Peter Salama

Health programmes and policies associated with decreased mortality in displaced people in postemergency phase camps: a retrospective study

BACKGROUND An estimated 35 million people have been displaced by complex humanitarian emergencies. International humanitarian organisations define policies and provide basic health and nutrition programmes to displaced people in postemergency phase camps. However, many policies and programmes are not based on supporting data. We aimed to identify associations between age-specific mortality and health indicators in displaced people in postemergency phase camps and to define the programme and policy implications of these data. METHODS In 1998-2000, we obtained and analysed retrospective mortality data for the previous 3 months in 51 postemergency phase camps in seven countries. We did multivariate regression with 18 independent variables that affect crude mortality rates (CMRs) and mortality rates in children younger than 5 years (<5 MRs) in complex emergencies. We compared these results with recommended emergency phase minimum indicators. FINDINGS Recently established camps had higher CMRs and <5 MRs and fewer local health workers per person than did camps that had been established earlier. Camps that were close to the border or region of conflict or had longer travel times to referral hospitals had higher CMRs than did those located further away or with shorter travel times, and camps with less water per person and high rates of diarrhoea had higher <5 MRs than did those with more water and lower rates of diarrhoea. Distance to border or area of conflict, water quantity, and the number of local health workers per person exceeded the minimum indicators recommended in the emergency phase. INTERPRETATION Health and nutrition policies and programmes for displaced people in postemergency phase camps should be evidence-based. Programmes in complex emergencies should focus on indicators proven to be associated with mortality. Minimum indicators should be developed for programmes targeting displaced people in postemergency phase camps.

Mental health status of human rights workers, Kosovo, June 2000

Human rights workers in humanitarian relief settings may be exposed to traumatic events that put them at risk for psychiatric morbidity. We conducted a cross-sectional survey in June 2000 to study the prevalence of psychiatric morbidity among 70 expatriate and Kosovar Albanian staff collecting human rights data in Kosovo. Among those surveyed, elevated levels of anxiety, depression, and posttraumatic stress disorder symptoms were found in 17.1, 8.6, and 7.1% respectively. Multiple regression analysis revealed that human rights workers at risk for elevated anxiety symptoms were those who had worked with their organization longer than 6 months, those who had experienced an armed attack, and those who experienced local hostility. Our study indicates that human rights organizations should consider mental health assessment, care, and prevention programs for their staff.

HIV surveillance in complex emergencies

Many studies have shown a positive association between both migration and temporary expatriation and HIV risk. This association is likely to be similar or even more pronounced for forced migrants. In general, HIV transmission in host-migrant or host-forced-migrant interactions depends on the maturity of the HIV epidemic in both the host and the migrant population, the relative seroprevalence of HIV in the host and the migrant population, the prevalence of other sexually transmitted infections (STIs) that may facilitate transmission, and the level of sexual interaction between the two communities. Complex emergencies are the major cause of mass population movement today. In complex emergencies, additional factors such as sexual interaction between forced-migrant populations and the military; sexual violence; increasing commercial sex work; psychological trauma; and disruption of preventive and curative health services may increase the risk for HIV transmission. Despite recent success in preventing HIV infection in stable populations in selected developing countries, internally displaced persons and refugees (or forced migrants) have not been systematically included in HIV surveillance systems, nor consequently in prevention activities. Standard surveillance systems that rely on functioning health services may not provide useful data in many complex emergency settings. Secondary sources can provide some information in these settings. Little attempt has been made, however, to develop innovative HIV surveillance systems in countries affected by complex emergencies. Consequently, data on the HIV epidemic in these countries are scarce and HIV prevention programs are either not implemented or interventions are not effectively targeted. Second generation surveillance methods such as cross-sectional, population-based surveys can provide rapid information on HIV, STIs, and sexual behavior. The risks for stigmatization and breaches of confidentiality must be recognized. Surveillance, however, is a key component of HIV and STI prevention services for forced migrants. It is required to define the high risk groups, target interventions, and ultimately decrease HIV and STI transmission within countries facing complex emergencies. It is also required to facilitate regional control of HIV epidemics.

No less vulnerable: the internally displaced in humanitarian emergencies

In 1999 the US Committee for Refugees estimated that there were 14 million refugees and 21 million internally displaced persons (IDPs) worldwide. The distinction between refugees and IDPs has important public health implications. It is noted that unlike refugees IDPs cannot invoke the same legal protections as refugees. Additionally no specific international humanitarian agency is responsible for providing them with protection and humanitarian assistance. To address the shortfalls in the protection of the rights of IDPs non-binding legal principles on internal displacement which draw on existing humanitarian and human rights as well as on analogous refugee law have been developed and disseminated. These principles list the important essential services that IDPs are entitled to: food potable water sanitation shelter and medical services. However responsibility for the protection of and provision of basic services to IDPs still rests with national governments. There is an urgent need for a specific international humanitarian agency to be given the mandate for providing such services so that tangible improvements in the health and welfare of IDPs to be attained.

HIV, syphilis, herpes simplex virus 2, and behavioral surveillance among conflict-affected populations in Yei and Rumbek, southern Sudan

Little is known about the HIV epidemic in conflict-affected southern Sudan. During 2002–2003, we conducted behavioral and biological surveillance surveys and sequential sampling in antenatal clinics in Yei, Western Equatoria, and Rumbek, Bar-el-Ghazal. HIV prevalence among individuals aged 15–49 years ranged between 0.4% in Rumbek town and 4.4% in Yei town, and among pregnant women between 0.8 and 3.0%, respectively. After the recent peace agreement, targeted prevention programmes are urgently needed to prevent further spread.

Emergencies in developed countries: are aid organisations ready to adapt?

Issues regarding the appropriateness of aid organizations have been raised since the rise in prioritization of programmatic responses to complex emergencies. These priorities and standards emerged due to the experiences of aid organizations responding to complex emergencies in developing countries. The acute and post-emergency phases of complex emergencies in developing countries primarily in Asia and Africa have been defined with regard to mortality and morbidity rates. These rates have often been used in assessments as health indicators for the whole population. Some aid organizations that responded to the Balkan crisis did not adapt the developing country paradigm for response to the needs of the situation. Problems arose concerning treatment of chronic diseases and mental health. The need for a new definition of the phases of complex emergencies which consider variables such as demographic characteristics and epidemiological disease profile is evident.