One World One Response

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Introducing a series on complex emergencies in

The Lancet less than two months ago, we noted that

Jan Egeland, the UNs emergency relief coordinator

on disaster reduction, was frustrated by the lack of

attention being given to natural disasters by the

international community. Now no longer, one

presumes. The devastation wreaked by the south-

Asian tsunami that struck on Dec 26, 2004, has kick-

started an unprecedented global response. Un-

qualified human empathy has been translated intounrestrained public acts of giving and helping that

have caught more cautious politicians unprepared.

There are huge lessons here for all heads of state to

learn, not least the need for a massive overhaul in the

way nations respond to episodes of humanitarian

crisis.

In addition to those who have died, the numbers of

people at risk of disease defy comprehension. WHO

estimates that 5 million people are presently without

access to basic services. Over 2 million people have

been displaced from their homes. And 15 million

children are either orphaned or separated from their

families. UNICEF has issued an urgent appeal for

US$81 million; WHO for $40 million. Yet the

international response to the publics generosity now

poses its own particular problems. According to US

Secretary of State Colin Powell, lack of money is not

the main difficulty facing relief efforts. Distribution

and coordination of aid are far bigger challenges. And

here there has been unnecessary confusion.

President Bushs delayed call for a US-led

humanitarian initiative seemed to conflict with the

UNs mandated role as principal coordinator of aglobal response. Former President Clintons proposal

for individual nations to take one-to-one respon-

sibility for assisting affected countries, while a

constructive suggestion given the scale of the

catastrophe, seemed to conflict with more

multilateral approaches. Meanwhile, even within the

UN system, the parallel efforts of WHO, UNICEF, and

the World Food Programme, each of which has been

rapid and robust, have demanded some kind of

central coordinationa necessity that remains

unfulfilled. The vital parts being played by amultiplicity of non-governmental organisations only

add to the grave need for strategic planning

Our recent attention to complex emergencies

underlined several critical issues that will now be

occupying those coordinating relief efforts. There is a

need for a continuous process of epidemiological

assessment across all affected regions. These

assessments will include surveys of mortality,

underlying risk factors (eg, prevalence of commu-

nicable diseases, such as measles), and nutritional

needs. It is surprising how often these measures are

not obtained. Their absence makes planning aneffective response almost impossible. While the

major causes of death in the immediate aftermath of

the tsunamitrauma, diarrhoeal disease, acute

respiratory infections, conditions affecting new-

borns, and malnutritionare predictable, these

remain commonly neglected aspects of almost all

emergency responses. The commonest under-

recognised needs are safe water supplies, basic

sanitation, and hygiene. The best way to make these

issues high priorities among those at risk is through

community mobilisation and outreachanother

under-recognised aspect of any response.

There will also be an obvious demand for high

population coverage with food and medicines. An

often forgotten challenge is the need to match food

provision with public-health intervention. Food acts

as a strong magnet for attracting people from

surrounding regions to the focal points of food

supply. Unless public-health serviceseg, safe water

are ensured, a rapid influx of people can overwhelm

pre-existing stretched resources, increasing rather

than diminishing risk. There will be additional special

needs in areas such as reproductive health (access tosafe blood transfusions and good obstetric care,

including caesarean section facilities), child (especially

neonatal) health, and mental health. All of these

demands require continuous monitoring. Although

the effects of the south-Asian tsunami have so far

been measured in numbers of casualties, mortality is

an insensitive measure of health risk. Better measures

will be needed in the weeks and months ahead.

Beyond these immediate priorities, what should be

the next steps in the global response? In the short-to-

medium term, several initiatives have already beendeclared. The UK, in its role as G8 chair, has led

welcome efforts on debt relief for countries affected

Editorial

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Editorial

by the tsunami. Chinese and Japanese political

leaders, together with Colin Powell and European

Commission President Jose Barroso, met this week at

the Asian Summit of Heads of State in Jakarta to pool

their thinking on ways forward. Next week will see a

UN-sponsored ministerial meeting to discuss pledges

of aid. But this visible concern and commitment

hides important weaknesses in the response so far,

weaknesses that illustrate severe and surprising

structural flaws in the international community.

Whatever statements are now being made by

presidents and prime ministers, there have beendisappointing political miscalculations. The most

extreme was Tony Blairs decision to continue his

holiday in Egypt while the bodies of his own country

people, let alone the corpses of tens of thousands

more, continued to wash up onto the shores of

south-Asian nations. His choice to remain on

holiday betrayed astonishingly derelict leadership

and cruel detachment. More importantly, Chinas

contribution to the tsunami response has been

meagre, not only in financial terms ($62 million,

against Japans $500 million) but also in logistics.China aspires to be a regional superpower. But its

lack of experience in joining multilateral pro-

grammes makes it an unusually weak partner. Asia

continues to rely on Japan as its regional centre of

geopolitical gravity. More encouragingly, the

European Union is now considering a proposal to

create a crisis management team to expand its

capacity to respond to civilian emergencies. As many

as 5000 experts across the EU might be part of this

on-call team, which could be deployed for

immediate relief and reconstruction.Still, there are disturbing uncertainties surrounding

efforts to upgrade global collaboration. Kofi Annans

leadership of the UN has been hit by US claims of

impropriety over the pre-war oil-for-food pro-

gramme in Iraq. This criticism has led Annan to

bolster his position by appointing a new chief-of-

staff, Mark Malloch Brown, formerly head of the

UNs development programme. But in the face of

this political storm, it will be hard for Annan to win

support for a stronger UNthe key reform that he

wished to leave as his legacy as secretary-general. A

further uncertainty resides in the World Bank. Under

the leadership of James Wolfensohn, the Bank has

adopted a far more pro-poor posture in its advocacy

and towards its loan arrangements. But

Wolfensohns liberalism sits uncomfortably with the

re-election of a conservative US president

determined to spend his recently won politicalcapital. The risk that the World Bank may retreat

from its more progressive development agenda is

real and worrying.

During this phase of continued crisis, we make two

proposals. The first is to create an inter-

governmental panelunder the umbrella of, but

structurally separate from, the UNto coordinate

emergency relief over the coming months in south

Asia. This panel should include representatives of

each affected country and be led by a person with

international stature, proven diplomatic ability,familiarity with global policy making processes, and

unbeatable communication skills. Former US

President Clinton, perhaps.

Second, we propose an International Commission

on Global Responses to Complex Emergencies. This

commission would draw on research evidence to set

out recommendations and mechanisms to respond

to man-made or natural disasters. Any catastrophe

should be the trigger for a regional or global

response that has been preplanned and tested in

extreme circumstances. It should not be, as it isacross the tsunami-hit regions of south Asia, that

competing agendas of governments, international

agencies, and aid organisations be allowed to

impede the publics wish that they put aside self-

interest in the spirit of pure human cooperation.

The Lancet

The Lancet today issues a call for papers describing experiences of health workers in countries affected by the south-Asian tsunami.

We want to publish descriptions of the conditions in which medical and public-health interventions are being delivered, the

challenges faced by relief workers, and reports of the health predicaments confronting local communities. These papers might

range from preliminary evaluations of responses to aid, to descriptive essays; from case reports, to photojournalism.

Please contact: [email protected]


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