Older people make up a significant and growing number of those affected by humanitarian crises, yet they are often not sought out or prioritised within the humanitarian response. Humanitarian agencies, donors, and international bodies neglect older people's health and nutrition. The gaps in knowledge and research about the needs of older people in emergencies are considerable. Older people are not monitored in emergencies and they are not prioritised despite evidence of disproportionate mortality and morbidity in this group. We call for policy changes by humanitarian agencies and donors to ensure that the needs of this vulnerable group are met

EY Chan

F Assefa

F Chappuis

Frances Stevenson

G Gavazzi

LB Shrestha

P Salama

P Spiegel

PB Spiegel

Unni Karunakara

English

PubMed

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PLoS Medicine

Ending neglect of older people in the response to humanitarian emergencies.

Karunakara, U

Stevenson, F

MSF Field Research

Essay
Ending Neglect of Older People in the Response to
Humanitarian Emergencies
Unni Karunakara
1,2*, Frances Stevenson
3
1Me ´decins Sans Frontie `res (MSF), Geneva, Switzerland, 2Mailman School of Public Health, Columbia University, New York, United States of America, 3HelpAge
International, London, United Kingdom
Introduction
At the heart of humanitarian action are
the principles of humanity and impartial-
ity. 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 expec-
tancy 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 human-
itarian 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 [3–6]. For exam-
ple, an assessment by Me ´decins Sans
Frontie `res (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 inter-
national 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 demo-
graphic 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 devel-
oped 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 stan-
dards for humanitarian assistance [21],
requires collection of sex- and age-disag-
gregated 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 dis-
aggregated 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).
The Essay section contains opinion pieces on topics
of broad interest to a general medical audience.
Citation: Karunakara U, Stevenson F (2012) Ending Neglect of Older People in the Response to Humanitarian
Emergencies. PLoS Med 9(12): e1001357. doi:10.1371/journal.pmed.1001357
Published December 18, 2012
Copyright:  2012 Karunakara, Stevenson. This is an open-access article distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are credited.
Funding: No specific funding was received for writing this article.
Competing Interests: The authors have declared that no competing interests exist. UK was elected
International President of Me ´decins Sans Frontie `res (MSF) in June 2010, and has been involved with MSF in
various capacities, including as a medical doctor, advisor, and board member since 1995. FS is Head of
Emergencies at HelpAge International, and has been involved with MSF in various capacities including Head of
Mission and board member since 1995.
Abbreviations: MSF, Me ´decins Sans Frontie `res; MUAC, mid-upper arm circumference; UN, United Nations;
WHO, World Health Organization
* E-mail: unni.karunakara@msf.org
Provenance: Not commissioned; externally peer reviewed.
PLOS Medicine | www.plosmedicine.org 1 December 2012 | Volume 9 | Issue 12 | e1001357Similarly, the nutritional status of chil-
dren under 5 years old, assessed by
measuring MUAC (mid-upper arm cir-
cumference), 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-communica-
ble chronic disease is neglected in human-
itarian 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 in-
creasing 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 hu-
manitarian 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 agen-
cies such as HelpAge International, there
is little evidence of humanitarian organi-
sations considering how best to meet the
needs of older people in emergencies. A
World Health Organization (WHO) re-
view 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 Systematically screening older people in nutrition surveys using MUAC.
N Providing adequate care in emergencies for chronic diseases and conditions,
including palliative care and pain relief.
N Ensuring that infection control programmes take into account the differing
presentation and needs of older people.
Research
N Researching the optimum nutritional support for older people in emergency
settings.
N Conducting operational research into the best way to ensure that older
people’s health needs are comprehensively met in humanitarian programmes.
N Conducting operational research to determine how best to improve older
people’s access to humanitarian assistance both in open settings and in
camps.
Funding
N Institutional funding bodies should ensure that the needs of older people are
included in project proposals where appropriate and funded.
Summary Points
N Older people make up a significant and growing number of those affected by
humanitarian crises, yet they are often not sought out or prioritised within the
humanitarian response.
N Humanitarian agencies, donors, and international bodies neglect older people’s
health and nutrition.
N The gaps in knowledge and research about the needs of older people in
emergencies are considerable.
N Older people are not monitored in emergencies and they are not prioritised
despite evidence of disproportionate mortality and morbidity in this group.
N We call for policy changes by humanitarian agencies and donors to ensure that
the needs of this vulnerable group are met.
PLOS Medicine | www.plosmedicine.org 2 December 2012 | Volume 9 | Issue 12 | e1001357Acknowledgments
We thank Beverley Collin and Sarah Venis for
editing assistance, Hannah Barton for reviewing
the literature, and Philippe Calain, Iveris
Martinez, and Jyotsna Puri for reviewing drafts.
Author Contributions
Wrote the first draft of the manuscript: FS.
Contributed to the writing of the manuscript:
UK FS. ICMJE criteria for authorship read and
met: UK FS. Agree with manuscript results and
conclusions: UK FS.
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Ending Neglect of older people in the response to Humanitarian Emergencies

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