Every year, millions of people around the world are forced into refugee conditions by wars and famines. Two studies, appearing in the July 30 Journal of the American Medical Association conclude that a combination of food shortages and infectious diseases, rather than fighting, are major causes of mortality among refugees. The authors say many deaths could be prevented with a rapid and effective humanitarian response.
One of the reports in JAMA contradicts a claim by the United Nations World Food Program that no famine occurred last year in Ethiopia. The head of the WFP, Catherine Bertini, said last September that a "timely intervention" by the U.N.'s emergency food agency prevented the starvation of thousands of Ethiopian refugees.
But research by medical epidemiologist Peter Salama of the U.S. Centers for Disease Control in Atlanta, Georgia, suggests otherwise.
In a study funded by another U.N. agency, the United Nations Children's Fund (UNICEF), and the non-governmental organization, Save the Children, Mr. Salama and his colleagues collected data on almost 600 households in the Somali city of Gode in Ethiopia from July through August 2000.
According to the CDC's Peter Salama, Gode was hard hit by famine during that six-month period. Of the 4,000 people living in the homes sampled, almost 300 people died during the famine, the vast majority of them children. Mr. Salama says people died of two things.
"A large portion of the mortality was due to malnutrition, as we suspected," he says. "But another portion was due to infectious diseases that are entirely preventable, such as measles."
According to the study, 39 percent of the children who died during the famine did not survive bouts with measles. Mr. Salama says vaccinating refugee children against measles is usually a top priority at the start of a famine.
"Unfortunately in all famine-related emergencies that don't involve people crossing borders as refugees, we tend to be a lot slower in our humanitarian response to measles," he says. "And what happened in this situation was people were attracted to central locations by a large amount of food aid and feeding programs and, unfortunately, a lot of those people were malnourished, and crowding also contributed to the spreading of measles and the severity of measles."
In its defense, the U.N.'s World Food Program now says it did the best it could in Ethiopia under difficult circumstances.
In a related article in JAMA, researchers looked at the effect of war on the treatment of tuberculosis patients in the West African nation of Guinea-Bissau. The investigators, led by Swedish infectious diseases specialist Per Gustafson, found that the number of deaths caused by TB went up during a brief civil war, from June to December 1998, compared to a peaceful period in 1997.
Dr. Gustafson says TB patients caught up in the civil war were three times more likely to die of their illness.
"The problem was the war came in waves." he says. "The war mainly engaged the capital city [Bissau]. And when the war started, the population fled outside the capital city. And outside the capital city, there was no access to tuberculosis medication."
"I think in many people's minds, the damage that is perceived is done from bombs dropping on cities, from acts of terrorism, guerilla tactics and so on and so forth; and not so much from the disruption of services that result in increased rates of mortality from otherwise controllable diseases," says Ronald Waldman of Columbia University's School of Public Health in New York and author of an editorial in JAMA.
And, Dr. Waldman believes more needs to be done to protect vulnerable refugee centers from armed intruders.