Overview of Military Medical
Humanitarian Emergencies
Learning Goals
Know
the terminology of HA ops
Appreciate the variety of organizations
involved in disaster relief & their
specific capabilities
Know the health priorities in HA ops
Acute situation affecting a large population
where either the population or its
government is incapable of providing its
basic needs
Many Types of Disasters
Humanitarian Emergencies
Man-Made Disasters
Technological
Chernobyl
Union Carbide Spill
Natural Disasters
Civil / Economic
War
Embargo
Genocide
Hurricanes
Drought
Volcano
Tsunami
Earthquake
Number of Humanitarian
Disasters Worldwide 1985-95
60
50
40
30
20
10
0
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
Manmade
Natural
Not All “Refugees” are the Same
Refugee
• Cross Political Boundaries
• 15 million (1997)
• Entitled to UN and int’l rights
IDP
(Internally Displaced Person)
• Stay within own country
• 20 million (1997)
• Harder to intervene, assist
Estimated Number of Displaced Persons Worldwide
1984 - 1997
30
25
20
15
10
5
0
'84
'85
'86
'87
'88
'89
'90
IDPs
'91
'92
'93
'94
'95
'96
'97
Refugees ECOSOC, U.S. Mission to U.N.
Civilian Deaths in Complex
Humanitarian Disasters
Country
Sudan
Ethiopia
Rwanda
Cambodia
Somalia
BosniaHerzegovina
Deaths
> 1 mill.
750k – 2 mill
500k – 1 mill
> 1 mill
500 k
200 k
Time Period
1983 – Pres
1984 – 1993
1994 – Pres
1975 – 1993
1988 – Pres
1992 - 1996
ECOSOC, UN 1996
How do you
measure
disaster
severity?
Crude Mortality Rate (CMR)
the number of deaths per
10,000 people per day
CMRs of Recent Emergencies
Date
Host Country Home Country Baseline CMR Crisis CMR
Jul 90
Jun 91
Apr 91
Mar 92
Jun 94
Jul 94
Ethiopia
Ethiopia
Turkey
Kenya
Burundi
Zaire
Sudan
Somalia
Iraq
Somalia
Rwanda
Rwanda
0.6
0.6
0.2
0.6
0.6
0.6
2.3
4.7
4.2
7.4
5.0
34.0
Infect. Dis Clinics NA Jun 95
The Vulnerable Suffer the Most
(Kurdish Population, Northern Iraq 1991)
70
60
50
40
30
20
10
0
0-5 yrs 6 - 14 yrs 15 - 44 yrs 45 + yrs
Other Vulnerable Populations
Unaccompanied
Minors
Lactating Mothers
Pregnant Women
Woman Head-of-Households
Type of Emergency Dictates
Response
Trauma Shelter
Earthquake
++++
Flood
+/-
Civil
Strife
++
Water
-
Food
-
Sanitation Medical
-
+
++++ ++++ +++ +++ +++
++++ ++++ ++++ ++++ ++++
Phases of Emergencies
0 - 30
D
--> D+30
– Chaos
– High CMR
– Assessment
30 - 60
 D+30
--> D+60
– Relief Tailored
– CMR drops
– Continuing
Assessment
60 -- ???
 D+60
onward
– Move
towards selfsufficiency
– CMR and
quality of life
returns to
baseline
The Players in Humanitarian
Emergencies
NATO
World Food Program
World Health Org.
Host
Government
OFDA
Host
Military
UNHCR
NGOs
NGOs
 Thousands
out there
 Most are small with an even smaller focus
– shoes for children, eyeglasses, irrigation training
 Most
specialize in a type of emergency relief
 Compete for aid money from private and
government donors
– majority (~ $5 billion) from governments in 1995
International Committee
of the Red Cross
 Unique
among NGOs in that its mission is
MANDATED by international law.
– Geneva Convention 1949 & Protocols of 1977
 Acts
principally in civil disturbance and has
RIGHT and DUTY to interfere in national
and international conflicts
 Brokers relief assistance, assures legal
protection for victims and POWs
 Has primary role in family reunification
International Committee
of the Red Cross
 Will
go to maximal lengths to maintain
NEUTRALITY
– fully discloses activities to all parties in a
conflict
– Refuses participation in any activity that may
be perceived as partial
 consequently,
the ICRC is self-sustaining including
airlift, logistics, and comm
– Neutrality agreement refused in Iran-Iraq,
Afghanistan; ignored in Chechnya
NGOs
Cooperative for American Relief Everywhere
Logistics, Food Aid, Camp Management ($300 M)
Doctors without Borders / MSF
Medical Care ($ 150 M)
Oxford Committee for Famine Relief
Water and Sanitation ($ 200 M)
Catholic Relief
Food Distribution
Save the Children Fund
Food Aid and Development
Irish Concern
Supplemental Feeding
USAID
• U.S. Aid for International Development
• coordinates US gov’t programs for int’l
development and response to disasters
• Disaster response is job of Office of Foreign
Disaster Assistance (OFDA)
• becomes involved when Asst Sec of State for
that region declares a state of disaster
USAID cont’d

