Viewpoint

What kind of evidence do we need to justify humanitarian medical aid?

Iron supplementation in children is recommended by WHO when prevalence of anaemia is above 40%. In Palestine, due to the emergency situation caused by the outburst of the second intifada, the nutritional situation of children is worsening and iron deficiency anaemia represent one of the most serious problem.

An emergency project which included universal iron supplementation (for 12,300 children), free treatment for common diseases and food supplementation to vulnerable families (for 3,275 children found anaemic or/and malnourished) and community health education was implemented in part of Hebron governorate.

To evaluate project's impact we performed two random surveys: one before and one after the project.

Before the project 30.1% of children (CI 95% = 24.5–35.6%) were found anaemic (<11 g/dl), while after the prevalence was 18.8% (CI 95% = 14.8–22.8%; decrease of 38%, p = 0.001). Levels and reduction in anaemia prevalence were different according to geographical areas: where prevention activities had been implemented in previous years, prevalence of anaemia was 17.1% and remained stable at lower levels (14.7%). In other areas it sharply declined from 47.4 to 21.7% (p < 0.0005): the declined was present only for children who received iron supplementation.

Comparison of anthropometrics index before versus after the project showed that low “weight for age” declined from 10.9 to 3.8% (p = 0.0006), low “weight for height” declined from 6.0 to 1.4% after (p = 0.0025).

With simple epidemiological tools we could demonstrate and measure the effectiveness of our interventions on the health status of the general population: a 50% reduction of anaemia and a 70% reduction of global acute malnutrition.

For humanitarian health-care practitioners bearing witness to violations of human dignity has become synonymous with denunciations, human rights advocacy, or lobbying for political change. A strict reliance on legal interpretations of humanitarianism and human rights is inadequate for fully understanding the problems inherent in political change. With examples from the HIV/AIDS epidemic in the USA, the Rwandan genocide, and physician-led political activism in Nepal, we describe three cases in which health practitioners bearing witness to humanitarian and human-rights issues have had imperfect outcomes. However these acts of bearing witness have been central to the promotion of humanitarianism and human rights, to the pursuit of justice that they have inevitably and implicitly endorsed, and thus to the politics that have or might yet address these issues. Despite the imperfections, bearing witness, having first-hand knowledge of humanitarian and human-rights principles and their limitations, and systematically collecting evidence of abuse, can be instrumental in tackling the forces that constrain the realisation of human health and dignity.

Mental health is becoming a central issue for public health complex emergencies. In this review we present a culturally valid mental health action plan based on scienti.c evidence that is capable of addressing the mental health effects of complex emergencies. A mental health system of primary care providers, traditional healers, and relief workers, if properly trained and supported, can provide cost-effective, good mental health care. This plan emphasises the need for standardised approaches to the assessment, monitoring, and outcome of all related activities. Crucial to the improvement of outcomes during crises and the availability to future emergencies of lessons learned from earlier crises is the regular dissemination of the results achieved with the action plan. A research agenda is included that should, in time, fill knowledge gaps and reduce the negative mental health effects of complex emergencies.

A pilot study was carried out among 223 war wounded and amputees in Sierra Leone in 2001 to investigate whether an intervention using proven medication for clinically diagnosed neuropathic pain would work in a developing country with limited health services. Compliance with medication was assessed in 79 patients and their pain and mood scores were assessed by questionnaire before medication and 6-10 months later. The pain and mood scores of 33 patients who stopped taking medication were compared for the initial and follow-up assessments indicating that, although the scores showed an improvement at follow-up, there was no significant improvement. Compliance was reasonable in 46 patients who continued with their medication, with 86.5% of possible doses collected, although many had difficulty understanding how to take the drugs properly. Their pain and mood scores showed significant improvement at reassessment indicating that pain will be reduced with a longer duration of treatment. This study showed that it is possible to run an effective intervention for neuropathic pain in Sierra Leone with intermittent expert involvement and MSF have been able to develop a protocol for the assessment and treatment of neuropathic pain that may be useful in other difficult settings in which they work.

Recognition of the need for evidence-based interventions to help to improve the effectiveness and efficiency of humanitarian responses has been increasing. However, little is known about the breadth and quality of evidence on health interventions in humanitarian crises. We describe the findings of a systematic review with the aim of examining the quantity and quality of evidence on public health interventions in humanitarian crises to identify key research gaps. We identified 345 studies published between 1980 and 2014 that met our inclusion criteria. The quantity of evidence varied substantially by health topic, from communicable diseases (n=131), nutrition (n=77), to non-communicable diseases (n=8), and water, sanitation, and hygiene (n=6). We observed common study design and weaknesses in the methods, which substantially reduced the ability to determine causation and attribution of the interventions. Considering the major increase in health-related humanitarian activities in the past three decades and calls for a stronger evidence base, this paper highlights the limited quantity and quality of health intervention research in humanitarian contexts and supports calls to scale up this research.

60 years ago, the Universal Declaration of Human Rights laid the foundations for the right to the highest attainable standard of health. This right is central to the creation of equitable health systems. We identify some of the right-to-health features of health systems, such as a comprehensive national health plan, and propose 72 indicators that reflect some of these features. We collect globally processed data on these indicators for 194 countries and national data for Ecuador, Mozambique, Peru, Romania, and Sweden. Globally processed data were not available for 18 indicators for any country, suggesting that organisations that obtain such data give insufficient attention to the right-to-health features of health systems. Where they are available, the indicators show where health systems need to be improved to better realise the right to health. We provide recommendations for governments, international bodies, civil-society organisations, and other institutions and suggest that these indicators and data, although not perfect, provide a basis for the monitoring of health systems and the progressive realisation of the right to health. Right-to-health features are not just good management, justice, or humanitarianism, they are obligations under human-rights law.