With some exceptions, children have had consistently higher mortality rates, two to three times higher than the adult rates in emergency settings, particularly in the early phases of a crisis. When refugees from Ethiopia settled in Sudan in the mid-1980s, more than one-half of the deaths occurred in children under five years of age. When northern Iraq’s Kurds fled to the border with Turkey in the wake of the 1991 Gulf War, two-thirds (64 percent) of all deaths occurred among the 17 percent of the population less than five years old. Mortality during the first month of the Goma crisis was high in all age groups since all were susceptible to cholera, the leading cause of death in that emergency. Sadly, however, the high adult mortality resulted in many orphans, for whom little care was available. These children were taken to makeshift, understaffed “orphanages,” and mortality rates among these children soared to unprecedented levels.

Women have also borne the brunt of both the direct and indirect consequences of violence. Rape, well known as a weapon of war in ancient times, is becoming increasingly recognized as an important weapon in our day as well. Its consequences are both immediate and long-lasting. Although it does not cause death, the pain and suffering it brings upon women, both physical and mental, is incalculable. In recognition of this problem, the UN Security Council in 2001 passed Resolution 1325, directing all those involved in armed conflict to act “to protect women and girls from gender-based violence, particularly rape and sexual violence.” As is the case with many other declarations of intent, however, the means to implement and enforce this resolution remain inadequate. In relief efforts, households headed by women are often at a disadvantage. One survey found such households had less ability to purchase food from local markets and received significantly fewer food and non-food items such as materials to keep their shelter water-resistant.

Providing the Basics

Food, clean water, sanitation facilities, shelter, and access to professional health care—they are, as for everyone, the basic needs of displaced people. When they are lacking, rates of morbidity and mortality rise dramatically. Some 38 percent of least-developed countries and 27 percent of other developing countries experienced a major armed conflict between 1990 and 2003, according to the Stockholm International Peace Research Institute’s Conflict Data Project, and the principal indirect causes of death in complex emergencies in developing countries are malnutrition, diarrheal diseases, acute respiratory infections (most often pneumonia), and malaria. By most accounts, these few diseases account for 60 to 95 percent of all deaths. Epidemics of infectious disease are common; the deaths in Goma, as mentioned above, were due to one of the most deadly cholera epidemics ever recorded. Outbreaks of measles have occurred frequently, and bacterial meningitis and hepatitis have also been problems.

Malnutrition, not often a cause of death in itself, is an important risk factor for displaced populations that grow dependent on the international community for food assistance. Mortality and malnutrition are strongly correlated. The Sphere Project, which sets professional standards for disaster response to which a large number of humanitarian agencies have agreed, has established 2,100 kilocalories per day as the minimum requirement per person. This level of assistance is not always met. As a result, during the 1992 conflict in Somalia, surveys put the prevalence of malnutrition among children at 47 to 75 percent. In southern Sudan the following year, surveys in displaced communities found malnutrition rates as staggeringly high as 81 percent.

Micronutrient deficiency diseases have also occurred frequently in war-affected populations. Now extremely rare in more stable settings, scurvy outbreaks have been documented many times in the Horn of Africa and following the conflict in western Afghanistan. Pellagra, caused by a diet deficient in niacin, has spawned public health crises among Mozambican refugees in Malawi and Angola’s internally displaced. Beri-beri, caused by inadequate dietary intake of thiamine, has occurred among Bhutanese refugees in Nepal.

During relief efforts, the first priority for intervention is, appropriately, to save lives by implementing programs such as mass measles vaccination campaigns, establishing supplementary and therapeutic feeding centers, and making curative medical services available. However, expatriate workers, for security reasons and because of their own unfamiliarity with their settings, often construct and work within the walls of clinics and hospitals. More recently, the importance of attending to the reproductive health needs of conflict-affected populations has been recognized. A minimal initial services package, consisting of the designation of a reproductive health coordinator in every complex emergency, condom distribution, and the practice of universal precautions to prevent the spread of HIV/AIDS, has been designed and promoted. Implementation is, however, not sufficiently widespread. While it is clear that depression and other psychosocial conditions might be quite prevalent in settings where people have been uprooted from their homes and communities and often have been separated from family members, there is no widespread agreement on how to measure the extent of this problem, much less on how to intervene effectively.

In addition, it is clear that further research is required in this area, there are important ethical concerns regarding the conduct of research in highly vulnerable, dependent populations. Chief among these is whether individuals who perceive themselves to be at the mercy of the international community for assistance, including the provision of food, water, and shelter, can ever provide the kind of informed consent required of research subjects.

Bandage to a Wound

A few words are in order regarding the international response to complex emergencies. A multi-donor evaluation of the Rwandan refugee crisis in Zaire in 1994 was harshly critical of the efforts of both UN agencies and voluntary relief organizations. Relief workers, as generous and willing to help out as they are, do not always possess the skills necessary to provide prompt and effective assistance to the populations they seek to serve. Efforts such as those made by the Sphere Project and others, to establish a set of standards for assessing and evaluating the quality of humanitarian intervention, are helping to professionalize the field. Short-term training courses and degree-granting programs in humanitarian response are being organized in both developing and industrialized countries, in order to better prepare those who intend to make humanitarian assistance their career. A better understanding of the epidemiology of public health in conflict-affected populations can only help to mitigate the public health consequences of these man-made disasters.