What should be done in acute emergencies?

SIR—Davis (Sept 28, p 868) convincingly challenges the assumption that children under age 5 years can be singled out as the most vulnerable group during acute emergencies and that, as a result, emergency public health interventions can be reduced to a standard package of child survival measures. We have witnessed in refugee camps how such focused strategies channelled a disproportionate share of scarce resources towards inefficient intensive feeding programmes for under-5s, in situations in which drinking water was lacking and diarrhoea rampant. In a highly absurd instance a 5-year-old marasmic child, not belonging to the target group of under-5s, was excluded from supplementary feeding. Age is often not the most important determinant of vulnerability—social factors are. Members of disrupted families (eg, female-headed households and unaccompanied minors) often suffer disproportionately, irrespective of age. That these result often from an adult death, be it before, during, or after flight, only adds to the arguments put forward by Davis. His focus is on emergency public health measures when survival is at stake, because of extreme crowding, lack of drinking water, basic shelter, and food. However, if the response to an emergency is adequate, then the situation can be brought under control within weeks, rather than months; and mass population displacement does not always result in a serious health crisis, especially when severe overcrowding can be avoided. Nevertheless, displacement-inducing situations tend to be long. The three case studies presented by Davis are still unresolved more than 2 years after their onset, and similar situations have rarely found a solution in less than a decade. Most of the world’s refugees and displacees are thus not facing an acute emergency. Most are living under conditions which could be qualified as chronic instability, be it in refugee camps, or as self-settled migrants. In these chronic situations, problems of displacement through flight are similar to those faced by those uprooted by development. The impoverishment can be understood through eight crucial dimensions: landlessness; joblessness; homelessness; marginalisation; increased morbidity and mortality; food insecurity; loss of access to common property assets; and social disarticulations. The type of assistance needed is not always well-known, but refugees usually have resilience and develop their own coping strategies. When their strategies for survival require mobility, external assistance—which demands they remain in one place—often undermines their ability to cope. As a consequence, many refugees and displacees choose not to be assisted and flee the protection granted by the aid-umbrella. In such situations targeting under-5s is probably even more counterproductive than in the emergency phase. Understanding people’s own coping mechanisms in unstable situations, and developing appropriate measures to