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.     

Changes in HIV/AIDS/STI knowledge, attitudes and practices among commercial sex workers and military forces in Port Loko, Sierra Leone

Sierra Leone suffered from 11 years of civil war (1991-2002) resulting in tens of thousands of deaths and mutilations together with massive population displacement. In 2001, ARC International, Sierra Leone conducted a baseline survey of 201 commercial sex workers (CSWs) and 202 military respondents on the knowledge, attitudes and practices surrounding HIV/AIDS and STIs in Port Loko, Sierra Leone. In 2003, a comparable post-intervention survey of 202 CSWs and 205 military respondents was performed. Comparison of baseline and post-intervention results showed that HIV/AIDS knowledge increased among both groups, with those able to name three effective means of avoiding AIDS increasing from 5 per cent to 70 per cent among CSWs, and 11 to 75 per cent among the military. Reported condom use during last sex increased among CSWs from 38 to 68 per cent and among military from 39 to 68 per cent. These results demonstrate that, despite the challenges inherent in a post-conflict country, good-quality AIDS-prevention programmes can be effective.     

Human immuno-deficiency virus and infant feeding in complex humanitarian emergencies: priorities and policy considerations

Issues surrounding mother-to-child transmission of HIV/AIDS pose considerable challenges in complex humanitarian emergencies. The risk of vertical transmission through breastfeeding is well recognised, but safe alternatives are limited by the social, economic and environmental conditions of emergency situations. In 2000, the World Health Organisation published a technical report on behalf of the UNFPA/UNICEF/WHO/UNAIDS Inter-agency Task Team on Mother-to-child Transmission of HIV which outlined revised recommendations for infant feeding by HIV-positive women. This paper outlines reasons why these recommendations may be insufficient during the initial stages of complex humanitarian emergencies and proposes recommendations for establishing infant-feeding policy. Methods of mother-to-child transmission of HIV are reviewed and recent research findings are discussed. Rationale for modifying the 2000 UNFPA/UNICEF/WHO/UNAIDS infant-feeding recommendations in complex emergency situations is explored from the perspective of the infant, the mother and humanitarian field staff. Ethical limitations and future priorities are considered. The paper concludes with recommendations and a policy decision-making framework for consideration during the initial stages of humanitarian crises.     

Substance use among populations displaced by conflict: a literature review

This paper reviews the literature on substance use among populations displaced by conflict. Of the 17 publications presenting primary data retained for review, all consider populations in or recovering from protracted conflict, the majority (10) in non-camp settings. Most studies (10) offer prevalence estimates, suggesting that substance use (such as of alcohol, opiates, or minor tranquilizers) is common in some displaced settings. Five describe harmful consequences of substance use among displaced populations (such as HIV transmission, tuberculosis treatment failure, gender-based violence, and economic problems). Three studies suggest risk factors for substance use problems (such as gender, trauma-related conditions, pre-displacement substance use, and socio-economic factors); two examine qualitatively the gendered nature of alcohol-related harm and its links with gender-based violence. One study examines an intervention. The evidence base is weak. Findings are used to develop a conceptual framework emphasizing the risk environment to inform further research, to encourage debate among researchers and practitioners, and to enable the development of interventions.     

Planning STI/HIV prevention among refugees and mobile populations: situation assessment of Sudanese refugees

This article reflects an investigation of knowledge, attitudes and behaviours and HIV/STI prevalence of Sudanese refugees and Ethiopian sex workers in 1992. It represents one of the earliest such investigations within an African refugee population. The investigation took place in the Dimma refugee settlement in south-western Ethiopia and study participants included Sudanese refugee men and women and Ethiopian female sex workers. Methods used for this investigation included focus group discussions, behavioural surveys and serologic testing. The main outcome measures of the investigation were HIV/STI knowledge, attitudes and behaviours and biological markers for HIV, syphilis and herpes simplex 2. The study findings indicate that in the early 1990s, knowledge about AIDS and condom use was low among Sudanese refugee women and not one reported having ever used a condom. Furthermore, sexual contact between refugee men and sex workers was frequent during the time of this study and the prevalence of HIV and other STIs was high. The results confirm a widely held assumption that highly mobile and transient populations in Africa are susceptible to STIs and HIV, in large part due to their knowledge, attitudes and behaviours.     

