Geneva Health Forum Archive

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Regaining Access to Public Health after an Emergency: Training Health Workers to Address the Shift from Relief to Development

Author(s): L. E. Pacifici*1, F. Riccardo2, M. Linetti3, E. Scaroni1, L. Nardi1, A. G. De Rosa1, G. Russo2, F. Rocca1, V. Vullo2
Affiliation(s): 1International Health Cooperation and Development, Italian Red Cross, 2Infectious and Tropical Diseases, Faculty of Medicine University “La Sapienza” of Rome, 3Training Programme (ECM), Italian Ministry of Health, Rome, Italy
Keywords: Public health, emergency, training
Background:

Past experience in relief operations has taught international relief workers that the late and post emergency phases are critical moments of change in the kind of assistance and support to provide to an affected country. The needs of beneficiaries as well as of the health system shift and more articulate programmes and activities have to be put in place in order to allow access to public health and help restore damaged health systems. Although this is not a priority for many International Organizations and NGOs the Italian Red Cross works both in relief and in development and has tackled the problem of transition specifically in a 14 day course in collaboration with the Faculty of Medicine Department of Infectious and Tropical Diseases of the University “La Sapienza” of Rome and with the Training Programme of the Italian Ministry of Health (ECM). Public Health and Tropical medicine specialists from national research institutions and universities, engineers, logistic staff, psychologists as well as communication and Water and Sanitation experts were invited. Senior Staff from major international organizations and NGOs were requested to hold interactive lessons on real field situations and challenges.

Summary/Objectives:

To provide relief workers not only coming from medical or nursing schools but also from economy, engineering and law school backgrounds with a comprehensive training package to help them acquire knowledge on the different aspects of relief during post and late emergency phases. The topics of the course ranged from psychology and psychological support to the relevant international laws and regulations that could apply to this context such as IHL and IHR 2005, from environmental health to epidemiology and infectious disease surveillance from ethical issues to quality assurance in public health delivery. The aim was not to produce experts as each participant had his or her own area of expertise, but to offer a global picture of the multi-sector approach to humanitarian aid and of the situation they would face on the field. The training was divided in theoretical and practical modules involving role playing and a final examination.

Results:

The course was organized in Rome between the 17th of May and the 22nd of June 2007 and lasted two weeks. Of the 30 participants 17 were women (57%). 44% were medical doctors, 17% were students or “stagiaires” and 17% were members of the Italian Red Cross. Pharmacists and lawyers each accounted for 7% of participants. Upon examination of the final qualitative tests 93% considered the topics were either relevant or very relevant to their training needs and the same proportion evaluated positively the quality of teaching. All participants evaluated the course as effective for their ongoing education on the subject. 17 of the 30 participants required the certification of the Ministry of Health for the training and undertook an evaluation test. 88% of those answered correctly to at least 80% of the questions.

Lessons learned:

The idea of a specific multidisciplinary course and the down to earth and practical approach that characterised the course were enthusiastically accepted by participants. The challenge of handling classes with people from very different backgrounds and experiences was counterbalanced by the added value of sharing different viewpoints and approaches.

A Surgeon’s Experience in Haiti

Author(s): M. Assal1
Affiliation(s): 1Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Switzerland
Background: On January 12, 2010, at 16.50, a devastating earthquake of high magnitude (7.0) struck the island of Haiti. Two hundred thousand lives were lost in the first few seconds. Those who survived the initial overwhelming event were left with severe physical and psychological injuries. There were a very large number of crush injuries to the extremities with or without associated fractures, multiple extremity fractures and more rarely axial (pelvic or spinal) fractures, open contaminated wounds, compartment syndromes, and traumatic amputations. The immediate psychological injuries comprised mostly of posttraumatic stress disorders.
The Swiss Humanitarian Aid Unit was rapidly deployed in Port au Price. The first medical team reached Port-au-Prince General Hospital on the 5th day after the earthquake and quickly began surgical activities after just 3 hours on site. The team consisted of one team leader, one orthopaedic surgeon, one general surgeon, two anesthesiologists, two pediatricians, one obstetrician/gynecologist, one anesthesia nurse and three polyvalent nurses. Medical equipment brought to the scene consisted of light equipment (surgical tools, dressing and casting material, some medication), in addition to some material already present in the Port-au-Prince General Hospital (operating tables, some medication, etc.). The team focused on providing medical and surgical care to children and traumatized pregnant women. Orthopaedic surgeons were on the frontline in providing acute care, with fracture stabilization using plaster of Paris, traction, or external fixation. Adequate débridement and delayed primary closure of wounds, fasciotomies, and amputations were also among the major orthopaedic procedures. In addition, all the routine medical and surgical emergencies of daily life needed to be addressed by the specialists of the same team. This was a substantial additional burden placed on our team.

