Lessons on humanitarian assistance.

Lessons on humanitarian assistance Miguel Gracia Antequera1 & Maria Morales Sua´rez-Varela2 Conflict almost completely destroyed Rwanda’s infrastructure in 1994. Natural disasters, as well as disasters caused by humans, have severely challenged humanitarian aid available within the country. In this study, we have analysed the experiences of nongovernmental organizations since the summer of 1994 to evaluate how these difficulties may be overcome. One of the problems identified has been restrictions on the ability to introduce effective health planning due to the poor quality of available local information. The implementation of effective plans that show due consideration to the environment and society is clearly necessary. Effective monitoring and detailed observation are identified as being essential to the continuity of existing humanitarian assistance. Voir page 609 le re´sume´ en franc¸ais. En la pa´gina 609 figura un resumen en espan˜ol. Introduction A nongovernmental organization’s project for taking health care to victims of strife in Rwanda is described. Conflict almost completely destroyed Rwanda’s infrastructure in 1994 and led to an urgent require- ment for assistance in the health field. Many nongovernmental organizations undertook projects aimed at alleviating the situation, and experiences gained during one of them are reported. Planning and implementation The nongovernmental organization concerned (the Adventist Development and Relief Agency) was already running a number of health centres in Rwanda, and consequently had some knowledge of the country’s population, resources and health infrastructure at the start of the conflict. One of these health centres was used as the base of operations. The initial requirement was to provide health care for some 700 000 people in a rural area of 400 km2 at about 1800 metres above sea level over a six-week period during the rainy season. However, it was intended not only to bring immediate relief but also to train persons who would be able to maintain progress once the project had ended. Special attention was given to the selection of personnel motivated to work in extremely difficult circumstances, taking into account the unpredict- ability of human behaviour, even among volunteers. Thorough medical checks were performed on the selected individuals and vaccination was provided against yellow fever, diphtheria, tetanus, poliomyeli- tis, hepatitis B and typhoid fever; vaccination against Japanese encephalitis, meningococcosis A and C, hepatitis A and rabies was optional. Prophylactic measures were taken against malaria and diarrhoea. In order to meet the particular circumstances of the emergency, preparations were made for giving caesarean sections and other forms of surgical care. Treatment protocols and schedules were drawn up so that rapid and effective responses could be achieved, with the help of specialists and a range of publications (1–6). Common expressions in the local dialect were learned in the interest of communication at the grass- roots level. The team members were each responsible for preparing and maintaining the health equipment they needed and for providing a small medicine chest containing epinephrine, antihistamines, corticoids, analgesics, nasal decongestants, preparations for topical skin treatment, antacids, antidiarrhoeals, laxatives, antibiotics, anxiolytics, wound dressings and other items. Their personal effects included bednets, sunglasses, lamps, batteries, water bottles, lighters, writing pads, ballpoint pens, passports, vaccination booklets and currency. Adjustments to plans had to be made because of unpredicted factors. For example, the population of the area was increasing by some 5000 daily as refugees poured in from Zaire (now the Democratic Republic of Congo). Allowances had to be made for short-term and long-term effects and for actual and potential risks. A study was made of the geographical position of the team’s headquarters in relation to routes of communication, supply points, health missions, hospitals, national police and army units, United Nations forces, and other bodies, with a view to planning for evacuation and the rapid location of sources of support. The emergency medical kit consisted essen- tially of injectables mentioned in the protocols. There was an adequate supply of syringes, needles, catheters and drip equipment. For cardiopulmonary resuscita- tion there were oropharyngeal and nasopharyngeal 1 Physician, Department of Pediatrics, Hospital ‘‘Dr Peset’’, University of Valencia, Valencia, Spain. 2 Epidemiologist, Clinical-Epidemiological Unit, Hospital ‘‘Dr Peset’’, University of Valencia, Apartado 1891, 46080 Valencia, Spain (tel: 346 3862500; fax: 346 3862579; e-mail: Maria.m.morales@uv.es). Requests for reprints should be addressed to this author. Reprint No. 3178 607Bulletin of the World Health Organization, 1999, 77 (7) # World Health Organization 1999 tubes, nozzles and facial masks, together with manual aspiration equipment, a laryngoscope with various blades, and endotracheal cannulae. Foley’s catheters, plastic bags, clip forceps, sterile gloves and reagent strips for urine and blood were also provided. The health care equipment provided by the nongovernmental organization’s personnel included elastic and adhesive bandages, wire and plastic splints, cervical collars, sterile gauze, triangular and other bandages, sticking plaster, dressings treated with Vaseline, scissors, forceps, scalpels with spare blades, suturing materials, silk, catgut, syringes, needles, disinfectant and saline. Other items of equipment in this category were provided on the spot. The logistic requirements included a radio transmitter providing a link with headquarters in Kingali, other health care groups in the area, and Nairobi and Burundi; and a cross-country vehicle for transporting drugs, health care materials, food, patients and so on, driven by a local bilingual