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.     

The use of cluster sampling to determine aid needs in Grozny, Chechnya in 1995

War broke out in Chechnya in November 1994 following a three-year economic blockade. It caused widespread destruction in the capital Grozny. In April 1995 Medical Relief International--or Merlin, a British medical non-governmental organisation (NGO)--began a programme to provide medical supplies, support health centres, control communicable disease and promote preventive health-care in Grozny. In July 1995 the agency undertook a city-wide needs assessment using a modification of the cluster sampling technique developed by the Expanded Programme on Immunisation. This showed that most people had enough drinking-water, food and fuel but that provision of medical care was inadequate. The survey allowed Merlin to redirect resources earmarked for a clean water programme towards health education and improving primary health-care services. It also showed that rapid assessment by a statistically satisfactory method is both possible and useful in such a situation.     

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.     

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.     

Dignity and the right of internally displaced adolescents in Colombia to sexual and reproductive health

In Colombia, national policies and laws on the protection of vulnerable populations pay specific attention to the sexual and reproductive health needs and rights of internally displaced adolescents. This paper describes how a United Nations Population Fund (UNFPA)-supported programme (September 2000-August 2004) on the sexual and reproductive health of internally displaced adolescents contributed to restoring their dignity as a precursor to promoting their sexual and reproductive health rights. Different forms of the arts were used as basic techniques to discover their body and to provide sexual and reproductive health information and education. The arts were found to play a key role in restoring their dignity. Although dignity appeared to be a determinant of greater awareness of rights, it did not lead to increased empowerment with regard to rights. The availability of and access to sexual and reproductive health services remains a problem and displaced populations continue to have little or no power to hold their authorities accountable.     

An adaptive governance approach to disaster-related behavioural health services

This paper explores the provision of disaster-related behavioural and mental health (DBH) services as a problem of institutional collective action in the United States. This study reviews the challenges that providers have in surmounting multi-organizational disconnects, unstable professional legitimacy, ambiguous information, and shifting disaster needs in developing a system for delivering DBH services. Based on the adaptive governance framework, it argues that existing protocols such as the National Incident Management System (NIMS) and Incident Command System (ICS) may be helpful in advancing collective action, but that real progress will depend on a recognition of norms, expectations, and credentials across many spheres-in other words, on the ability of responders to continuously adjust their procedures and administrative boundaries for behavioural health institutions.     

The impact of refugees on the health status and health services of host communities: Compounding bad with worse?

Although there have been a number of recent developments in our understanding of refugee health problems that have influenced policies and action, the effects of refugees on the health status and services of host communities remain relatively neglected. This article sets out to explain why this is an important issue with implications for policy, planning surveillance and evaluation, training and research.
The first sections outline some of the problems facing host governments and communities in Africa and discuss the changing rhetoric between the first and second International Conferences for Assistance to Refugees in Africa. A number of possible ways in which refugees could affect the individual, agent and environmental causes of disease are considered, as are the characteristics of the refugees, the host communities and the response which may all modify this impact.
Policy implications of the impact of the refugees, both negative and positive, are discussed, and detailed consideration is given to the pros and cons of integrated and parallel approaches to health care provision. The need to monitor carefully the health status and services of host communities is emphasized and recommendations are made for this and other essential developments relating to training and research.     

Workplace response of companies exposed to the 9/11 World Trade Center attack: a focus‐group study

The terrorist attacks of 11 September 2001 (9/11) left workplaces in pressing need of a mental health response capability. Unaddressed emotional sequelae may be devastating to the productivity and economic stability of a company's workforce. In the second year after the attacks, 85 employees of five highly affected agencies participated in 12 focus groups to discuss workplace mental health issues. Managers felt ill prepared to manage the magnitude and the intensity of employees' emotional responses. Rapid return to work, provision of workplace mental health services, and peer support were viewed as contributory to emotional recovery. Formal mental health services provided were perceived as insufficient. Drawing on their post‐9/11 workplace experience, members of these groups identified practical measures that they found helpful in promoting healing outside of professional mental health services. These measures, consistent with many principles of psychological first aid, may be applied by workplace leaders who are not mental health professionals.     

