Enhancing health in complex emergencies:
The broader research agenda1
I BACKGROUND
1. Complex Political Emergencies and health:
The public health effects of complex humanitarian emergencies in general and complex
political emergencies in particular include high direct and indirect mortality, and the collapse
of health systems. There is an overall increase in health needs of individuals and
communities, mass population displacements, a breakdown in infrastructure leading to poor
housing, water and sanitation, a lack of food security and an increase in psychosocial
problems. There is also a growing body of evidence revealing an increase in communicable
diseases, some of which had been previously controlled. More than 65% of epidemics take
place in unstable countries.
The term 'complex political emergencies' describes a broad range of phenomena, ranging
from civil and ethnic wars to guerrilla and rebel insurgencies. Many of these CPEs result in
protracted conflict situations and long-term instability. Their impact impinges on all aspects
of community; the economy, livelihoods, education, human rights, social cohesion and civil
society. Health, under these complex circumstances, needs to be negotiated in the context
of the interaction of the nature of conflict, the coping dynamics within communities and the
capacity of health systems to respond to the short and longer-term health needs.
2. The cost of not understanding:
There is an increasing body of knowledge, particularly on the technical aspects of
humanitarian responses like therapeutic feeding centres or implementing vaccination
campaigns. During acute phases of emergencies, the needs are often clear and there is
usually a consensus on what to do. However, the rationale for making program choices in
the protracted phases is far less obvious. Without the minimal evidence base, current aid
practices can easily become inappropriate, inefficient, intrusive, and sometimes even
disruptive. The lack of a common understanding often leads to an incoherent and
fragmented health response. Particularly when interventions are linked to political agendas
and based on the perceptions, blueprints and values of providers. Sound health and
demographic data are often lacking. Even more than in acute situations, programs need to
take better account of the demands and dynamics of communities.
3. Toward appropriate, effective, efficient and equitable interventions:
The significance of preventing violent political conflict cannot be overemphasized. However,
current realities dictate that we need to develop a body of evidence on which to base health
related practice to promote health, prevent disease, strengthen resilience and coping
mechanisms of communities, and to foster sustainable health systems during conflicts as
well as in the transition period directly after. The overall research goal is to contribute to the
identification of a set of evidence-informed methods and approaches, which allows for
development of sensitive and effective options for action at community and health system
level, appropriate to each context. This working paper highlights those features and effects
of acute and protracted conflict that are poorly understood. It identifies key research
questions and proposes a process for addressing these. Research in this context includes
any form of systematic information collection and analysis required to supporting policy and
decision-making.
1
This paper was developed at the TDR/SEB Sponsored meeting: Surviving crisis: how systems and
communities cope with instability, insecurity and infection (Manila 3-7 April 2002) and subsequently further
refined. Contributors: Andre Griekspoor, Markus Michael, Enrico Pavignani, Pascale Allotey, and Anthony
Zwi.
1
II RESEARCH ISSUES
1. Impact of conflict on health status / burden of disease
Susceptibility to ill health is increased in times of stress as occurs in conflict situations. Data
is needed on general patterns of morbidity and mortality as baseline information for planning,
monitoring and the evaluation of external and internal responses to conflict.
Conflicts pose an impediment to infectious disease control and eradication. While there is
some evidence of the role of conflict in the re-emergence of previously controlled infectious
diseases, this has not been well documented due to the complexities of maintaining
information systems in emergencies. We need to understand not only the impact of these
diseases on the affected populations, but also the effect of conflict situations on patterns of
disease and the disease agents.
Better understanding is required of the determinants of the excess mortality and morbidity
related to CPEs. For instance, which determinants can be controlled and how can control be
achieved in a cost-effective manner? In addition, the differential effects on health and health
systems of different types, causes and characteristics of conflict (cause, duration, intensity,
and stage) are not well understood.
2. Response of communities, care providers, health services and health systems to
conflict
Individuals and groups have different levels of vulnerability to various types of conflict and its
impacts, due to poverty, gender, age, social capital, ethnicity or religious identity. Individual
health services, and the health system as a whole, similarly have differential degrees of
vulnerability. The coping response to conflict is likely to depend on a wide range of factors
including the degree of resilience, availability of resources and intervention from external
agencies. But the dynamics of resilience and coping, and the possible approaches to
strengthening these, are not yet well understood.
The ability of health systems to continue to perform despite adversity, including ongoing
conflict and inadequate resources, is variable. Decline is usually gradual until a point is
reached after which systems may collapse more precipitously. Prior to this point of collapse,
the objective for external interventions would be one of support and maintenance, whereas
beyond the breaking point more radical ‘resuscitation’ approaches are likely to be needed to
bring the health system back to a functional level.