Children's Experience of Conflict Related Emergencies: Some Implications for Relief Policy and Practice

This paper challenges the limited models of childhood, conflict and relief which determine most humanitarian interventions targeting children in conflict related emergencies. In particular, it notes the tendency of relief programmes to focus on "spectacular" groups of children (orphans, child combatants and refugees) at the expense of larger child populations indirectly affected by conflict. This relief bias is attributed to an inappropriate 'apocalypse model' of conflict which sees relief interventions only as repair. The bias also lies in a mistakenly universalist model of childhood and a medical paradigm which pathologizes children's experience in conflict and characterizes children as passive victims rather than active survivors. The paper argues for greater recognition of the wider social experience of children in conflict, and for relief practice which takes account of childhood resilience and children's different roles and capacities in coping with conflict. Appropriate interventions must engage with the wide variety of indigenous coping mechanisms involving children and not simply replicate a standard package of relief interventions in every emergency, based on simplistic and universalist interpretations of children's experience of conflict.     

台风等重大灾害性事件的风险认知及预警机制

通过调查受灾民众及未受灾民众对台风等重大灾害性事件的风险认知及预警情况,比较两者的差异,为政府对重大灾害性事件建立预警管理模式提供依据。研究结果表明:①受灾民众和未受灾民众对重大灾害性事件的风险认知水平低,受灾民众对台风的风险认知明显高于未受灾民众(P<0.01);②两者对提升防灾意识的意愿强烈但对防灾资讯关心程度不够,且受灾民众明显更关心防灾资讯(P<0.01);③两者在通过某项预防措施可以避免灾害所造成的损失和撤离危险地区的问题上意见基本一致,但未受灾民众对政府辅助撤离更具有依赖性(P<0.01,P<0.05);④受灾民众比未受灾民众更相信科学家对灾害的预警能力(P<0.01),但均对目前的灾害预警系统满意度一般。     

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).     

Women at risk: gender and AIDS in Africa

AIDS in Africa is a gender, development and rights issue involving power and differential access to resources. The risk situations for women in stressed development contexts of war, destabilisation and displacement, and the many contexts of transactional sex, are poorly understood by policy makers and the medical community. The dominant epidemiological paradigm has focused on female 'prostitutes' in a number of African cities. The limitations of this approach are discussed, as are the different contextualised meanings of sexual exchange. The importance of women's experience of sexually transmitted diseases and HIV and their perceptions of risk are stressed, as is the need for non-judgmental services linked to primary and comprehensive health care, and for sensitive, qualitative research. It is argued that all women who engage in unprotected penetrative sex are at risk. Most health promotion messages, however, construct an image of women as prostitutes ('Avoid prostitutes') or seek to mobilise women as carers and educators of families and communities.     

Coping strategies developed as a result of social structure and conflict: Kosovo in the 1990s

The end of 1989 brought with it political and economic decisions which resulted in Kosovo being stripped of its autonomy and the Albanian population being expelled from their jobs. These facts combined with ethnic tensions created a decade of conflict and oppression affecting hundreds of thousands of innocent civilians. Thousands of Kosovars moved overseas to seek work to support families at home, altering the way of life of the population of Kosovo irredeemably. The loss of income had serious repercussions on food security throughout the 1990s; possibilities of purchasing food were diminished, control on goods in 1998 reduced availability of foodstuffs, conflict affected accessibility to markets and shops and consequently food intake and nutritional status was compromised. The most vulnerable were those who had no family members overseas. Mass displacement of population due to ethnic cleansing during the war of spring 1999, further jeopardised food security status. Destruction at this time rendered large parts of Kosovo useless and resulted in a shift in the determinant of vulnerability in the post-war period: destruction of houses, land, livestock and agricultural products as well as loss of family members, became a far more pertinent indicator of food insecurity. The strong and clear links between conflict, socio-economic issues and food security are highlighted and discussed in this paper.     

