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. Write a brief summary of the main ideas presented (300 words). Here is a rubric for this assignment: A summary is a concise paraphrase of all the main ideas in an essay or article. See more information on summarizing in these links,… 2. Following the summary of the article, you selected formulate an open-ended question that would generate a discussion on the topics covered this week. The questions should lead discussions and not answered in a yes or no format. Your classmates will write a short response essay to your question. Here are examples of open-ended questions from the Module 1 Readings:
As a health provider, physician, nurse how can learning (reading/writing) narratives influence their work in providing health care?
What is the significance of narrative medicine?
How long should a health provider spend with a patient to listen to their stories. Explain your response
How does narrative medicine affect the sick, or people with health issues?


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Journal  of  Global  Health  Perspectives  |  
Understanding Complex Humanitarian Emergencies in the
Horn of Africa: Causes, Determinants, and Responses
Daniel Chacreton
University of South Florida College of Public Health FL, USA
Corresponding Author: [email protected]
Over the past one hundred years, billions of dollars and countless man hours have been spent on
humanitarian relief efforts, yet these humanitarian emergencies are continually occurring, and
some at even greater frequencies than ever witnessed before. The contemporary approach to
humanitarian aid has, thus far, in many cases, led to little or no sustainable change in the
communities of interest. The purpose of this paper is to explore and identify the reasons these
emergencies continue to occur, gain an understanding for why many aid efforts have largely
been ineffective in the Horn of Africa, and to present alternative approaches to humanitarian aid.
To accomplish this aim, a thorough review of pertinent articles and documents outlining the
region’s past and present was conducted. The research has highlighted the fact that the complex
emergencies occurring in the region today cannot be credited to a single catalyst or event. Those
working in humanitarian aid need to make a concerted effort, using evidence based public health,
to understand and address these emergencies and all of their driving factors, be they religious,
political, climactic, tribal, or any other cause identified.
Journal  of  Global  Health  Perspectives  |  |  December  21,  2013  
Copyright  ©  2013  First  Aid  WorldWide.  All  rights  reserved.  
Many situations can be categorized as a humanitarian emergency. Famine, drought, civil war,
ethnic violence, and any number of events that place a large number of people at risk can be
correctly classified as large scale emergency situations. However, there are occasions when
multiple hazards coalesce in a way as to make them difficult or impossible to deal with
separately. These “complex emergencies” can involve any combination of the mass displacement
of a population, disease outbreak, social or political instability, and food or resource shortages
[31]. The difficulties involved in dealing with emergencies of this nature, are what make
complex emergencies such a serious concern for humanitarian aid workers. In medicine, to
eliminate a disease we must identify what causes, prevents, and effectively treats it. This same
model of disease intervention can be applied to humanitarian aid efforts. For this reason, this
paper will attempt to identify and explore all variables affecting the present humanitarian
situation in the Horn of Africa.
Region and History
The Horn of Africa includes the nations in the eastern most point of Africa. Although, there is
some debate over exactly which nations make up the Horn, for the sake of simplicity, this paper
will adopt the World Health Organization’s (WHO) classification. The WHO considers the Horn
to include Somalia, Eritrea, Djibouti, Ethiopia, Kenya, Rwanda, Burundi, and Uganda [29]. Over
the years, many of these nations, like much of Africa, have developed reputations for civil strife
and political unrest. When we examine the course of history in the region, it is clear that this area
has never been considered a bastion of stability.
Going back to the fifth century A.D, the Aksum Empire, a predominately Judeo-Christian
culture, ruled much of what is now Ethiopia with, what was believed to be, the Punt Empire, as a
neighbor to the east [11]. As time passed, the empire of Punt gave rise to the Ifat Sultanate,
which occupied primarily the same geographic region. This transition was all but complete by
the during the twelfth century A.D [2]. However, during the tenth century A.D., the Arabian
empire began to work its way into the Horn of Africa. The Arabian Empire establishing trading
posts in an area where the Ifat Sultanate would later develop, bringing with it, Islamic culture.
