Healthy Dialogues: April 2011
April 13, 2011
The Healthy Dialogues blog strives to create a conversation every month about a current topic in health. We pick key experts, from both inside and outside CSIS, to answer one question each week. We hope that by stringing these answers together, an interesting and complex picture of the topic will be created. An integral component of this blog is you! If you have a topic you'd like us to address next month, tell us. If you have a question you'd like us to answer next week, ask it. We want to hear what's on your mind.
In the past year, the events in Japan, Haiti, Pakistan, and elsewhere have put increased attention on emergency response. This month's blog is dedicated to responding to health needs during crisis situations: natural disasters, humanitarian emergencies, or situations in fragile states. Specifically, entries will focus on immediate priorities in the first 60-90 days of response, the necessary communications required to coordinate, the challenges that arise, and how the international community's response to crises has changed over the years.
We are excited to have an expert group of contributing writers answer questions this month. Writers include:
Ambassador William Garvelink, Deputy Coordinator for Development for the Feed the Future Initiative, USAID
Mathew Morgan, Communications Officer, American Red Cross
Leonard Rubenstein, Visiting Scholar, John Hopkins School of Public Health
Dr. Ron Waldman, Global Health Fellow, USAID and Professor of Clinical Population and Family Health, Columbia University
Mark Ward, Acting Director, USAID's Office of Foreign Disaster Assistance
Adele Waugaman, Senior Director, Technology Partnership, United Nations Foundation
Question: How has thought evolved in the past decade on the value and the operational requirements for effective health interventions in fragile/conflicted states?
In the past decade, health and health systems in conflict-affected states have been subject to intensified study and intervention. Despite certain knowledge gaps, our understanding of the indirect effects of war and instability on population health – ranging from infectious disease to severe psychological distress – has grown. At the same time, initiatives to both expand services and establish, support, or rebuild health systems have taken place in countries as diverse as Liberia, Afghanistan, Pakistan, Democratic Republic of the Congo, Timor-Leste, Kosovo, Iraq, South Sudan, Rwanda, and Sierra Leone.
Donor commitments to post-conflict health systems have been mostly driven by pre-existing political commitments rather than strictly health-related considerations. And while the results of these efforts are decidedly mixed, they have nevertheless yielded experience and growing consensus about methods for developing systems of care in these challenging environments – with an emphasis on increasing capacities of Ministries of Health to plan, organize, and manage primary care services, and meet immediate health needs while developing a system. The experience also points to the need for changes in the structure of donors’ health programs, length of resource commitments, effective financial mechanisms, and decision-making control.
These adjustments have been hampered not only by traditional structures of development aid, but lack of clarity about policy on health development in conflict-affected states. Despite the fact that the worst health indicators are associated with conflict-affected or unstable states, U.S. global health policy, including the Global Health Initiative, remains largely silent about them...
Question: In post-disaster environments, communication infrastructures are often compromised. In your experience, what was the single most effective solution you saw organizationally or technically to enable communication, both amongst responders and with affected populations?
While twin forces of urbanization and climate change have compounded the effects of disasters over recent decades, advances in technology have had a similarly drastic effect on the ability of disaster responders to quickly communicate with affected people. Mobile phones empower people to receive essential information and engage in dialogue with authorities about their needs.
Phone service, for example, was quickly restored after the Haiti earthquake that devastated the urban area of Port-au-Prince in 2010. As mobile phones reach the majority of Haitians, Trilogy International Partners developed a messaging application that allowed the Red Cross to send text messages via SMS (short message service) to phone users in targeted geographic areas. By contrast, traditional SMS services require broadcast messages be delivered to every subscriber on a carrier’s network.
In practice, this means that a Red Cross officer can select one or more cell phone towers and send messages to all mobile phones within range of those towers. The Red Cross can then:
- Provide Haitians with advice and offers of aid that are relevant to their particular circumstances. While this approach must complement other public education and outreach, it allows for near-instantaneous communication regardless of the area or population size;
- Engage in two-way communication. In order to truly meet needs of Haitians, the Red Cross must engage beneficiaries in an ongoing conversation about their needs and questions; and
- Benefit from a capability that has driven unprecedented response rates. Red Cross programs and services can be adjusted as needed to adapt to a dynamic and complicated environment
In emergencies, communication can mean the difference between life and death. Responses to large-scale humanitarian crises like political conflicts and natural disasters are no exception.
As number of natural disasters and civil conflicts rise worldwide, so too does access to communications technologies. Challenges like climate change, and the interlinked food, fuel and financial crises increasingly define our geopolitical landscape. To build resilience in the face of these more frequent and complex humanitarian emergencies, the ongoing revolution in human connectivity may provide our greatest opportunity.
Today there are more than 5.3 billion cell phone subscriptions worldwide. The fastest growing mobile markets are in emerging economies. In many places where there are no paved roads or running water, mobile networks are connecting the unconnected. Along with the uptake in cell phone usage is the rise of the mobile internet, which is fueling the rapid growth of web-based social networking.
These tools, and improved access to these tools, are enabling a new culture of community driven communications that is challenging and changing the nature of disaster response. Technology is enabling people to increasingly be at the heart of humanitarian aid.
Take, for example the 2010 earthquake that devastated Haiti....
Question: What lessons have you learned in getting humanitarian operations, especially those in the health sector, working effectively during crisis state settings and what are the critical priorities in the first 60-90 days of a response?
