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Although every hospital needs a security plan for the support of immobile patients who do not possess autonomous escape capabilities, little information exists to assist in the development of practical patient evacuation methods.
Hypothesis:
1) In hospitals during disasters, incident leadership of the fire authorities can be supported effectively by hospital executives experienced in the management of mass casualties; and 2) As an alternative for canvas carry sheets, rescue drag sheets can be employed for emergency, elevator-independent, patient evacuation.
Methods:
A hospital evacuation exercise was planned and performed to obtain experiences in incident command and to permit calculation of elevator-independent patient transport times. Performance of incident leadership was observed by means of pre-defined checklists. The effectiveness and efficiency of carrying teams with five persons each were compared to those with a rescue drag sheet employed by a single person.
Results:
Incident command for hospitals during a disaster is enhanced considerably by pre-defined and trained executives who are placed at the immediate disposal of the fire authorities. For elevator-independent patient transport, the rescue drag sheet was superior to conventional carrying measures because of a reduced number of transport personnel required to move each patient. With this method, patient transport times averaged 54 m/min. flat and 18 seconds for one floor descent.
Conclusion:
Experiences from a hospital during an evacuation exercise provided decision criteria for changes in the disaster preparedness plan. Hospital incident leadership was assigned to executives-in-charge in close co-operation with the fire authorities. All beds were equipped with a rescue drag sheet. Both concepts may help to cope with an emergency evacuation of a hospital.
The growth of the humanitarian aid industry has led to the proliferation of relief programs and the rapid rise in the number of relief personnel working in the field. One major necessity in developing successful international programs is appropriately trained field personnel. The purpose of this study was to evaluate the educational practice and training methods for field workers by non-government organizations (NGO).
Of the 53 organizations surveyed, 64% responded that they sent health care workers to acute human emergencies. A majority of organizations, 31/53 (59%), used manuals as the primary method of training for workers before going into the field. Eighty-five percent of organizations (45/53) supplied their workers with trip briefings from prior personnel before going into the field, and 91% (48/53) had an on-site coordinator. Only 34% (18/53) provided classroom teaching or orientation prior to departure. The average number of months spent by workers abroad was ≤1 for nearly half (49%) of the NGOs. Only 34% (18/53) of the NGOs required that personnel had previous international experience.
Training of humanitarian workers varies significantly between nongovernmental organizations. Lack of standardization in training programs and wide variation of provider preparedness indicates the need by NGOs for enhanced training for field personnel.
Recently, Indonesia has experienced six major provincial, civil, armed conflicts. Underlying causes include the transmigration policy, sectarian disputes, the Asian economic crisis, fall of authoritarian rule, and a backlash against civil and military abuses. The public health impact involves the displacement nationwide of >1.2 million persons. Violence in the Malukus, Timor, and Kalimantan has sparked the greatest population movements such that five provinces in Indonesia each now harbor > 100,000 internally displaced persons. With a background of government instability, hyperinflation, macroeconomic collapse, and elusive political solutions, these civil armed conflicts are ripe for persistence as complex emergencies.
Indonesia has made substantial progress in domestic disaster management with the establishment of central administrative authority, strategic planning, and training programs. Nevertheless, the Indonesian experience reveals recurrent issues in international humanitarian health assistance. Clinical care remains complicated by absences of treatment protocols, inappropriate drug use, high procedural complication rates, and variable referral practices. Epidemiological surveillance remains complicated by unsettled clinical case definitions, non-standardized case management of diseases with epidemic potential, variable outbreak management protocols, and inadequate epidemiological analytic capacity. International donor support has been semi-selective, insufficient, and late.
The militia murders of three UN staff in West Timor prompted the withdrawal of UN international staff from West Timor for nearly a year to date. Re-establishing rules of engagement for humanitarian health workers must address security, public health, and clinical threats.
The war in Kosovo in 1999 resulted in the displacement of up to 1.5 million persons from their homes. On the subsequent return of the refugees and internally displaced persons, one of the major challenges facing the local population and the international community, was the rehabilitation of Kosovo's public health infrastructure, which had sustained enormous damage as a result of the fighting. Of particular importance was the need to develop a system of epidemic prevention and preparedness. But no single agency had the resources or capacity to implement such a program. Therefore, a unique six-point model was developed as a collaboration between the Kosovo Institute of Public Health, the World Health Organization, and an international, nongovernmental organization. Important components of the program included a major Kosovo-wide baseline health survey, the development of a provincewide public health surveillance system, rehabilitation of microbiology laboratories, and the development of a local capacity for epidemic response. While all program objectives were met, important lessons were learned concerning the planning, design, and implementation of such a project. This program represents a model that potentially could be replicated in other post-conflict or development settings.
