Epidemiological Models

Populations suffer both the direct and indirect effects of a conflict. Direct effects include injuries, deaths, disabilities, human rights and international humanitarian law abuses, and psychological stress. Indirect effects actually contribute to the majority of mortality and morbidity due to population displacement, disruption of food supplies, and destroyed health facilities and public health infrastructure. At least three epidemi-ological models exist that may guide the current practice of the humanitarian response effort.

Developing Country Model

The health profile for countries in Africa and Asia during the acute phase of a conflict or war is usually identified by moderate or severe malnutrition, outbreaks of communicable diseases, and often both. Three-fourths of all epidemics of the last decade took place in the context of a CE. Epidemiological indicators show high crude mortality rates and, if disaggregated, expose the vulnerability among the populations as to age (children under 5 years and the elderly) and gender (women and female-headed households). There is a linear relationship between under age 5 childhood mortality (per 1000) and the percentage of nations engaged in armed conflict. The worst conditions and highest mortality rates are recorded among orphaned and unaccompanied children. High case fatality rates were common among malnourished children in Somalia, with measles contributing to between 50 and 81% of deaths. As such, all children in developing countries in conflict should receive measles vaccine and vitamin A supplementation to mitigate the complication rate of measles and other infectious diseases, such as diarrheal and respiratory diseases. Malaria, HIV, and STDs also take a severe toll. Once humanitarian assistance reaches these populations the mortality rates should decline, and the priorities in camps should become ensuring security and fuel and rebuilding the basic public health infrastructure. Abuses against women and failures in reproductive health have led to high rates of STDs and pregnancy in refugee camps. Immediate assistance in CEs comes in the form of WHO Emergency Health, Surgical, and Safe Birthing Kits, which provide care for a 10,000 population for 3 months, and safe birthing and surgical kits. Medical and nursing assets more often needed under this model include public health, preventive medicine and infectious disease specialists, primary care, obstetrics and gynecology, and family practice and emergency medicine personnel.

Developed Country Model

Countries such as Iraq, the former Yugoslavia, Macedonia, and Kosovo had relatively healthy populations with demographic profiles similar to Western countries. The few epidemics and low prevalence of malnutrition among children and infants were superseded by undernutrition and chronic diseases among the elderly, who could not flee the conflict or were unable to access health care. In these settings war-related trauma from advanced weaponry contributed to the primary mortality. Rape and traumatic exposures commonly contributed to psychological morbidity. For such models the desired expatriate medical and nursing care includes surgery, anesthesia, and emergency medicine.

Smoldering Country Model

Both Haiti and the Sudan have unique problems relating to long-standing conflict and unrest that prevent progress in health, healthcare delivery and access, disease prevention, and education. Except for high rates of HIV/AIDS, Haiti represents a health profile in disease last seen in the United States in the early 1900s. Massive deforestation has led to severe environmental collapse, which contributes inextricably to chronic health and infrastructure loss. Haiti represents a developmental as well as an emergency situation. The Sudan has experienced war since 1955 and as such its children grow up chronically malnourished and know only a culture of violence, with little access to health care and education. Reproductive health is an unknown luxury, and most health care must be imported.

Whatever the epidemiological model, the larger humanitarian community has found itself often unprepared and at times overwhelmed with the demands for assistance.

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