Dr. Ron Waldman
Following the Haiti earthquake of January 12, 2009, a variety of factors contributed to the atmosphere of ultimate chaos that reigned for the first few months of the relief effort. First and foremost were the circumstances of the disaster themselves – a major seismic event occurred in close proximity to the shoddily constructed capital city of the country, resulting in 230,000 deaths, hundreds of thousands of injuries, the literal (not to mention the functional) collapse of the government, and the abrupt end of whatever semblance of ‘normal’ life had previously existed. Major population movements both away from and towards the shattered city were impossible to track. Whatever health care facilities remained standing were absurdly and obscenely overcrowded, under-staffed, and inadequately supplied.
Despite all this, two things worked remarkably well. First, food distribution. A combination of agencies including the World Food Programme, USAID’s Office for Foreign Disaster Assistance, and US Department of Defense forces working together with Menustah (the UN military contingent that had been on-site prior to the earthquake) devised a workable system of vouchers and established a network of distribution sites that were secured and made functional in record time. Food availability, the lack of which could have provoked major outbreaks of civil unrest, never became a problem. Second, a breakdown in public health never occurred. For reasons which are not completely understood, but which probably have a lot to do with good luck, the world did not witness the “disaster after the disaster” – a public health collapse caused by large numbers of people living in crowded conditions with inadequate shelter and essentially no sanitation facilities. No important epidemics of diarrhea, respiratory illnesses, vector-borne diseases such as malaria and/or dengue, or other important communicable diseases were detected. On the public health front, things remained relatively calm and under control from January until October, when the much-publicized and discussed cholera outbreak occurred. Although more could have been done to restore both public and private sector activity, including more rapid removal of rubble from the earthquake area, more rapid resettlement of the large displaced population, and more rapid rehabilitation of the health system and other vital societal functions, this six month relative lull in action allowed relief efforts to concentrate on providing intermediate-term care for physical rehabilitation, some repair of damaged facilities, and the matching of available resources (human, material, financial) to the new needs of clinics and hospitals...
Disease Early Warning System – Key Aspects of the 2010 Pakistan Flood Response
The 2010 floods were by far the worst natural disaster in Pakistan’s history. Flooding of almost biblical proportions ultimately affected more than 20 million people and covered one-fifth of the country’s territory. More than eight million people were displaced. The extraordinary international and Pakistani relief effort reached millions with emergency shelter, food and clean water, but many more could only find refuge on higher ground along highways and river embankments.
The massive population displacement, coupled with damage and disruption to infrastructure, raised urgent public health issues. Waterborne diseases are already a concern in Pakistan. According to the World Health Organization (WHO), in an average year diarrheal diseases are the fourth most common cause of death in Pakistan, accounting for roughly 9 percent of all deaths countrywide. And this was no average year.
For USAID’s Office of U.S. Foreign Disasters Assistance, our highest strategic priority was avoiding an epidemic outbreak of cholera, a disease already endemic in Pakistan. But while we faced a huge challenge, we had already tucked an ace up our collective sleeve, called the Disaster Early Warning System, or DEWS.
In 2008, USAID, along with Pakistan’s Ministry of Public Health and the WHO, funded a disease surveillance system of permanent and mobile health clinics and laboratories to track individual cases and respond rapidly to treat and isolate communicable cases from the surrounding populace...
Ambassador William Garvelink
A rapid health assessment is essential for a properly-grounded and successful emergency response. Its purpose is to provide decision-makers, on the ground and at headquarters, with the necessary information to make key decisions quickly. It is important to collect only decision-critical information and to distinguish between emergency and chronic needs. The focus is prevention. It is important to identify the most vulnerable populations, priority interventions, special concerns and actual and potential bottlenecks.
The most critical indicator of the severity of any health emergency is the crude mortality rate for children under 5 years and to focus on the five big killers—malnutrition, measles, acute respiratory infections, diarrheal diseases and malaria. Other essential information include the availability of water (preferably potable), food and immunization rates. Basic information on the prevalence of HIV/AIDS, cultural factors and diseases endemic to the region will round out the rapid assessment along with determining the local and international humanitarian infrastructure at the site which can be relied on or mobilized.
Of course, even when we know the essential steps that need to be taken in responding to a crisis, challenges always present themselves.
In 1996 in Rwanda, for example, health experts had been in the refugee camps in eastern Congo (then Zaire) as well as at the Rwandan-Congolese border as refugees crossed back into Rwanda. The humanitarian experts had detailed information on the health status and knew that their overall condition was good. To be safe, however, the Office of Foreign Disaster Assistance at USAID set up temporary health posts along the roads which the Rwandan refugees traveled as they walked back into Rwanda. These posts were stocked with essential medicines and supplies, basic foods and some supplementary feeding items. The surprise was that there were so many refugees on the roads that the health posts could not resupplied. Helicopters rather than vehicles were needed to keep the clinics equipped. The helicopter response was delayed and limited while trucks resupplied the posts where they could. Fortunately the refugees were in good shape and the distances were not great for many. Most completed their travel home with only limited assistance from the humanitarian community.
In Albania in 1999, to provide another example, international health experts were at border with Kosovo as the Kosovars crossed into Albania. At the border, experts assessed the health status of the refugees, their demographic composition and special needs (many were traumatized and there were a lot of unaccompanied minors). We at USAID knew the government’s local humanitarian infrastructure was weak, based on meetings earlier in the capital city of Tirana. The unique problem was the inability of the Albanian customs service to take the decisions to allow emergency medical and other humanitarian supplies into the country duty-free and then to facilitate the rapid clearance of these items. A humanitarian expert was quickly attached to the Prime Minister’s office. The necessary decisions were then taken by the Prime Minister and our expert set up a system to allow for the immediate clearance of these urgent medical and humanitarian supplies.