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.     

Normalising the Crisis in Africa

Developmental relief has become the central doctrine of 'good practice' in humanitarian responses to complex political emergencies. This is despite the fact that a proliferation of such emergencies reflects a failure of development for people in those countries in crisis. Drawing on case study material from Sudan, Somalia, Rwanda and Uganda, this paper challenges assumptions made about the efficacy of developmental relief models in complex emergencies. The trend towards developmental relief practices coincides with an increasing acceptance of higher levels of humanitarian distress in Africa. Myths of aid dependency and the pursuit of sustainable programming in the midst of war are linked to a global reduction in aid. The mantra of 'local solutions to local problems' locates the causes of crises firmly within those societies in crisis. It provides a premise for international disengagement, and the denial of international responsibility for the genesis and prolongation of humanitarian crises in Africa. Assigning solutions to the poor, the marginalised and victimised through enhanced 'participation' and local financing of services sustains a myth that development is occurring, when in fact levels of distress are rising.     

Media messages and the needs of infants and young children after Cyclone Nargis and the WenChuan Earthquake

Infants and young children are vulnerable in emergencies. The media plays an important role in aid delivery and has a positive impact when reports are accurate. However, the media has been implicated in encouraging harmful aid in the form of donations of infant formula and other milk products. Internet‐based media reports were collected after Cyclone Nargis in Myanmar and the WenChuan Earthquake in China (2008) and examined for content related to infant and young child feeding. Common messages identified included that: babies are vulnerable; stress prevents breastfeeding; and providing infant formula saves lives. Messages rarely reported included that: artificial feeding is dangerous; and breastfeeding protects infants. This analysis suggests that current patterns of media reporting may encourage harmful aid and increase child morbidity and mortality. Aid organisations should encourage the media to report accurately on the needs of infant and young children in emergencies so as to improve aid delivery.     

Matching response to context in complex political emergencies: 'relief', 'development', 'peace-building' or something in-between?

There is an ongoing debate over the value and pitfalls of the policy and practice of 'linking relief and development' or 'developmental relief' in aid responses to complex political emergencies (CPEs). Driven by concerns about relief creating dependence, sometimes doing harm and failing to address root causes of emergencies despite its high cost, pursuit of both relief and development has become a dominant paradigm among international aid agencies in CPEs as in 'natural' disasters. In CPEs a third objective of 'peace-building' has emerged, along with the logic that development can itself help prevent or resolve conflict and sustain peace. However, this broadening of relief objectives in ongoing CPEs has recently been criticised on a number of counts, central concerns being that it leads to a dilution of commitment to core humanitarian principles and is overly optimistic. This paper addresses these issues in the light of two of the CPEs studied by the COPE project: Eritrea and Somalia/Somaliland. It is argued that the debate has so far suffered from lack of clarity about what we mean by 'relief', 'development' and, for that matter, 'rehabilitation' and 'peace-building'. The wide spectrum of possible aid outcomes does not divide neatly into these categories. The relief-development divide is not always as clear-cut, technically or politically, as the critics claim. Moreover such distinctions, constructed from the point of view of aid programmers, are often of little relevance to the concerns of intended beneficiaries. Second, there has been insufficient attention to context: rather than attempting to generalise within and across CPE cases, a more productive approach would be to examine more closely the conditions under which forms of aid other than basic life support can fruitfully be pursued. This leads to consideration of collective agency capacity to respond effectively to diverse needs in different and changing circumstances.     

Conflict, the Continuum and Chronic Emergencies: A Critical Analysis of the Scope for Linking Relief, Rehabilitation and Development Planning in Sudan

The concept of the ‘relief-to-development continuum’ has been the subject of renewed interest in recent years. Concerned by the rise in relief budgets over the past decade and the absolute fall in development aid resources, support has been growing for the concept of developmental relief. In the context of complex political emergencies, it has been argued further that as effective development aid can reduce vulnerability to the impact of natural hazards, so it might also be used to contribute to a process of conflict prevention. In this way, the concept of the relief-development continuum has become entwined with broader discussions about the contribution of official development assistance to conflict management. Drawing on a Review of Operation Lifeline Sudan (OLS), this paper cautions against uncritical application of the concept of the continuum in complex political emergencies, and of rehabilitation in particular, in the current Sudanese context. It argues that in order to move legitimately from relief aid programming to development aid programming, three fundamental conditions must be in place: first, a minimum level of security, respect for human rights and humanitarian access. Second, empirical evidence from the field needs to demonstrate that the emergency is over. Finally, moving from relief to development aid programming is contingent on donor governments accepting the legitimacy of national governmental structures and of the rebel movements. In other words, for donor governments, moving along the continuum is in significant part determined by foreign policy considerations, not only technical ones. Consideration needs to be given to the actual and perceived legitimation of the different movements that a move to rehabilitation might be seen to imply. The paper argues that none of these conditions had been satisfied in Sudan by mid-1997. Instead of a process of normalisation paving the way to long-term development, the current situation in Sudan is better described as a chronic political emergency. In such a context, uncritical pursuit of developmental strategies may negatively affect the welfare of conflict-affected populations.     