In disaster, deploys a DART (Disaster
Assistance Response Team) composed of experts
– they evaluate and prioritize overall relief needs
– release pre-positioned disaster relief commodities
stockpiled in disaster-prone regions (plastic sheeting,
water containers, chain saw kits, body bags, hard
hats, gloves, water purification supplies
– review NGO / UN proposals and “award” funds for
the hands-on work of relief
Other Governmental Agencies
European Community
Humanitarian Organization (ECHO)
Overseas Development Agency (UK)
Canada International Developmental Agency
(CIDA)
Japan International Cooperation Agency (JICA)
United Nations
 Limited
ability to provide unless invited by
a host government
 UN Chapter VII provides for forceful
intervention only if “international security”
is threatened
UN Agencies
• UN High Commissioner for Refugees
•coordinates a material response
•advocacy for displaced people rather than on camp
management
• World Food Program
• coordinates delivery of food stuffs
More UN Agencies
UNICEF
– a fund, not an agency
– can provide assistance without permission of host
government
– focuses on social programs for kids, pregnant and
lactating women
•World Health Organization
• Consultation and policy in preventive and curative health care
Still More UN Agencies
UN
Development Program
– coordinates pre-disaster UN programs

Off. for Coord. of Humanitarian Affairs
– Created 1992 to coordinate all UN agencies and liaison with
NGOs, militaries
U.S. Military

Increasingly drawn into HA operations
Why the U.S. Military?
 Speed:
no other organization can mount as
large a logistical operation as rapidly
 Security:
arrives fully prepared to secure
people and material
Why the U.S. Military?
 Transportation:
Possess array of
assets to deliver
anything, anywhere,
anytime
Why the U.S. Military?
 Logistics:
Can maintain supply lines in
austere environments
 Command and Control: well-defined
structure
 Self-sufficiency
 Specialty Units: Engineers, Medical
Drawbacks of U.S. Military
Participation
 Medical
Care: Oriented to combat
casualty care, not civilian disaster victims
 Focus: Short term objective driven; not
aimed at re-development
 Political Ramifications
 Expense ...
Humanitarian Operations are
Expensive
 Difficult
to provide cost-effective assistance
 Somalia: $ 100 M per month
 Ethiopia: coalition airlift for famine of 1980s
was cost-inefficient and provided no medium
or long-term benefit (good publicity, though)
Cost of 1 C-130 flight
with 15 tons of grain
=
Cost of purchasing a 30
ton capacity grain truck
and fueling it for 6 months
Root Causes of Mortality
 Disruption
of food sources
 Disruption of Health Services
 Loss of Shelter
 Disrupted Sanitation
 Loss of Income
 Crowding
 Lack of Water
Leading Causes of Death in
Humanitarian Disasters in the
Developing World
•
•
•
•
•
Diarrhea / Dehydration
Measles
Malaria
Respiratory Infections
Malnutrition
Causes of Death, by %
Wad Kowli Camp, Sudan, 1985
Malaria
Resp. Infection
Measles
Diarrhea
MMWR 41:RR-13
Causes of Death,by %
Malawi, 1990
Malnutrition
Resp. Infection
Malaria
Malaria
Other
Diarrhea
Measles
MMWR 41:RR-13
Causes of Death, by %
Lisungwe Camp, Malawi, 1990
Measles
Diarrhea
Malaria
Resp
Malnutrition
Other
MMWR 41:RR-13
CMR by Malnutrition Prevalence
16
14
12
10
8
6
4
2
0
<5
5-9.9
10-19.9 20-39.9
>40
Malnutrition Prevalence (%)
malnutrition = < 80% Wt/Ht of WHO Reference Population
Ten Essential Emergency
Relief Measures
#1
Rapid Assessment
of magnitude, environment, needs,
local response capacity
Assess the “Standard of Care” and stick to it!
#2
Provide Shelter and Clothing
exposure to elements increases vulnerability
as well as caloric requirements
#3 Provide Adequate Food
minimum of 2000 kcal / person / day
equitable distribution system
targeted feeding programs for the most vulnerable
“Low-value” foods work best
#4
Sanitation and Clean Water
minimum of 3-5 L / person / day
(~ 20 is comfortable)
#5
Diarrhea Control Program
personal hygiene, improved sanitation,
proper medical management of dehydration
#6
Prophylax Against Measles
Vaccine to most susceptible, quarantine,
Vitamin A supplementation
#7
Primary Care Algorithms
Based on prevalent diseases, resources, and
local standards of care
#8
Disease Surveillance
Necessary to monitor interventions
and re-align priorities
#9
Organize Human Resources
Most under-recognized asset -disaster victims themselves
# 10
Coordinate Activities
Establish liaison with local government,
local military, int’l groups, NGOs
Change your frame of
reference. You are there to
provide the local standard of
care, not the “American”
standard of care.