person capable of providing explanations required at checkpoints. A primary health care operation was conducted at the Rwankeri Health Centre. The treatment protocols proved to be of great value, since any health worker with basic diagnostic judgement was able to apply them, using the available medicaments. Patients’ health problems were tackled and attention was drawn to the need for correct hygiene, patient care and food preparation, and to essential procedures for dealing with wounds, diarrhoea and other matters. The population received basic educa- tion in hygiene and health, and training was given to three health workers from the community. Various contacts were vital for implementation, monitoring and follow-up. Spain, the home country of the nongovernmental organization, was not repre- sented diplomatically, so relations were established through Switzerland. Contact was made with local authorities, nongovernmental organizations, teachers, clergymen and other persons who could help to ensure widespread awareness of and participation in the project. Local people were recruited for manual work, cleaning, cooking, translation, health care and other tasks. Their involvement not only materially benefited the population but also increased the effectiveness of the project. Monitoring and follow-up An average of 200 patients were seen daily during the six-week period, and a record was kept of age, sex, diagnosis, treatment and, where possible, course, permitting identification of the commonest health problems (see Table 1). Malaria occurred mainly among the refugees from Zaire (because of the altitude there were no vector mosquitos in the area). In order to take account of the massive immigration that was taking place, the percentages in the table are based on an estimate of the average population during the intervention period. These statistics were communicated to the national authorities engaged in organizing health services. Also noteworthy, though less frequent than the conditions indicated in the table, were cases of abortion, complicated delivery, traumatism, tetanus and otitis. The disease pattern encountered was as had been expected, given the prevailing environmental and climactic conditions. The training of three local people enabled the work to continue after completion of the project, as was confirmed by another group from the same nongovernmental organization which visited the health centre four months later: it was estimated that 80% of its activities were being maintained even though there was no physician in charge. n Acknowledgements The authors thank the members of the Spanish health team and the many Rwandan colleagues who contributed to the findings reported here. Table 1. The most common health problems in the Rwankeri area Conditions Proportion of population affected (%) Upper respiratory tract infections 22 Intestinal parasites 15 Pneumoniaa 7 Rheumatism 6 Amoebic diarrhoea 5 Bacterial diarrhoea 4 Scabies 4 Oesophageal and gastroduodenal 3 pathologies Malaria 2 Ophthalmological disorders 2 Severe malnutrition 2 Umbilical and inguinal hernias 2 Tinea 2 Cutaneous ulcers and abscesses 2 Policy and Practice 608 Bulletin of the World Health Organization, 1999, 77 (7) Re´sume´ Enseignements tire´s de l’aide humanitaire Le conflit de 1994 a presque entie`rement de´truit l’infrastructure du Rwanda. Des catastrophes naturelles ont encore aggrave´ la situation et se´rieusement complique´ les ope´rations d’aide humanitaire dans le pays. Dans cette e´tude, nous avons analyse´ le travail accompli par plusieurs organisations non gouvernemen- tales depuis l’e´te´ de 1994 afin de de´terminer comment pourraient eˆtre surmonte´es ces difficulte´s. Nous avons notamment constate´ qu’il e´tait difficile de bien planifier les actions de sante´ a` cause de la mauvaise qualite´ des informations locales disponibles. Or l’e´laboration de plans efficaces qui tiennent duˆment compte de l’environnement et du contexte social est a` l’e´vidence une ne´cessite´. Il apparaıˆt qu’une surveillance efficace et des observations de´taille´es sont essentielles au maintien de l’aide humanitaire en place. Resumen Lecciones sobre la asistencia humanitaria Los conflictos acaecidos en Rwanda en 1994 destruyeron casi por completo la infraestructura de ese paı´s, y los desastres naturales, unidos a los causados por el hombre, han dificultado enormemente la ayuda huma- nitaria allı´ disponible. En el presente estudio hemos analizado la experiencia de las organizaciones no gubernamentales desde el verano de 1994, a fin de evaluar co´mo podrı´an superarse esas dificultades. Uno de los problemas identificados son las limitaciones impuestas por la deficiente calidad de la informacio´n local disponible a la hora de intentar llevar a cabo una planificacio´n sanitaria eficaz. Hay una manifiesta necesidad de aplicar planes eficaces que presten la debida atencio´n al medio ambiente y a la sociedad. Se sen˜ala que una vigilancia eficaz y una minuciosa observacio´n son factores esenciales para garantizar la continuidad de la actual asistencia humanitaria. References 1. Berkow R, ed. The Merck manual of diagnosis and therapy. 15th edn. Rahway, NJ, Merck, Sharp and Dohme, 1987. 2. Me´decins sans Frontie`res. Clinical guidelines – diagnostic and treatment manual. Paris, Hatier, 1994. 3. Principales conduites a` tenir en dispensaire. Niveau auxilie`re me´dical [Principal procedures to follow in clinics. Medical auxiliary level]. Paris, Me´decins sans Frontie`res, 1990. 4. Stanford JP. Guı´a de terapeutica antimicrobiana. [Guide to antimicrobial treatment]. Madrid, Dı´az de Santos, 1991. 5. Warren KS, Mahmoud AF. Tropical and geographical medicine. New York, McGraw Hill, 1984. 6. The use of essential drugs. Report of a WHO Expert Committee on Essential Drugs. Geneva, World Health Organization, 1992 (WHO Technical Report Series, No. 825). Lessons on humanitarian assistance 609Bulletin of the World Health Organization, 1999, 77 (7)