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á
. Discuss how you will organize and conduct this initial assessment in MoShe. What
are the specific information/data to be collected and how you will go about getting this
information/data. You have a maximum of two weeks for this assessment.
Due to the impact from a prolonged period of contact, further exacerbated by
natural disasters there is a strong need for additional humanitarian relief work within
MoShe. The people of MoShe have suffered immeasurable disruption, terror and
suffering as a result of the political instability that has wracked the country since the
monarchy rule was ended in 1960 with a coup. In order to begin offering support and
aid to the affected populace of MoShe an initial assessment is needed in order to
understand the requirements of the population, and how to best support those needs.
As the fighting and instability continues between warring factions there is a strong need
to conduct a quick assessment, which allows for a quicker provision of support. As our
organization, Save Them All (STA), is committed to becoming established over the long
term supporting programs within the Siongo continent, a rapid assessment may not
prove sufficient to enough of an understanding of MoShe͛s biggest needs. A more in-
depth analysis that would be recommended, utilizing a variety of survey techniques,
observational insight and aggregation of health indicators that will allow for a stronger
picture to be developed regarding the status and needs of the various groups within the
population.
In order to begin the assessment the first priority would be ensuring the security
of the team entering MoShe. With the significant violence among the warring guerrilla
groups as well as the PRM, there is a significant risk to any foreign groups working
within the region. As there is little to no functioning government there would be
difficulty securing protection from them and as such there would be a need to
coordinate with other groups working within the country including the UNHCR who is
currently managing the Vihiga refugee camp. Additionally I would require all team
members are required to have completed the UN Operations security training; this will
help ensure they are self-aware and prepared to manage the challenging and dangerous
situations that are involved when working in a conflict zone.
There are four main areas around which data collection should occur:
background information, population, health status and environmental conditions. A fifth
and often-overlookedconsideration would be an evaluation of the local response
capacity. Given the long-standing disruption throughout MoShethe local capacity has
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likely been significantly impacted, if not completely diminished. Focusing on background