Many factors came together and led to an eventual decline in the strength of the Aksum trade
network and economy, and the rise of the Ifat Sultanate and trade network. For example, the
continued eastward growth of Christian empires, the comparable westward growth of Islamic
empires, like Ifat, and regional angst caused by news of a series of European incursions into the
Middle East, in what became known as the Crusades, all created a powder keg waiting for the
smallest spark [2]. These early economic, power, and theological struggles would, by the
fourteenth and fifteenth centuries, turn into all-out war.
The warring, between vying factions in the region, continued on and off until the late nineteenth
century, when both the economic and societal fatigue, caused by prolonged wars and the
introduction of European forces, began to show their affects [2, 32]. The opening of the Suez
Canal in 1869, which allowed ships from Europe a more direct route to Asia, significantly
increased the strategic importance of the Mediterranean area [8], which in turn increased
international interest in the region, for both strategic economic and military purposes [16]. By the
early 1900s, much of the Horn of Africa was under either British or Italian control [10]. These
Copyright  ©  2013  First  Aid  WorldWide.  All  rights  reserved.  
two nations partitioned the region into agreed upon colonies and protectorates [19]. While these
borders were agreed upon in Europe, this was not the case on the ground in Africa. As the
nations in the Horn began to gain independence, by the mid nineteenth and early twentieth
centuries, the old land disputes once again arose. Many of these conflicts, which have their roots
in battles, began, but not ended in the distant past, continue today.
The Impact of Politics
It has been said that, “public health is politics.” This is has proven to become an incredibly apt
statement, when we begin to consider the causes and origins of many complex emergencies. To
understand, and confront, complex emergencies we must understand where, how, and why they
began. More often than not, complex emergencies are a direct outcome of war, both inter and or
Political disputes over land and ideologies led to war between Ethiopia and Somalia, in 1977
[25]. Over the next decade, the military, political, social situation in Somalia quickly
deteriorated, culminating in the ousting of the nation’s longtime leader Siad Barre. His
overthrow set in motion a series of events which ended in Somalia’s eventual descent into chaos
and failed statehood. The state of perpetual war in Somalia has had devastating affects on its
people. According to the United Nations High Commissioner for Refugees [28], there are
currently 770,154 Somali refugees living abroad, which is the 3rd largest refugee group from one
nation behind only Afghanistan and Iraq. The gravity of this number is further emphasized by the
fact that Somalia is a nation with a population estimated at just above ten million individuals [6].
In fact, in 2009 alone, 119,000 Somalis, or one percent of the nation’s population, fled the
country out of fear for their safety [28].
The majority of those who fleeing Somalia find themselves in Kenya, which hosts the third
largest number of refugees in relation to size of its economy [28]. Such massive movement of
desperate and poorly supplied individuals has a deleterious impact on the economies, health
systems and governments of all nations involved. It has been estimated that the cost of opening a
second refugee camp in Jordan, to host refugees fleeing the Syrian Civil War, was $28 million
(US), with a monthly operating cost of $140 million [12]. Such massive investments in nations
operating with limit budgets can have far reaching effects.
A very similar, yet not as volatile, situation is seen in Eritrea. After Eritrean liberation from Italy,
in 1941, the United Nations, led by Great Britain, felt that in order to better safeguard the Horn
of Africa from Soviet intrusion, Eritrea should become part of Ethiopia [10]. The UN General
Assembly resolution of September 15, 1952 [19], was intended to loosely link Ethiopia and
Eritrea, however, Haile Selassie I, then the Emperor of Ethiopia, took this opportunity to change
Eritrea’s national language along with their flag, move many Eritrean national industries into
Ethiopia, and start a very harsh and brutal campaign to minimize dissention [30]. Needless to
say, the systematic annexation of Eritrea was met with immediate resistance and open hostilities.
For nearly fifty years, the fighting between these nations continued, until December 12, 2000,
when both nations signed a border demarcation agreement [15]. Much like Somalia, the people
of Eritrea have borne the brunt of the damage from years of combat. Despite the fact that Eritrea
only has a population of close to six million people, giving it the 108th largest population in the
world, it was the ninth largest contributor to the world’s refugee population, as of 2010 [26].
Journal  of  Global  Health  Perspectives  |  |  December  21,  2013  
Copyright  ©  2013  First  Aid  WorldWide.  All  rights  reserved.  
