Paul Spiegel

War and mortality in Kosovo, 1998–99: an epidemiological testimony

BACKGROUNDnThe total number, rates, and causes of mortality in Kosovo during the last war remain unclear despite intense international attention. Understanding mortality that results from modern warfare, in which 90% of casualties are civilian, and identifying vulnerable civilian groups, are of critical public-health importance.nnnMETHODSnIn September 1999 we conducted a two-stage cluster survey among the Kosovar Albanian population in Kosovo. We collected retrospective mortality data, including cause of death, for the period of the conflict.nnnFINDINGSnThe survey included 1197 households comprising 8605 people. From February, 1998, through June, 1999, 67 (64%) of 105 deaths in the sample population were attributed to war-related trauma, corresponding to 12,000 (95% CI 5500-18,300) deaths in the total population. The crude mortality rate increased 2.3 times from the pre-conflict level to 0.72 per 1000 a month. Mortality rates peaked in April 1999 at 3.25 per 1000 a month, coinciding with an intensification of the Serbian campaign of ethnic cleansing. Men of military age (15-49 years) and men 50 years and older had the highest age-specific mortality rates from war-related trauma. However, the latter group were more than three times as likely to die of war-related trauma than were men of military age (relative risk 3.2).nnnINTERPRETATIONnRaising awareness among the international humanitarian community of the increased risk of mortality from war-related trauma among men of 50 years and older in some settings is an urgent priority. Establishing evacuation programmes to assist older people to find refuge may prevent loss of life. Such mortality data could be used as evidence that governments and military groups have violated international standards of conduct during warfare.

The Application of Geographic Information Systems and Global Positioning Systems in Humanitarian Emergencies: Lessons Learned, Programme Implications and Future Research

Geographic information systems (GIS), global positioning systems and remote sensing have been increasingly used in public health settings since the 1990s, but application of these methods in humanitarian emergencies has been less documented. Recent areas of application of GIS methods in humanitarian emergencies include hazard, vulnerability, and risk assessments; rapid assessment and survey methods; disease distribution and outbreak investigations; planning and implementation of health information systems; data and programme integration; and programme monitoring and evaluation. The main use of GIS in these areas is to provide maps for decision-making and advocacy, which allow overlaying types of information that may not normally be linked. GIS is also used to improve data collection in the field (for example, for rapid health assessments or mortality surveys). Development of GIS methods requires further research. Although GIS methods may save resources and reduce error, initial investment in equipment and capacity building may be substantial. Especially in humanitarian emergencies, equipment and methodologies must be practical and appropriate for field use. Add-on software to process GIS data needs to be developed and modified. As equipment becomes more user-friendly and costs decrease, GIS will become more of a routine tool for humanitarian aid organisations in humanitarian emergencies, and new and innovative uses will evolve.

Health programmes and policies associated with decreased mortality in displaced people in postemergency phase camps: a retrospective study

BACKGROUNDnAn estimated 35 million people have been displaced by complex humanitarian emergencies. International humanitarian organisations define policies and provide basic health and nutrition programmes to displaced people in postemergency phase camps. However, many policies and programmes are not based on supporting data. We aimed to identify associations between age-specific mortality and health indicators in displaced people in postemergency phase camps and to define the programme and policy implications of these data.nnnMETHODSnIn 1998-2000, we obtained and analysed retrospective mortality data for the previous 3 months in 51 postemergency phase camps in seven countries. We did multivariate regression with 18 independent variables that affect crude mortality rates (CMRs) and mortality rates in children younger than 5 years (<5 MRs) in complex emergencies. We compared these results with recommended emergency phase minimum indicators.nnnFINDINGSnRecently established camps had higher CMRs and <5 MRs and fewer local health workers per person than did camps that had been established earlier. Camps that were close to the border or region of conflict or had longer travel times to referral hospitals had higher CMRs than did those located further away or with shorter travel times, and camps with less water per person and high rates of diarrhoea had higher <5 MRs than did those with more water and lower rates of diarrhoea. Distance to border or area of conflict, water quantity, and the number of local health workers per person exceeded the minimum indicators recommended in the emergency phase.nnnINTERPRETATIONnHealth and nutrition policies and programmes for displaced people in postemergency phase camps should be evidence-based. Programmes in complex emergencies should focus on indicators proven to be associated with mortality. Minimum indicators should be developed for programmes targeting displaced people in postemergency phase camps.

