Disasters and Complex Humanitarian Emergencies

1. Disasters and Complex Humanitarian Emergencies Tennessee Psychological Association Carol Etherington, MSN, RN, FAAN November 2, 2012

2. Global Catastrophic Events • Crete/ Santorini Tsunami 1645 BC (100,000) • Holland Sea Flood 1228 (100,000) • Bubonic Plague 1346-52 (25 million) • Calcutta EQ 1737 (300,00) • Flu Epidemic – 1918 (25 to 100 million) • Chinese Flood – 1931 (3.7 mil disease, drowning/ starvation) • Peruvian Avalanche – 1962 (3000 dead) • Bhopal India Chemical Accident – 19 84 (3000) • SE Asia Tsunami – 2004 (250,000)

3. High Profile U.S. Events • Johnstown, PA Flood 1889 (3000 dead) • San Francisco Earthquake- 1906 (3000 dead) • Nashville Train Wreck 1918 (101 dead) • Pearl Harbor 1941; D-Day 1944 • Coconut Grove Fire Boston, MA. 1942 (491 dead) • Vietnam War 1963 - 1975 • Three Mile Island 1979 • Hyatt Regency Walkway, Kansas City 1981 (113 dead) • Oklahoma City Bombing 1995 • Hurricanes- Galveston/06, Camille, Andrew, Katrina, Sandy • Tornados (Nashville Area) 1974, 1998, 2005; Flood 2010 • Persian Gulf War; Iraq War; Afghanistan • Sept. 11

4. Disasters/Traumatic Events • Natural: usually have warnings; may or may not have preparation time • Man-Made Accidental: dependent on circumstances • Man Made Intentional: dependent on circumstances

5. Anatomy of a Disaster • Predromes: early warnings • Pre-Impact • Impact • Post- Impact (Honeymoon, Disillusionment) Post Traumatic Stress<> Acceptance <> Recovery or Post Traumatic Stress<>Denial/Unremitting Emotion<>PTSD

6. The Characteristics of Natural Disasters • Extreme devastation, injuries, and death • Number of natural disasters is increasing, affecting larger numbers of people and causing more economic losses, but proportionately fewer deaths • Biggest relative impact is in developing countries and with the poor • Disasters damage infrastructure, including health infrastructure (contrast impact of a hurricane in Haiti versus U.S.)

7. The Health Burden of Natural Disasters • Tens of thousands die each year from natural disasters • Direct and indirect health effects vary by disaster • Earthquakes: kill quickly and lead to many injuries with other long-term effects • Volcanoes: deaths due to mud and ash • Tsunamis: immediate drowning, few injuries • Floods: increase in diarrheal disease, respiratory infections, and skin diseases; Mud Slides • Wildfires; Droughts, which can be deadly when combined w/conflict

8. What is a Complex Humanitarian Emergency (CHE) • A major humanitarian crisis of a multi-causal nature that requires a system-wide approach. • CHEs have been a major political, security and public health feature of the post-Cold War world. These man-made disasters account for more morbidity and mortality than all natural and technological disasters combined. • To deliver effective aid during CHEs, international relief agencies must have a solid understanding of the political and social climates in which they are operating. • They should base their health interventions on objective epidemiological data, especially standardized rates of morbidity and mortality.

9. Characteristics of CHEs • CEs have had greater impact on health in the last decade than natural disasters • Occur over prolonged periods of time • Combatants often target civilians • Often systematic abuse of human rights • Large numbers of people are displaced • Disruption of society leading to shortages of food and water; corruption, lessening civil interaction • Migration may lead to additional problems

10. Health Effects • Early in CHE, most deaths from diarrheal diseases, respiratory infections, measles or malaria • Diarrheal diseases in refugee situations • Measles in camps • Nutritional deficiencies • Violence against women often rampant; rape is used as a strategy of war, survival sex sometimes neessary

11. Addressing Health • Organize camps with safety and security in mind • Develop contingency plans for areas of probable conflict • Have materials and human resources staged to address displacement and health problems • Carry out an assessment of the displaced population; establish disease surveillance system • Strive for crude mortality rate below 1 death per 10,000 persons

12. Health Effects • Ensure that environmental and personal hygiene are maintained in camps • Provide 15 liters of water per person per day • People should not have to walk more than 500 meters to a water source • People should not have to wait more than 15 minutes for their water • Provide appropriate sanitation • Distribute food rations by family

13. Other General Interventions • Need to address diarrhea, measles, malaria, and pneumonia • Malnutrition is of exceptional importance • Continuing assessment of the health situation; critical in both natural disasters and CHEs • Practice prevention as soon as possible to prevent/curtail: outbreaks of disease, rising tensions; stay apprised of illness and unrest in surrounding areas of camps with local community as well as DPs

14. In 225 conflicts that occurred during the 20th century, 72 million deaths were conflict related; nearly half were civilians. They accounted for 35-65% of war related deaths and injuries

15. Evolving Role of Humanitarian Response • Distant History • International Red Cross (Henri Dunant) • American Red Cross (Clara Barton) • United Nations – UNICEF • NGOS/PVOs/VOLAGs – proliferated in the ‘90s • Faith Based Groups • More NGOS, GOs, GONGOS and UNIVERSITIES – proliferated even more in the ‘00s

16. Evolving Mental Health • WWI - shell shock • WWI - Combat fatigue • Vietnam – PTSD • Crime Victims – Crisis Intervention; rape trauma syndrome, battered wife syndrome • Rescue Personnel – CISD

17. Primary victims – direct injury, witness to injury and death; witness to terrible scenes • Secondary – loss of loved ones/friends, social structure, home, work, place of worship • Tertiary – rescue personnel or other caregivers In war and civil conflict, there is an abundance of all – as well as many categories that we probably have not even thought of.

