Establishing moral bearings: ethics and expatriate health care professionals in humanitarian work

Expatriate health care professionals frequently participate in international responses to natural disasters and humanitarian emergencies. This field of practice presents important clinical, logistical and ethical challenges for clinicians. This paper considers the ethics of health care practice in humanitarian contexts. It examines features that contribute to forming the moral landscape of humanitarian work, and discusses normative guidelines and approaches that are relevant for this work. These tools and frameworks provide important ethics resources for humanitarian settings. Finally, it elaborates a set of questions that can aid health care professionals as they analyse ethical issues that they experience in the field. The proposed process can assist clinicians as they seek to establish their moral bearings in situations of ethical complexity and uncertainty. Identifying and developing ethics resources and vocabulary for clinical practice in humanitarian work will help health care professionals provide ethically sound care to patients and communities.     

Violence and complex humanitarian emergencies: implications for livelihoods models

This paper explores the nature of the violence that characterises complex humanitarian emergencies and the related implications for modelling livelihoods systems. While noting the importance of livelihoods approaches in complex humanitarian emergencies, it deliberates the limitations of sustainable livelihoods frameworks when applied in environments marked by protracted instability. Adaptations to the model are discussed, with a particular focus on the relationships among violence, assets and liabilities within livelihoods systems. Political economy of violence theories intimate that the assets on which livelihoods systems are constructed in peaceful times may instead become life-and livelihood-threatening liabilities in periods of conflict. Adaptations to livelihood systems in violent settings require that analysts consider violence from policy, institutional and process perspectives. It is suggested that vulnerability should be re-conceptualised as endogenous to livelihoods systems in violent settings. Building on the work of others, a livelihoods model adapted for complex humanitarian emergencies is presented.     

The dual imperative in refugee research: some methodological and ethical considerations in social science research on forced migration

Social scientists doing fieldwork in humanitarian situations often face a dual imperative: research should be both academically sound and policy relevant. We argue that much of the current research on forced migration is based on unsound methodology, and that the data and subsequent policy conclusions are often flawed or ethically suspect. This paper identifies some key methodological and ethical problems confronting social scientists studying forced migrants or their hosts. These problems include non-representativeness and bias, issues arising from working in unfamiliar contexts including translation and the use of local researchers, and ethical dilemmas including security and confidentiality issues and whether researchers are doing enough to 'do no harm'. The second part of the paper reviews the authors' own efforts to conduct research on urban refugees in Johannesburg. It concludes that while there is no single 'best practice' for refugee research, refugee studies would advance its academic and policy relevance by more seriously considering methodological and ethical concerns.     

Revisiting Sphere: new standards of service delivery for new trends in protracted displacement

The proportion of people living in protracted displacement, as well as the duration of this displacement, is increasing. International humanitarian standards for services provided in protracted displacement are based on the Sphere Standards, which were formulated using evidence and experience from acute phase emergencies. However, the majority of protracted emergencies are in the post‐emergency phase. This paper discusses trends in displacement, outlines reasons why using the Sphere Standards as minimum standards of service provision in protracted displacement does not adequately meet the needs of these populations, and analyses areas where greater standards of service provision are necessary. An expansion of the evidence base regarding determinants of morbidity and mortality in protracted emergencies is needed. This, followed by a joint approach to designing new, effective standards focused on proactive policies, will allow the humanitarian community more appropriately to serve and enable the millions of people currently living in protracted displacement.     

Ethical Codes in Humanitarian Emergencies: From Practice to Research?

Notable strides have been made in recent years to develop codes of conduct for humanitarian intervention in conflicts on the part of international NGOs and UN organisations. Yet engagement by the academic and broader research communities with humanitarian crises and ongoing complex political emergencies remains relatively ad hoc and unregulated beyond the basic ethical guidelines and norms developed within universities for research in general, and within the governing and representative bodies of particular academic disciplines. This paper draws on a case study of research on humanitarian assistance to Liberia during that country's civil war from 1989 to 1996. The difficulties faced by humanitarian agencies in Liberia led to the development of two key sets of ethical guidelines for humanitarian intervention: the Joint Policy of Operations (JPO) and Principles and Policies of Humanitarian Operations (PPHO). This paper seeks to address what lessons, if any, these ethical guidelines, together with different experiences of conducting research in war-torn Liberia, can provide in terms of the role of academic researchers--and research itself--in humanitarian crises.     