No less vulnerable: the internally displaced in humanitarian emergencies

In 1999 the US Committee for Refugees estimated that there were 14 million refugees and 21 million internally displaced persons (IDPs) worldwide. The distinction between refugees and IDPs has important public health implications. It is noted that unlike refugees IDPs cannot invoke the same legal protections as refugees. Additionally no specific international humanitarian agency is responsible for providing them with protection and humanitarian assistance. To address the shortfalls in the protection of the rights of IDPs non-binding legal principles on internal displacement which draw on existing humanitarian and human rights as well as on analogous refugee law have been developed and disseminated. These principles list the important essential services that IDPs are entitled to: food potable water sanitation shelter and medical services. However responsibility for the protection of and provision of basic services to IDPs still rests with national governments. There is an urgent need for a specific international humanitarian agency to be given the mandate for providing such services so that tangible improvements in the health and welfare of IDPs to be attained.

Developing Public Health Indicators in Complex Emergency Response

During the past decade, indicators for the assessment, monitoring, and evaluation of services provided by humanitarian organizations to populations affected by complex emergencies (CEs) were developed to improve the effectiveness and accountability of humanitarian response. The quality of data used to develop individual indicators and their relationship to positive health outcomes varies greatly. This article states the essential characteristics necessary for the development and implementation of effective indicators in CE response and proposes the establishment of an evidence-based grading system. The importance of trend analysis and the modification or addition of various indicators and their thresholds, according to phase and location of CEs, are stressed. Limitations in the development, implementation, and interpretation of these indicators, including those outside of the organizations control are discussed. More evidence-based research is needed as to the type and thresholds of indicators that lead to improved health outcomes in populations affected by CEs. The use of indicators by non-governmental organizations, and how they affect their programs decision-making in different phases and settings within CEs need further study. Finally, the establishment of a regulating body with the authority to enforce the attainment of standards by use of these indicators is necessary to avoid inappropriate humanitarian assistance causing loss of life in the future.

HIV, syphilis, herpes simplex virus 2, and behavioral surveillance among conflict-affected populations in Yei and Rumbek, southern Sudan

Little is known about the HIV epidemic in conflict-affected southern Sudan. During 2002–2003, we conducted behavioral and biological surveillance surveys and sequential sampling in antenatal clinics in Yei, Western Equatoria, and Rumbek, Bar-el-Ghazal. HIV prevalence among individuals aged 15–49 years ranged between 0.4% in Rumbek town and 4.4% in Yei town, and among pregnant women between 0.8 and 3.0%, respectively. After the recent peace agreement, targeted prevention programmes are urgently needed to prevent further spread.

Emergencies in developed countries: are aid organisations ready to adapt?

Issues regarding the appropriateness of aid organizations have been raised since the rise in prioritization of programmatic responses to complex emergencies. These priorities and standards emerged due to the experiences of aid organizations responding to complex emergencies in developing countries. The acute and post-emergency phases of complex emergencies in developing countries primarily in Asia and Africa have been defined with regard to mortality and morbidity rates. These rates have often been used in assessments as health indicators for the whole population. Some aid organizations that responded to the Balkan crisis did not adapt the developing country paradigm for response to the needs of the situation. Problems arose concerning treatment of chronic diseases and mental health. The need for a new definition of the phases of complex emergencies which consider variables such as demographic characteristics and epidemiological disease profile is evident.