The debate over nuclear, chemical and biological weapons weapons of mass destruction (WMD) has so far centred on the preparedness and protection of relief workers caught up in a Middle Eastern war. The challenge for the humanitarian community is, however, much broader. Should humanitarian agencies respond to WMD victims? If so, what preparation, training and equipment do they need? For every victim of a nerve-gas attack, for instance, intubation may be needed, and oxygen administered that is one medic per patient. In the event of a biological-weapon attack, victims may need to be vetted and quarantined are refugee and displacement camps capable of this? Are camps designed to allow rapid construction of decontamination units for new arrivals should this be necessary? This article, based on a study by Merlin and the London School of Hygiene and Tropical Medicine, looks at whether, and how, agencies should plan to respond to WMD use.
WMD and the humanitarian imperative
Humanitarian organisations are required to take all possible steps to prevent or alleviate suffering arising out of conflict or calamity, and to act with sufficient independence to ensure that their assistance is impartial. Many agencies have extensive experience in providing services at short notice to large numbers of displaced people. They are not, however, trained, equipped or staffed to deal with issues of decontamination, unusual clinical diagnosis or treatment, hazard control and psychological care after a WMD event. This highly specialised knowledge, training and equipment currently resides almost solely with the military, which means that Western militaries alone may be in a position to render humanitarian assistance to WMD victims. Working with belligerent forces while maintaining core principles of neutrality, independence and impartiality poses particular difficulties for humanitarian agencies. While this continued dependence on the military is a cause of concern, at a minimum it may at least be worth considering acquiring some of the public-health capacity to assist victims of WMDs in the future.
How should agencies respond to the use of WMD?
Agencies will need to develop an independent, neutral capacity to respond to casualties of a WMD event, whether deliberate or accidental.
One of the major obstacles facing agencies is translating medical knowledge into treatment guidelines, emergency response kits and standards. Turning information about WMD into guidelines, procedures and protocols still needs to be done. At present, there is a wealth of confusing information that needs to be analysed and translated into aid-speak.
A starting point would be adapting existing clinical information into an accessible format for humanitarian workers in the field. Ensuring that staff have access to treatment protocols were key recommendations to emerge from an examination of health facilities response to the 1995 sarin nerve-gas attack in Tokyo. Although Japanese health workers lacked treatment protocols and training to care for casualties caused by chemical weapons, they did have a sophisticated hospital system with access to laboratories and a wide range of treatments. NGO field staff at present only have themselves and whatever supplies happen to be to hand.
Common protocols need to be agreed to enable the rapid collection of epidemiological information for effective early warning. The assumption that biological or chemical agents will be instantly apparent, and immediately identified, is questionable. Where agencies suspect that a WMD may be used, they may need surveillance and epidemiological systems in place. The design and standards for these systems need to be user-friendly, and practical enough to be implemented at field level.
Emergency drugs and equipment stock lists need to be reviewed and adapted to include materials essential to the care of victims of at least chemical or biological warfare. In some instances, it may be appropriate to have these materials packaged into kits to allow pre-positioning and rapid deployment. Current emergency kits contain some of the drugs required, but probably not in sufficient quantities. Clinicians responding to the sarin attack, for example, used up to ten times normal doses to save life. Decisions also need to be made regarding the potential provision of skilled supportive care, such as oxygen and intubation, which is not usually available in relief settings, but which can be critical to survival after exposure to certain chemicals and toxins.
Non-medical protocols and kits for water, shelter, nutrition and sanitation will also need reviewing. Decontaminating vehicles, people and equipment will require greater quantities of water, bleach and soap. Clothing may become an essential supply, since decontamination may necessitate the destruction of the clothes of people suspected of contact with biological and chemical agents. The design of IDP and refugee camps may have to be altered to allow the segregation of people believed to be infected with biological agents. Limiting the spread of infectious diseases may require quarantine for hundreds of thousands of people. How will this be managed if food has still to be distributed in quarantined areas?
The creation of an independent team skilled in biology, toxicology, public health and psychology, and accessible by telephone, radio or internet link, would enable NGO field staff to obtain immediate support in interpreting data, clinical management, protection and control methods. Some humanitarian staff may also need to be trained in the essential elements of early recognition, medical treatment and care of victims. This may be difficult and hard to imagine doing, but Western militaries train their medical personnel, so it should be possible for humanitarian organisations to do the same.
In sum, protocols, standards, systems, kits and supplies in both the medical and non-medical aspects of emergency relief work need to be reviewed and adjusted as necessary. This will take a considerable amount of work. Fortunately, a lot of the information needed to do this is available, albeit not in a format or style suited to humanitarian relief.
The need for coordination
It is very unlikely that, in the event of WMD use, individual agencies will be able to provide effective humanitarian assistance by themselves. Even more than in other types of emergencies, coordinated action will be the key to protecting and saving the lives of victims. Since coordination remains difficult, a platform of cooperation between those agencies willing to engage with WMD is probably necessary. In research for the WMD study, we found that many agencies saw their role as supportive or subordinate to the military, and so looked to non-neutral coordination for their direction. Rather than argue over the merits of such a stance, it is at least worth flagging up that agencies will probably need to ascertain in advance which of their number could respond to a WMD event if required. Agencies with a common view of impartiality, neutrality and independence may wish to consider creating a small, multi-agency, multi-sectoral humanitarian assessment team, protected and equipped to function in high-risk areas. While it is hard to imagine many volunteering for such a task, the job of independently assessing suspected WMD events may fall to the humanitarian community. In the event of a nuclear accident in North Korea, for instance, what is the regime more likely to accept a NATO assessment team, or one from the humanitarian community?
Hope for the best, prepare for the worst?
WMD has particular resonance and urgency at the moment. Yet even if the current Middle Eastern situation subsides, an event involving WMD appears increasingly likely, and could occur in many places in the world. The humanitarian community has a choice: it can either prepare to intervene to assist victims, or it can opt out. By starting work now, agencies may gradually develop a neutral, impartial and independent capacity to respond to WMD. The alternative is to hope that WMDs are never again used, or leave the response to others if they are.
Geoff Prescott is Chief Executive Officer, Merlin.
This article is based on a study entitled Hope for the Best Prepare for the Worst: How Humanitarian Organisations can Organise To Respond to Weapons of Mass Destruction (London: London School of Hygiene and Tropical Medicine/Merlin, January 2003). The report was written by Geoff Prescott, Linda Doull, Egbert Sondorp, Hilary Bower and Aroop Mozumder. It is available at: www.lshtm.ac.uk/hpu/docs/wmd.pdf; and at www.merlin.org.uk.
References and further reading
Damian Whitworth, Gas, Plague and Ricin, The Times, 9 January 2003.
C. Kelly, Humanitarian Response to the Use of Weapons of Mass Destruction, Humanitarian Times, 20 November 2002.
International Rescue Committee, Iraq: The Urgent Need for Humanitarian Co-ordination and Dialogue, Briefing Document (Washington DC: IRC, 18 November 2002).
World Health Organisation, Public Health Response to Biological and Chemical Weapons: WHO Guidance, second edition, 2001, www.who.int/emc/book_2nd_edition.htm.
H.C. Holloway, et al., The Threat of Biological Weapons: Prophylaxis and Mitigation of Psychological and Social Consequences, JAMA, 278 (5), 1997.
Centers for Disease Control and Prevention, Interim Recommendations for the Selection and Use of Protective Clothing and Respirators against Biological Agents, www.cdc.gov.