information, an understanding of the historic, geo-political, economic and social factors
that have contributed to the current situation in MoShe. As presented in the
background dossier (i.e. case study) provided to the team, STA has a strong grasp on the
historic and geo-political factors playing into the current situation. This information
could be supplanted by additional first-hand observations by the team regarding the
current social and economic climate.
The task of gathering information about the population of MoShe will be
challenging, as there is a need to interact with many different groups who are currently
at odds with each other. Information gathered would include the size and composition
of the various demographic groups in MoShe. Particularly important would be an
examination of the three major tribal groups, the Nutsha, Langho and Har(and
additional smaller groups), andthe impact felt by each. A further examination into the
religious division across these ethnic groups could help shed light on what sides of the
conflict each group falls. Further information that would be gathered involving the
people of MoShe would be more detailed information regarding the population and
how it is distributed. This could be based on the most recent (2008) population estimate
however there would be a need to use predictive techniques to understand how the
population has changed since conflict has broken out. As mentioned above, a thorough
understanding of the population will help identify vulnerable groups, which allows for a
more tailored response as to what the inhabitants of MoShe need.
The next component of the information gathering would be the vital health
information of the population. This includes surveying the current health infrastructure
to understand its current capacity. Additionally various surveys of the health status of
different population sub-groups would be performed to gain an understanding of the
health and nutritional status of MoShe͛s inhabitants. Nutritionalindicators could include
Height for Weight, Height for Age, MUAC (among children), typical dietary intake among
other things. Further the health survey would focus on developing an understanding of
the common health problems that are found within MoShe beyond what was indicated
in the background dossier. Finally surveys would enquire about current morbidity rates
as well as mortality rates, both among particular groups (ie infant mortality, deaths from
childbirth, mortality under 5 years old etc) and across the overall population groups.
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The final aspect of the information-gathering phase would involve gathering data
regarding the environmental conditions that need to be accounted for. This includes
surveys to gather information about the current state of the water supply, be it wells
and surface water (ponds, lakes, streams) or municipal sources. Further information
regarding the sanitation and latrine situation will help build a strong understanding of
water and sanitation issues currently present. This is particularly important in areas
where large amounts of individuals are living after being displaced as a result of the
conflict (both Internally Displaced Persons as well as refugees at camps in neighboring
countries). The close living quarters that these situations entail offer a dangerous means
for disease to quickly spread through polluted water sources. Further environmental
information that would be critical to planning aid provisions would be roads and other
infrastructure elements. As seen with the Haiti disaster, limited infrastructure would
complicate efforts to bring large amounts of personnel equipment and supplies into the
country (Dolmetsch, 2010; Cox, 2010). Consideration of the logistical challenges that
would be involved with a response would be of the utmost importance as MoShe is a
landlocked country without easy access, further complicated as various countries
including Hola have already closed their border with MoShe.
In order to properly collect the information discussed above, a variety of tools
will be used to generate a practical picture of MoShe͛s most pressing needs. First key
informant interviews will allow for a great amount of information to be gleaned from
individuals ranging from tribal leaders, community health workers, to healthcare
personnel. Further needs understanding would come from interviews and group
discussions among members of different ethnic and religious subsets of the MoShe
population. These two points of information will provide a strong picture of what are
current pressing needs and what is seen as the largest priority at the current moment.
Further insight can be gained from community surveys utilizing the nutritional metrics
mentioned previously to estimate nutrition status of MoShe͛s citizens. Furthermore
checklists and questionnaires can be used to gather additional information regarding
health practices, current eating and nutrition information, psychological effects
stemming from conflict exposure and other details. Finally examining medical records
available in clinics and hospitals (it remained unclear from the case study if there was
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still healthcare infrastructure intact) could offer clues about overall population traits
with regards to disease and morbidity.
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c
Cox, Lauren &Salahi, Lara. (January 14, 2010). ͞Haiti Earthquake Medical Aid May Take ͚Military͛-Style
Operation͟ ABC News.Retreived from: http://abcnews.go.com/Health/HaitiEarthquake/medical-aid-haiti-
earthquake-military-style-organization/story?id=9555705
Dolmetsch, Chris. (January 22, 2010). ͞UN Urges Haiti Coordination as Supplies Flood Airport͟
Bloomberg.Retreived from: http://www.businessweek.com/news/2010-01-22/un-urges-haiti-relief-
coordination-as-supplies-flood-airport.html
Onyango, Monica (January 28, 2011) ͞Health Assessments & Meeting Basic Needs of Displaced
Populations.͟ Class Lecture ʹ IH 755
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á . Discuss what you see as some of the opportunities and challenges which an aid
agency may encounter in starting projects inside MoShe? What suggestions would you
give in an attempt to overcome some of the challenges you mention? Justify your
answers. (
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c As mentioned throughout the plans for an initial assessment by a team from STA
(Save Them All), there are a variety of significant issues that must be addressed in order
to start combatting the public health and humanitarian crisis currently faced in MoShe.
Given the many years of unrest and disorder faced as a result of the variety of political
factions struggling to maintain power, there is a significant burden on the wellbeing of
MoShe͛s inhabitants.This situation also represents the largest obstacle to setting up aid
and relief projects within the country, as working within areas of conflict can endanger
aid workers. The security of aid teams working within such an environment remains
critical to establishing programs that remain functional and effective over long periods
of time. As mentioned by Brabant in his article, there is a pressing need for an increased
focus on ͞conflict analysis and monitoring, threat assessment and incident analysis,
since together these form the basis for appropriate security management.͟ (Brabant,
1998) Without a strong understanding of the current and impending political
developments that are liable to occur, aid agencies can unnecessarily expose their
teams to harassment, violence and even kidnap. The ability for STA teams to work
beyond the metropolitan areas of MoShe would be impeded by the insecurity and
quasai-lawlessness that is prevalent only a short distance beyond city limits.
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The continued lack of a functioning central government makes the situation