The Sphere Project’s Relevance to Emergency Health Assessments and Interventions

Author(s): A. Nadig1
Affiliation(s): 1The Sphere Project, The Sphere Project, Geneva, Switzerland
Keywords:

Health services in emergencies, HIV and AIDS, Psycho-social issues, Measles Communicable diseases, Non-communicable diseases, Reproductive Health

Background:

The Sphere Project’s Handbook (Humanitarian Charter and Minimum Standards in Disaster Response), is recognised as a key reference tool for effective and quality-oriented coordination of emergency interventions. It is a collection of minimum standards in disaster response, covering four technical sectors. One of these sectors is Health Services, which also includes psycho-social health.

Methods:

The presentation will provide a brief introduction to the Sphere Project, including the rationale behind its inception. It will then turn to the four life-saving sectors included in the Handbook, with special focus on “Health Services” and the linkages between it and the other three sectors (Water and Sanitation, Food and Nutrition, Shelter and Non-food items). The presentation will then turn to the revision process of the current Sphere Project Handbook (2004 edition). By April 2010, the text for the 2010 Handbook edition will be available in draft form and can be shared with the conference participants.

Results/Conclusions:

The main focus of the presentation will be on the proposed changes to the chapter content. All those changes are influenced by recent developments in humanitarian action, in particular in the fields of disaster risk reduction, climate change and an evolving understanding of the importance of protection. Cross-cutting issues, in particular psycho-social issues and focus on vulnerabilities, will further shape the new text. The Sphere revision process aims at being broadly consultative and consensus-based, bringing together agreed-upon best practice. Therefore, we can share experiences of concrete application of Sphere in emergency health interventions. The Sphere Project is an NGO initiative, launched in 1997. It aims at improving quality and accountability in disaster response.

Capacity Building for Mental Health and Psychosocial Support in Humanitarian Emergencies: The Challenges of Training

Author(s): C. Colliard1
Affiliation(s): 1Development & Training Department, Centre for Humanitarian Psychology, Geneva, Switzerland
Keywords: Mental health, psychosocial support, humanitarian emergencies, training, psycho-education, capacity building, evaluation, research.
Background:

With the growing concern around the impact of climate changes and the potential development of more violence and conflicts to come, and consequently more mass victimization, there will be a growing need for quality training. In recent years, the Sphere Project and the IASC Guidelines on Mental Health and Psychosocial Support in Emergencies have issued principles and good practices(also in the areas of capacity building and training),which have contributed to awareness, better implementation of programs and the growth of a distinct body of knowledge in these fields. However, after evaluating programs on post-disaster scenes (Iran, Sri Lanka, Pakistan&,the speaker has observed a huge gap in the recruitment and training of qualified international and national/local staff after disasters, in both areas of mental health and psychosocial support.

Methods:

There are many factors involved: countries affected by disasters and conflicts do not always have policies in place in those areas prior to the disaster; training programs have to be created from scratch on an ad hoc basis; local staff are victims themselves and have to be trained into self care alongside attending victims; training in community psycho-education is usually done also on an ad-hoc basis; evaluations and monitoring of training programs are practically non existent. In general, training methodologies in the context of emergencies, both mental health and psychosocial support and education, have been poorly researched and lack scientific validation.
Overall, such programs in post-emergency areas remain quite inconsistent and sketchy, as each humanitarian organisation gives their own training in line with their own objectives. Finally, evaluation and research on mental health and psychosocial training and capacity building in emergencies are still quite thin and lack scientific evidence.

Results/Conclusions:

The speaker suggests that trainings should not be a series of one-off and ad-hoc events, but built into a coherent whole, spanning both mental health and psychosocial education practices as complementary fields. This means pre-deployment contingency planning by the international community and governments. Effective training programs would then not only bring more professionalism to national/local staff in emergencies, but also change the communities’ attitudes toward mental illness by extending psycho-education practices that could avoid stigmatisation. Such training programs would also gain strength if there was a coordinating mechanism in the impacted areas, thus avoiding duplication. Furthermore, training programs should be planned in the perspective of sustainable development, by mobilising the communities’ resources, such as primary health care centres, schools, local authorities and integrated into the local culture and community traditions. Evaluation and monitoring tools for mental health and psychosocial education programs in non-western countries should be created and validated. Finally, research into training methodologies and practices in post-emergency contexts should be created in order to build evidence based practices, thus strengthening local professionalism.

