This is the first in a series of articles on conducting research during complex humanitarian emergencies.

The United Nations (UN) defines a complex humanitarian emergency (CHE) as “a humanitarian crisis in a country, region, or society where there is total or considerable breakdown of authority resulting from internal or external conflict and which requires an international response that goes beyond the mandate or capacity of any single and/or ongoing UN country program” [1]. Such emergencies require adapted, focused, and pragmatic field responses to be organized within short time frames, often under difficult accessibility, security, and climate conditions. Over the years, operational efficiency in the field has increased thanks to research carried out during CHEs.

Early on following its inception in 1971, the international medical humanitarian organization Médecins Sans Frontières (MSF) conducted its medical missions with enthusiasm but little standardization, focusing more on individual care than on optimized public health approaches. Growing field experience, mainly acquired in refugee camps, rapidly led to the identification of ten major public health priorities for CHEs (Box 1).

Critical analysis of data collected by MSF field workers generated questions about the effectiveness of MSF's operational responses (Box 2). Recognizing the importance of epidemiological surveillance and systematic monitoring of CHE activities, MSF created its own research center, Epicentre, in 1987 with the aim of addressing those questions [2].

Twenty years later, Epicentre has developed into a large team of over 40 professionals in the headquarters in Paris, offices in Geneva and Brussels, and a field station in Mbarara, Uganda. Through partnerships with national and international institutions, universities, and research groups, Epicentre has gained recognition in the field of CHE research and, in 1995, became a World Health Organization (WHO) collaborative center for research in epidemiology and control of emerging diseases. To this day, Epicentre is dedicated to improving field operations in CHEs.

In this article, we review Epicentre's 20 years of experience conducting research during CHEs and show how such research has been critical in improving field response.

Rapid Assessments and Survey Methods

Rapid assessments in CHEs, often based on population surveys, help guide emergency response by measuring mortality rates, prevalence of malnutrition, and coverage of basic needs (food, water, shelter).

Over the past 20 years, Epicentre has conducted nearly 100 mortality surveys, most of them under difficult field conditions. One illustrative example is the survey conducted in July 1994 among 800,000 Rwandan refugees in Goma, Zaïre [3]. Anyone walking along the road between Goma and Katale every morning knew, by looking at the bodies piling up along the road, that the health situation was extremely severe. The survey showed that, in the first month alone, more than 10% of the population had died, 88% from diarrhea [4]. The Goma survey, like many others, highlights the role of field epidemiology in properly quantifying events, even in the most chaotic situations. The data were used for programmatic and planning purposes, and, in some instances, as advocacy material.

Survey sampling schemes used in CHEs were originally explored by the United States Centers for Disease Control and Prevention [5]. Among these schemes, cluster sampling (in which the population of interest is divided into groups, or clusters, and a random sample of these clusters is selected), initially developed by WHO for the estimation of vaccine coverage, is often the only option since it is rarely possible to survey the entire population [6]. When samples of adequate size and sufficient number of clusters are drawn, estimates are precise enough for planning purposes. Research for realistic alternatives (such as sampling based on global positioning systems) is ongoing [7].

Estimating population size, which is important for needs assessment, remains difficult [8,9]. While satellite photos could represent a quick and valuable alternative to the methods currently in use, humanitarian organizations operating on foreign soil have limited access to such pictures.

Responding to Infectious Disease Outbreaks

In a CHE, overcrowding, inadequate shelter, poor water and sanitation, collapse of health services, and the breakdown of existing infectious disease control programs can markedly increase the burden of communicable diseases and the risk of epidemics. In such a context, early detection and prompt, well-conducted outbreak investigations are essential to guide adapted responses.

Micronutrient Deficiencies and Malnutrition

Improving Diagnostic Tools

Diagnostic tools adapted to field conditions can serve two purposes—diagnosis of individuals and confirmation of an outbreak. Few rapid diagnostic tests (RDTs) are designed for use in CHEs, and little is known about their performance in such a context. However, the use of RDTs can potentially improve the capacity of case detection and the efficacy of treatments. Epicentre has tested the performance of several RDT kits, which are now used in the field.

