Conflict, camps and coercion: the ongoing livelihoods crisis in Darfur

This paper presents the findings of a study commissioned by World Food Programme (WFP) in early 2006 to enhance understanding of how the conflict in Darfur has affected livelihoods and markets, and of the effects of food aid. The livelihoods of many in Darfur were devastated early on in the conflict, principally through the widespread looting or destruction of assets and highly restricted population movements, which struck at the heart of pre-conflict livelihoods. Livelihood strategies for most people are now restricted, poorly remunerated and often associated with high risk of attack. Patterns of coercion and exploitation have also become entrenched; and markets and trade, the lifeblood of Da fur's economy pre-conflict, severely disrupted. Against this backdrop the impact of food aid on livelihoods in Darfur has been overwhelmingly positive. The paper proposes a number of preconditions for investment in recovery in Darfur, and recommends ways in which livelihoods can be supported in the current context of ongoing conflict.     

Risk factors for mortality during the 2002 landslides in Chuuk, Federated States of Micronesia

This study examines health effects resulting from landslides in Chuuk during Tropical Storm Chata'an in July 2002, and suggests strategies to prevent future mortality. In August 2002, we conducted a cross-sectional survey to identify risk factors for mortality during landslides, which included 52 survivors and 40 surrogates for 43 decedents to identify risk factors for death. Findings suggest that 1) females had a higher mortality rate from this event than males, and 2) children aged 5–14 years had a 10-fold increase in mortality when compared with annual mortality rates from all causes. Awareness of landslides occurring elsewhere and knowledge of natural warning signs were significantly associated with lower risks of death; being outside during landslides was not associated with reduced mortality. In Chuuk, improving communication systems during tropical storms and increasing knowledge of natural warnings can reduce the risk for mortality during landslides.     

Risk of flood-related mortality in Nepal

In July 1993, severe flooding devastated Sarlahi district in Nepal. The next month, a follow-up study of a large population cohort was undertaken. The study is unique in that a prospective research database was used to verify residency prior to the flood and to confirm vital status afterwards. It evaluated 41,501 children aged between two and nine years and adults aged 15-70 in 7,252 households. Flood-related fatality rates were 13.3 per 1,000 for girls and 9.4 per 1,000 for boys, 6.1 per 1,000 for women and 4.1 per 1,000 for men. Flood-related fatality rates for children were six times higher than mortality rates in the same villages a year before the flood (relative risk (RR) = 5.9, 95 per cent confidence interval (CI) 5.0-6.8). Flood-related fatality was associated with low socio-economic status preflood (RR = 6.4, 95 per cent CI 2.7-20.0), and having a house constructed of thatch (RR = 5.1, 95 per cent CI 1.7-24.5).     

Returning home: resettlement of formerly abducted children in Northern Uganda

This exploratory qualitative study considers the subjective resettlement experiences of children forced into armed conflict in Northern Uganda from the perspectives of 11 former child combatants and 11 adult community members. A thematic analysis was performed on the narrative data. The bioecological model was used to provide a conceptual framework for key themes. Major findings included the overarching impact of ongoing armed conflict on returnees' lives, the important role of the family in supporting children's resettlement, the harassment of former child soldiers by community members, and the community's inability to support systematically the returning children in tangible ways. This study recommends that humanitarian services at all levels strengthen the capacity of families to care for the material and psychoemotional needs of former child soldiers within their communities.     

The Accuracy of Mortality Reporting in Displaced Persons Camps During the Post-emergency Phase

For humanitarian organisations, accurate data are essential to identify emerging health problems and determine programme needs. We visited 45 post-emergency phase displaced persons camps and collected three months' mortality data which we compared with organisations' routine mortality reports. Organisations reported 612 deaths and we identified 741 deaths, for a mortality-reporting ratio, defined as the number of organisation-reported deaths divided by the number of investigator-identified deaths, of 83 per cent. For the majority of camps which under-reported deaths, mortality reporting ratios were significantly higher for women than men, and for camps with central mortality registers rather than those without. In the few camps which over-reported deaths, these occurred primarily among children younger than five years of age, probably due to the inclusion of abortions and stillbirths. Despite the overall under-reporting of deaths by humanitarian organisations, the existing health information systems appear to estimate mortality rates adequately in these post-emergency camps. However, organisations should improve the precision and completeness with which they report the characteristics of deaths in order to provide valuable data to target their programmes at the most vulnerable people.     