People with Disabilities at Times of Disaster and Crisis

Author(s): Nicolas Heeren1
Affiliation(s): 1Department of Programmes, Methods & Techniques, Handicap International, Lyon, France
Key issues:

Recent natural disasters in the world (Gujarat, Bam, Kashmir and Yogyakarta) and man-made crises (war in Sierra Leone, Balkans, Iraq, Afghanistan) have unfortunately shown that people with disabilities tend to be disproportionally victims of disaster and conflict. We know that among the poor a much larger part of the population is living in a disabling situation compared to the overall population. An HI study found that 60% of the people with disabilities were overlooked in one specific emergency response. Indeed, disability is often an integral part of emergency situations, and yet it is not taken into account by most of the players in the rush during an emergency. People with disabilities should enjoy the same rights as anybody else. Disability results from a combination of temporary or permanent impairment, and environmental and sociocultural barriers. Existing coping mechanisms of people with disabilities are confronted with a new environment while their support system is also dramatically altered by the crisis. The following list highlights some factors that may make a PWD more vulnerable during an emergency situation: - PWDs tend to be invisible in emergency registration systems. - Lack of awareness and misinterpretation of the situation and communication difficulties (What happened? What do I do? Where is my family?) lead to a lack of comprehension on the part of the PWDs of the disaster and its consequences. - PWDs are often excluded from disaster response efforts and particularly affected by changes in terrain resulting from disaster. - Because of inadequate physical accessibility, or loss or lack of mobility aids or appropriate assistance, PWDs are often deprived from rescue and evacuation services, relief access, safe location/adequate shelter, water and sanitation, etc. - Emotional distress and trauma caused by a crisis situation often have long-term consequences on people with disability. These challenges can be met through anticipated action by both specialised and generalist actors. In the disaster context, two cases have to be differentiated: a) people who were disabled before the actual disaster took place; b) people who have become disabled as a result of the disaster. Whereas, for the latter group, medical interventions and access to health services (including psychological support) have to be organised in the first days after an emergency, for the former group, while medical attention is useful, more often social and economic interventions are necessary. This also means that the many other actors involved in emergency responses should become disability confident. The intervention and debate will focus on practical answers HI has been able to implement in recent crises, both natural and manmade. It will include special needs and issues from the specialisation/mainstreaming debate; disability services; awareness and training; early warning systems; adapted search and rescue; refugee camp management; and the link with long-term development processes. Finally, the special case of psychological trauma suffered by both victims and medical professionals will be addressed.

Meeting challenges:  How to guarantee the right to aid and services during an emergency for people with disabilities? How to take into account people with disabilities before, during and after emergencies through direct action of specialised actors and create disability confidence among generalist emergency actors?
Conclusion (max 400 words):

If we want to reduce the disproportioned impact of disasters on people with disabilities, a combined effort of specialised and generalist actors, both local and international, needs to be developed. In absence of genuine disaster-preparedness, clever mix interventions can reduce greatly the number of people who suffer from crisis and disaster.

GHF2006 – Opening Ceremony

Session Outline

Wednesday, August 30 2006, 17:45-19:30
Welcome messages
Prof. Louis Loutan, President of the Geneva Health Forum Organizing Committee 
Mr. Bernard Gruson, Chief Executive Officer, Geneva University Hospitals 
Prof. Claude Le Coultre, Vice-Dean of the Faculty of Medicine, University of Geneva
Mr. Pierre-François Unger, President of the Council of State of Geneva 
International Development and Access to Health
Micheline Calmy-Rey, Federal Councillor, Head of the Federal Department of Foreign Affairs, Switzerland 
Access to Victims of Conflicts and Catastrophes
Jakob Kellenberger, President, ICRC, Switzerland
Access to Health: A Right for all?
Mary Robinson, President, Realizing Rights: The Ethical Globalization Initiative, USA

Session Documents

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GHF2008 – PS33 – Access to Health Services in Crisis and Fragile States

Session Outline

Parallel session PS33, Monday, May 26 2008, 16:00-17:30, Room 15
Chair(s): Paul Bouvier, ICRC Senior Medical Advisor, International Committee of the Red Cross, Switzerland, Pierre Hoffmeyer, Head, Division of Orthopedics and Department of Surgery, University Hospitals of Geneva, Switzerland 
Obstacles in Relation to the Health Workforce: Accessibility of Services in Fragile States and Conflict Zones
Salam Ismael, Founder and Director, Doctors for Iraq Society, Iraq 
Kosova’s Response to Ethnic Segregation in Health Care and its Challenges in Peace
Alush Gashi, Minister of Health and Member of Parliament, Republic of Kosovo 
First Aid: A Vector for Access to Health in Challenging Contexts 
Eric Bernes, First-Aid Programmes, International Committee of the Red Cross, Switzerland 
Where There Is No Access to Services: ICRC Field Surgical Teams in Darfur  
Marco Baldan, Chief Surgeon, International Committee of the Red Cross, Switzerland