The years of corrupt and nepotistic ruling by Siad Barre, in Somalia, created a great deal of
resentment and anger in those whom were not in his favor. As displayed earlier, unresolved
conflicts and historical wrongs have a way of festering, and growing into resentments so deep
they become nearly unresolvable. In this way, blood feuds are born. The decisions made decades,
even centuries, ago have created the intractable problems that continue to plague the Horn of
Africa today.
Politics is possibly the largest causative factor when it comes to complex emergencies. At times,
government officials, in both developed and developing nations, can act in their personal or
ideological best interest and not in that of their citizens. Still worse, in cases like the Rwanda
genocide of 1994, where an estimated 800,000 Rwandans lost their lives [24], governments can
directly work to cause physical harm to their own citizens. In Uganda, the extremely brutal
dictator Idi Amin was responsible for the murders of over 300,000 of his own citizens, over the
course of eight years [21]. Humanitarian aid workers owe it to the people they seek to help, to
consider the political variables of a situation before planning an intervention. Beginning an aid
effort without doing so can be counterproductive and even place individuals at risk of greater
harm in the long-run.
Food & Resource Insecurity
Wars are costly and demanding endeavors. The deleterious impacts of war affect a nation’s
economy in a variety of ways. The destruction of infrastructure, the loss of human capital, and
the reallocation of funds from development projects to defense spending, all have negative
effects on the population. Take for example the nation of Ethiopia. From 1974 to 1990 the
nation’s military expenditures increased from an estimated $5.7 million (U.S) to $124.3 million
(US) [13]. This reflects a 2080.70% increase in defense spending. During that same time period,
Ethiopia’s expenditures on health decreased from 6.1% to 3.2% of nation expenditures [13]. It is
estimated that Ethiopia’s conflict with Eritrea, has cost Ethiopia $2.9 billion, between 1998 and
2000   [3]. Between 1999 and 2000 Ethiopia spent an estimated $777 million dollars (US) on
defense [3], which was forty-nine percent of their total expenditures for the fiscal year. When
compared to U.S. spending during the wars in Iraq and Afghanistan, in 2010, the most expensive
year up to that point, the U.S. spent $689 billion dollars on defense, which is a substantial
amount, but still only 20.3% of all expenditures [7]. Some nations have been at war for such an
extended period of time, that no real development has occurred in decades, as is the case in
Somalia. The lack of health infrastructure, government safety nets, and economic opportunities
leaves these countries frighteningly vulnerable to economic and environmental shocks.
Refugees are a principally vulnerable population, often living in improvised camps outside of
their native communities. They frequently struggle to survive in unfamiliar environments with
little to no safety nets and are forced to live in the absence of the social support systems of their
home communities. A study of individuals displaced by the Ethiopian famines of the mid-1980’s
found that the crude mortality rate (CMR) for those living in the refugee camps was 7 to 10 times
higher than what was recorded for locals living in the same region [5]. While we do not possess
the technology to completely control droughts and famines, with planning and adequate
resources, we can mitigate their harmful sequela. The fact that individuals must flee their
Copyright  ©  2013  First  Aid  WorldWide.  All  rights  reserved.  
homelands in order to find food and water shows that these nations are not strong enough
economically or lack the political will to provide for and protect their people.
During complex emergencies, the problem of malnutrition is of great concern. The Center for
Disease control (CDC) found that in refugee populations with protein energy malnutrition (PEM)
rates lower than 5%, a CMR of 0.9 per 1,000 population was recorded [5]. However, in camps
with PEM rates of greater than forty percent, CMR rates reach as high as 177 per 1,000
population. Although refugees often receive food rations, the limited nutritional makeup of their
diets makes them especially susceptible to micronutrient deficiencies. One group of researchers
documented an elevated number of scurvy cases, which is caused by vitamin C deficiencies, in
Ethiopian refugees hosted by Somalia and Sudan. In their study, scurvy rates were found to be as
high as forty four percent in some camps [9].
Vitamin A deficiency can be a very serious situation leading to stunted growth, septicemia,
exophthalmia, and, in serious cases, death [23]. The CDC reported signs of vitamin A deficiency
in 7% of Somali children, in the late 1980’s [5]. The 2011 famine in Somalia put an estimated
750,000 at risk of death by starvation [26]. The serious problems that can arise from food and
resource insecurity explain why it is one of the most important determinant to the outcome of
complex emergencies.
