Ending Neglect of Older People in the Response to Humanitarian Emergencies

Unni Karunakara and Frances Stevenson argue that humanitarian policy and practice must adapt to ensure that the needs of older people in humanitarian emergencies are addressed.


Introduction
At the heart of humanitarian action are the principles of humanity and impartiality. All people have equal value and dignity; the exclusion of an individual or a group on the grounds of nationality, religion, or politics is contrary to the humanitarian ethos [1]. We suggest that neglect on the grounds of age should be added to this list. But first, what do we mean by ''older''? Variation in life expectancy between countries makes it difficult to agree upon the age at which someone becomes old. The United Nations (UN) definition is 60 years and older, but in developing countries, where most humanitarian crises occur, 50 years is an appropriate cut-off and the one we use in this article [2].
Emergency aid has failed to address the needs of older people in emergencies [3]. High death rates among older populations in crises are common, partly due to their inherent vulnerability and partly due to services that inadequately deal with their needs often because these are not well identified or understood [3][4][5][6]. For example, an assessment by Médecins Sans Frontières (MSF) of how it met the needs of older people in emergencies in Haiti and South Sudan showed that after initial registration of individuals at health clinics, disaggregated data beyond the under-5 and over-5 year age groups were not collated [7]. Issues with mobility and vision that increase in prevalence with age can mean that older people are more at risk in crises and are less able to access care and support [8,9]. Vulnerable groups such as older people are therefore likely to bear a disproportionate share of health problems [10]. Thus, specific interventions are often necessary to prevent these groups from suffering disproportionately.
Here we describe the neglect of older people's health and nutrition needs by humanitarian agencies, donors, and international bodies. Our aim is to stimulate thinking and action on how older people are treated in humanitarian emergencies.

Ageing Population
Global changes in conflicts and demographic changes mean that older people constitute a growing number of those affected by humanitarian crises [11]. The population of older people in developing countries is growing faster than in developed countries [12]. By 2050, more than 80% of older people will live in developing countries, compared to the 60% who do so today, where disasters are more likely to occur and their effects are greater [13]. In some areas, particularly remote rural areas, high HIV prevalence, conflict, and economic migration have led to high proportions of older people [14].
Older people are less likely to flee in times of conflict due to hardships associated with travel and reluctance to leave home, land, and possessions [15,16]. They face constraints to returning home after long periods of displacement [17]. Many are not able to travel to health facilities, stand in queues for food distributions, carry heavy packages of food or containers of water, or compete with younger people for relief supplies [18]. And, contrary to a common assumption, older people are often not cared for within their families. Following the 2010 floods in Pakistan, around 10% of the older population was living without family support [19]. In camps for internally displaced people in Darfur, half the older people live alone [20].

How Are Older People Neglected? In Monitoring and Surveillance
Effective humanitarian assistance relies on assessment and surveillance data. Almost all guidance, such as the Sphere Handbook that defines minimum standards for humanitarian assistance [21], requires collection of sex-and age-disaggregated data. In practice, most adult data are aggregated, leaving the profile and needs of older groups invisible [22]. MSF did an exploratory analysis of 2012 data from the South Sudan refugee crisis. During a 6-week period, data were disaggregated by age into under 5, 5-50, and .50-year-olds. The mortality rate in the oldest group was over four times that of the 5-to 50-year-olds and over twice that of the under 5 s, during a time when the crude mortality rate was just below the emergency threshold (one death per 10,000 population per day) (Philipp du Cros, personal communication).
Similarly, the nutritional status of children under 5 years old, assessed by measuring MUAC (mid-upper arm circumference), is the standard indicator of whether a nutrition intervention is needed in the general population. However, few nutrition surveys are carried out among older adults [18]. HelpAge International did a nutrition survey in the refugee camps of Dadaab, Kenya, with the aim of influencing standard practice. It showed that older people were vulnerable to malnutrition, although they had not been included in other nutritional surveys or in supplementary or therapeutic nutrition programmes [23].

In Guidelines for Chronic and Communicable Disease
Older people have specific health risks and needs. Global ageing is recognised as a major driver of non-communicable disease in developing countries where older people are at especially high risk of cardiovascular disease, strokes, diabetes, and dementia [24]. Yet non-communicable chronic disease is neglected in humanitarian responses, and there are virtually no guidelines for the management of chronic medical conditions after disasters [25]. The latest revision of the Sphere Handbook, however, recognises the increasing evidence of acute complications from chronic diseases in disasters and encourages their treatment [21].
Older people may also be at increased risk from communicable diseases [26,27]. Yet older people are rarely identified as an at-risk group for communicable diseases or their specific needs considered by infection control programmes [28].

By Donors
Institutional donors do not treat humanitarian assistance for older people as a priority. Although in 2010 12.5% of the world's population was older than 60 years, analyses of humanitarian projects funded through the UN Consolidated Appeals Process revealed that just 0.3% included any activity that specifically targeted the needs of older people, while in 21 countries there were no projects targeting older people in the past 2 years [29,30].

By Humanitarian Agencies
Aside from research by specialist agencies such as HelpAge International, there is little evidence of humanitarian organisations considering how best to meet the needs of older people in emergencies. A World Health Organization (WHO) review of the needs of older people in emergencies noted that humanitarian agencies ''do not assess older people's needs, nor . . . address their needs'' [31]. The MSF study highlighted a lack of specific organisational policies on meeting the needs of older people even though they were viewed as a vulnerable group. MSF's response to their needs was variable and unexpectedly better in the emergency setting of Haiti than in the slow-onset emergency of South Sudan [7]. MSF is in the process of translating these research findings into operational policies and practice.

Next Steps
From analysis of the literature, reviews of MSF programmes and policies, and discussion within our organisations, we have identified priority areas for action and research for humanitarian agencies, research institutes, international bodies, and donors (Box 1). As the numbers of older people affected by humanitarian crises and disasters increase, humanitarian actors need to adapt policy and practice to ensure that the needs of older people are consistently and continually considered and that this vulnerable group is no longer neglected.

Box 1. Priority Areas for Including Older People in Humanitarian Agendas
Practice and policy N Collecting age-disaggregated data on who is accessing humanitarian assistance to ensure that older people are not being excluded.
N Ensuring all surveillance, needs, and vulnerability assessment data are disaggregated for older age groups.   N We call for policy changes by humanitarian agencies and donors to ensure that the needs of this vulnerable group are met.