Internal displacement in Burma

The internal displacement of populations in Burma is not a new phenomenon. Displacement is caused by numerous factors. Not all of it is due to outright violence, but much is a consequence of misguided social and economic development initiatives. Efforts to consolidate the state by assimilating populations in government-controlled areas by military authorities on the one hand, while brokering cease-fires with non-state actors on the other, has uprooted civilian populations throughout the country. Very few areas in which internally displaced persons (IDPs) are found are not facing social turmoil within a climate of impunity. Humanitarian access to IDP populations remains extremely problematic. While relatively little information has been collected, assistance has been focused on targeting accessible groups. International concern within Burma has couched the problems of displacement within general development modalities, while international attention along its borders has sought to contain displacement. With the exception of several recent initiatives, few approaches have gone beyond assistance and engaged in the prevention or protection of the displaced.     

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.     

The health sector gap in the southern Africa crisis in 2002/2003

The southern Africa crisis represents the first widespread emergency in a region with a mature HIV/AIDS epidemic. It provides a steep learning curve for the international humanitarian system in understanding and responding to the complex interactions between the epidemic and the causes and the effects of this crisis. It also provoked much debate about the severity and causes of this emergency, and the appropriateness of the response by the humanitarian community. The authors argue that the over-emphasis on food aid delivery occurred at the expense of other public health interventions, particularly preventative and curative health services. Health service needs were not sufficiently addressed despite the early recognition that ill-health related to HIV/AIDS was a major vulnerability factor. This neglect occurred because analytical frameworks were too narrowly focused on food security, and large-scale support to health service delivery was seen as a long-term developmental issue that could not easily be dealt with by short-term humanitarian action. Furthermore, there were insufficient countrywide data on acute malnutrition, mortality rates and performance of the public health system to make better-balanced evidence-based decisions. In this crisis, humanitarian organisations providing health services could not assume their traditional roles of short-term assistance in a limited geographical area until the governing authorities resume their responsibilities. However, relegating health service delivery as a long-term developmental issue is not acceptable. Improved multisectoral analytical frameworks that include a multidisciplinary team are needed to ensure all aspects of public health are dealt with in similar future emergencies. Humanitarian organisations must advocate for improved delivery and access to health services in this region. They can target limited geographical areas with high mortality and acute malnutrition rates to deliver their services. Finally, to address the underlying problem of the health sector gap, a long-term strategy to ensure improved and sustainable health sector performance can only be accomplished with truly adequate resources. This will require renewed efforts on part of governments, donors and the international community. Public health interventions, complementing those addressing food insecurity, were and are still needed to reduce the impact of the crisis, and to allow people to re-establish their livelihoods. These will increase the population's resilience to prevent or mitigate future disasters.     

Changing tracks as situations change: humanitarian and health response along the Liberia–Côte d'Ivoire border

In recent years, protracted crises and fragile post‐conflict settings have challenged the co‐existence, and even the linear continuum, of relief and development aid. Forced migration has tested humanitarian and development paradigms where sudden‐onset emergencies, violence and displacement arise alongside ongoing development work. Drawing on Médecins Sans Frontières interventions in the region from December 2010 to May 2011, this paper examines aid and healthcare responses to displacement in Côte d'Ivoire and Liberia; it focuses on challenges to the maintenance of preparedness for such foreseeable emergencies and to adaptation in response to changing situations of displacement and insecurity. This ‘backsliding’ from development to emergency remains a substantial challenge to aid; yet, in exactly such cases, it also presents the opportunity to ensure access to medical care that is much more urgently needed in times of crisis, including the suspension of user fees for medical care.     

Mortality,violence and lack of access to healthcare in the Democratic Republic of Congo

The people of the Democratic Republic of Congo for decades have been living in a situation of chronic crisis. Violence, population displacement and the destruction of infrastructure and health services have devastated the health of the population. In 2001, Médicins Sans Frontières conducted a survey in five areas of western and central DRC to assess mortality, access to health-care, vaccination coverage and exposure to violence. High mortality rates were found in front-line zones, mainly due to malnutrition and infectious diseases. In Basankusu approximately 10 per cent of the total population and 25 per cent of the under-five population had perished in the year before the survey. Humanitarian needs remain acute across the country, particularly near the front line. Infectious-disease control and treatment are a priority, as is increasing access to health-care. Humanitarian assistance must be increased considerably, especially in rural areas and zones that have been affected directly by conflict.     

Rights,Standards and Quality in a Complex Humanitarian Space: Is Sphere the Right Tool?