The analytical framework of water and armed conflict: a focus on the 2006 Summer War between Israel and Lebanon

This paper develops an analytical framework to investigate the relationship between water and armed conflict, and applies it to the ‘Summer War’ of 2006 between Israel and Lebanon (Hezbollah). The framework broadens and deepens existing classifications by assessing the impact of acts of war as indiscriminate or targeted, and evaluating them in terms of international norms and law, in particular International Humanitarian Law (IHL). In the case at hand, the relationship is characterised by extensive damage in Lebanon to drinking water infrastructure and resources. This is seen as a clear violation of the letter and the spirit of IHL, while the partial destruction of more than 50 public water towers compromises water rights and national development goals. The absence of pre‐war environmental baselines makes it difficult to gauge the impact on water resources, suggesting a role for those with first‐hand knowledge of the hostilities to develop a more effective response before, during, and after armed conflict.     

Using design effects from previous cluster surveys to guide sample size calculation in emergency settings

A good estimate of the design effect is critical for calculating the most efficient sample size for cluster surveys. We reviewed the design effects for seven nutrition and health outcomes from nine population-based cluster surveys conducted in emergency settings. Most of the design effects for outcomes in children, and one-half of the design effects for crude mortality, were below two. A reassessment of mortality data from Kosovo and Badghis, Afghanistan revealed that, given the same number of clusters, changing sample size had a relatively small impact on the precision of the estimate of mortality. We concluded that, in most surveys, assuming a design effect of 1.5 for acute malnutrition in children and two or less for crude mortality would produce a more efficient sample size. In addition, enhancing the sample size in cluster surveys without increasing the number of clusters may not result in substantial improvements in precision.     

Impact of drought‐related vaccination on livestock mortality in pastoralist areas of Ethiopia

Under a national Livestock Policy Forum in Ethiopia the impact of livestock vaccination during drought was assessed in order to inform the development of a best‐practice guideline. For each of the different types of vaccine used during drought years there was no significant difference in livestock mortality, for any species, in vaccinated compared with non‐vaccinated herds. The limited impact of vaccination on livestock mortality was attributed to weaknesses in the design and implementation of vaccination programmes, including use of inappropriate vaccines, low vaccination coverage, problems with vaccine dosing, incorrect timing of vaccination and problems with vaccine storage. If these weaknesses could be overcome vaccination could be a useful means to protect livestock assets, with considerable benefit‐cost ratios. Vaccination should be conducted as a standard preventive measure during normal years, and programme design should be informed by participatory epidemiological studies.     

The politics of AIDS and condoms for stable heterosexual relations in Africa: recent evidence from the local print media

Although there has been considerable attention to increasing mortality rates and economic problems in areas of Africa hardest hit by AIDS, in this paper I examine the epidemic's impact on stable heterosexual relations. By identifying salient cultural themes pertaining to marriage and fertility, I examine people's emerging responses to policy injunctions to use condoms and limit their sexual partners. I draw policy conclusions for the fate of children whose mothers die from AIDS, threats to female education in the wake of the AIDS epidemic and the likelihood of condom acceptance.     

Images of war: using satellite images for human rights monitoring in Turkish Kurdistan

In areas of war and armed conflict it is difficult to get trustworthy and coherent information. Civil society and human rights groups often face problems of dealing with fragmented witness reports, disinformation of war propaganda, and difficult direct access to these areas. Turkish Kurdistan was used as a case study of armed conflict to evaluate the potential use of satellite images for verification of witness reports collected by human rights groups. The Turkish army was reported to be burning forests, fields and villages as a strategy in the conflict against guerrilla uprising. This paper concludes that satellite images are useful to validate witness reports of forest fires. Even though the use of this technology for human rights groups will depend on some feasibility factors such as prices, access and expertise, the images proved to be key for analysis of spatial aspects of conflict and valuable for reconstructing a more trustworthy picture.     

Rehabilitation: strategic, proactive, flexible, risky?

