Conflict and health: Public health and humanitarian interventions: developing the evidence base

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Abstract
Why is evidence on the agenda? Current debates regarding evidence based medicine 7 8 and evidence based policy9 have permeated all spheres of health care, including those associated with humanitarian health. Basing policies and practice on the best available evidence is essential to maximising the value of available resources. Key questions regarding the nature of evidence remain: in addition to evidence of effectiveness and efficiency, evidence related to other dimensions of health interventions, such as their humanity, equity, local ownership, and political and financial feasibility, is important. How these relate to humanitarian principles of independence, impartiality, and neutrality warrants further analysis and debate. Magnitude of the problem A wealth of evidence has accumulated over the past 25 years on the massive effect of war on public health. 3 10 Refugees and internally displaced people typically experience high mortality immediately after being displaced10; the most common causes of death are diarrhoeal diseases (including cholera and dysentery), measles, acute respiratory infections, and malaria, often exacerbated by malnutrition. 10 11 Morbidity from communicable diseases and psychological distress is common, 12 13 and injuries from firearms, antipersonnel landmines, interpersonal violence, and other causes have not been adequately explored and documented. Disabilities related to injury are likely to require long term health care, and providing such care may be costly. 10 14 Food insecurity, crowding, poor access to water and sanitation, and stress increase susceptibility to illness. The damage and breakdown of infrastructures increases exposure to disease and diminishes opportunities for health. 5 15 Recent data on the negative consequences of sanctions and embargoes further illustrate these points.16 Excess mortality occurs especially in children,11 and unaccompanied and orphaned children and pregnant women are especially vulnerable to a variety of diseases. 17 18 Increasing knowledge Although there is a wealth of technical knowledge on which to base effective programmes, there are many constraints to implementing timely, efficient, and effective relief programmes. Conditions that are common in the area affected by disaster are often exacerbated, and displaced people may introduce novel infections into a host community or may become susceptible to conditions present within the area to which they have fled. 19 20 Lack of resistance to infection, immaturity of the immune system in very young children, and immunosuppression associated with malnutrition make children especially vulnerable. Despite dramatic improvements in emergency relief, the American Public Health Association concluded that “a large body of information documents the inability of the international community to prevent high rates of suffering and death in virtually all refugee situations … major failings in logistics, administration and an inability to establish sustainable programs are serious barriers to providing effective emergency relief.”21 These problems can be compounded by reactive and often ineffective practices sometimes carried out by inexperienced field teams. 22 23 In one study, experienced logisticians from a variety of non-governmental organisations, given a hypothetical crisis, were in little agreement about how best to provide essential emergency provisions, such as blankets, water, and fuel: “such a lack of consensus among experienced crises operators is both surprising and of concern.”24 These and other reports suggest that relief programmes tend to be ad hoc and would be more effective if they were based on the most up to date and valid knowledge bases, drew on a cadre of more rigorously trained professionals, and assured earlier and more effective programme planning and coordination.25 Accountability There is increasing recognition that relief efforts must be accountable both to the affected populations (potential “beneficiaries”) and to their donors. However, there are often few data regarding how potential recipients value or prioritise the aid response. Clearer conceptualisation of what affected populations seek from the international humanitarian response to their needs would be valuable. The UK Department for International Development has indicated a commitment to promoting good practice in humanitarian relief 26 through support to efforts such as the Sphere Project,27 which aims to establish minimum standards for good practice in the humanitarian field, and the Ombudsman Project, 28 29 which seeks to develop an accountability structure to ensure that the views of beneficiaries can be heard and that humanitarian agencies are more accountable to the populations they seek to serve. Governments, in turn, must expect to be challenged on their initiatives to reduce or manage conflict, as should donors in relation to their humanitarian and development assistance policies and practices. Value for money The large sums of money disbursed in response to complex emergencies, and the high costs of providing health care in these settings, has led to donors' concerns with “value for money.” Research to identify more effective and efficient approaches to the delivery of aid should therefore be promoted. Indeed, there has been little study to examine the effect of aid on the duration, magnitude, or outcome of war. Returning home to East Timor, November 1999 (Credit: ED WRAY/AP PHOTO) A detailed critique of the international response to the 1994 Rwanda crisis concluded that in the face of massive resources from governments and the general public (in the order of $1.4bn between April and December 1994),3 several factors, notably an enhanced level of policy coherence (see box), would have increased effectiveness and value for money.3 There is a dearth of relevant literature on the cost effectiveness of humanitarian interventions, with few...