Malaria RDTs must be reliable, cheap, and user-friendly, particularly if used in CHEs. In addition, the performance of the test is maximized if the local epidemiology of the disease and the immunity of the population are taken into account. MSF/Epicentre has tested several commercially available malaria RDTs under field conditions. Beyond the classical evaluation of the sensitivity and specificity of the tests, our studies focused on practical considerations such as ease of use, shelf life, and storing conditions [29,30]. This approach, although usually neglected by researchers, is critical to maintaining field-oriented research in response to questions raised by the humanitarian community.

Other RDTs, adapted to the specific conditions of CHEs, are crucially needed [31]. In 2003, Epicentre conducted a randomized clinical trial assessing the sensitivity and specificity of a latex agglutination RDT (Pastorex) for Neisseria meningitidis serogroup A during a meningitis epidemic in Niger [32]. Results from 484 samples showed 88% sensitivity and 93% specificity, suggesting that this RDT could be a favorable alternative to current diagnostic tests. Other promising tools such as a dipstick for diagnosis of Shigella flexneri and Shigella spp. [33] and a one-step RDT for cholera [34] need to be evaluated in field conditions.

Lessons Learned

Finding pragmatic and efficacious answers to public health questions generated by the field has led Epicentre research activities over the last 20 years. Such an intimate and continuous link between field operations and applied research is unusual in the world of humanitarian response to CHEs. The nonstop interaction between field actors and researchers has been key in developing an original research agenda and conducting successful projects, which help improve the quality and effectiveness of the operational response. This, in turn, enhances the capacity of the scientific community and of aid agencies to cope with increasingly complex humanitarian crises.

Since the creation of Epicentre in 1987, a number of operational and clinical research projects have been conducted. Constraints faced in CHEs, too often underestimated, make research projects particularly challenging. Conditions of their success include rigorous technical and logistic support, close collaboration with local authorities, and fully mobilized national and international staff.

The role of epidemiologists extends beyond their traditional scientific research functions to a broader range of responsibilities, including exchanges with field workers to help generate research ideas and reconciliation of rigorous methods with local constraints. External ethical review, written informed consent, and involvement of the local community are some of the systematic mechanisms that helped Epicentre carry out research projects that respect the principles of ethical human subjects research.

The results of the research conducted by MSF/Epicentre and others over the last two decades have shown the limitations of current therapeutic and preventive resources for most of the diseases prevalent in developing countries. The Drugs for Neglected Diseases Initiative (DNDi), initially promoted and funded by MSF in 2003, focuses on developing new drugs or formulations for patients suffering from the world's most neglected diseases [35]. Today, 22 DNDi research and development projects are under way, with the goal of developing six to eight new treatments in the next ten years [36]. Some projects have been implemented within MSF CHE programs, with Epicentre providing research and data analysis support.

Next Steps

Looking towards the future, Epicentre continues to address unanswered questions in the field epidemiology of CHEs. Among these, the aim is to continue to improve the control of infectious diseases and patient management, including easy-to-use and cheap alternative therapeutic regimens and preventive strategies. Conducting high-quality research in CHEs means testing new techniques in remote areas, while taking into consideration all usual aspects of logistics and ethics. Improved survey methods and surveillance systems are continuing challenges for the future. Some under-researched areas should be further explored. The ultimate goal remains to address questions aimed at significantly improving the health status of affected populations.

Supporting Information

Acknowledgments

Special thanks to Elizabeth Ashley, Rebecca Freeman Grais, Jean-Paul Guthmann, Anne-Laure Page, and Oliver Yun, who contributed to improve the manuscript with their suggestions. Additional reviewing was done by Rebecca Freeman Grais and Oliver Yun. As this paper is written at the time of Epicentre's 20-year anniversary, we wish to thank all the teams (from Epicentre, but also MSF, and partners) who contributed to, or realized, the work presented in this paper.