Rehabilitation after armed conflict is a direct intellectual descendant of thinking about rehabilitation after natural calamity. It is related, generally, to poverty reduction and, operationally, to associated action at the micro level. This history has limited its strategic conceptualisation and, in particular, its links with reconciliation and state re-legitimation and also with macro-economic stabilisation and renewed growth. In post-war--or more generally, a lull in conflict with the potential to become permanent--a country's rapid, focused, prioritised action within a strategic framework is urgent. It is not risk-free for political and natural disasters as well as for those with economic and social bases. Flexibility, learning from initial experience and asking intended household beneficiaries about their needs in advance can reduce risk as can pre-positioning of contingency or standby resources to avert post-war calamities (for example, drought, flood) and catastrophes (renewed violence) from delaying and discrediting rehabilitation efforts.     

The Changing Nature of Conflict and Famine Vulnerability: The Case of Livestock Raiding in Turkana District, Kenya

The context of famine in Turkana has changed in recent years as the role played by livestock raiding in contributing to famine has increased. External responses to famine in Turkana have largely been drought driven, for example, food assistance and livestock restocking programmes, which have failed to meet the real needs of herders. The role of armed conflict in the form of raiding has been overlooked as a common feature of societies facing famine and food insecurity.The traditional livelihood-enhancing functions of livestock raiding are contrasted with the more predatory forms common today. The direct impact of raiding on livelihood security can be devastating, while the threat of raids and measures taken to cope with this uncertainty undermine herders' livelihood strategies. Self-imposed restrictions on mobility negatively affect the vegetation of both grazed and ungrazed pastures and restrict the available survival strategies. Predatory raiding leads to a collapse in the moral economy. Some implications of this for relief and development policy are considered, including approaches to conflict resolution.     

Earthquake mortality in Pakistan

A strong earthquake, measuring 7.6 on the Richter scale, hit northern Pakistan on 8 October 2005, causing massive destruction, including an official death toll of 73,276. Four cross-sectional surveys were performed in late 2005 to assess mortality before the event, on the day, and subsequently. Two surveys were community-based and two were situated in camps for internally displaced persons. Crude mortality rates were low in the 3.5 months preceding the earthquake (less than 0.1 deaths per 10,000 per day) and slightly higher in the six-to-eight weeks after the earthquake (ranging from 0.10–0.43 per 10,000 per day). On 8 October 2005, approximately two per cent of the population in one community survey died and around five per cent in the other three surveys. Children less than five years and adults more than or equal to 50 years tended to have a higher risk of mortality on the day of the disaster. These results corroborate the high mortality caused by the earthquake.     

Children and fighting forces: 10 years on from Cape Town

It is 10 years since the adoption of the Cape Town Principles and Best Practices on the Prevention of Recruitment of Children into the Armed Forces and on Demobilization and Social Reintegration of Child Soldiers in Africa. The field of programming for the reintegration of children associated with armed forces and armed groups has made significant strides in this period. However, important gaps in the knowledge base remain. This paper examines empirical evidence that supports lessons learned from work with children formerly connected with fighting forces. It evaluates what is known, where promising practice exists, and lacunae in five programming areas: psychosocial support and care; community acceptance; education, training and livelihoods; inclusive programming for all war-affected children; and follow-up and monitoring. While the 2007 Paris Commitments to Protect Children from Unlawful Recruitment or Use by Armed Forces or Groups mark an emerging consensus on many issues, there is still a critical need for more systematic studies to develop the evidence base supporting intervention in this area.     

Evaluation of Two Kurdish Refugee Camps in Iran, May 1991: The Value of Cluster Sampling in Producing Priorities and Policy

Following the end of the Gulf war in March 1991, Kurdish refugees from Iraq crossed the border into Western Iran. To plan public health interventions and to assist in priority setting for scarce resources, a rapid epidemiological assessment of two camps, Hafez and Kaliche, was conducted in May 1991. A 30 cluster sampling method was used to determine the demographics of the camp population, the morbidity and mortality from certain diseases, and the nutritional status of the children <5 years of age. The estimated population of the camps at the time of the survey was 28,500 and 22,500 for Hafez and Kaliche respectively; children < 5 years of age accounted for approximately 25 per cent of both camp populations. The mortality rate was highest in Hafez and estimated to be 2.5/10,000 per day (95%CI:0.3–5) for adults (> 14 years of age) and 4.9/10,000 per day (95%CI:2.4–7.4) for children. Diarrhoeal and respiratory diseases accounted for major morbidity in both camps with diarrhoea the commonest stated cause of death. Little malnutrition was found but it was greater in Hafez where 6 per cent (19/327) of the children between 1 and 5 years of age had a mid upper arm circumference (MUAC) <12 cm and eleven (5.2 per cent) of the 211 children measured for height and weight were below 80 per cent of the median (95%CI:2.6%;7.8%). The survey identified that morbidity and mortality were less severe than in the Kurdish camps on the Turkish border and provided information for camp authorities to plan appropriate relief interventions.     

