Responding to emergencies: more than ‘first aid’

Has the humanitarian sector come of age? What lessons can we learn from past experience? What needs to be reformed so that we can better respond to people’s health needs in emergencies? Egbert Sondorp, from the London School of Hygiene and Tropical Medicine, introduces this new issue of Health Exchange and invites you to make your own contribution to the debate via this website.

The number of humanitarian non-governmental organisations (NGOs) expanded rapidly during the 1980s and 1990s. This growth came about in part as a result of the many conflicts after the Cold War, the ability of the NGOs to work in difficult circumstances and across borders, and an increased desire from donor agencies to channel funding through NGOs. Currently, there are around 300 permanently established NGOs that provide humanitarian assistance. Others may spring up in response to a specific emergency. The bulk of NGO humanitarian assistance goes through only six NGO consortia: CARE, Catholic Relief Services, Médecins Sans Frontières (MSF), Oxfam, Save the Children and World Vision. NGOs, the International Red Cross and Red Crescent Movement, a range of UN agencies and donors make up what we usually refer to as the international humanitarian system.

Assistant nurse Benjamin Beh in Zwedru, Grand Gedeh county, Liberia
Photo: Simon Rawles, Merlin

Humanitarian assistance has become big business, a major industry some would say. In 2010, almost 16 billion US dollars were available. While food aid received by far the largest share, the next largest sector was the health sector, with a share of around 1.4 billion USD.

Does this mean that the humanitarian sector has come of age? Some argue that good progress has been made. Others say that the same old mistakes still hamper the system, with problems about coordination always high on the list. The recently held Second Annual World Conference on Humanitarian Studies, in Boston, provided an interesting example. In one sense, the very establishment of this World Conference, which provides a venue where scholars and practitioners can meet to discuss the many aspects of humanitarian work, is the sign of a sector coming of age. In one of the opening speeches there was indeed talk of progress made, of the increased evidence base in quite a few areas and of improved mechanisms for coordination, including the cluster system.

Later on, someone made a presentation on a study in Haiti, on the not-so-positive effects the relief operations had on the community and the health system following the 2010 earthquake. Someone in the audience moaned: “Why don’t we overcome the problem of not doing capacity building during crisis; what we already know is needed for three decades?”

Two of the articles in this issue on responding to emergencies clearly show this mix of feelings in relation to recent progress made in the system and to the health cluster. The health cluster is one of the results of a major reform process of the humanitarian system in 2005. Ron Waldman argues that despite a number of positive changes, it is not yet enough.

Some sweeping reforms of the reforms are needed. Linda Doull looks at the health cluster system from the perspective of a NGO. Merlin contributes a lot to the health cluster, both at country and global level, but this comes with a price. It is resource intensive and may pose a risk to the agency’s independence.

Humanitarian health work in the 1980s was initially primarily based on work in refugee camps. Lots of the knowledge built up during those days was laid down in MSF’s Refugee Health book and in the Sphere Handbook. Much of this knowledge could also be applied in natural disaster situations, or in the more acute phases of armed conflicts. However, prolonged, less intensive conflict comes with a set of different requirements, including the need to find ways to support the local health system. The paper by Emily Burn and Yasmin Mohamed from THET describes such a situation in the extremely difficult context of Somaliland. Only the long term partnership that THET could offer seems to be able to gradually find the right way to strengthen the health system in this environment. Fiona Campbell describes the need for a long-term partnership under the fragile conditions that Liberia and DRC pose. She also points to the tension existing between the need for a long-term perspective and the short funding cycles of donors in these (post-) emergency settings.

Mental health and care for disabled people were definitely neglected areas in those early days. As Katia Eloi Cenat from Handicap International describes, much can be done in this field, provided the resources can be found for these activities that do not receive the limelight of the media. While mental health now receives much more attention, the field still suffers from conceptual ambiguities as to the best intervention options, for individuals as well as communities. Willem van de Put is nevertheless cautiously optimistic that more evidence will become available to identify the right interventions in the right context.

During major disasters most focus is usually on aid brought in from the outside. Much less attention is given to what the local population is able to do, particularly during the first hours. Hardly any attention at all is given to efforts prior to a disaster, in terms of risk management and disaster planning. Maria Hamlin Zuniga describes what can be done through civil society in terms of preparedness and risk reduction.

A more recent development is the attention for humanitarian crises in urban environments. For instance, internally displaced people (IDPs) may end up in cities, difficult to trace and difficult to assist. Ronak Patel and Fredrick Burkle describe the lack of health care in urban slums as a humanitarian crisis. Some may not agree on labelling this a humanitarian crisis, at least not one that is amenable to a ‘quick fix’, where the humanitarian community is still at its best. But equally the ‘development community’ may not have an answer. The article describes a number of interesting examples where health gains can be achieved through grassroots approaches.

Disasters and other emergencies will always be different from each other. The context determines the effects and options for intervention. Every new event comes with new lessons, as is clearly described in Ryuki Kassai’s piece on the recent disaster in Japan.

The collection of papers in this issue provides a fascinating insight in many aspects of humanitarian health work that proves to involve so much more than just first aid. While lessons have been learned over the years, still more learning is needed. The recent launch of the new edition of the Sphere Handbook ( is a clear sign of the ongoing learning. Replacing the 2004 edition, the new edition aims to consolidate best practice that has emerged over recent years.

We intend to post more articles on humanitarian health work in the September issue. But please do not wait to post your comments on the articles in this issue on the website. Quite a few issues raised are calling for further debate!

If anyone would like to contribute an article for the September update, please contact Alison Dunn at

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