Ronald J. Waldman

Lessons learned from complex emergencies over past decade

Major advances have been made during the past decade in the way the international community responds to the health and nutrition consequences of complex emergencies. The public health and clinical response to diseases of acute epidemic potential has improved, especially in camps. Case-fatality rates for severely malnourished children have plummeted because of better protocols and products. Renewed focus is required on the major causes of death in conflict-affected societies--particularly acute respiratory infections, diarrhoea, malaria, measles, neonatal causes, and malnutrition--outside camps and often across regions and even political boundaries. In emergencies in sub-Saharan Africa, particularly southern Africa, HIV/AIDS is also an important cause of morbidity and mortality. Stronger coordination, increased accountability, and a more strategic positioning of non-governmental organisations and UN agencies are crucial to achieving lower maternal and child morbidity and mortality rates in complex emergencies and therefore for reaching the UNs Millennium Development Goals.

Rebuilding health systems to improve health and promote statebuilding in post-conflict countries: A theoretical framework and research agenda

Violent conflicts claim lives, disrupt livelihoods, and halt delivery of essential services, such as health care and education. Health systems are often devastated in conflicts as health professionals flee, infrastructure is destroyed, and the supply of drugs and supplies is halted. We propose that early reconstruction of a functioning, equitable health system in countries recovering from conflict is an investment with a range of benefits for post-conflict countries. Building on the growing literature about health systems as social and political institutions, we elaborate a logic model that outlines how health systems may contribute not only to improved health status but also potentially to broader statebuilding and enhanced prospects for peace. Specifically, we propose that careful design of the core elements of the health system by national governments and their development partners can promote reliable provision of essential health services while demonstrating a commitment to equity, strengthening government accountability to citizens, and building the capacity of government to manage core social programs. We review the conceptual basis and extant empirical evidence for these mechanisms, identify knowledge gaps, and suggest a research agenda.

Transforming health systems to improve the lives of women and children

Ambitious quantitative goals for reducing mortality and increasing access to health interventions are nothing new to the areas of child maternal and reproductive health. They are the standard fare of global declarations and national 5-year plans. They come. They go. What makes the Millennium Development Goals (MDGs) different? With health firmly embedded in this wider poverty-reduction initiative which has garnered unprecedented consensus and support from governments and multilateral organisations the global health community has a rare opportunity to break through to new ways of thinking about the obstacles now blocking improvements in the health of women and children and to translate that thinking into bold new steps to meet goals 4 and 5 (table). For the UN Millennium Project Task Force on Child Health and Maternal Health the potential breakthrough lies in putting health systems at the centre of MDG strategies and in addressing these systems not only as delivery mechanisms for technical interventions but also as core social institutions—as part of the very fabric of social and civic life. In high-mortality countries today especially for the poorest populations health systems are frequently the source of catastrophic costs humiliating treatment and deepening social exclusion. But a different way is possible. Health systems can be a vehicle for fulfilling rights for active citizenship and for true democratic development—poverty reduction in its fullest sense. (excerpt)

Gender, Social Support, and Posttraumatic Stress in Postwar Kosovo

The effects of social support and traumatic experiences on mental health in conflict situations may be different by gender. The Kosovo Emergency Department Study was conducted in July and August 2001 to assess mental health 2 years after the end of the war in Kosovo. Of 306 emergency department patients (87.7% response rate), all were ethnic Albanian, 97.4% had experienced traumatic events, and 89.5% had posttraumatic stress symptoms. Women and persons who experienced more traumatic events had higher posttraumatic stress scores. Persons with social support had lower posttraumatic stress scores. In a final model, social support had a greater protective effect for women, whereas traumatic events had a greater detrimental effect on men. Two years after the war in Kosovo, there remained a high prevalence of posttraumatic stress symptoms, particularly among women with low social support. Interventions targeting social support may be important public health efforts in the postwar context.

The Association Between Inadequate Rations, Undernutrition Prevalence, and Mortality in Refugee Camps: Case Studies of Refugee Populations in Eastern Thailand, 1979–1980, and Eastern Sudan, 1984–1985

A review was conducted of nutrition and mortality data collected among Tigrayan refugees in Eastern Sudan (1984-85) and Cambodian refugees in Thailand (1979-80) 2 populations of comparable size. The Cambodian refugee population showed a rapid decline in mortality rates during the acute phase of the emergency--from 10/1000/month to 1/1000/month within 1 month. These changes were associated with rapid improvement in nutritional status and the provision of adequate rations soon after the arrival of the refugees in Thailand. By contrast mortality rates in the Tigrayan refugee population in late 1984 and 1985 were unusually high (14-24/1000/month) and prolonged. The high mortality was associated with persistently high prevalence rates of undernutrition (14-50%) among children 5 years of age. Inadequate amounts of food (1360-1870 kcal/person/day) were distributed to this population during the 1st 5 months after their arrival; in addition a severe measles outbreak in the camps added to the high mortality. The reported high undernutrition prevalence in the Tigrayan refugee camps persisted despite supplementary feeding programs for which enrollment and attendance rates among identified undernourished children were low. The close association of mortality with undernutrition leads us to conclude that refugee relief programs should give highest priority to ensuring that adequate rations are distributed. This requires better anticipation of and more timely response to refugee movements by international relief agencies. (authors)

The Cure for Cholera — Improving Access to Safe Water and Sanitation

The best intervention for long-term cholera control is the development and maintenance of water and sewage treatment systems. But many people in low-income countries still lack access to safe water supplies and even modestly improved sanitation facilities.

Impact of the Ebola outbreak on health systems and population health in Sierra Leone.

Background The current Ebola outbreak has proved devastating to vulnerable populations in West Africa. Health needs assessments were conducted in two districts of Sierra Leone to identify and quantify the impact of the outbreak on population health and health systems. Methods Mixed qualitative and quantitative methods were employed including interviews, focus groups, and interrogation and analysis of data from health facilities, district health records and burial teams. T-tests were performed to compare periods before and during the outbreak. Results A breakdown in relations between the health system and communities was demonstrated leading to marked and significant reductions in utilization of health facilities including: paediatric all-cause and malaria admissions, maternity admissions and attendance in the community. High avoidable all-cause mortality was identified (3.4 times higher than normally registered for the period, 42% deaths in children ,5 years, 2% attributed to Ebola). Negative impacts on the health workforce, health system leadership and governance, and disruption of health programmes and systems were demonstrated. Reductions in vaccination coverage and a rise in teenage pregnancy were noted. Conclusions The findings indicate a public health emergency as a legacy of the Ebola outbreak. Sustained commitment of the international community is required to support health system re-building.

Evaluation of the Benefits and Risks of Introducing Ebola Community Care Centers, Sierra Leone

These centers could lead to a decline in cases, even if virus containment is imperfect.

Prioritising health care in complex emergencies

Stabilization of the health of refugees and internally displaced persons is the primary objective of emergency relief. Prominent causes of morbidity and mortality have been identified; but prioritizing the emergency health problems has always been problematic in areas experiencing refugee crises. Although measles is listed by Medecins Sans Frontieres as the second most urgent priority the worlds emphasis is on the eradication of poliomyelitis which is not an important cause of morbidity or mortality. It is noted that reproductive health issues have received increased attention. On the other hand infant mortality rates have also increased. Without a systematic approach in addressing priorities the situation would get worse. Carefully targeted appropriately designed applied research is recommended to be helpful in finding solutions.

World Health Organization and emergency health: if not now, when?

In light of the recent Ebola epidemic, Francesco Checchi and colleagues argue that the World Health Organization’s response to health emergencies is not fit for purpose and put forward six proposals to reform WHO’s crisis response