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Round Table Tuberculosis in Complex Emergencies Rudi Coninx A Round table Tuberculosis in complex emergencies Rudi Coninx a Abstract This paper describes the key factors and remaining challenges for tuberculosis (TB) control programmes in complex emergencies. A complex emergency is “a humanitarian crisis in a country, region or society where there is total or considerable breakdown of authority resulting from internal or external conflict and which requires an international response that goes beyond the mandate or capacity of any single agency and/or the ongoing United Nations country programme.” Some 200 million people are believed to live in countries affected by complex emergencies; almost all of these are developing countries that also bear the main burden of TB. The effects of complex emergencies impact on TB control programmes, interfering with the goals of identifying and curing TB patients and possibly leading to the emergence of MDR-TB. There are many detailed descriptions of aid interventions during complex emergencies; yet TB control programmes are absent from most of these reports. If TB is neglected, it may quickly result in increased morbidity and mortality, as was demonstrated in Bosnia and Herzegovina and in Somalia. TB is a major disease in complex emergencies and requires an appropriate public health response. While there is no manual to cover complex emergencies, the interagency manual for TB control in refugee and displaced populations provides valuable guidance. These programmes contribute to the body of evidence needed to compile such a manual, and should ensure that the experiences of TB control in complex emergencies lead to the establishment of evidence-based programmes. Bulletin of the World Health Organization 2007;85:637–643. الرتجمة العربية لهذه الخﻻصة يف نهاية النص الكامل لهذه املقالة. .Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español In 2004 there were 9 million new cases where there is total or considerable affect entire countries (e.g. Afghanistan, and approximately 2 million deaths from breakdown of authority resulting from Democratic Republic of the Congo, tuberculosis (TB). Control programmes internal or external conflict and which Somalia, Timor-Leste) or parts of a coun- are difficult at the best of times, but the requires an international response that try (e.g. Darfur, southern Sudan). direct and indirect health and health- goes beyond the mandate or capacity of Situations that affect large civilian system effects of complex emergencies any single agency and/or the ongoing populations through war or civil unrest, complicate these programmes to such an United Nations country programme.” 1 food shortages and population displace- extent that many organizations choose These emergencies are characterized ment also result in excess mortality and not to implement them. However, as by extensive violence and loss of life; morbidity. These are caused not only TB is recognized as a major cause of massive population displacement; wide- by violence, but also by preventable mortality in long-term complex emer- spread damage to societies and econo- communicable diseases.3 Several of the gencies, several agencies have taken up mies; the need for large-scale, multifac- direct and indirect effects 4 of complex the challenge of establishing control eted humanitarian assistance; political emergencies impact on TB control pro- programmes in these circumstances. and military constraints that hinder or grammes: they interfere with the goals They have met the WHO targets for prevent humanitarian assistance; and of identifying and curing TB patients, successful programmes (to detect at least significant security risks for humanitar- and may lead to the emergence of 70% of estimated new smear-positive ian relief workers in some areas. MDR-TB, thereby compromising – or cases and successfully treat at least 85% Some 200 million people are be- at least complicating – future control of all detected smear-positive cases) lieved to live in countries affected by programmes. without increasing the rates of multi- complex emergencies. Almost all of There are detailed descriptions of drug-resistant TB (MDR-TB). these are developing countries which aid interventions during complex emer- This paper describes the key factors also bear the main burden of TB: ap- gencies in many countries, including and the remaining challenges for suc- proximately 80% of all TB patients live Afghanistan, the Democratic Republic cessful tuberculosis control programmes in sub-Saharan Africa and Asia.2 Hu- of the Congo,5 Kosovo,6 Sudan,7 and in complex emergencies. A complex manitarian aid workers all over the world Timor-Leste. However, TB control pro- emergency is defined as “a humanitar- face the major challenge of controlling grammes are absent from most of these ian crisis in a country, region or society TB during complex emergencies that reports as humanitarian aid workers a International Committee of the Red Cross, 29 Layards Rd, Colombo 05, Sri Lanka. Correspondence to Rudi Coninx (e-mail: [email protected]). doi: 10.2471/BLT.06.037630 (Submitted: 14 October 2006 – Final revised version received: 1 February 2007 – Accepted: 5 February 2007) Bulletin of the World Health Organization | August 2007, 85 (8) 637 Round table Tuberculosis in complex emergencies Rudi Coninx concentrate on the most obvious killers of many major aid agencies, produced a major challenge to set up (or maintain) during the acute phase of a complex consensus document intending to set health-care structures in precarious con- emergency: diarrhoeal diseases, measles, minimum standards.18 This document ditions, often in situations with little acute respiratory infections, malaria and says that poorly implemented TB con- or no effectual government. Often it is other infectious diseases.8 As TB is not trol programmes have the potential to pointless to ask for political commit- a visible killer in the acute phase it is do more harm than good, and warns ment as authorities not only have other rarely a priority in complex emergen- programme managers about the public priorities, especially in the initial phases cies, and often is left for the rehabilita- health risks of suboptimal programmes, of a conflict, but also may be unable to tion phase.9 But complex emergencies i.e. programmes with < 85% cure rate commit resources. Health infrastructures include situations of chronic conflict and fewer than six months of treat- may have been destroyed, or those that and political instability, often cover- ment.19 Programme manuals for refugee remain may have staff with basic train- ing entire countries for long periods, situations describe minimal conditions ing only. TB control is complicated and health-care workers are forced to and absolute contraindications for start- further by the concurrent epidemic of address issues beyond the immediate ing TB programmes20 in refugee set- HIV/AIDS and the enforced movement emergency. If TB is neglected it may tings. Often these are the hallmarks of of populations at short notice. Security quickly result in increased morbidity a complex emergency, e.g. open warfare problems hinder the logistics of supply- and mortality, as was demonstrated or a very unstable population, and also ing medicines and supplies on a regular in Bosnia and Herzegovina 10 and in valid contraindications. basis, and make it extremely difficult Somalia.11 Health-care workers now rec- Public health workers who agree to to follow up patients regularly. Poor ognize that TB (also HIV/AIDS) may be the International Standards for Tubercu- coordination between agencies with responsible for a relatively large propor- losis Care 21 know the standards against overlapping health programmes also tion of deaths among both adults and which they will be held accountable. may further complicate provision of children.12,13 TB is a major disease in These may be difficult to achieve in situ- health care. complex emergencies14 and requires an ations affected by the constraints typical The reconstruction of TB services appropriate public health response.15 of complex emergencies. Confronted has been described in the post-conflict By nature, TB programmes are with requirements for high standards phase as stressing coordination and col- multifaceted and complex. It is an ad- of care and bombarded with warnings laboration 9 or needing international ditional challenge to implement these about the risks of a suboptimal TB support.26 Experiences from several on- programmes in emergency situations control programme, many aid agencies going complex emergencies (such as in that affect large numbers of a civilian choose to wait until the situation has Afghanistan or the Democratic Republic population. Such situations produce stabilized and to concentrate on more of the Congo) suggest that the major constraints related to poor infrastruc- obvious and urgent health-care prob- impediments to establishing national ture, which is often destroyed; lack of lems. But complex emergencies often TB control programmes are: mobile human resources, often themselves af- last. Is it appropriate to delay when TB populations; destroyed infrastructure; fected by the emergency; and difficult prevalence rates exceed 300 per 100 000 lack of coordination and/or interest logistics, sometimes complicated by se- per year, and we know that absence of in TB treatment; scarce and/or poorly curity and/or ethnic issues. HIV/AIDS treatment, poor nutrition and general qualified human resources; difficulties
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