Political drivers of epidemic response: foreign healthcare workers and the 2014 Ebola outbreak

This study demonstrates that countries responded quite differently to calls for healthcare workers (HCWs) during the Ebola epidemic in West Africa in 2014. Using a new dataset on the scale and timing of national pledges and the deployment of HCWs to states experiencing outbreaks of the virus disease (principally, Guinea, Liberia, and Sierra Leone), it shows that few foreign nations deployed HCWs early, some made pledges but then fulfilled them slowly, and most sent no HCWs at all. To aid understanding of such national responses, the paper reviews five theoretical perspectives that offer potentially competing or complementary explanations of foreign government medical assistance for international public health emergencies. The study systematically validates that countries varied greatly in whether and when they addressed HCW deployment needs during the Ebola crisis of 2014, and offers suggestions for a theory‐driven inquiry to elucidate the logics of foreign interventions in critical infectious disease epidemics.     

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.     

Looking forward: Disasters at 40

This paper reflects on contemporary studies of and responses to disasters, highlighting the importance of historical, spatial, and intersectional modes of analysis, and draws on the author's ongoing research on Southern‐led and local community responses to displacement in the Middle East. Acknowledging the plurality of ‘international communities of response’, it begins by critiquing the depiction of selected responses to disasters as ‘positive’ ‘paradigm shifts’, including in reference to the ‘localisation of aid, and the United Nations’ Regional Refugee and Resilience Plan for Syria. Next it turns to three key themes that are central to disasters studies: migration; forced displacement; and Southern‐led responses to disasters. Among other things, the paper argues that exploring the principles and modalities of South–South cooperation, rather than promoting the incorporation of Southern actors into the ‘international humanitarian system’ via the localisation agenda, presents a critical opportunity for studies of and responses to disasters.     

The ethical contours of research in crisis settings: five practical considerations for academic institutional review boards and researchers

The number of research studies in the humanitarian field is rising. It is imperative, therefore, that institutional review boards (IRBs) consider carefully the additional risks present in crisis contexts to ensure that the highest ethical standards are upheld. Ethical guidelines should represent better the specific issues inherent to research among populations grappling with armed conflict, disasters triggered by natural hazards, or health‐related emergencies. This paper seeks to describe five issues particular to humanitarian settings that IRBs should deliberate and on which they should provide recommendations to overcome associated challenges: staged reviews of protocols in acute emergencies; flexible reviews of modification requests; addressing violence and the traumatic experiences of participants; difficulties in attaining meaningful informed consent among populations dependent on aid; and ensuring reviews are knowledgeable of populations' needs. Considering these matters when reviewing protocols will yield more ethically sound research in humanitarian settings and hold researchers accountable to appropriate ethical standards.     

Embedded wisdom or rooted problems? Aid workers' perspectives on local social and political infrastructure in post‐tsunami Aceh

This paper analyses the role of local social, cultural, and political institutions in post‐disaster reconstruction projects. It contends that such institutions are important considerations within community‐driven reconstruction initiatives, but are often viewed with ambivalence by external aid organisations. This paper draws upon in‐depth qualitative interviews with aid workers involved in the post‐tsunami reconstruction in Aceh, Indonesia, to establish: (i) what roles community institutions were suited to play in the reconstruction; (ii) what were the limitations of community institutions when engaging with external aid agencies; (iii) how did external aid agencies engage with local community institutions; and (iv) how did external aid agencies perceive community institutions.     

Formal and informal material aid following the 2010 Haiti earthquake as reported by camp dwellers

Following the 2010 Haiti earthquake, more than two million people moved to temporary camps, most of which arose spontaneously in the days after the earthquake. This study focuses on the material assistance people in five Port‐au‐Prince camps reported receiving, noting the differences between assistance from formal aid agencies and from ‘informal’ sources such as family. Seven weeks after the earthquake, 32% of camp dwellers reported receiving no assistance whatsoever; 55% had received formal aid, typically a tent or tarpaulins; and 40% had received informal aid, usually in the form of cash transfers from family living abroad. While people were grateful for any material aid, cash was more frequently considered timely and more effective than aid‐in‐kind. Should this study be indicative of the greater displaced population, aid agencies should consider how they might make better use of cash transfers as an aid modality.     