The application of geographic information systems and global positioning systems in humanitarian emergencies: lessons learned,programme implications and future research

Geographic information systems (GIS), global positioning systems and remote sensing have been increasingly used in public health settings since the 1990s, but application of these methods in humanitarian emergencies has been less documented. Recent areas of application of GIS methods in humanitarian emergencies include hazard, vulnerability, and risk assessments; rapid assessment and survey methods; disease distribution and outbreak investigations; planning and implementation of health information systems; data and programme integration; and programme monitoring and evaluation. The main use of GIS in these areas is to provide maps for decision-making and advocacy, which allow overlaying types of information that may not normally be linked. GIS is also used to improve data collection in the field (for example, for rapid health assessments or mortality surveys). Development of GIS methods requires further research. Although GIS methods may save resources and reduce error, initial investment in equipment and capacity building may be substantial. Especially in humanitarian emergencies, equipment and methodologies must be practical and appropriate for field use. Add-on software to process GIS data needs to be developed and modified. As equipment becomes more user-friendly and costs decrease, GIS will become more of a routine tool for humanitarian aid organisations in humanitarian emergencies, and new and innovative uses will evolve.     

Waiting for Peace: Perspectives from Action-oriented Research on the Humanitarian Impasse in the Caucasus

Cease-fires in the Caucasus during the past five years have prevented large-scale life-threatening emergencies and created space for peace negotiations. Yet genuine conflict resolution and normalisation have proven elusive, frustrating the return of uprooted populations and constraining reconstruction. This paper reviews a series of seven strategy sessions held in Moscow and the Caucasus in late 1998 to reflect upon the performance of humanitarian agencies and stimulate greater synergies with diplomatic actors. An experiment in promoting discussion of recently conducted independent policy research throughout the north and south Caucasus, the series resulted in a fresh look at the issues in the region and at agency headquarters. The generic nature of the policy challenges gives the experience potential relevance well beyond the region.     

Estimating the Capacity of Warehouses

The required capacity of warehouses for use in humanitarian emergencies is very often overestimated. This paper reviews some of the principal factors affecting warehouse capacity for emergency humanitarian operations in developing countries. The growing difference between modern commercial warehousing practice and the approach typically used in humanitarian emergencies is highlighted. The principal constraints on capacity are identified and discussed. A simple method for estimating the storage capacity of warehouses for emergency operations is then presented.     

Cross-sectional survey methods to assess retrospectively mortality in humanitarian emergencies

Since the rates and causes of mortality are critical indicators of the overall health of a population, it is important to evaluate mortality even where no complete vital statistics reporting exists. Such settings include humanitarian emergencies. Experience in cross-sectional survey methods to assess retrospectively crude, age-specific, and maternal mortality in stable settings has been gained over the past 40 years, and methods appropriate to humanitarian emergencies have been developed. In humanitarian emergencies, crude and age-specific mortality can be gauged using methods based on the enumeration of individuals resident in randomly selected households—frequently referred to as a household census. Under-five mortality can also be assessed through a modified prior birth history method in which a representative sample of reproductive-aged women are questioned about dates of child births and deaths. Maternal mortality can be appraised via the initial identification of maternal deaths in the study population and a subsequent investigation to determine the cause of each death.     

HIV risk and prevention in emergency-affected populations: a review

While basic guidelines on HIV prevention in emergencies have been available for several years, international agencies involved in the provision of health services have not placed sufficient priority on the prevention of the human immune deficiency virus (HIV) and other sexually transmitted infections (STIs) in complex emergencies. This paper reviews the factors that may increase the risk of HIV transmission in populations affected by complex emergencies and outlines recommendations for research and programmes. Research into the most appropriate methods of carrying out HIV surveillance and interventions in these settings is needed. In the post-emergency phase programmes need to be far more extensive than those offered under the Minimal Initial Services Package (MISP). While the potential for stigmatization represents an important constraint, there is a need to prioritize HIV/STI interventions in order to prevent HIV transmission in emergency-affected populations themselves, as well as to contribute to regional control of the epidemic.     

