THE PUBLIC HEALTH ASPECTS OF COMPLEX EMERGENCIES AND REFUGEE SITUATIONS

Populations affected by armed conflict have experienced severe public health consequences mediated by population displacement, food scarcity, and the collapse of basic health services, giving rise to the term complex humanitarian emergencies. These public health effects have been most severe in underdeveloped countries in Africa, Asia, and Latin America. Refugees and internally displaced persons have experienced high mortality rates during the period immediately following their migration. In Africa, crude mortality rates have been as high as 80 times baseline rates. The most common causes of death have been diarrheal diseases, measles, acute respiratory infections, and malaria. High prevalences of acute malnutrition have contributed to high case fatality rates. In conflict-affected European countries, such as the former Yugoslavia, Georgia, Azerbaijan, and Chechnya, war-related injuries have been the most common cause of death among civilian populations; however, increased incidence of communicable diseases, neonatal health problems, and nutritional deficiencies (especially among the elderly) have been documented. The most effective measures to prevent mortality and morbidity in complex emergencies include protection from violence; the provision of adequate food rations, clean water and sanitation; diarrheal disease control; measles immunization; maternal and child health care, including the case management of common endemic communicable diseases; and selective feeding programs, when indicated. ∗The US Government has the right to retain a nonexclusive, royalty-free license in and to any copyright covering this paper. 283 284 TOOLE & WALDMAN INTRODUCTION Disasters may quickly reverse the substantial gains made during the past two decades by primary health care initiatives in developing countries. A disaster may be defined as a relatively acute situation created by man-made, geophysical, weather-related, or biological events that adversely impacts on the health and economic well-being of a community to an extent that exceeds the local coping capacity. In the case of acute natural disasters such as earthquakes and hurricanes, the direct public health effects are immediate and often devastating. Most deaths and injuries occur during the first few hours following impact and any secondary public health effects are related to displacement of the affected population, destruction of public utilities, and disruption of basic health services. Following the acute response phase of search and rescue, surgical triage, and management of injuries, the public health priorities consist of infrastructure repair, restoration of health services, and rehabilitation of public utilities, especially water supplies. Long-term public health consequences have only occurred following those natural disasters–such as floods– that have destroyed food crops or led to prolonged population displacement in unsanitary camps or settlements. Outbreaks of communicable diseases are rare following acute natural disasters. These problems have not been documented in industrialized countries such as the United States; however, outbreaks of diarrheal disease, hepatitis, and malaria have occurred following some acute natural disaster