How can we characterise the degree of resilience and vulnerability of health systems and
communities? How can we assess effectively the status of communities and health
systems confronted with crisis with regards to their ability to cope? How does the degree
of resilience and vulnerability differ within or between communities? What is the
interaction between displaced and resident populations? What are the socio-economic
and cultural factors that determine the degree of vulnerability, resilience and coping of
communities?
Is it possible to identify the point of irreversible decline, beyond which ‘conservative’
interventions to maintain community or service functionality are likely to prove
ineffective? What are the short- and long-term results of providing limited but ongoing
maintenance or development support as opposed to the more radical approaches of
establishing parallel services or pouring in large amounts of additional funding,
introduced to sustain flagging health systems?
2

What adaptations do health services make in order to continue functioning in times of
adversity and conflict? What lessons can be learned from these adaptations, and how
can these be built upon to support health care services in current or future conflicts?
3. Rationale, features and effects (short and long-term) of interventions
There are two main levels of intervention in emergencies – internal interventions from
existing health services and the communities affected, and external intervention, which is
usually a response from the international community, whether through the United Nations or
civil society. There is relatively little formal documentation, however, on the contributions of
external agencies to improving health in unstable situations.
In addition, the documentation of experiences remains privileged information within
organisations at best, or is poor or non-existent at worst. As a result, lessons learned reside
with individuals, and are neither conceptualised nor debated in the public domain or
transferred to others. The visibility of humanitarian interventions, coupled with the difficulty of
measuring their effectiveness, fuels endless debates that cannot be clarified without an
understanding of what constitutes good practice. The research areas that arise as a result of
these issues include:






What strategies have been used to maintain local Ministry of Health (MoH) planning and
policy-making capacities in war situations? What role can health policy development play
in better co-ordination and coherence of the humanitarian assistance, how can it be used
to link relief efforts with national capacity building?
How do the dynamics between internal and external stakeholders, who often have
conflicting interests, influence implementation of health policy (for example attempts to
regulate the private pharmacies, accreditation of unofficially trained health workers, or
reform efforts from centralised secondary health care systems to primary health care)?
How does the interplay between stakeholders evolve?
Given the limited, often inadequate and decreasing resources, which are typical in
chronic conflict settings, what are the different choices that health care providers and
health system planners might make in order to cope? How can they strike the most costeffective balance between preventive and curative care, between enhancing the quality
of care for individuals who access services and approaches which are more population
and public health-oriented and which seek to prioritise amongst a range of potentially
conflicting needs? What are the trade-offs between effectiveness, efficiency, equity and
sustainability of these different strategies to health service provision?
What mechanisms should be adopted to promote uniformity of treatment guidelines and
protocols (for example for malaria and other infectious diseases, drug policies, etc)
among humanitarian agencies providing assistance and care in a conflict or post-conflict
environment? What are the trade-offs when international standards of care are of higher
quality and costs compared to what was locally feasible within pre-existing resource
constraints?
What role does the military (occupying, peace keeping and rebel forces) play in the
provision of effective health services? Do they play a role in spreading tropical diseases,
in creating potential for evolution of parasites in endemic areas and/or in producing
solutions to infectious disease problems?
What is the role of traditional health practice in the health of communities in conflict or
crisis situations? Does traditional health care get strengthened or weakened in times of
crisis? What can be done to determine which elements of traditional practice may be
health-promoting or protecting (e.g. those focused on mental health), while recognising
that other elements may be dangerous to health (e.g. some traditional medicine used
instead of antibiotics for STDs).
3
III CONSTRAINTS TO RESEARCH
Undertaking research in this area is challenging. There is a need to examine critically the
existing data, as well as to develop innovative research strategies to investigate how
communities and health systems survive conflict. The current challenges to systematic
research in this area include:
 A lack of local research capacity, particularly in countries where conflicts have become
chronic.
 Research in conflict situations is fraught with high risks for academic institutions and
individual researchers: the risk for personal security, of not being able to adapt the study
design to the ever-changing situation or even to be cut short, and the risk of findings to
be too sensitive to be published
 Organisations involved in emergency management are action-oriented and do usually
not consider research as a priority.
 Organisations that could potentially fund research, both those who fund emergency
programs as well as those who traditionally fund health research in development
settings, do not consider research in emergencies a priority.
 No prominent academic institution has so far made health in conflict a core area of
research.
 Research in conflict situations is fraught with ethical dilemmas which include putting
informants into danger; concentrating efforts on research when there is pressure to
rather deliver life saving services, and the potential for coercion of research participants
who are in a vulnerable situation.
 Experimentation is required to identify how academic institutions, researchers, and
humanitarian organisations can better interact with one another so as to contribute
together to improving the quality, effectiveness and efficiency of both emergency and
longer-term development responses to conflict.
IV CONCLUSIONS AND RECOMMENDATIONS
This paper provides an overview of the main gaps in understanding the dynamics of health,
and the functioning of communities and health systems, in CPEs. Areas for research are
identified and the costs of not investing in better understanding are presented. Working on
this research agenda will facilitate / foster research and capacity building, creating wider
consensus, and will provide a focus for eliciting funds, establishing partnerships, and
promoting lesson-learning in organisations and agencies.
However, these are merely the first steps towards better performance based on best
evidence. Awareness of the need to refine and respond to this research agenda needs to be
raised with donors, humanitarian agencies and academic institutions. Some of the required
research can and needs to be programmed into operational planning. Other research
questions are too extensive for most single agencies and would require commissioned
action oriented studies. Therefore, we propose:
1. Wide dissemination of this research agenda
2. An international consultation between academics, implementing agencies, health
authorities of conflict affected countries and donors to:
 Consolidate the research agenda
 Raise funds to allow for commissioned studies related to the agenda
 Establish a management structure to further promote the establishment of these
funds, the research agenda, and the transparency and accountability of
procedures
3. Annual sessions on progress made in research conferences like the Global Forum for
Health Research.
4