Doing the Right Thing: Relief Agencies, Moral Dilemmas and Moral Responsibility in Political Emergemcies and War

In recent years a new generation of relief workers and relief agencies has become embroiled in the heat of civil wars and political emergencies, and the humanitarian community has had to revisit its fundamental principles and address the ethics of what it does. This paper sets out to continue this important debate by emphasising that ethical analysis should always be an essential part of humanitarian practice. The paper seeks to recognise the difficult moral choices relief agencies are facing today and gives some practical guidelines to relief agency staff when confronting the ethics of a given situation. In particular, it hopes to introduce some ethical principles into the debate about humanitarianism and contribute to the moral vocabulary which is being developed to improve relief agencies' ethical analysis. The paper starts by looking at the essential characteristics of a moral dilemma, and the way in which other types of tough choice can masquerade as moral dilemmas. It then introduces some basic moral principles surrounding the key ethical notions of action, consequences and moral responsibility in an effort to show how relief agencies might begin to develop a process of ethical analysis in their work. Finally, it explores how relief agencies might develop a more intuitive form of ethical analysis based on an organisational conscience and moral role models.     

The impact of workplace exclusion on the humanitarian response to the refugee crisis in Lebanon

A contemporary issue of major concern is the millions of people fleeing homelands owing to political and socioeconomic challenges and seeking assistance elsewhere throughout the world. An effective response to this crisis includes support models that meet the various needs of refugee populations. In the complex system of humanitarian action, aid workers, among a multiplicity of actors, are the most important assets. This study utilised an inclusion–exclusion theoretical lens to examine the impact of their workplace experiences on activities in the context of the refugee crisis in Lebanon. In-depth interviews were held with 36 humanitarian practitioners, representing five international organisations that are involved in refugee aid programmes in the country. The study led to a new understanding of the link between inclusion and exclusion and the effectiveness of the humanitarian response to emergencies. In addition, it yielded new insights into apprehension about the national–international divide and its consequences for humanitarian assistance.     

The Afghan experiment: the Afghan Support Group, Principled Common Programming and the Strategic Framework

From 1997 to 2001, the international community put in place unique mechanisms to address the challenges to providing humanitarian assistance in Taliban-run Afghanistan. The Afghan Support Group (ASG), Principled Common Programming (PCP) and the Strategic Framework (SF) constituted a precedent-setting experiment that consumed thousands of hours in implementation in donor capitals and in the field. This article, written from the perspective of the leading donor of humanitarian assistance to Afghanistan, assesses the extent to which this Afghan experiment succeeded in increasing coherence on assistance policy issues, improving efficiency in assistance programmes and added synergy between assistance and peace efforts; identifies factors that limited further achievements; suggests how the mechanisms could have been improved; and analyses whether the overall effort politicised humanitarian assistance. The article concludes that the record of achievement was sufficiently promising that the ASG/PCP/SF experiment should be considered for application in other complex humanitarian emergencies.     

The Historical Development of Public Health Responses to Disasters

The first of a series of state-of-the-art reviews commissioned to mark Disasters' 21st anniversary, this paper considers key publications on public health aspects of natural disasters, refugee emergencies and complex humanitarian disasters over the past twenty-odd years. The literature is reviewed and important signposts highlighted showing how the field has developed. This expanding body of epidemiological research has provided a basis for increasingly effective prevention and intervention strategies.     

Between war and peace: humanitarian assistance in violent urban settings

Cities are fast becoming new territories of violence. 1 The humanitarian consequences of many criminally violent urban settings are comparable to those of more traditional wars, yet despite the intensity of the needs, humanitarian aid to such settings is limited. The way in which humanitarian needs are typically defined, fails to address the problems of these contexts, the suffering they produce and the populations affected. Distinctions between formal armed conflicts, regulated by international humanitarian law, and other violent settings, as well as those between emergency and developmental assistance, can lead to the neglect of populations in distress. It can take a lot of time and effort to access vulnerable communities and implement programmes in urban settings, but experience shows that it is possible to provide humanitarian assistance with a significant focus on the direct and indirect health consequences of violence outside a traditional conflict setting. This paper considers the situation of Port‐au‐Prince (Haiti), Rio de Janeiro (Brazil) and Guatemala City (Guatemala).     

