Week 1 (1-45)

Question 1

What are disasters?

Answer 1

Overall a small contributor to the global burden of injury

media attention

artificial distinction between natural and man made - all are man made

where and how people are forced to live

vulnerability of affected community

poverty

main threat to health is mass movement of people - not orthopaedic injury

Question 2

What is the epidemiology of disasters?

Answer 2

Last quarter of century: 3 million deaths, 1 million people affected

annually 250,000 deaths

£23 billion cost

increasing by incidence

by 2100, 17 of 23 cities with .10 million inhabitants will be within at risk zones

Question 3

About natural disasters

Answer 3

Tsunami
Pakistan earthquake
Haiti

Developing world locations
resources overwhelmed
delayed, haphazard international response
average of 2 earthquakes > richter 8 per year
33 earthquakes with > 1000 deaths since 1980
injuries, number, severity

Question 4

What is the sub-saharan African shortage of workforce?

Answer 4

falls short of the WHO guidelines of 25 doctors per 100k population

Question 5

Orthopaedic surgeons distribution

Answer 5

80% of all orthopaedics surgeons are in developed countries (26 of 191 nations)

only 40 in 8 east African countries - population of 200 million

problems - recruiting surgeons, medical migration

Question 6

What is the need due to conflict?

Answer 6

160 wars and armed conflicts in 1945
mostly developing world
50 currently
22 million killed, 3x as many injured
90-100 million landmines
500 million small arms
125 million AK 47
? duration

Question 7

What is a complex emergency?

Answer 7

Combine any of:

natural disaster
conflict
famine
mass population movement
social and political breakdown
Ongoing, not time limited
haiti

Question 8

What is the delivery of emergency disaster assistance like?

Answer 8

Chaotic aftermath of natural disaster
Local infrastructure and resources overwhelmed
Delayed & inaccurate assessment
Lack of coordination between agencies / govts
Competition between NGOs
Inefficiency, duplication
Lack of accountability
Short term volunteers, no continuity of care

Question 9

What is the UN (IASC) cluster system?

Answer 9

• 2005 UN review of global humanitarian system
• Coordination be strengthened
• Central emergency response fund
• Clusters
• Increase capacity
• Leadership (WHO for health, UNHCR for IDPs, WFP in logistics))
• Agreed objectives
• Accountability
• Field-level coordination
• Global (11) or field level ( number may vary)
• Pakistan earthquake
• Timor-Leste 2009
• Accountable to UN ERC ( Baroness Amos)
• Participation not mandatory: ICRC, MSF etc

Question 10

What is DFID/UK aid?

Answer 10

· UK is 2nd largest bilateral humanitarian aid donor
· £528 million in 09/10
· Mostly via partners
· 11% on humanitarian emergencies
· ECHO £100m, ICRC £66m
· Small amount of “direct” aid; Ops team (CHASE OT) and UKISAR

Question 11

What is the disasters and emergencies committee (DEC)?

Answer 11

· Created 1963
· Up to 15 charities working in disaster field (currently 14)
· Joint fundraising
· Response focal point
· Co-operation & coordination
· Accountability & effectiveness
· Each member:
§ Income > £4m / yr
§ Emergency work > £10m / yr
§ Good governance

Question 12

What did the recommendations of the 2007 crisp report include?

Answer 12

links between NHS and developing world (THET)
education and training
improved UK medical response to disasters (database, coordination, release of staff)

Question 13

About the Haiti earthquake…

Answer 13

· 12 January 2010
· Richter 7.0
· First “mega-urban” less developed world disaster
· 200,000 dead, 300,000 injured
· Within 1 month
§ 600 organisations
§ 274 in health field
· “Wild market” , not coordinated help
· UK major donor
§ DFID £7.5 million
§ DEC £101 million
· UK Human resources
§ Initial assessment team(4), 64 SAR
§ No database
§ Minimal pre-training
§ Short duration
§ No coordination

Question 14

What is the international emergency trauma register (IETR)?

Answer 14

• Following Haiti earthquake
• Meeting of DFID / DoH & interested NGOs
• Hosted by UK Med
• Database of volunteers
  – Accredited / trained
  – Up to date
  – Prospective agreements with employing Trusts for timely release for reasonable duration
  – Funding
  – First used for Libya conflict 2011

Question 15

What is the humanitarian emergency response review (HERR)?

Answer 15

· Commissioned by Sec of State
· Chaired by Lord Ashdown
· Reported March 2011
· 40 recommendations:
§ Anticipation , resilience
§ Leadership
§ Innovation
§ Accountability
§ Partnership
§ Delivering differently
§ …..

‘Incorporate surgical teams into first phase deployments, especially after earthquakes.’

