Public Health Challenges During a Humanitarian Crisis

As the conflict in Israel and Gaza escalates, the humanitarian health effects are worsening. In this interview, Dabney P. Evans, PhD, MPH, associate professor of global health and director of Emory's Center for Humanitarian Emergencies, discusses the cascading public health problems that arise during humanitarian crises and how public health professionals and leaders can approach these challenges.

In terms of public health, what are the most common issues that will arise during humanitarian crises? What are we seeing in Gaza specifically? 

Health needs exist in every situation. What we can expect during humanitarian emergencies is that whatever conditions are already present in any given situation are going to be exacerbated by the crisis. For example, if you are in a context in which malnutrition is present, that malnutrition would be exacerbated by any humanitarian emergency—in fact, famine can be a complex humanitarian emergency in and of itself. But most frequently what we see is rises in infectious disease. Measles in particular is one that is highly transmissible. And so typically one of our first actions in a humanitarian crisis would be to do a universal measles vaccination campaign.

We also will see other forms of infectious disease, so we can see waterborne disease. Some examples include cholera and typhoid as well as other diarrheal diseases. These infections can be particularly dangerous since they cause dehydration very quickly. 

Of course, living through a pandemic, we're all familiar with respiratory diseases like COVID, but also flu and other viral infections, which also can be present and exacerbated when large groups are clustered together and when health systems are weakened as often happens in humanitarian emergencies.

All of these health issues are particularly impactful on vulnerable populations, which can include children, particularly those under age five, pregnant people, and elderly people. Additionally, people with non-communicable diseases or chronic conditions like diabetes or heart disease, will likely have difficulty meeting their regular medical needs, for example, having access to medication.

In Gaza, we are learning that up to two-thirds of health facilities are not functioning. This means that people who require medical care are not able to receive it—and if they do receive care, it is likely suboptimal. We know that large numbers of people have been displaced and that many have been injured as a result of the conflict. This is in addition to ongoing health needs. For example, there are estimated to be 50,000 pregnant people in Gaza, each of whom need prenatal care alongside support during childbirth.   

Bottom line: War and conflict are bad for health. 

What types of public health supplies can be the most helpful or needed during a humanitarian crisis?

When we think about humanitarian crises, we tend to think about three different buckets, and those are health care goods, facilities, and services.

• Facilities are the most straightforward. Those are health care centers, hospitals, clinics, ambulatory centers, the same facilities that we would see in any setting—whether those are permanent health centers or ad hoc mobile clinics.

• The second bucket would be health care goods. Those are materials such as medications, including the essential medicines on the World Health Organization's essential medicines list. Such goods may also include fuel, which is required to run health equipment like incubators and generators.
• And then when we think about services—and those are most closely aligned with health care professionals. There are many things that people can do for themselves, especially those who have non-communicable diseases or chronic conditions in terms of treating and taking care of their own health. For example, a person with diabetes may know how to give themselves insulin or treat a low blood sugar. However, there are always going to be situations in which people need professional medical advice and treatment. This is especially important for situations where there are acute injuries, but also includes non-acute medical diagnoses and treatment. So, it’s critical that there are health care professionals who can provide services to the people that need them.

What about health care delivery and access?  

When we think about access and delivery, we tend to think about the AAAQ framework. This comes from the United Nations—and particularly General Comment 14, which details the right to health. And so that's where this AAAQ framework comes from. The acronym stands for availability, accessibility, acceptability, and quality.

• Availability has to do with the quantity of health care facilities, goods, and services—including essential medicines—and their distribution in each context.

• Accessibility includes geographic or physical accessibility, financially availability (affordability), and information availability. Importantly, accessibility also includes the notion of non-discrimination which is that all individuals must be able to have equitable access without discrimination. Can people actually get information, can they reach care, and can they afford it, independent of their identity?

• Acceptability relates to the question, "Are the health care goods, facilities, and services culturally appropriate for the context and respectful of medical ethics?"
• And then the question of health care delivery really speaks to quality, and that is quality in terms of medication, of course, making sure that medications are not expired or of poor quality, but also making sure that health professionals have adequate training and are able to interact appropriately, again, coming into that acceptability framework for people that are receiving care.

In terms of public health supplies and aid, what is needed most in Gaza?

In recent days, humanitarian aid has slowly begun to flow into Gaza. The aid that is currently flowing in is a drop in the bucket and much more is needed to ensure that the health needs of the population are met.  Keeping these humanitarian corridors open will be a priority for ensuring that the situation does not worsen further.

What other types of public health challenges may become a problem during times of crisis?

I would highlight two issues that are known to be exacerbated during emergencies and which may not receive as much attention or support as is truly necessary.

The first is gender-based violence. We know from prior humanitarian emergencies that gender-based violence increases during emergencies. As a result, any preparedness efforts need to plan for meeting survivors' needs and ideally having plans to prevent violence. Importantly we have guidance on responding in emergencies and so we have a clear north star on what needs to happen including preventive measures, clinical care and referrals for survivors, needs assessments, and the provision of psychosocial support.   

That leads me to the second issue, which is mental health. Physical health needs may be immediately apparent and often require urgent care. At the same time the mental effects of humanitarian crises and particularly trauma are often unattended since they may be less visible. Yet we know that physical and mental health are intertwined. We also know that trauma—especially early in life—can have short- and long-term consequences so part of any humanitarian response must include meeting the physical and mental health needs of those affected.