The Sphere Project (consisting of both the Humanitarian Charter and Minimum Standards for Disaster Response) has made prominent contributions to the debates, thinking and work on the quality of assistance and accountability of aid agencies. However, since its inception in 1997, several agencies expressed concerns regarding Sphere's approach, many of which were confirmed by the Sphere evaluation (2002/3). The present article restates these concerns, and addresses more fundamental issues regarding Sphere's cornerstone. It questions the validity of Sphere's rights-based approach, which consists of a tenuous link between the rights of affected populations and standards for technical interventions. Sphere is founded on "the right to assistance", although this right does not exist in international law. Its elaboration would entail solving several complex legal and political issues, which Sphere fails to address. This article also questions the validity and usefulness of universal standards for technical performance in helping relief agencies provide adapted assistance to disaster-affected populations, in line with their mandates and principles. It suggests that Sphere's approach and content largely reflect the concerns, priorities and values of technical professionals in Northern agencies, leaving limited space to genuine "participation" by affected populations and partners from the South.     

Citizen feedback in a fragile setting: social accountability interventions in the primary healthcare sector in Sierra Leone

Fragile and conflict‐affected states are frequently characterised by their inability to fulfil three core governance functions: provision of security, effective delivery of basic public goods and services, and managing political participation and accountability. This article explores the utility of social accountability interventions in fragile environments. Successful social accountability interventions can lead to joint examinations of public service standards by service‐users and providers, resulting in collaborative improvement efforts. The few available studies of such interventions implemented in fragile or conflict‐affected states show reasons for optimism as well as challenges. This article advocates the continued use of social accountability methods in fragile settings and provides examples of social accountability interventions in the health sector in Sierra Leone. The study suggests that social accountability can improve interaction between citizens and public service providers. Successful social accountability interventions can also lead to better quality and more accessible public services, which, in turn, can enhance state legitimacy.     

Providing health services during a civil war: the experience of a garrison town in South Sudan

The impact of conflict, particularly conflict arising during civil wars, on the provision of healthcare is a subject that has not been widely considered in conflict‐related research. Combatants often target health services to weaken or to defeat the enemy, while attempts to maintain or improve health systems also can comprise part of counter‐insurgency ‘hearts‐and‐minds’ strategies. This paper describes the dynamics associated with the provision of health services in Malakal, an important garrison town in South Sudan, during the second Sudanese civil war (1983–2005). Drawing on the concepts of opportunity hoarding and exploitation, it explores the social and political dynamics of service provision in and around the town during the war. These concepts provide a useful lens with which to understand better how health services are affected by conflict, while the empirical case study presented in the paper illustrates dynamics that may be repeated in other contexts. The concepts and case study set out in this paper should prove useful to healthcare providers working in conflict zones, including humanitarian aid agencies and their employees, increasing their understanding of the social and political dynamics that they are likely to face during future conflict‐related complex emergencies.     

Two solitudes: post‐tsunami and post‐conflict Aceh

In August 2005, after the devastating tsunami in the Indian Ocean Basin, a Memorandum of Understanding (MoU) for the cessation of hostilities was signed by Aceh's longstanding adversaries—the Government of Indonesia and the Free Aceh Movement (GAM). The tsunami was a major catalyst for ‘disaster diplomacy’—international political pressure, which, this paper argues, was an important ingredient in creating conditions for the MoU, although the situation within Aceh also shaped the peace process. Based on interviews conducted in 2006 and 2007 with government officials, GAM representatives and fighters, and non‐governmental organization staff in Aceh, this paper finds that assistance for tsunami survivors far exceeds that available for conflict survivors and ex‐combatants. The formation of these two solitudes—the tsunami‐affected and the conflict‐affected—compounds challenges for sustaining peace in Aceh. This research points to an enduring lack of livelihoods for former fighters and conflict victims that may threaten a sustainable peace.     

Women, Health and Humanitarian Aid in Conflict

The burden of political conflict on civilian populations has increased significantly over the last few decades. Increasingly, the provision of resources and services to these populations is coming under scrutiny; we highlight here the limited attention to gender in their provision. Women and men have different exposures to situations that affect health and access to health-care and have differential power to influence decisions regarding the provision of health services. We argue that the role of women in planning is central to the provision of effective, efficient and sensitive health-care to conflict-affected populations.