Question 16

About emergency projects…

Answer 16

· Unpredictable level of activity
· “on-the-bus..off-the-bus”
· ?Duration
· Funding
· Security
· Very few organisations able to mount field hospitals

Question 17

About Foreign Medical Teams and their involvement in disasters…

Answer 17

· Huge increase in FMTs responding to sudden onset disasters (SODs)
· WHO cluster report
· Classification
o Outpatient
o Inpatient emergency surgical care
o Inpatient referral care
o Specialist teams
· Minimum standards
· ! Most lives are saved by early local provsion not FMTs

Question 18

What is the military involvement in humanitarian assistance?

Answer 18

· Long history of military involvement in disaster situations
§ Affected country
§ Foreign troops
· Contentious
· “Oslo” guidelines
· Advantages
§ Strategic planning
§ Surge deployment
§ Logistics / communications
· Future Reserves report 2011

Question 19

What is disaster risk reduction (DRR)?

Answer 19

· Artificial distinction between “natural” and “man made
· “At risk” areas can be identified
· Measures taken to protect vulnerable populations
Investment in infrastructure as emergency preparedness

Question 20

What sit eh hypo framework for action (HFA)?

Answer 20

World conference in Kobe, Japan 2005
Building resilience of nations and communities to disasters by 2015
168 signatories
5 Priorities:
DRR as national / local priority
Assess risks, enhance early warning
Innovate / educate to build resilience
Reduce risk factors
Strengthen disaster preparedness

Question 21

About disaster/development…

Answer 21

Increasingly humanitarian aid and development aid is merging
Funding and access post disaster is opportunity for development

Question 22

About typhoons…

Answer 22

Mature tropical cyclone
Develops in the western North Pacific
Throughout year, but mostly June-November
Factors:
o Warm sea temperature
o Atmospheric instability
o High humidity
o Coriolis force

Question 23

What is the UK international emergency trauma register?

Answer 23

· Crisp report recommendation (2007)
· Revisited in wake of Haiti earthquake
· Joint initiative DFID / DoH / NGOs
· Administered by UK-Med
· Surgeons, anaesthetists, emergency physicians
· Aims for prospective agreements with Trusts
· Website www.uk-med.org/trauma
· Activated by Secretary of State
· Under Merlin / Save project

Question 24

What is Manilla?

Answer 24

· Merlin coordinator attending WHO / MOH cluster meetings
· “Level 1” response
· Logistic support
· Personal contacts
· Initial tasking N Palawan
· Team arrived 14 Nov
· Re-tasked Northern Cebu

Question 25

About HMS Daring…

Answer 25

· Type 45 destroyer
· Complement 190
· Lynx helicopter
· Tasked to assess impact on remote outlying islands
· UKIETR team:
o 2 x ER physicians
o 2 x ER nurses
o 1 x GP
o 1 x plastic surgeon

Question 26

About Tacloban…

Answer 26

· Leyte Island, Philippines
· Eastern Visayas region
· Population 221,000
· Highly urbanised city
· Transportation hub
· First landfall of Haiyan
o Wind
o Storm surge wave

Question 27

AUSMAT staffing…

Answer 27

· c50 Australian staff
· 1 x medical director
· 4 x ED physicians
· 2 x surgeons (1 ortho, 1 general surgeon)
· Firemen as logisticians
· Mostly from Northern Australia
· Exercised together

Question 28

WHO cluster meeting tacloban

Answer 28

· Daily 1700 WHO DoH cluster meting at EV hospital
· Coordination of medical teams
· Assessment of outlying areas
· Commissioning response, eg mental health

Question 29

Extraction from Tacloban…

Answer 29

· By 23/24 November fewer injuries presenting
· Emphasis of healthcare assistance moving to:
- Primary healthcare
- Paeds/O&G
- Water/sanitation
- Shelter
- Reconstruction of local healthcare infrastructure

Question 30

Save the children field hospital - tacloban

Answer 30

· tacloban team contributed to over 1000 consultations and 100 operations
· save now commissioned to provide UK civilian field hospital
· on location, treating patients within 72 hours…

Question 31

What is the nature of war and conflict?

Answer 31

The essence of war/conflict is the implied or actual use of force
War/conflict is the process of organised and purposeful use of violence of one human group against another
War implies an act by a sovereign nation state
Conflict often undeclared and intra-state in nature
Massacre, genocide and criminal behaviour
The question of legality!

Question 32

What is the legality of war and conflict?

Answer 32

How effective is international law in legislating global conflict?
Blunt tool for increasingly complex states of warfare
Rule of law dissolving within a state
Rarely universal consensus
No enforcement within a state
Enforcement by other countries dependent on politics?
International laws slow to adapt to changing nature of war ie increase in intrastate conflict, technology

Question 33

What are the traditional concepts of war?

Answer 33

Symmetric (conventional) Warfare (Clash of equals)
Asymmetric Warfare (Clash of unequals)
Protracted struggle (Giap/Vietnam, IRA, Basques) – Terrorist war?
Manoeuvrist Approach vs attrition (exploiting uncertainty)
Technocentric Warfare (Standoff, Remote, Drones) – Wars of the future?