The ineffective health systems that are usually associated with countries locked in prolonged war
and complex emergences, places their citizens at increased risk of disease and infection related
morbidity and mortality. Many diseases that have been eliminated, or largely controlled, in the
developed world continue to cause a great deal of suffering in the Horn of Africa. This region of
the world is disproportionality at risk of meningitis, diarrheal diseases, malaria, HIV/AIDS,
tuberculosis, acute respiratory infections, and polio [2]. Cholera, although preventable through
vaccination and improved sanitation, has remained endemic and, at times, epidemic in this
region. One of the worst outbreaks of cholera occurred in Somalia, in 1985, when 6,560 cases
were confirmed with over 1,000 of those resulting in death [5].
Another important, but often understudied aspect of these complex emergencies is mental health.
The atrocities committed in this region scar not only the body, but also the mind. Surveys of
Rwandan children, conducted after the 1994 genocide, found that seventy-eight percent of them
experienced the death of an immediate family member [1].This study also found that twenty-five
percent of these children spent 4 to 8 weeks hiding alone [1], in order to survive the massacre.
Still more horrifying, sixteen percent of the children reported hiding under dead bodies to escape
detection [1]. These events would be difficult for any adult to cope with, let alone a child.
Unmanaged grief or fear can lead to social and psychological disorders like depression and posttraumatic stress disorder. It is imperative that these societies deal with their grief properly, to
avoiding falling into a cycle of despair, resentment, and mistrust that can corrupt a nation. It has
been said that, “Man can live about forty days without food, about three days without water,
about eight minutes without air, but only for one second without hope” (Unknown author). The
psychological impacts of complex emergencies are too important to not be a fundamental aspect
of intervention, planning, and emergency response.
Journal  of  Global  Health  Perspectives  |  |  December  21,  2013  
Copyright  ©  2013  First  Aid  WorldWide.  All  rights  reserved.  
Possible Solutions
Contemporary responses to complex emergencies generally follow a uniformed progression,
regardless of the intervening organization. The first concern with, many humanitarian responses,
is the organized resettlement of the endangered population, in a new and safer area [27]. Once
the immediate safety needs are met the provision of food, water, and other essential resources
needed to survive becomes the most primary concern [27].The comprehensiveness of the
intervention is generally dependent on the resources available to the organization, and their
partners, conducting it. Interventions can be extremely basic, providing only shelter, food, and
water. On the other hand, they can be fairly comprehensive, including medical and dental
healthcare, reproductive health counseling, capacity building, and mental health programs. The
primary, and often only, goal of many complex emergency responses is to limit the immediate
morbidity and mortality associated with these events. The thinking behind this model, which we
will call the “Contemporary Complex Humanitarian Response (CCHR) model,” is to save lives
today and worry about everything else at later date. While the cost of planning for the mitigation
of the tertiary consequences of complex emergencies can, understandably, be prohibitive, too
often this stage of intervention planning and funding are neglected.
When it comes to the immediate protection of life, well managed, refugee camps do preform
admirably. Legros et al. [16] reported administering oral cholera vaccines to eighty-three percent
of the population, in a Ugandan refugee camp. This worked out to be 63,200 doses given at a
total cost of just over fourteen dollars (US) [16]. While, ideally, covering ninety percent of the
population is the goal, significant, population-wide protection has been achieved with the
coverage of only fifty percent of a community [17]. A coverage rate of fifty percent would lead
to an eighty-nine percent reduction in cholera cases [17]. Even the less grand interventions in
refugee camps can have a large impact. Peterson et al. [20] discovered that the simple presence
of soap in a family dwelling, regardless of regularity of use, has protective attributes against
diarrheal diseases. Dwellings without soap were 1.25 times more likely to have an inhabitant
contract a diarrheal disease [20]. It is clear that these interventions save lives. However, to be
sure we, as a public health community, are taking the most effective course of action, we must
evaluate the costs associated with the interventions we lead.
Although, the CCHR model has been adopted by the majority of humanitarian aid organizations,
it is not the only model of humanitarian emergency response. A few researchers have presented
the idea of helping by not helping. In their book “Dead Aid: Why Aid is Not Working and How
There is a Better …
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