Session Documents

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GHF2010 – PS25 – Rebuilding Post-Conflict Health Systems: Challenges and Opportunities

Session Outline

Parallel session PS25, Tuesday, April 20 2010, 16:00-17:30, Room 2
Chair(s): Yves Etienne, Head, Assistance Divisions, International Committee of the Red Cross, Switzerland, Davide Mosca, Director, Migration Health Department, International Organization for Migration, Switzerland
Ethics in the Delivery of Humanitarian Health Assistance: Learning from the Narratives of Health Workers
Lisa Schwartz, Clinical Epidemiology and Biostatistics, McMaster University, Canada
Managing a Health Crisis with Limited Health Systems Capabilities
Lenias Hwenda, Executive Education, IHEID, Switzerland
Health Sector Support: A Bridge to Peace in the Northern Caucasus
Khassan Dzgoev, Lecturer, Department of Surgery, State Medical Academy, Vladikavkaz, Russian Federation
Ensuring Provision of Appropriate Physical Rehabilitation Services: From Emergency to Long-Term
Claude Tardif, Head of Physical Rehabilitation Programmes, Health Unit, Assistance Division, International Committee of the Red Cross, Switzerland

Session Documents

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Session Video

This session is available to watch using Dudal. To watch it you will need to have Java installed on your computer.

Session Report

Submitted by: James Reynolds-Brown (ICVolunteers); Contributors: Josefine Ridderstrale (ICVolunteers)

Theo Verhoeff of ICRC. Photo by V. Krebs, ICVolunteers.org

A series of short presentations covering the increasingly complex work of following immediate crisis response with effective capacity building systems. Case studies from the North Caucasus, Afghanistan and from the recent experience of the ICRC highlight the issues involved and various attempts to address them.

Yves Etienne and Davide Mosca chaired this series of presentations looking at the longer term implications for health systems in the short and long post-conflict terms. Mr Etienne, setting the tone for the rest of the presentations, reminded the audience of the difficulties in making the link between an emergency situation and reconstruction phases. A new paradigm of chronic-crisis situations, where the ICRC and similar agencies found it difficult to tell whether a conflict situation had ceased or simply paused, was emerging.

Lisa Schwartz of McMaster University gave a presentation on dealing with ethical and moral distress in returning health workers. Her team’s study of several health workers had uncovered ethical challenges where no response to a situation would be without a moral dilemma. Covering her slides in detail, Dr Schwartz noted four main themes from her research as the cause of moral and ethical distress: resource scarcity, social inequities, the policies and agendas of aid agencies, and the roles and interactions with western norms. Her recommendation for the future was to find a new approach to pre-deployment training and providing support for moral distress and the ability to talk about it.

A comment from the audience pointed out that it took courage to dig into these ethical issues, and suggested that the role of impartiality should also be built into any new approach for pre-deployment training. The audience member also agreed with the notion that the creation of ‘space’ for health professionals was key.

Khassan Dzgoev gave a view on health sector support as a means to achieving and embedding peace in the North Caucasus, a region of recent armed conflict. Each of the three republics, North Ossetia, Chechnya and Ingushetia, had suffered serious problems with their health systems, consisting of underfunding, destruction of services, poor laboratory quality, lack of professional training, and problems diagnosing TB/HIV. The Swiss Agency for Development and Cooperation (SDC) had focussed on these areas and produced several steps for improvement. Laboratory services had been strengthened or re-established, a DOTS strategy had been implemented, training had been provided, and prevention/prophylactic services had been enhanced. A key element of the work had been cooperation between the three republics, especially in the fields of training, ministerial effort and medical collaboration. The work of a trusted third party, competent professionals, and a clear focus on health concerns had been some of the most important success factors.

Yves Etienne agreed with the principle of Dr Dzgoev’s talk in stating “health should be stronger than politics”.