Question 34

What is symmetrical warfare?

Answer 34

Similar power, resources and strategies (varying execution)

Question 35

what is asymmetrical warfare?

Answer 35

(Mack 1975)– imbalance in forces, and/or strategies eg established army and resistance (undermanned and underequipped) – insurgency/terrorist as well as counterinsurgency/terrorism

Question 36

How does the use of warfare vary?

Answer 36

varying use dependent on Military (use to describe varying indirect/unconventional strategies of weaker actors) vs academics seeking to explain the weak versus the strong
Warfare methods are on a continuum between attrition (wear down through continuous loss of personnel and supplies/equipment, often won by armies with greater resources) manoeuvre (killing by stragegically disrupting the enemy, often used by smaller, more cohesive, well trained armies)

Question 37

What is the conflict analysis framework?

Answer 37

Actors
Who are the primary actors in the conflict? Who are the secondary actors? Who else has influence over events?

Root Causes
What is driving the conflict? What are the needs and fears of each group?

Issues, Scope and Stage
What are the key issues for each side? What phase is the conflict in? Who is suffering the most?

Power, Resources and Relationships
What are the resources and capacities of each side? What is the state of the relationship among the leaders? What are the existing channels of communication?

History of the Relationship
Did the parties ever co-exist peacefully? What were the previous attempts at a settlement, and why did they fail? Was there a pattern to the failures?

Question 38

What is the spectrum of conflict?

Answer 38

Military Assistance (early Vietnam)
Humanitarian Operations (Early Balkans)
Peace Support Operations (Balkans later)
Low intensity Operations (Britain’s Colonial Wars)
Mid Intensity Operations (Falklands war – Limited use of available weapons)
High Intensity Operations (Iraq 2003 - Full and Integrated use of full range of weapons)

Question 39

What has been the evolution of war?

Answer 39

• Ethnic violence
• Genocide
• Rwanda, Croatia, Bosnia, Kosovo, break-down of communism
• Civil violence
• East Timor, Sudan
• Arab Spring:Egypt, Syria
• Post-interstate war: Iraq, Afghanistan
• Interstate war
• Iraq x 2 , Afghanistan

Since WWII, reduction in interstate wars but significant rise in intrastate conflict (93 wars in 70 countries between 1990-95 = a quarter of all conflict deaths since WWII), subsequent lull until 9/11

Question 40

What is the modern era of war?

Answer 40

Characterised by world wide terrorism on an unprecedented scale
Emergence of non-state actors (militias, gangs, war lords)
Intra-state conflict rather than inter-state war
Emergence of international terrorist groups – Al-Quaeda & ISIL
Unheralded terrorist outrages
The west’s response – expeditionary warfare
Elusive enemy leading to asymmetric war
Stand off weapons - incidental or deliberate targeting of civilians
“Bombing the enemy back to the stone age”
Hatred and rage
The emergence of failed & rogue states
The elephant in the room - Globalisation

Question 41

What are the threats to the west?

Answer 41

Bombs is Europe and US (and elsewhere)
Suicide bombings
CBRN threats
o Dirty bombs
o Chemical 7 biological attacks
o Chimeras
Cyber warfare
Hybrid warfare (Frank Hoffman)

Question 42

Global death by conflict

Answer 42

How easy is it to collect data in this context?
Who’s responsibility
Controversy around Iraq
Lancet surveys:
2004 (without Fallujah) & 2006
Direct & indirect deaths
Higher estimates than Iraqi Health Ministry, UN
Divided belief; govts, epidemiologists Iraq Body Count
Iraq body count:
UK & US academics
media based estimates
Most quoted estimates – criticised by the conservative right but used over Lancet
Criticism of cluster sampling (Spagat)

Question 43

What are failed states?

Answer 43

No consensus definition
failure in state sovereignty
loss of authority for enforcing legislature
loss of sole legitimate use of force
non-provision of public service
reduced interaction with international community
Consequences
Corruption & criminality
Intervention by non-state actors
Internally displaced people and refugees
Economic decline

Question 44

Force alone is inadequate - what are alternative ways forward?

Answer 44

By all means use force but should be limited, focused & not be a recruiting sergeant for terrorist groups
Force alone will fail
Northern Ireland as a case example
Deal with world poverty
Resolve civil conflicts before they inter-nationalise
Interdicting terrorist & rogue state funding
Focus on recruitment & radicalisation
Pressuring totalitarian and authoritarian states
Look at wider causes and consequences of conflict
Achieve the UN’s Millennium Development Goals

Question 45

What is the future of war?

Answer 45

No precise science: unpredictable
Adversaries (state/non-state) and threats (conventional and unconventional) will blur
Range of threats to spread with proliferation of WMD, cyberspace and novel irregular threats
Battle of narratives will be key
The qualitative and quantitative advantage may no longer be assumed
Climate Change
Pandemics
Global arena no longer the elephant in the room