extremely volatile, as there remains a continual threat of attempts to seize power by the
warring militia factions. This is only further exacerbated by ͞tribal, religious and regional
loyalties͟ as mentioned in the background dossier provided on MoShe. This represents a
potential confidence building opportunity however as there is a chance for lasting bonds
to be established with the various groups currently present within MoShe. By reaching
out to explain the mission intent of STA, there is a possibility to establish a great deal of
trust among residents of a country that have been habitually mistreated and given false
hope by each successive group that has seized power. Further challenges are dictated by
the environment and natural hazards that are endemic to the region. The resulting
impact from ͞earthquakes, floods, landslides, fires, windstorms, epidemics and pest
infestations (locusts etc)͟ would cause large scale disruption throughout the country.
The impact of such natural hazards would force major disruptions to both the local
populace as well as any aid projects underway within the country. The impact from this
would cause many to potentially lose their access to shelter, safe drinking water as well
as food. The infrastructure throughout the country would be greatly impacted by such
disasters and would likely cause supply and logistical challenges in maintaining ongoing
programs. This would only be further complicated by the landlocked nature of the
country which means that a vast majority of supplies likely have to be flown into the
country as trucking through neighboring countries may not be a feasible option.
There is a strong opportunity to create a lasting impact on the health status of
children and infants throughout the country, through the establishment of a system to
provide vaccinations. As reported in the background dossier, there is a high prevalence
of measles among the internally displaced and refugee population. This has been
somewhat addressed through injections being given at refugee camps, however
children who have remained within MoShe currently suffer a much lower vaccination
rate for this particularly deadly disease. There will be potential barriers to overcome
from parents and other community leaders who may fear vaccination attempts.
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However, the earlier opportunity examined that would work to build up trust among
these key opinion leaders can potentially mitigate this barrier.

c
Brabant, K. V. (1998), Cool Ground for Aid Providers: Towards Better Security Management in Aid Agencies. Disasters,
22: 109ʹ125.doi: 10.1111/1467-7717.00080
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ácUNHCR has divided -
   
into three smaller camps (‘ ccc ). The
populations in these camps are as follows:  
-95,000,  
-85,000;  
-
100,000. STA plans to implement the following programs in camp A.

The Vihiga refugee camp has been established for about four years and is
currently under management by the UNHCR. Developing a system to effectively handle
the water and sanitation needs for the camp is of the highest priority. Given the
established nature of the refugee camp there are certain differences to tackling this
problem some, which make the process more difficult. Given the established nature of
the camp, there is no need to perform a site analysis to select placement for the camp.
Further the choice to co-locate near permanent water sources will have already been
made and so the proper way to begin a water and sanitation program would be to
evaluate the existing system and identify shortfalls in what is currently being provided.
The current size of the camp, as well as the continued influx of refugees, is undoubtedly
placing a strain on the local water supply and proper planning to ensure that it remains
a viable source of clean water is crucial. In order to work in an organized fashion four
critical components of the water and sanitation supply need to be defined. The four
aspects are the objectives of said program, contingency planning, the action phase
where objectives are implemented and finally the logistical considerations that are
needed to ascertain the program͛s stated objectives.
The objectives of the water and sanitation program can be listed as a series of
bullet points to outline the critical components of the response, which can then be
broken out further.
×c Site evaluation to examine the current water supply and the ability for
the water source to meet the daily and continued water needs of the
camp
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×c Parasitic and microbial analysis of the water supply to determine the