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.     

Culture,local capacity,and outside aid: a community perspective on disaster response after the 2009 tsunami in American Sāmoa

Research on diverse cultural contexts has indicated that aid organisations often fail to leverage local, culturally‐grounded resources and capacities in disaster‐affected communities. Case‐study methodology was employed to explore the relationship between local and external disaster response efforts in American Sāmoa following the earthquake and tsunami on 29 September 2009 in the southern Pacific Ocean, with a specific focus on the role of culture in defining that relationship. Interview and focus group data from 37 participants, along with observational data, suggested that the local response to the event was swift and grounded in Samoan cultural systems and norms. External aid was viewed as helpful in some respects, although, on the whole, it was seen as a disruption to village hierarchies, social networks, and local response efforts. The study discusses the implications for the role of outside aid in diverse cultural contexts, and makes suggestions for improving the ecological fit of post‐disaster interventions.     

Implementation of a medical command and control team in Switzerland

In case of a major incident or disaster, the advance medical rescue command needs to manage several essential tasks simultaneously. These include the rapid deployment of ambulance, police, fire and evacuation services, and their coordinated activity, as well as triage and emergency medical care on site. The structure of such a medical rescue command is crucial for the successful outcome of medical evacuation at major incidents. However, little data has been published on the nature and structure of the command itself. This study presents a flexible approach to command structure, with two command heads: one emergency physician and one experienced paramedic. This approach is especially suitable for Switzerland, whose federal system allows for different structures in each canton. This article examines the development of these structures and their efficiency, adaptability and limitations with respect to major incident response in the French‐speaking part of the country.     

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.     

Displacement as a predictor of functional impairment in tsunami‐exposed children

Thirty months after the Indian Ocean tsunami of 26 December 2004, thousands of families in Aceh Province, Indonesia, remained in temporary barracks while sanitation conditions and non‐governmental organisation support deteriorated. This study sought to determine the factors associated with functional impairment in a sample of 138 displaced and non‐displaced Acehnese children. Using multivariate linear regression models, it was found that displacement distance was a consistent predictor of impairment using the Brief Impairment Scale. Exposure to tsunami‐related trauma markers was not significantly linked with impairment in the model. Paternal employment was a consistent protective factor for child functioning. These findings suggest that post‐disaster displacement and the subsequent familial economic disruption are significant predictors of impaired functioning in children's daily activities. Post‐disaster interventions should consider the disruption of familiar environments for families and children when relocating vulnerable populations to avoid deleterious impacts on children's functioning.     

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.     

Putting houses in place:1 rebuilding communities in post‐tsunami Sri Lanka

This paper interrogates the social and political geographies of resettlement and reconstruction of temporary and permanent shelters, which are fundamental to rebuilding tsunami‐affected communities. War and ethnic cleavages are an endemic feature of Sri Lanka's social polity, and uneven development processes in the country are clearly visible. This paper draws attention to these spaces of inequality by drawing on in‐depth interviews and participant observation carried out in Eastern and Southern Sri Lanka. It argues that communities' concerns and anxieties regarding displacement and resettlement have tended to be articulated against prevailing fault lines of war and inequality. This is the backdrop against which communities negotiated the recovery process. My fieldwork shows that it is critical to understand that disaster and development relief are ingrained within context specificities. Relief efforts therefore need to recognise that the process of ‘putting houses in place’ should be embedded within local social relations.     

Apples, Pears and Porridge: The Origins and Impact of the Search for 'Coherence' between Humanitarian and Political Responses to Chronic Political Emergencies

During the 1990s a consensus emerged within the international humanitarian system that there was a need to enhance the 'coherence' between humanitarian and political responses to complex political emergencies. Closer integration between aid and political responses was seen to be necessary in order to address the root causes of conflict-induced crises, and to ensure that aid did not exacerbate political tensions. This paper explores the theory and practice of coherence over the past decade. It argues that, by sleight of hand, the coherence agenda has been reinterpreted such that humanitarian action has become the primary form of political action, rather than merely a substitute for it. The coherence agenda has been driven by geopolitical events, domestic policy considerations in donor countries and the more parochial concerns of aid policy, and is reflected in a number of substantive changes in the humanitarian architecture. Many of the tenets of this 'new humanitarianism' have been embraced by the majority of relief agencies, and thus legitimised it. The paper concludes that political humanitarianism, as opposed to active engagement by political and military actors, is flawed ethically and technically. It will provide neither an effective palliative for the ill effects of war, nor address its causes.