Caring for Children Amidst Chaos: Guidelines to Maintain Health
Burton, Adrian, Environmental Health Perspectives
It is a simple fact that young children are those most likely to die during humanitarian crises caused by famine, war, and natural disasters. Relief agencies are keenly aware of this and do their utmost to save as many young lives as possible as well as maintain the standard of health care children enjoyed before disaster hit. A 2006 report by the National Research Council, Child Health in Complex Emergencies, suggests, however, that these agencies' efficiency in terms of safeguarding child health might be increased if a set of common, comprehensive, evidence-based clinical guidelines were available for use by all.
The report defines a complex emergency as a situation of armed conflict, population displacement, food insecurity (which could be caused by extended drought, some other natural disaster, or other circumstances), or some combination of these situations with an associated increase in mortality and malnutrition. In addition, during the acute phase, the mortality rate will be at least double that of baseline.
Currently, the report shows, some agencies have their own guidelines for addressing certain areas of child health during emergencies, but lack them for others. Many, however, use guidelines produced by authorities such as the WHO and UNICEF--guidelines that were produced for stable, noncrisis situations, and that might therefore be less applicable in emergency settings. Still others have a distinct lack of clinical guidelines. In addition, many of those guidelines that do exist have either never been assessed for effectiveness or are aimed at physicians, when it is actually personnel with less medical training--including field-instructed volunteers not formally trained in the care of children--who often take on the bulk of child health care provision. Further, these guidelines may not be in a language local health workers understand.
The report throws down a daunting challenge: to produce a single set of locally adaptable clinical guidelines covering all child health problems likely to be encountered in emergency situations, then tailor them to the different expertise levels necessary and translate them into several different languages. This gargantuan task begs the question of whether this is feasible from the viewpoint of human and financial resources. Do relief agencies have the time, money, and personnel to devote to such a project? What would be the forum for such a venture? Who would provide leadership? Would the fear of surrendering independence hinder the adoption of common clinical guidelines by some agencies? In short--can this be done?
Why Child Health?
Children under the age of 5 regularly bear the brunt of the death toll associated with complex emergencies. The medical literature eloquently shows the need for special attention to child health in such situations. According to a 4 August 1993 JAMA report, of all those who died in the 1991 Kurdish refugee crisis, two-thirds were under 5 years of age. In the 10 April 1993 issue of The Lancet, another team reported that during the 1992 Somali famine, 74% of all children under age 5 in displaced persons camps died. Four years later, in the 5 April 1997 issue of The Lancet, yet another team reported that in 1996, 54% of all the deaths among refugees from Rwanda and Burundi who fled to eastern Zaire were under the age of 5.
"In today's conflicts, civilians are the main victims of war, and children bear a disproportionate degree of that burden," explains Richard Brennan, director of the Health Unit of the International Rescue Committee (IRC), a New York-based relief agency. "This problem is demonstrated no more clearly than in the Democratic Republic of Congo, where a recent countrywide survey showed that almost half of the deaths have been among children under the age of five years. The vast majority fall victim not to violence, but to the silent, indirect health consequences of conflict--diarrhea, malaria, pneumonia, and malnutrition. …