EDITORIALS

The challenges of securing health in humanitarian crises

Altaf Musani^I; Guido Sabatinelli^II; Theadora Koller^III,1; D avid Nabarro^IV

^IRegional Adviser, Emergency and Humanitarian Action, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
^IIWHO Representative in Sudan, Khartoum, Sudan
^IIITechnical Officer, Department of Health Action in Crises, World Health Organization, 1211 Geneva 27, Switzerland
^IVRepresentative of the Director-General for Health Action in Crises, World Health Organization, Geneva, Switzerland

By early 2004 more than one million people had sought to escape violence and suffering in the three states of the Darfur region of Sudan. More than 180 000 of these displaced people are refugees in Chad; the majority, however, remain in Darfur, crowded into more than 100 camps scattered across 540 000 km². They are dependent on external help for protection, adequate supplies of safe drinking-water, facilities for sanitation, sufficient nourishment, reliable shelter, effective prevention of disease outbreaks, and access (particularly for women) to essential health services — including hospital care.

After visiting Darfur in July 2004, Dr LEE Jong-Wook, Director-General of WHO, appealed for more humanitarian assistance to prevent suffering and death. So far, the extent of the international humanitarian response has been inadequate. Globally, as many as 2 billion people in more than 40 countries face high risks from crisis conditions. Responses to their needs, and to their risks of suffering and death, are just not satisfactory.

Focused preparation is the key to better response. Priorities are: assessments of people's health conditions; coordinated response strategies and joint action to tackle suffering and reduce deaths; prompt identification of gaps in the response and prompt action to fill the gaps; and repair of local systems that are essential for better health.

Since the start of the Darfur crisis, priority has been given to the generation of reliable information for the assessment, analysis and monitoring of the health needs of internally displaced persons. An Early Warning and Response Network (EWARN) was established for communicable diseases and conditions of particular concern, such as women's sexual and reproductive ill-health. Two disease outbreaks — shigellosis and hepatitis E — were detected and confirmed by EWARN, whose data helped in the planning and monitoring of key health interventions. EWARN also confirmed that measles incidence fell after the measles vaccination campaign in June 2004 backed by WHO, UNICEF and the ministry of health. A systematic mortality survey is under way throughout Darfur to detect mortality rates and calibrate the surveillance system. Joint surveillance and reporting systems are vital for targeting responses and securing the financial and institutional support needed for essential humanitarian interventions.

Coordination and joint action are critical for responding effectively to all aspects of complex humanitarian crises. This is especially the case when the security status and accessibility of communities is constantly changing and humanitarian actors are thinly spread across a vast geographical area with very little infrastructure, as in Darfur. Coordinated strategies, together with effective collaboration on logistic and communication systems, has proved essential to the achievement of health outcomes. Experience in Darfur emphasizes that health sector coordination and joint action should become the norm in all crisis response work.

For joint action to make a difference, priorities must be identified and the right responses must be implemented promptly and effectively. This means making sure that the focus is on priority conditions and that the necessary staff, equipment and infrastructure are available to deploy resources to where they are needed.

A team of experienced professionals able to assess needs and coordinate joint actions to respond to outbreaks — and willing to work in extremely demanding conditions — was dispatched to work in Darfur between May and July 2004. These public health coordinators, epidemiologists, nutritionists, and water and sanitation experts, supported by experts in logistics, communications, engineering and field administration, have made an extraordinary difference to health outcomes.

Logistics support is essential if expert personnel are to function effectively in insecure and difficult environments: they need vehicles, information technology equipment, essential medicines, and the wherewithal for accommodation. When the safety of staff is at risk, personnel need to be in a position to comply with security procedures. The lesson from Darfur is that if this human and logistic capacity were applied in all crises and placed at the disposal of national governments, the United Nations and nongovernmental organizations, it should result in a more satisfactory health response and reduced morbidity and mortality.

Crisis response work must contribute to the recovery of local and national systems in ways that take account of needs and realities on the ground. United Nations agencies, nongovernmental organizations and other partners are helping Sudanese groups in Darfur to establish primary health-care capacity, rehabilitate hospitals, improve laboratories so that they support public health programmes, and minimize user charges so that people in need can gain access to care.

Although many displaced people are dying under appalling conditions in the Darfur states, many more deaths are being prevented through intense, often heroic, work by health professionals in extremely difficult circumstances. The lessons of their endeavours must be applied in other crisis situations, now.

1 Correspondence should be sent to this author (email: kollert@who.int).