level of contaminants or other hazardous components present that could
create a health hazard
×c Projections to establish the expected number of refugees that will
continue to arrive in order to accurately predict and prepare for future
water needs of the camp
×c Planning for treatment of the water to help ensure the safety of camp
residents against disease
×c Sanitation assessment of the current latrines present in the camp,
including an appraisal for the management of waste to ensure that it
doesn͛t taint the water supply
×c Further analysis is warranted to begin establishing the epidemiologic
origin for the dysentery and cholera outbreak that is currently a challenge
for the camp
×c Planning for construction of new latrine locations, and if warranted
reconstruction of shelters or other structures to make room for new
latrines to be built within the camp
These bullets outline the major objectives to establishing a water and sanitation plan
within the camp. With a current estimated population of 95,000 individuals, Camp A
represents the second largest among the three sub-camps within the Vihiga refugee
zone. In order to supply this many individuals with water there is a need to ensure that
the water supply can offer a minimum necessary amount per day at levels established
by the UNHCR. As mentioned in the UNHCR͛s Technical Support Document entitled
͚Access to water in Refugee Situations͛ there is a need to ensure an average of more
than 20 litres per person per day. (UNHCR ʹ Techincal Support Section) For a population
of 95,000 that means there needs to be a supply of 1.9 Mln liters on average on a daily
basis.Further the UNHCR recommends that water taps be adequately placed throughout
the camp so as to provide water to 80-100 individuals (200-300 from a ͚hand tap͛
outlet). This means that there will be a need to lay additional piping for a greater
number of water supply pointsthrouhgout the camp. This is particularly important
because of the huge amounts of energy that refugees would otherwise expend carrying
water back to their residence, a major problem for a group that is likely suffering from
undernutrition and/or malnourishment as a result of long-time disparity in their home
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country from internal strife. The widespread complaints of the current disease
prevalence for water-borne diseases would indicate that the current supply merits
further examination in the form of water testing to determine the safety of the water.
A full audit of the water supply from its groundwater source through the water
system to the points of distribution can identify weaknesses that can be strengthened
with building projects to enhance the quality of the water supply. This audit will likely
identify areas where potential contamination points exist and they can then be
mitigated. Forward thinking will be essential during the audit phase as the influx of
refugees can likely be expected to continue increasing the number of residents within
the camp, which will place a greater demand on the water system.
Finally the sanitary needs of the camp needs to be considered, as it is a critical
component to inhabitant wellbeing. Crowded living conditions, particularly in camps
such as Vihiga, can serve as hotbeds of disease. The chilling reports of the continuing
cholera epidemic currently gripping Haiti underscore the necessity of effectively
planning for proper waste management.(Karunakara, 2011). The current placement of
latrines remains inadequate, leaving many to abandon their use and leave their waste
throughout the camp. Another objective that needs to be considered regarding the
outlying placement of latrines is security. Although security likely falls under the control
of another aid group working in conjunction with the UNHCR, coordination remains
essential. This will involve working with the organization tasked with security to secure
latrines so that camp residents may use them without fear of violence. Gender based
sexual assaults have been reported in the areas around the latrines particularly after
dark, a trend that needs to be halted. Finally the objectives and planning stage should
conduct an audit to find new areas for placement of latrines, finding the means to
integrate them closer into the camps living areas. By placing latrines only at the edges of
the camp, the original planners erected invisible barriers to their use because of the
distance many have to travel just to reach the toilet facilities.
Contingency planning will involve preparing for the inevitable expansion of the
camp as new residents arrive. Although the UNHCR recommends that smaller camp
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sizes (of around 10,000 residents) be maintained when possible, there is a clear
expectation that the current population of 95,000 at Camp A will swell in number as
new refugees arrive. This will necessitate careful planning so that new residents can be
accommodated while still working to improve the living conditions and not allowing the
increasing population size to detrimentally impact current residents.
First steps in taking action to address the water and sanitation challenges would
be to begin construction of new latrine areas. The placement of these new latrines is
essential to achieve the highest possible utility for residents (which will encourage
utilization and hopefully mitigate disease spreading potential from freely deposited
human waste). By placing them properly throughout the camp there is the potential to
greatly reduce the incidence of dysentery and cholera within the camp. An example of
ideal placement of latrine and water faucet areas from the UNHCR technical support
document is shown below. While this represents an ideal placement of shelters, latrines
and water collection points, the fact that the camp has already been established for
about four years needs to be remembered. This document serves to guide the setup of
new camps and so the suggestions aren͛t entirely feasible however the adequate
spacing between water and latrines is a point that should be considered when new
latrine sites are established. The team will need to broach the sensitive subject of
relocating some shelter spaces in order to create gaps within the residential areas that
can accommodate the growing latrine need. This needs to be done carefully so as to not
create a distrust from the refugees as they have been displaced in a very traumatic
manner by previous fighting in MoShe. This means that any attempt to move these
individuals once again may very well be met with significant resistance.
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(UNHCR ʹ Technical Support Section Document)

Further the action stage needs to consider what needs to take place in order to
ensure that adequate supplies and manpower can be brought into the region. As the
refugee camp is located a good distance from most developed areas, this represents a
significant logistical challenge. There is likely a need to fly resources into the region
utilizing the airport that adjoins the capital city of MoShe, Mamba. This will likely be a
costly endeavor because of the expensive nature of air transport, however there are not
many alternatives considering the landlocked nature of MoShe. Proper convoy planning
and procedures as outlined by the UN Security Training course will be used in order to
ensure that the resources make it to the camp. Although it isn͛t stated in the document
if there is a water border within Butere (the country where Vihiga camp is located) this
may be a more reasonable consideration when planning supply delivery. This would
require additional logistical and planning considerations, as there would invariably be a
need for negotiations with the government of Butere to secure the passage of the goods
and personnel through the country to the camp͛s location. All in all the management of
water and sanitation issues represents a significant challenge that will present an
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ongoing set of issues that need to be continually evaluated and mitigated to effectively
provide the necessary facilities and services to the population of camp A within Vihiga
camp.
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͞Access to water in Refugee Situations; Survival, Health and Dignity for Refugees͟ UNHCR ʹ Technical
Support Section, Division of Operational Support ʹ Online Resource Guide: Retreived from:
http://www.un.org/waterforlifedecade/pdf/unhcr_water_brochure.pdf
Karunakara, Dr. Unni. (24 January, 2011). ͞Inadequate cholera response in Haiti largely because
of failed aid structure.͟ Retrieved from http://www.bostonhaitian.com/node/354
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á Write a reflection paper on ‘ of the articles/documents assigned for this class
(required or recommended). To complete this assignment, please answer the following
questions