During the past two decades, there has been tremendous investment in the ability to intervene in disaster settings, and significant barriers remain to providing appropriate services to populations affected by natural and manmade calamities. Many of the barriers to providing effective assistance exist within the NGO community, and illustrate emerging needs for international agencies. These emerging needs include improving methods of recipient participation to promote the local health system, developing improved methods for quality assurance, enhancing options for personnel development, and addressing long-term needs of reconstruction and rehabilitation. Relief agencies face challenges on all levels to develop sound practices in providing humanitarian assistance that can lead to long-term benefits to populations affected by disaster.
For millions of people world-wide, surviving the pressure of extreme events is the predominant objective in daily existence. The distinction between natural and human-induced disasters is becoming more and more blurred. Some countries have known only armed conflict for the last 25 years, and their number is increasing. Recently, humanitarian sources reported 24 ongoing emergencies, each of them involving at least 300,000 people “requiring international assistance to avoid malnutrition or death”. All together, including the countries still only at risk and those emerging from armed conflicts, 73 countries, i.e., almost 1.8 trillion people, were undergoing differing degrees of instability.
Instability must be envisioned as a spectrum extending between “Utopia” and “Chaos”. As emergencies bring forward extreme challenges to human life, medical and public health ethics make it imperative for the World Health Organisation (WHO) to be involved. As such, WHO must enhance its presence and effectiveness in its capacity as a universally accepted advocate for public health. Furthermore, as crises become more enmeshed with the legitimacy of the State, and armed conflicts become more directed against countries' social capital, they impinge more on WHO's work, and WHO must reconcile its unique responsibility in the health sector, the humanitarian imperative and the mandate to assist its primary constituents.
Health can be viewed as a bridge to peace. The Organization specifically has recognised that disasters can and do affect the achievement of health and health system objectives. Within WHO, the Department of Emergency and Humanitarian Action (EHA) is the instrument for intervention in such situations. The scope of EHA is defined in terms of humanitarian action, emergency preparedness, national capacity building, and advocacy for humanitarian ^principles. The WHO's role is changing from ensuring a two-way flow of information on new scientific developments in public health in the ideal all-stable, all-equitable, well-resourced state, to dealing with sheer survival when the state is shattered or is part of the problem. The WHO poses itself the explicit goals to reduce avoidable loss of life, burden of disease and disability in emergencies and post-crisis transitions, and to ensure that the Humanitarian Health Assistance is in-line with international standards and local priorities and does not compromise future health development. A planning tree is presented.
The World Health Organization must improve its own performance. This requires three key pre-conditions: 1) presence, 2) surge capacity, and 3) institutional support, knowledge, and competencies. Thus, in order to be effective, WHO's presence and surge capacity in emergencies must integrate the institutional knowledge, the competencies, and the managerial set-up of the Organization.
The majority of deaths associated with complex emergencies are attributed to infants and children under the age of five years. Most of these deaths are related to preventable diseases such as malnutrition, diarrhea, and malaria. Infant feeding emergencies have emerged as a major factor in complex emergencies. This paper reviews the current information relative to infant feeding, and uses four case studies as educational tools for the management of infant feeding emergencies.
Child mortality rates in refugee population have been linked directly to protein-energy malnutrition (PEM). Breast feeding has many advantages over all other forms of feeding for children up to the age of two years of age. These advantages are discussed in detail in this paper. In addition, the appropriate and inappropriate uses of breast-milk substitutes (BMS) are discussed. Breast feeding also may play a role in the spread of HIV infections from the mother to the infant. However, in the setting of complex emergencies in the developing world, the risk of an infant dying of malnutrition and infection when not breastfed is likely to be greater than is the risk of death due to HIV acquisition through breastfeeding.
The physiology of lactation is reviewed with particular reference to the roles of prolactin, oxytocin, and the feedback inhibitor of lactation (FIL) hormone. No medications have been demonstrated to augment milk production that can be used in a practical sense in complex emergencies. Lastly, the principles promulgated by the WHO and UNHCR for the feeding of infants and children in emergencies and for milk powder distribution are summarized.
This paper describes the areas in which the Geneva Conventions no longer are adequate as a source of legal description or prescription for the challenges faced by physicians working in complex emergencies. It covers the conceptual pitfalls facing the medical profession in connection with humanitarian interventions, which often are conventional military operations, but are not recognized as such because they may vary in some respects from more familiar forms of interstate conflict. Emerging categories of combatants who pose a major threat during complex emergencies also are identified.
Opportunities to meet these challenges with the tools and culture of medicine are explored, and are proposed to the medical community as an opportunity for leadership. The paper proposes that new, epidemiological standards should be developed in order to identify the outbreak of armed conflicts and the trigger points for application of international humanitarian law. Such could replace the political model that presently underlies international humanitarian law. It also argues that international humanitarian law is not the starting point for application of humanitarian standards in war zones, but rather is built upon a peacetime medical culture that must be replicated in complex emergencies as a precursor to effective application of the law.
