Failures of emergency relief
Authors: D P Southall
Journal: Journal of the Royal Society of Medicine (2005)

Following the Asian tsunami on 26 December 2004 in which 224 000 people died, 2005 has been a bad year for the poorest and most vulnerable and especially those living in areas of armed conflict.

Two recent reports contain a number of valuable suggestions for the better management of global emergencies.1,2

Oxfam's statement (18 October 2005) presents an outstanding response to the problem.1 It covers many issues, perhaps the most important being the role of existing extreme poverty in compounding the effects of natural events. This view is also echoed by Jan Egeland, the Emergency Relief Coordinator for the United Nations (UN) as follows: ‘Twenty million lives are at risk in forgotten and neglected crises in Western, Central, Eastern and Southern Africa. These are the silent tsunamis of our time’.3 Poverty prevention is the key, with one study showing that a disaster in a country with a high level of development kills an average of 44 people compared with 300 in a poorly developed country.4

This reality is placed in perspective by the latest earthquake in Pakistan where the Government is unable to spend more than 1% of its gross domestic product (GDP) on health because it uses between 75% and 80% to repay debt and service defence. The latter concerns its ongoing conflict with India over disputed territories in Kashmir, the epicentre of the earthquake. As a result, its state sector hospitals are barely functioning and completely unable to cope with large numbers of injuries from a natural disaster. Basically, a health emergency exists all of the time in Pakistan, as it does in most of the other poor countries in the world, particularly those in sub-Saharan Africa. In Pakistan a country of 150 million people, 27 530 mothers die each year during pregnancy or childbirth and 1538 children under 5 years die each day.5 If the UK was to have the same population size as Pakistan, the equivalent would be 216 mothers per year and 27 children per day.5

A second point made by Oxfam is how international support following many emergencies is determined more by media profile or political criteria than by humanitarian need—inevitable in this imperfect world. Many of the worst disasters, which have been happening for years and involve armed conflict, remain irregularly and inadequately reported. Since 2003 in the Darfur region of Sudan, more than 200 000 people have died from conflict. In the Democratic Republic of Congo (DRC) 2.3 million people have been displaced from their homes by war.1 Rich arms-trading countries must take the blame for much of this suffering. For example, the sale of 66 Hawk combat training aircraft to India by the UK in 2004,6 brought in US$ 1.7 billion. Such sales pressurize Pakistan to keep at level pegging with India to buy more arms for itself instead of improving its health services. Many rich arms-trading countries, such as the USA, have provided training and arms to both sides in conflicts (e.g. in the DRC).7

One of the most harmful failures of the world's response to sudden disasters is the delay in aid reaching those affected. Every hour can mean death or great suffering, especially in poorly-resourced countries where analgesic drugs are a luxury and a hospital emergency department for a population of 2 million looks like that in Figure 1. The UN's Emergency Relief Coordinator is currently presenting a plan to address this problem.2 The plan involves delegating responsibility to individual UN humanitarian agencies to collaborate with non-governmental organizations (NGOs) to provide clustering of expertise that could respond quickly. He proposes a Central Emergency Response Fund that could be rapidly deployed to UN agencies and NGOs and a strengthening of coordination between UN headquarters and the field. Oxfam calls for this fund to be US$1 billion.1 In this respect, it must not be forgotten that the most effective responders in the health sector will be local health workers who should be given maximum support.



Figure 1

A standard emergency room in a government hospital in Pakistan



The experience of Child Advocacy International (CAI) in emergencies would strongly support the above two proposals. In addition, it would recommend that a map of the UN, international and local NGOs working in every poor country be produced and kept up to date by the UN coordinator. When and if a natural or man-made disaster occurs in one of these countries, immediate support both in funds and resources could then be made instantly available to these agencies first so that there is minimal delay in implementation. The funds raised by appeals and governments should also first target those agencies with local knowledge and capacity before supporting assessments and actions by agencies who have no prior involvement in the country. Such mapping would also identify the areas where the population becomes vulnerable. For example, the food crisis in Niger could have been predicted many months before many hundreds of thousands of people were dying of starvation. Mapping by the UN could and should have prevented the appalling suffering resulting from this preventable emergency.

Individual governments in poor countries, no matter how they are perceived by the international community, must be supported in taking primary responsibility and actions for the response to an emergency. Ideally, with support from the UN, they should have in place a disaster emergency plan similar to that developed in the UK by the Advanced Life Support Group (Major Incident Medical Management and Support [MIMMS]).8 Such plans require structured training and cost relatively small amounts of funds. Countries should also work with their neighbours in preparing for their responses to emergencies.

The governments of rich countries must also be taken to account over their failure to provide adequate responses to the UN's appeals for the more than 16 million people at immediate risk in 10 neglected emergencies in Africa. In 2004 there was an annual US$ 1.3 billion shortfall in response to the UN's appeals;1 unacceptable levels of suffering and death will be the result. One helpful measure would be the re-distribution of donated funds, if excessive for one emergency, to another (perhaps less media profile) one. Certainly there appeared to be huge sums of monies donated in the UK for the Asian tsunami and yet very little to Niger, where suffering and deaths were relatively neglected.

Finally, the earthquake in Pakistan has again indicated the need for air support in those emergencies that involve a difficult terrain. The UN should have an advance plan that can provide, when needed, immediate air transport (such as helicopters) from the nearest countries to any new disaster. Long-standing military campaigns in the region should also be included in this mapping of preparedness by the UN. Military leaders must be willing to provide air transport and heavy engineering support if requested. Although it has now agreed to provide additional military air transport to help Pakistan over the earthquake,9 it was unacceptable for NATO initially to have refused a request by the UN for such assistance.10

In conclusion, there are and always will be disasters. The governments of every country should be prepared and able to act immediately if one occurs. Countries with extreme poverty—especially if they are also experiencing armed conflict—are most at risk and everything possible should be done to overcome these persisting evils. The trading of arms by rich to poor countries must end. The UN must follow through with its plans to better prepare for and manage emergencies, especially in the immediate aftermath. It is imperative that the mapping of the available capacity for an emergency response within every country (particularly the vulnerable poor countries) should be urgently prepared by the UN.