Drawing upon an early article, Complex Humanitarian Emergencies: A Major

Global Health Challenge, I would like to reflect on the major points of disparity and
disease that have been outlined as central to the incidence of most complex
humanitarian emergencies. There are three major detriments to a population that is
embattled in a complex humanitarian emergency, whether caused by natural disaster or
civil unrest, instability and violence. Disease, food access & nutrition and finally violence
directed towards certain groups have become defining components of what comprises a
complex humanitarian emergency. Disease, particularly preventable infectious disease
have been consistently found to be the major cause of morbidity and mortality in almost
every CHE that displaces large groups of people. This is generally facilitated by the
displaced population finding themselves either forced to move repeatedly and having
non continuous access to water and other staple items or the crowded conditions that
are found within camps housing refugees or IDPs.
Another major point looked at access to consistent food sources and the
resulting malnutrition that is found among victims of CHEs. Acute protein-energy
malnutrition is a significant factor in morbidity and mortality among the affected
population. As I have learned through my nutrition class with Kirk Dearden this
semester, nutrition (or the lack thereof) can be found to be a culprit behind many
childhood deaths in developing settings. The weakened immune system response allows
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for a much greater impact from disease and infection that a healthy individual may have
otherwise been able to fight off. This was echoed by the article which states: ͞Although
food scarcity is the major cause of malnutrition during most CHE, concurrent illnesses,
especially chronic or recurrent diarrheal disease, may also be a significant factor.͟
(Brennan, 2001)
Finally a third commonality found in almost any CHE is the impact from violence.
Those particularly affected include vulnerable groups such as single women, children
and the elderly. Particularly vulnerable groups are women who are often subjected to
sexual violence. This has been an issue that is gaining more notoriety with respect to the
impact from CHEs, as it has become more discussed in recent years. I found it
interesting that this was mentioned as the main source of violence resulting from CHEs,
as I would have expected a larger impact that results across whole populations as a
result of civil conflict in a region or country (I may have read into that assertion wrong͙)
Something that hadn͛t occurred to me previously was how differently assistance
can occur depending on the status of a displaced group. Between refugees (those who
have transitioned across borders to neighboring countries) and internally displaced
persons there are significant differences in how aid can be provided. Once I read it I
agreed wholeheartedly that it is much more difficult to meet the humanitarian needs of
an IDP population. This is driven by the challenge of gaining access during the course of
a CHE, the potential for violence (generally the same violence that caused the group to
be displaced) and security of both IDPs and program staff, and finally the lack of a clear
international mandate by the UN. These three factors combine to make it exceedingly
difficult to meet the needs of this group. As they don͛t have a defined status as do
refugee populations (under the 1951 UN convention on the status of refugees) there is
little international ability to mandate their protection, support or otherwise provide
assistance.
I take issue with the assertion that major population displacements are a
prominent feature of most of today͛s CHEs. Although this is a broadly defined assertion,
I understand it to mean that large numbers of refugees are generated as they are forced
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to cross international boundaries in order to find a location that allows them to setup
(albeit temporary) living shelter, often in the form of aid camps. I think Haiti is an
example, although much of Port-au-Prince was leveled, there is still a large percentage
of the cities population living within close proximity to the city. They have shifted to
camps out of necessity as most structures were destroyed, but the general sentiment
among the Haitian resident group is to stay close to where they once were living. This
may shift as problems continue to develop such as the cholera epidemic but that
remains to be seen if significant numbers of Haitians will relocate away from the camps
into the countryside away from Port-au-Prince. This article creates a clear understanding
of what defines a CHE as well as discussing the major impacts that such events tends to
have on a population and so the link to disasters and response management is fairly
evident.
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Brennan, Richard J; Nandy, Robin. ͞Complex humanitarian emergencies: A major global health challenge.͟
Emergency Medicine. (2001) 13, 147-156