Complex emergencies emerged as a new type of disaster following the end of the Cold War, and have become increasingly common in recent years. Human activity including civil strife, war, and political repression often coexist with and contribute to natural phenomena such as famine. They frequently result in high mortality, population displacement, and the disruption of civil society and its infrastructure. This article reviews the context of recent complex emergencies, and their expected health consequences, such as diarrhea, measles, malnutrition and outbreaks of infectious disease, and the disruption of mechanisms of disease control and surveillance. However, the complex nature of these emergencies also may have unexpected consequences, such as hindering understanding of their causes or limiting the attention paid to them by the public. This paper discusses the context and consequences of complex emergencies from the health standpoint, and explores some of their unexpected effects.
Translation is a vital activity in Complex Emergencies (CEs) in which the responders and the affected populations do not share the same language or culture. This particularly applies to CEs in developing countries in which a lack of local resources usually results in the importation of foreign aid workers. This paper describes many of the common issues surrounding translation that can affect CE response effectiveness, issues that frequently are not appreciated by aid workers, including clinicians. The authors describe how these issues can arise, their effects, and outline approaches to addressing them.
During the last five years, the debate on the performance of humanitarian assistance has intensified. The motivation to “do better” has come both from within the humanitarian agencies as well as from pressure exerted by the donors and the media. Paradoxically, until now, the voice of those who are to benefit from this assistance has not been heard.
This paper is an overview of the most important initiatives to increase the quality of humanitarian assistance. The introduction of the logical framework and the increasing body of knowledge made available through guidelines have improved project management by measuring process and outcomes. Increasingly, evaluations are used to give account and to learn from experiences. But, current evaluation practice must develop in a wider variety of approaches more appropriate to create change of the operations in the field. Some agencies oppose new developments like the Sphere and the Humanitarian Accountability Projects, arguing that standards and regulation would undermine necessary flexibility to adjust responses to the local context, or be a threat to their independence. Nonetheless, standards are considered to be a prerequisite as reference to assess performance. Furthermore, it is hoped that a new breakthrough will be achieved by improved accountability towards beneficiaries.
An option to address some of the gaps in the current quality assessment tools was to widen the perspective on performance from projects to the organisations behind them. Quality management models may provide the required framework, and they also can be used to embed current initiatives by organisations. Humanitarian organisations may want to develop forms of self-regulation rather than waiting for accreditation by donors. Another area in which progress is needed is a system-wide approach to performance. At this level, the influence of political actors, donors, national governments, and other representatives of the parties in a conflict also should be assessed. It is their legal obligation to protect the basic right to assistance of persons affected by disasters, as enshrined in international law.
This lesson examines mechanisms that can be used for the evaluation of a program or project. The principal concern raised is whether the project has met its stated goals and objectives and whether the project has resulted in producing benefits to the affected society. Short-term (immediate) and long-term (developmental) contributions are discussed. The importance of projects contributing to increasing the absorbing capacity of the affected community for the next event is stressed. Twelve problems commonly encountered in program execution are defined. Optimal management attempts to identify potential pitfalls in advance, designing and implementing mechanisms to avoid them, and to deal with them if they should become manifest. Simply meeting the goals and objectives of the sponsoring organization is inadequate, as all responses must be coordinated and approved by the national coordinating agency. Thus, not only is the effectiveness of the project in meeting the defined goals and objectives important, but the project must be assessed in terms of the overall impact of the project on the society. Reference is made to using the structure provided by the Health Disaster Management: Guidelines for Evaluation and Research in the Utstein Style as promulgated by the Task Force on Quality Control of the World Association for Disaster and Emergency Medicine and the Nordic Society of Disaster Medicine.
After the success of relief efforts to the displaced Kurdish population in northern Iraq following the Gulf War, many in the US military and the international relief community saw military forces as critical partners in the response to future complex emergencies (CEs). However, successes in subsequent military involvement in Somalia, Rwanda, the former Yugoslavia, and other CEs proved more elusive and raised many difficult issues. A review of these operations reinforces some basic lessons that must be heeded if the use of military forces in humanitarian relief is to be successful. Each CE is unique, thus, each military mission must be clearly defined and articulated. Armed forces struggle to provide both security and humanitarian relief, particularly when aggressive peace enforcement is required. Significant political and public support is necessary for military involvement and success. Military forces cannot execute humanitarian assistance missions on an ad hoc basis, but must continue to develop doctrine, policy and procedures in this area and adequately train, supply, and equip the units that will be involved in humanitarian relief. Militaries not only must cooperate and coordinate extensively with each other, but also with the governmental and non-governmental humanitarian relief organizations that will be engaged for the long term.