Humanitarianism and Local Service Institutions in Angola

The role of local service institutions is not a major focus of current discourse on humanitarianism and complex emergencies. These institutions, in the few places where they are mentioned, are usually presented as either the seed of civil society and future democracy, or as pawns and components of the predatory economic, political and military élites. Few would deny that examples can be found which conform to both of these stereotypes. This simplistic representation of local institutions ignores the perspectives of the actors themselves — the nurses, extension agents, school teachers and others who actually staff most NGO-supported projects. The debate has focused on what ‘we’ should do; the moral dilemmas of aid agencies and their expatriate staff, inevitably leading to the question of whether or not humanitarian workers should stay or leave situations in which aid may be causing more harm than good. Without denying the fundamental importance of these issues, it is important to consider also how the discourse has unfortunately moved away from those humanitarian workers who have no such choice, since they live there. Current concerns about keeping humanitarian aid from feeding local political and military struggles may inadvertently and paradoxically serve to constrain room for man?uvre in the field, particularly among those individuals with the greatest tacit understanding of the predatory environment. There is a need to understand how actors in local service institutions make sense of their own situations, including the factors which frame their moral dilemmas and their day-to-day choices. By analysing the organisational processes within local service institutions, this study is intended to provoke consideration of how these individuals and their institutions may be effectively supported in complex emergencies through a focus on how they themselves deal with danger and complexity. It is suggested that there is a value in considering the lessons learnt in recent years about how service organisations in the North function in turbulent environments. This experience points to the importance of allowing workers the discretion to develop a relationship with their clients, and in so doing make sense of a confusing and ambivalent environment.     

Humanitarian information systems and emergencies in the Greater Horn of Africa: logical components and logical linkages

Natural and man-made emergencies are regular occurrences in the Greater Horn of Africa region. The underlying impoverishment of whole populations is increasing, making it more difficult to distinguish between humanitarian crises triggered by shocks and those resulting from chronic poverty. Shocks and hazards can no longer be seen as one-off events that trigger a one-time response. In countries that are both poor and exposed to frequent episodes of debilitating drought or chronic conflict, information needs tend to be different from the straightforward early warning/commodity accounting models of information systems that have proven reliable in past emergencies. This paper describes the interdependent components of a humanitarian information system appropriate for this kind of complex environment, noting the analytical links between the components and operational links to programme and policy. By examining a series of case studies from the Greater Horn region, the paper demonstrates that systems lacking one or more of these components will fail to provide adequate information--and thus incur humanitarian costs. While information always comes with a cost, the price of poor information--or none--is higher. And in situations of chronic vulnerability, in which development interventions are likely to be interspersed with both safety nets and emergency interventions on a recurrent basis, investment in improved information is a good investment from both a humanitarian and a financial viewpoint.     

Global factors shaping the future of food aid: the implications for WFP

Food aid is a key component of a humanitarian response but its use in other programming contexts is subject to numerous criticisms. Even in humanitarian emergencies food aid is often late, unreliable and out of proportion to other elements of the response. Three major factors will shape the future of food aid. First, mechanisms of food aid governance are being reviewed and may undergo major changes—particularly the Food Aid Convention now that hopes have diminished for an Agreement on Agriculture at the World Trade Organisation. The second significant factor is donor agency trends. Overall levels of food aid have dropped fairly steadily in recent decades and there are several discernible trends in resource allocation, procurement and the use of food aid. The third factor is an emerging body of best practice that will define acceptable standards of food aid programming in the future.     

Challenges in humanitarian information management and exchange: evidence from Haiti

There is a growing recognition of the critical role information management can play in shaping effective humanitarian response, coordination and decision‐making. Quality information, reaching more humanitarian actors, will result in better coordination and better decision‐making, thus improving the response to beneficiaries as well as accountability to donors. The humanitarian response to the 2010 Haiti earthquake marked a watershed moment for humanitarian information management. Yet the fragmented nature of the response and the use of hierarchical models of information management, along with other factors, have led some observers to label the Haiti response a failure. Using an analytical framework often found in humanitarian emergencies, this study analyses challenges to information flow in the Haiti case and the implications for effective humanitarian response. It concludes by offering possible paths for overcoming such challenges, and for restoring the value and utility of humanitarian information management and exchange in humanitarian relief settings.