Women and children last: An essay on sex discrimination in disasters

In general, little attention has been given to differential survival between the sexes in disasters. Consideration of physiological differences between males and females would suggest that, all things being equal, morbidity and mortality after disaster, particularly where food shortage is involved, should indicate an excess male mortality. Such statistics as exist in disasters, as in chronic underdevelopment, show that it is females and especially girl children who are at highest risk. The basis of this lies in sex discrimination which is implicit in most social systems.     

Mortality rate and confidence interval estimation in humanitarian emergencies

Surveys are conducted frequently in humanitarian emergencies to assess the health status of the population. Most often, they employ complex sample designs, such as cluster sampling. Mortality is an indicator commonly estimated in such surveys. Confidence limits provide information on the precision of the estimate and it is important to ensure that confidence limits for a mortality rate account for the survey design and utilise an acceptable methodology. This paper describes the calculation of confidence limits for mortality rates from surveys using complex sampling designs and a variety of software programmes and methods. It contains an example that makes use of the SAS, SPSS, and Epi Info software programmes. Of the three confidence interval methods examined—the ratio command approach, the modified rate approach, and the modified proportion approach—the paper recommends the ratio command approach to estimate mortality rates with confidence limits.     

Post-conflict health reconstruction: search for a policy

Despite increasing experience in health reconstruction in societies emerging from conflict, the policy basis for investing in the development of equitable and effective health systems in the wake of war remains unsettled. Consideration of post-conflict health reconstruction is almost entirely absent in donor policies on global health. Practically by default, health programmes are seen increasingly as an element of stabilisation and security interventions in the aftermath of armed conflict. That perspective, however, lacks an evidence base and can skew health programmes towards short-term security and stabilisation goals that have a marginal impact and violate the principles of equity, non-discrimination, and quality, which are central to sound health systems and public acceptance of them. A better approach is to ground policy in legitimacy, viewing health both as a core social institution and one that, if developed according to human rights principles, including equity, non-discrimination, participation and accountability, can advance the effectiveness and the quality of governance in the emerging state.     

Refugee health care: Similar but different?

The present review sets out to identify differences between refugees and other more stable communities living in less developed countries: demographic, mortality, morbidity, nutritional and selected epidemiological data are discussed. Although generalizations are difficult because of the variability of refugees and their differing circumstances, the health problems and diseases do not appear to differ qualitatively, although they may be quantitatively more severe.
The areas of particular concern lie not so much with the problems but with approaches to their solutions: the need to respond rapidly and appropriately to emergencies, the importance of attending to the priorities of nutrition, shelter, sanitation and water; and the necessity of providing services which are sufficiently flexible and sensitive to the changing needs of the refugees as they move from the acute emergency to the long-term settlements.
The review highlights certain areas where insufficient information is currently available, notably mental illness and the long-term issues of health and development, and outlines the implications of the conclusions for policy makers, with particular reference to training and research.     

The ethical contours of research in crisis settings: five practical considerations for academic institutional review boards and researchers

The number of research studies in the humanitarian field is rising. It is imperative, therefore, that institutional review boards (IRBs) consider carefully the additional risks present in crisis contexts to ensure that the highest ethical standards are upheld. Ethical guidelines should represent better the specific issues inherent to research among populations grappling with armed conflict, disasters triggered by natural hazards, or health‐related emergencies. This paper seeks to describe five issues particular to humanitarian settings that IRBs should deliberate and on which they should provide recommendations to overcome associated challenges: staged reviews of protocols in acute emergencies; flexible reviews of modification requests; addressing violence and the traumatic experiences of participants; difficulties in attaining meaningful informed consent among populations dependent on aid; and ensuring reviews are knowledgeable of populations' needs. Considering these matters when reviewing protocols will yield more ethically sound research in humanitarian settings and hold researchers accountable to appropriate ethical standards.