humanitarian Coordinator, as well as the host country government authorities. The cluster lead is the ‘provider of last resort’, which means they must do their utmost to ensure an adequate response. Where that response is lacking, it is their responsibility to seek assistance from others, such as the Humanitarian Coordinator or the host government. Any organization responding to a humanitarian crisis and working in a specified area of response (e.g. health) is welcome to attend any relevant cluster meeting.

Emergency Medical Teams

The medical response to the earthquake in Haiti resulted in many issues, particularly regarding variable standards of care. As a result, the WHO in collaboration with others developed the ‘Emergency Medical Team (EMT) Initiative’. This sets out a series of minimum standards for various levels of medical team response and includes clinical care, waste management and logistics. Teams may be civilian or military. EMTs are verified to meet the WHO standard, and agree to work with the WHO and the government’s Ministry of Health in responding to a health crisis. Nations experiencing sudden onset disaster can be confident any EMTs who have successfully undergone WHO verification who are deploying to their country will meet preset minimum standards of health care and will provide well-trained and self-sufficient medical teams. Australian and New Zealand Medical Assistance Teams (AusMATs & NZMATs) have been verified for type I (primary health care both fixed and mobile) and AusMAT type II (field hospital) levels of care.

Before you go

The Internet and electronic media are increasingly being used in innovative ways by humanitarian agencies. It is now possible to follow evolving disasters on several websites, such as UN affiliated sites, Red Cross sites, major NGOs and MSF sites and explore what each particular organization is doing. OCHA has an excellent website called Reliefweb ( www.reliefweb.int ) which gives regular updates on all crises. Relevant data can also be sourced from gapminder ( www.gapminder.org ). In most humanitarian crises, the health issues are predictable (e.g. orthopaedic injuries with earthquakes). It is important to be aware of the literature and to scan previous reports of health issues within the region where you are intending to travel before you leave. As soon as clusters are operational, they will report recent data for the affected region, as will the local Ministry of Health. Where possible, it is preferable to be in contact with these organizations prior to departure. WHO publish on the internet some excellent manuals on diagnosing and managing cases in humanitarian crises and have prepacked medical kits (Interagency Emergency Medical Kits). WHO also publish the EMTs guideline often referred to as ‘the blue book’ which is available online. The Sphere guidelines are another essential resource and the Australian Medical Assistance Team training manual is also helpful.

Personal attributes

Working under difficult conditions imposed by a humanitarian crisis demands special qualities. It is certainly not glamorous and often much of what has been learned from training and practice in the West is either irrelevant or needs modification to suit local conditions and resources. In general the main requirements are:

• flexibility, versatility and ability to improvise;

• appropriate qualifications and sufficient clinical experience along with the ability to work independently in extreme conditions;

• cultural awareness and sensitivity;

• good interpersonal and communication skills and the personality to get along with all types of people;

• willingness to follow leadership and direction;

• good predeployment preparation, including appropriate vaccinations and insurance arrangements;

• acceptance of security and health risks both by the individual and their family.

Camps for refugees and internally displaced persons

Persons fleeing war or persecution escape in a variety of ways. They may be integrated within the local community or be accommodated by friends and relatives. Typical, however, is the mass movement of populations either across a country or a border into temporary accommodations or camps. It is under these circumstances that the displaced are most at risk, as they are not accommodated in isolation. There are generally interactions with a local population, which are not necessarily cordial. There may also be important political and ethnic factors within the displaced population themselves, which can lead to tensions or even violence within camps. This scenario was tragically demonstrated in the post-Rwandan holocaust camps in 1994. Camps themselves can sustain conflict in some areas, for example, the West Bank and the camps on the Thai–Cambodian border that were used as refuges by Khmer Rouge and became a platform from which they could carry on the war.