18. Individual Risk Factors • Loss of loved ones or friends • Life threatening danger or physical harm • Exposure to gruesome death, or bodily injury • Extreme environmental or human violence or destruction • Loss of home and possessions • Lack of social support • Intense emotional demands • Extreme fatigue, weather exposure, hunger, or sleep deprivation • Extended exposure to danger, loss, emotional/physical strain • Exposure to toxic contamination • Proximity to the disaster

19. Population Risk Factors • Security • Internal /civil society conflict • Ill trained/too few caregivers • Culturally inappropriate interventions • Poor knowledge base of actual need • Poor assessment > poor program • No long term plan • False hopes and promises

20. Vulnerable Groups • Children • Fragile Elderly/Disabled • Serious and Persistent Mentally Ill • Chronic illness/injury • Economically Disadvantaged • Ethnic Minorities/Marginalized Groups • Veterans • Refugees/IDPs e.g. non native speakers

21. CDC: GUIDING PRINCIPLES FOR MENTAL HEALTH • No one who experiences a disaster is untouched by it • Most people pull together and function during and after a disaster, but their effectiveness is diminished • Mental health concerns exist in most aspects of preparedness, response and recovery • Disaster stress and grief reactions are “normal responses to an abnormal situation.” ; Survivors respond to active, genuine interest and concern. • Disaster mental health assistance is often more practical than psychological in nature (offering a phone, distributing coffee, listening, encouraging, reassuring, comforting). • Disaster relief assistance may be confusing to disaster survivors. They may reject disaster assistance of all types.

22. CDC: Survivor Needs & Reactions(Responses differ, but there are common needs)CDC • Concern for basic survival • Grief over losses: loved ones; valued/meaningful possessions; • Fear and anxiety about personal safety and physical safety of loved ones • Sleep disturbances, including nightmares and imagery from the disaster • Concerns about relocation and the related isolation or crowded living conditions • A need to talk, often repeatedly, about events and feelings associated with the disaster • A need to feel one is a part of the community and its recovery efforts

23. Reactions that Signal Possible Need for Mental Health Referral(Many responses to trauma can be expected, but some are cause for extra attention/concern.) CDC • Disorientation: dazed, memory loss, unable to give date/time or recall recent events • Depression: pervasive feeling of hopelessness & despair, withdrawal from others • Anxiety: constantly on edge, restless, obsessive fear of another disaster • Acute psychosis: hearing voices, seeing visions, delusional thinking • Inability to care for self: not eating, bathing, changing clothing or handling daily life • Suicidal or homicidal thoughts or plans • Problematic use of alcohol or drugs • Domestic violence, child abuse or elder abuse

24. Longer-Term Effects Checklist(Potential down-stream consequences of exposure to a natural or human-caused disaster ….. for victims and responders) • Nightmares • Intrusive thoughts • Uncontrolled affect • Relationship problems • Job/school related problems • Decreased libido • Appetite change • Blame assignation

25. CDC: Sources of Stress for Responders • Role ambiguity; Lack of clear tasks; Mismatching skills with tasks • Lack of team cohesion; Ineffective communication • Discomfort with level of danger or hazardous environment • Lack of/ too much autonomy • Intense local need for information ; getting accurate information out • Database/technology issues • Laboratory specimen tracking, reporting; resources/equipment shortages • Command and control ambiguities • Re-integration barriers; coworkers have to pick up your work • Lack of understanding or appreciation for what you have been through; lack of interest in the role you have had

26. DISPLACED PERSON CATEGORIES • Refugees • Anyone who, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, or membership of a particular social group or political opinion, is outside the country of his nationality and is unable, or, owing to such fear, is unwilling to avail himself to the protection of that country. • Asylum-seekers • Persons who have applied for asylum or refugee status, but who have not yet received a final decision on their application. • Internally Displaced Persons (IDPs) • People forced to leave their homes or places of habitual residence as a result of, or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or situations of natural or human-made disasters, and who have not crossed an international border. • Immigrants • In popular usage, generally understood to be a person who migrates to another country, usually for permanent residence and admitted to the U.S. as a lawful permanent resident.

27. Undocumented • Previously referred to as "undocumented or illegal aliens“; in a country without legal papers or (in the case of the U.S.) without a current non-immigrant visa such as H-1B. • Trafficked Persons • The term "trafficking" is used by international agencies to describe activities violence for certain exploitative purposes including prostitution. • Trafficking in human beings is probably the fastest-growing business of organized crime. • Although trafficking afflicts men and women equally, rough estimates by the UN suggest that between 700,000 to 2 million persons trafficked across international borders annually are women and girls. (http://www.unfpa.org/gender/trafficking.htm)

28. Refugees The 1951 UN Convention defines a refugee as “anyone who, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, or membership of a particular social group or political opinion, is outside the country of his nationality and is unable, or, owing to such fear, is unwilling to avail himself to the protection of that country.”

29. “Durable Solutions” for Refugees • Voluntary repatriation • Returning to one’s home country, considered the most desirable solution • Local integration • Establishing roots in the host or asylum country, may be an option if returning home is not feasible due to ongoing instability or conflict • Resettlement to a third country • For individuals not sufficiently protected in the original host country and/or who are considered particularly vulnerable (e.g. disabled/injured, women-at-risk, mixed ethnicity)

31. Refugees in the U.S.

32. Competition for scarce resources plays an increasingly important role in provoking conflicts and human displacement The result: more displaced persons around the world, including refugees and others to the U.S. and other developed countries. UNHCR Global Report 2009