Mental health in South Sudan: a case for community‐based support

This paper² provides a snapshot of the mental health situation in South Sudan between 2013 and 2016, taking account of the personal reflections of both authors who were engaged in mental health and psychosocial support (MHPSS)³ programming in the country at this time.⁴ It begins by presenting an overview of MHPSS activities from this period, including governmental and non‐governmental organisation (NGO) services, and relevant research and coordination mechanisms. It goes on to illustrate the challenges to the provision of support, as well as the overarching structural, governance, and human resource constraints faced by the sector. Finally, recommendations are put forward for improving services and care for people suffering from psychosocial and mental health issues, as well as suggestions for areas of focus in the future. The importance of an integrated, community‐based model is emphasised, and opportunities for organisations engaged in reconciliation efforts and mental health service provision to collaborate are proposed.     

Privatisation and outsourcing in wartime: the humanitarian challenges

The tendency today to privatise many activities hitherto considered the exclusive preserve of the state has given rise to sharp debate. The specific nature of humanitarian emergencies elucidates in particularly stark contrast some of the main challenges connected to the privatisation and outsourcing of essential public services, such as the provision of drinking water and health care. Privatising the realms of defence and security, which are at the very core of state prerogative, raises several legal and humanitarian concerns. This article focuses on the roles and responsibilities of the various parties involved in armed conflicts, especially those of private companies engaged in security, intelligence and interrogation work, and in the provision of water supply and health services. It highlights the need for humanitarian and development actors to grasp better the potential risks and opportunities related to privatisation and outsourcing with a view to supplying effective protection and assistance to communities affected by war.     

From concept to practice: the long road to operationalising protection

For the past two decades, humanitarian actors have been grappling increasingly with the complex issue of protecting civilians. The definition of protection adopted by humanitarians is considered to be too broad to provide effective operational direction. This paper aims to contribute to recent initiatives to operationalise protection. Teasing out a broad typology of humanitarian protection through an examination of the scope, objectives, and strategies of a range of humanitarian actors, it suggests, would result in better identification of gaps and the channelling of efforts to support a system‐wide protection response. Emphasising recent calls for collective analysis as a means of eventuating protection, the paper also draws attention to the contested understanding that may arise concerning solutions to protection crises. Closely entwined with politics, protection defies neat technical solutions. The paper concludes that deepening knowledge of how communities conceive their own interests may provide the basis for a collective protection response.     

A comparison of health provision and status in ban napho refugee cAMP and nakhon phanom province, northeastern Thailand

Health care provision and health status in Ban Napho Refugee Camp is compared with that of the surrounding Nakhon Phanom Province for the year 1988. Records for the period 1984–88 were also examined to compare trends in health status. Personal experience of health services in the Camp and visits made to local schools and health facilities were also used in the comparison. Although direct comparison was difficult (because of the mobile nature of the camp population and problems to do with the interpretation of statistics), it was found that health care for refugees was more comprehensive, at a primary level, than for the Thai population of the surrounding Province. Access to primary health care facilities in the Camp was, moreover, easier and free of charge. This may explain the higher use of health facilities in the Camp but, despite this, health and nutritional status appeared to be worse in the Camp than in the Province. Possible reasons for the difference in reported health status and the use of facilities are discussed.     

Measuring the impact of rehabilitation services on the quality of life of disabled people in Cambodia

The present study aimed to measure the quality of life (QOL) of disabled people in Cambodia and the impact of rehabilitation services. The categories of services were: physical rehabilitation (prosthetics/orthotics with physiotherapy); community-based rehabilitation; and (3) labour market assistance. The 164 respondents were from a range of urban and rural settings. The results suggest that QOL was substantially lower among disabled Cambodians who had received no rehabilitation services compared to those who had received one of the three categories of rehabilitation services. QOL scores tended to be highest, however, among those who had received a combination of all three services. The results also highlighted the vulnerability of certain sub-groups who may need specific provision in planning, policy-making and service delivery. The present study suggests that an integrated approach may be the best way to maximise the impact of individual rehabilitation services in Cambodia.     

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.     

