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Humanitarian Medicine

Humanitarian assistance is universal in that it seeks to assist those whose livelihoods and health are impacted by conflict, disaster or displacement. However, the backgrounds and expertise of those who provide it and the places which they work are diverse. Humanitarian medicine differs from the typical practices of medicine, whether locally or ‘globally,’ in that it deals with the complex humanitarian emergencies as ‘situations of disrupted livelihoods and threats to life produced by warfare, civil disturbance and large-scale movements of people, in which any emergency response has to be conducted in a difficult political and security environment.’

Often working without extensive auxiliary or administrative staff, providers of effective humanitarian relief sometimes need to work beyond the traditional confines of their training, while also respecting the principles of medical ethics.

The provision of healthcare in humanitarian crises is complex and can often be characterised by unstable or chaotic settings with high morbidity and mortality and insufficient time and resources. Treating patients in such environments may first require humanitarian workers to negotiate for humanitarian space, sometimes with armed combatants, and to design a clinical practice layout with reflects the security and contextual realities of the community that they are serving.

See: What could humanitarian surgery be?

The healthcare provider may be called on to run clinics or nutritional centres, combat epidemics, support surgery, carry out vaccination campaigns, or strengthen hospital management. Further, humanitarian workers must have a nuanced understanding of the specific contexts in which they work, especially in complex emergencies involving armed conflict, in which additional socioeconomic and political intricacies are often present.

Working effectively in Borno, Nigeria, requires an understanding of malnutrition, cholera, malaria, and an emphasis on water and sanitation.

Working in Yemen, by contrast, involves supporting surgical, maternal, and inpatient care for a population long exposed to conflict and reduced access to healthcare. Treating Syrian refugees in Jordan means a focus on chronic and non-communicable diseases.

Principles of Humanitarian Medicine

Humanitarian medicine has developed tremendously over the preceding decades, but in a way that still recognises its origins in the nineteenth century Red Cross Movement. The Red Cross’s Founder was Henri Dunant, a Swiss Businessman who encountered thousands of soldiers of multiple nationalities lying wounded near Solferino, Italy, during the 1859 War of Italian Unification. Dunant assisted the wounded and wrote a book about the experience, highlighting the need for a cadre of pre-trained volunteers ready to assist in emergencies and calling for the establishment of an international relief society. His idea was that aid workers should be allowed to enter the battlefield unarmed as long as they agreed to remain neutral in a conflict. The Red Cross Movement was born out of this idea, and Dunant went on to participate in the drafting of the Geneva Conventions that enshrine the concepts of rules in war, and of protection for humanitarian assistance. The Red Cross is now universally recognised as the guardian of international humanitarian law.

Humanity, neutrality, impartiality, and independence are widely accepted humanitarian principles, forming the bedrock of humanitarian assistance. The United Nations (UN) Office for the Coordination of Humanitarian Affairs (OCHA) summarises these key principles as follows:

Humanity: human suffering must be addressed wherever it is found. The purpose of humanitarian action is to protect life and health and ensure respect for human beings.

Neutrality: humanitarian actors must not take sides in hostilities or engage in controversies of a political, racial, religious, or ideological nature.

Impartiality: humanitarian action must be carried out on the basis of need alone, giving priority to the most urgent cases of distress and making no distinctions on the basis of nationality, race, gender, religious belief, class or political opinions.

Independence: humanitarian action must be autonomous from the political, economic, military, or other objectives that any actor may hold with regard to areas where humanitarian action is being implemented.

Response Phases  

The acute, active phase of an emergency response is often considered a core activity period of humanitarian response, but in reality, preparations start well before a possible disaster, and extends well beyond the initial response. Humanitarian action can be seen as a relief-to-development continuum, although lines are often blurred. (See Fig 2.2)

Preparedness Phase

The objective is to reduce the risks associated with a humanitarian crisis by addressing the source of the vulnerability and likelihood of an event occurring and preparing for the possibility of an unfortunate event to happen.

Short Term: relief phase

The first relief is usually done by the population themselves during and immediately after an event. In the days and weeks that follow the onset of the emergency, a coordination mechanism for the aid is put in place by OCHA in agreement with the government.

Intermediate: reconstruction, early recovery

This is the period of time when the focus of the humanitarian actors shifts to starting reconstruction and rehabilitation of the community. During this phase, the government can re-establish, the pre-crisis government mechanism.

Long term: transition to development

This covers the period of gradual exit of the international humanitarian actors and handover of activities to the population and government.

Emergency Operations

Humanitarian crisis response requires three elements:

➊Staff trained for emergency operations

➋Emergency stock strategically located

➌Emergency procedures

Emergency situations often require different approaches to allow an immediate response which emphasizes speed and flexibility. A fast response can start with incomplete information, and is equivalent to the idea of ‘launching a missile first and then guiding it.’

Most organisations use a ‘push-pull’ strategy, including the use of prepositioned kits in their warehouses to start an operation.

Push-pull strategy

Push

At the start of a crisis response, a rapid assessment can be done to allow an organisation to estimate what goods are needed.

These goods are then ‘pushed’ towards the crisis from stock.

During this initial response, a team typically conducts a more thorough needs assessment, while other members of the team are providing services and distributing necessary supplies.

Pull

As the initial response finishes (about 2-3 weeks), improved needs assessment allows the team to clearly determine needs.

They then order, or ‘pull’ the goods towards them as needed.

The ‘who’ and ‘what’ of aid

With the increasing number of international humanitarian responses, it is useful to consider what goods and services are being provided-and who, in the absence of humanitarian crisis, should provide them. For this, it is useful to categorise goods:

➮Public goods: goods provided by the state and whose delivery is a crucial part of the social contract between the state and its citizens. Citizens pay tax and in return, public goods are provided which confer legitimacy on the state.

➮Private goods: goods normally provided by a private company in a competitive market.

➮Mixed goods: goods that are provided by both the private and the public sectors.

 Right to Health and Legal Advocacy

The right to health and to healthcare is a fundamental human right in all situations of peace or conflict. However, it falls short of being applied concretely to many patients around the world due to individual states’ health policies and financial commitments to affordable medical care and an international context where the price of drugs is an obstacle for numerous LIC or MIC. Further, in situations of war, despite prohibitions by IHL, attacks on the wounded and sick, healthcare facilities, and personnel are occurring at an increasingly alarming rate. Whether or not they are dismissed as a mistake, ‘justified’ by the loss of protected status or committed with the intention to spread terror, they lead to practical deprivation of healthcare to the population. The healthcare workers in developing countries, may face retribution for speaking out on the injustices faced by their patients, so human rights organisations and INGOs therefore can play a key role in giving voice to healthcare workers’ and patients’ demands. If there is a medical intervention that is not accessible or suboptimal for a given population, simply raising awareness about the need for change may not be enough. medical advocacy uses testimonies and data to create strong argument for change.

Medical Advocacy

Medical advocacy can be a tool to address seemingly uncompromising medical challenges and has developed in many ways. Organisations, such as Physicians for Human Rights (PHR), use medicine and science to document and draw attention to mass atrocities and severe human rights violations, focusing on the protection of medical institutions and health professionals working on the frontline.

Another approach has been Health Care in Danger Project, an initiative from the ICRC and Red Crescent Movement aimed at increasing awareness and addressing the issue of violence against patients and healthcare workers, facilities, and vehicles, and ensuring safe access to healthcare in armed conflict.

Physicians for Human Rights: https://phr.org

Health Care in Danger Project: HCiD – home

Source: OXFORD HANDBOOK OF HUMANITARIAN MEDICINE