The work of the International Committee of the Red Cross (ICRC) in long-term physical rehabilitation projects was covered by Theo Verhoeff. The ICRC, in recognising that those with physical disabilities arising from conflict situations needed assistance in social integration and medical support beyond the conflict phase, sought to address their long term needs through access to rehabilitation services; the ‘physical rehabilitation continuum’. The ICRC had established the Special Fund for the Disabled (SFD), to complement the work of its Physical Rehabilitation Programme (PRP). Although the main objectives of the PRP and SFD are the same, their respective responsibilities are different. The PRP substitutes itself for the national authority, while the role of the SFD is just to support the re- or newly-established national authority. Giving some statistics, Mr Verhoeff noted that the PRP had 90 projects in 25 countries, and the SFD had 64 projects worldwide. He summed up by noting that the SFD can help embed physical rehabilitation programmes, the help is appreciated by all parties including donors, that sustaining services is a challenge, and that success depends on the commitment of nations, organisations and donors.

Yves Etienne noted that once a programme, such as the provision of prosthetics to children, had started, many organisations found it difficult to end that programme and had not considered the need for near permanent involvement in the programme; the work of the SFD was key to sustainability.

For the final session, Pierre Gauthier preceded a short film, ‘A new life for Mohsin’ with some pithy words. Echoing the other presenters, he noted that providing patient services is not enough, you have to consider the social integration of a patient. The ICRC had sought to institutionalise this in various projects, including this particular one in Kabul. The film, about social integration in Afghanistan, covered the work of an ICRC unit in Kabul in rehabilitating patients and providing for their re-integration into their family and the wider society. They were able to provide micro-credit, home based support services and had established a local workshop for the production of mobility aids.

Obesity and Under-Nutrition among Western Sahara Refugees: The Emerging Threat of Double Burden of Malnutrition in Emergencies

Author(s): C.S. Grijalva-Eternod1,2, J.C.K. Wells3, M Cortina-Borja4, N. Salse-Ubach5,M. Tondeur2 ,C. Dolan2 ,C. Meziani6, C. Wilkinson7, P. Spiegel7, A.J. Seal1,2
Affiliation(s): 1Centre for International Health & Development, UCL Institute of Child Health, London, UK, 2Emergency Nutrition Network, Oxford, UK, 3MRC Childhood Nutrition Research Centre, UCL Institute of Child Health, London, UK,  4MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, London, UK, 5Independent Consultant, Barcelona, Spain, 6Tindouf Sub-Office, United Nations High Commissioner for Refugees, Tindouf, Algeria, 7Public Health and HIV Section, Division of Programme Support and Management, United Nations High Commissioner for Refugees, Geneva, Switzerland
1st country of focus: Not applicable
Relevant to the conference theme: Emergencies
Summary (max 100 words): We assessed under-nutrition and overweight prevalence in Western Sahara women (15-49 years) and children (6-59 months) living in refugee camps for over 35 years. Both were found highly prevalent - the former among children, the latter among women. At the household level, more households presented cases of overweight than underweight. The number of households presenting both was high (19.9%). The results highlight the need to focus attention on non-communicable diseases within the humanitarian sector with special focus on refugees living a protracted emergency.
Background (max 200 words): Vulnerable groups experiencing epidemiological transitions are known to suffer both under-nutrition and obesity. Yet, it is unknown whether this double burden affects food aid dependent refugees living in protracted emergencies.
Objectives (max 100 words): We aimed at assessing the double burden of malnutrition among Western Sahara refugees living in a protracted emergency for over 35 years.
Methodology (max 400 words): We implemented one stratified cluster nutrition survey in four Western Sahara refugee camps in Algeria. We sampled 2005 households collecting anthropometric indicators in 1608 children (6-59 months) and 1781 women (15-49 years). We estimated the prevalence of global acute malnutrition, stunting, underweight and overweight in children and the prevalence of underweight, overweight and central obesity in women. Households were first classified according to the presence of cases of each indicator. Households were later classified as underweight, overweight or double burden if they presented cases with under-nutrition or overweight, alone or in combination, or normal if no cases were found.
Results (max 400 words): In children, prevalence of global acute malnutrition was 9.1%, stunting 29.1%, underweight 18.6% and overweight 2.4%.; whereas in women 5.1% were underweight, 53.7% were overweight or obese and 71.4% had central obesity. A larger proportion of households presented cases of central obesity (47.2%) or overweight (38.8%) in women compared to those presenting stunting (19.5%) or underweight (13.3%) in children, nonetheless the latter were high. Overall, overweight (43.6%) households were most commonly followed by underweight (20.5%) and double burden-affected (19.9%) households. Similar results were found if households were classified as primarily obese instead of overweight.
Conclusion (max 400 words): Obesity and under-nutrition are highly prevalent and co-existing among Western Sahara refugees. The results highlight the need to focus attention on non-communicable diseases within the humanitarian sector. Results also raise the complex challenges of incorporating obesity prevention and treatment of associated co-morbidities into aid policies, without drawing resources away from providing essential life-saving interventions to tackle under-nutrition.