Using evidence to improve reproductive health quality along the Thailand-Burma border

The Mae Tao Clinic, located on the Thailand-Burma border, has provided health services for illegal migrant workers in Thailand and internally displaced people from Burma since 1989. In 2001, the clinic launched a project with the primary aim of improving reproductive health services and the secondary aim of building clinic capacity in monitoring and evaluation (M&E). This paper first presents the project's methods and key results. The team used observation of antenatal care and family-planning sessions and client exit interviews at baseline and follow-up, approximately 13 months apart, to assess performance on six elements of quality of care. Findings indicated that improving programme readiness contributed to some improvement in the quality of services, though inconsistencies in findings across the methods require further research. The paper then identifies lessons learned from introducing M&E in a resource-constrained setting. One key lesson was that a participatory approach to M&E increased people's feelings of ownership of the project and motivated staff to collect and use data for programme decision-making to improve quality.     

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.     

Health and social impacts of a flood disaster: responding to needs and implications for practice

Carlisle in northwest England suffered its worse floods for more than 180 years in 2005. A study, reported here, was undertaken to assess the health and social impacts of these floods via in‐depth, taped individual and focus‐group interviews with people whose homes had been flooded and with agency workers who helped them. Respondents spoke of physical health ailments, psychological stress, water health‐and‐safety issues related to the floods, and disputes with insurance and construction companies, which they felt had caused and exacerbated psychological health problems. Support workers also suffered from psychological stress. Furthermore, it was found that people had low expectations of a flood and were not prepared. The findings are presented in five sections covering flood risk awareness, water contamination issues, physical health, mental health, and impact on frontline support workers. The discussion focuses on the implications of the findings for policy and practice vis‐à‐vis psychological health provision, contamination issues, training and support for frontline support workers, matters relating to restoration, and preparation for flooding.     

Kabrit ki gen twòp mèt: understanding gaps in WASH services in Haiti's IDP camps

Despite the enormous infusion of post‐quake aid to Haiti, cholera had killed more than 8,000 people by January 2013. Based on two mixed‐method studies of a random sample of 108 internally displaced person (IDP) camps and 168 interviews with agency representatives and recipients, this article examines the prevalence of factors that have proven most relevant to the rapid spread of cholera, particularly the provision of water and sanitation services in IDP camps. The study reveals that 30% of IDP camps had no toilets and 40% had no access to water before the outbreak, with only minimal progress after three months. Using bivariate and multivariate statistical analyses, this article explores patterns in the gaps of services with a range of variables such as NGO camp management, municipality and landowners. It offers several theoretical and policy explanations for low level of services, concluding with a series of recommendations for better coordination and management.     

Rebuilding and strengthening health systems and providing basic health services in fragile states

The international community has compelling humanitarian, political, security and economic reasons to engage in rebuilding and strengthening health systems in fragile states. Improvements in health services and systems help to strengthen civil society and to restore legitimacy to governments. Effective engagement with fragile states to inform the design of health programmes and selection of interventions depends on donor coordination and an understanding of health system challenges. Planning requires consideration of allocation (services to be delivered), production (organisation of services), distribution (beneficiaries of services) and financing. The criteria for selecting interventions are: their impact on major health problems; effectiveness; the possibility of scale-up; equity; and sustainability. There are various options for financing and models of engagement, but support should always combine short-term relief with longer-term development. Stakeholders should aim not only to save lives and protect health but also to bolster nations' ability to deliver good-quality services in the long run.     

Brief description of the effects on health of the earthquake of 3rd March 1985 – Chile

Chile is one of the most seismically active countries in the world. Earthquakes are periodic phenomena that test the quality of construction, as well as the capacity of the population to adapt to sharp changes in socio-environ-mental conditions.
Experience in this regard has demonstrated the desirability of being prepared, at the institutional level and at the level of the general population, to carry out investigations and to begin measures to cope with these catastrophes, in order to reduce damage and the interruption of normal life to a minimum.
In this paper some general aspects of the social and health impacts of the earthquake of 3rd March 1985 are examined. The shock affected the central area of Chile which contains 61% of the total population.
The earthquake occurred at 19:50 hours on Sunday, 3rd March, and was of magnitude 7.8. Recorded personal losses included 180 dead and 2,575 injured, and around 200,000 damaged or destroyed dwellings. The destruction also affected the infrastructure of the public services, such as energy, road, telecommunications and water supply, giving rise to an emergency in the provision of assistance.
Special reference is made to the effects, on the health care infrastructure, drinking water supply and, less important, on the behavior of some communicable intestinal diseases that are highly endemic in the area under study.