Máire A Connolly, Michelle Gayer, Michael J Ryan, Peter Salama, Paul Spiegel, David L Heymann
Lancet 2004; 364: 1974-83
World Health Organization, Geneva, Switzerland (MA Connolly MBBCh, M Gayer MBBS, M J Ryan MBBCh, D L Heymann MD); UNICEF, Kabul, Afghanistan (P Salama MBBS); and UNHCR, Geneva, Switzerland (P Spiegel MD)
Correspondence to: Dr Máire A Connolly, Complex Emergencies Programme, Communicable
Diseases, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
Communicable diseases, alone or in combination with malnutrition, account for most deaths in complex emergencies. Factors promoting disease transmission interact synergistically leading to high incidence rates of diarrhoea, respiratory infection, malaria, and measles. This excess morbidity and mortality is avoidable as effective interventions are available. Adequate shelter, water, food, and sanitation linked to effective case management, immunisation, health education, and disease surveillance are crucial. However, delivery mechanisms are often compromised by loss of health staff, damage to infrastructure, insecurity, and poor co-ordination. Although progress has been made in the control of specific communicable diseases in camp settings, complex emergencies affecting large geographical areas or entire countries pose a greater challenge. Available interventions need to be implemented more systematically in complex emergencies with higher levels of coordination between governments, UN agencies, and non-governmental organisations. In addition, further research is needed to adapt and simplify interventions, and to explore novel diagnostics, vaccines, and therapies.
More than 200 million people live in countries in which complex emergencies affect not only refugees and internally displaced people, but the entire population. Although 10 million refugees are under the protection of the UN High Commissioner for Refugees and can benefit from health interventions, internally displaced people and the conflict-affected population are often dependent on weakened governments (or antigovernment forces), UN agencies such as WHO and UNICEF, and non-governmental organisations for delivery of health services. In most complex emergencies, communicable diseases alone, or more commonly in combination with malnutrition, are the major cause of illness and death (see table). Notable exceptions to this rule are the complex emergencies that took place in the former Yugoslavia, Chechnya, and Georgia.
The highest excess morbidity and mortality often occurs during the acute phase of the emergency. Death rates of over 60-fold the baseline have been recorded in refugees and displaced people, with over three-quarters of these deaths caused by communicable diseases.1 The main causes of morbidity and mortality are diarrhoeal disease - including cholera and dysentery - acute respiratory infection, measles, and malaria, with HIV/AIDS and tuberculosis becoming increasingly important.2 Children are at particular risk; of the ten countries with the worst mortality rates for children aged under 5 years, seven are affected by complex emergencies.3
The excess morbidity and mortality caused by communicable diseases during complex emergencies is largely avoidable, as appropriate interventions are available. Experience has shown that, when these interventions are implemented in a timely and coordinated manner, deaths and disease are substantially reduced.