Key Questions:

• • What are the public health implications of hurricanes, tsunamis, cyclones, typhoons, floods, earthquakes, droughts, and related disasters?

• • What is the role of international actors and agencies in disaster assessment, response, preparedness, and mitigation?

Ecological disasters,¹ provoked by so-called “natural events” such as major storms and earthquakes, can cause a great deal of suffering—mortality, disability, and displacement—and typically elicit (at least in the short-term) a highly visible global response from the public, governments, multilateral agencies, and a range of humanitarian and nongovernmental organizations (NGOs) and donors. Ecological disasters lay bare miserable social conditions that are otherwise not top public health priorities locally or globally.

LMICs undergo approximately the same number and intensity of ecological shocks as richer nations, but experience many more deaths. Moreover, within countries, poorer regions suffer disproportionate deaths and disability from disasters as well as far greater suffering and loss of possessions and livelihoods (Strömberg 2007). Disasters exacerbate the pre-existing deprivation experienced by disadvantaged communities, as witnessed in Nepal’s severe April 2015 earthquake and aftershocks, which killed more than 7,600 people, injured 16,000, destroyed 300,000 homes, and displaced over 3 million people (Shrestha 2015). The extensive and long-term damages that accompany many crises (and often go unaddressed) contribute to cycles of poverty, disaster, disease, and death.

Nonetheless, the scale of disasters can be deceptive. Despite Western media sensationalizing, with few exceptions, disasters have a large impact locally and may provoke significant morbidity and social disruption while contributing only a small fraction of global or even local mortality. The nearly 6 million children under five who die annually from preventable causes (roughly 16,000 per day) are the daily equivalent of over twice the number who died in the 2015 Nepal earthquake. In Nepal alone, about 20,000 children under 5 died in 2015 (WHO 2016). Yet this news did not enter into mainstream media coverage. This is not to diminish the importance of crises but to put them in perspective, especially in the context of the limited attention garnered by ongoing needs as opposed to emergencies.

In this section we review two kinds of ecological disasters—water-related and earthquakes (heat waves are discussed in chapter 10)—and explore the health implications of and responses to these events.

Major Storms, Floods, and Tsunamis

Earthquakes

Second to water disasters, earthquakes are the ecological disasters that cause the greatest damage to people and infrastructure. Earthquakes affect most regions from the Americas and Caribbean to Europe and Asia, where China’s 2008 Sichuan earthquake killed up to 90,000 people. Infrastructural prevention and preparedness play key roles in mitigating the impact. For example, a December 2003 earthquake struck Bam, Iran killing an estimated 50,000 of the city’s 200,000 residents, leaving over 100,000 homeless, and destroying approximately 60% of the city’s buildings, many made of mud bricks (including the 2,000-year old Citadel). The high death toll was attributed to lax enforcement of municipal construction regulations (Kenny 2009).

Illustrating the complexities of response is the massive 2005 7.6 magnitude earthquake that struck Kashmir (a territory claimed by both India and Pakistan, and beset by ongoing struggles for self-determination against an increasingly militarized Indian presence). Due to the remote, widespread, and mountainous earthquake zone—and Pakistan’s refusal of assistance from Indian defense force helicopters unless they were loaned and flown by Pakistani pilots—rescue assistance was delayed (McGirk 2005). Yet hostilities also gave way to mutual cooperation during the relief effort (Rajagopalan 2006). An estimated 75,000 people lost their lives, with 76,000 injured, 2.8 million left homeless, and 2.3 million lacking secure access to food and essential goods (Brennan and Waldman 2006) in an area marked by poverty and a dearth of health infrastructure. Emergency response crews undertook mass vaccination for measles and sought to establish water and sanitation services. With over half the region’s health facilities destroyed, provision of health care—with special attention to women’s access—became a primary focus of relief. Yet overcrowding, poor sanitation, and limited access to potable water remained ongoing impediments.

Because lack of coordination had been identified as a contributing cause of death in prior disasters, the UN’s OCHA implemented a new “cluster” approach in Kashmir. A lead agency was identified within each sector to improve coordination, quality, consistency, and predictability of the relief effort. Clusters were established to address health, emergency shelter, water and sanitation, logistics, camp management, protection, food security, nutrition, telecommunications, education, and reconstruction. While the cluster approach has been cited as increasing effectiveness of humanitarian aid thanks to greater coordination, it has also been marred by turnover in on-the-ground leadership, limits on inclusiveness, and inadequate accountability to affected populations (Humphries 2013).

Concerns mounted in Kashmir as winter set in and millions faced food deprivation and exposure to the cold. The efforts were also hampered by “relief fatigue,” as the Indian Ocean tsunami that struck 10 months earlier had occupied so much attention on the global stage. Though the earthquake caused an estimated US$5 billion in damages, the World Bank delivered just US$470 million in recovery aid.

Shifting from Response to Preparedness

The UN General Assembly declared the 1990s the International Decade for National Disaster Risk Reduction to highlight the need to increase preparedness and response capacity. Disaster risk reduction’s prevention component involves actions that lessen the chances of a disaster occurring. For example, aiding farmers to diversify their crops and sources of income may prevent occurrence of (p.341) famine. The companion preparedness component encompasses activities that reduce the impact of the disaster when it happens (CARE 2001), such as making a disaster plan, building seawalls, and requiring buildings to be earthquake-proof. The Pan American Health Organization (PAHO) has an extensive disaster preparedness unit that supports member states in training around emergency response, risk communication, health logistics, mass casualty management, emergency care and treatment, and other competencies (PAHO 2010). Preparedness also rests on ongoing societal attention to redressing racial/ethnic, class, gender, and geographic inequities in education, housing, nutrition, transport, and other domains, because the most marginalized populations are usually hit hardest by disaster. Especially when humanitarian organizations are involved, preparedness activities can be difficult to plan, fund, and implement because they blur the lines between relief and development, domains that are often organized into narrowly focused silos (Kopinak 2013).

Furthermore, local politics and economic interests can clash with preparedness priorities. Take, for example, Sanjoy Ghosh, an Indian aid worker with the Association of Voluntary Agencies for Rural Development for the North East, who was making great strides erecting permanent flood protections and lessening flood impact on local populations in Assam (Mahanta 2013). His 1997 abduction and assassination by the United Liberation Front of Assam was likely linked to the logging industry, which saw sizeable revenues from constructing annual flood barriers and considered Ghosh’s efforts a business menace.

At the international level, early warning systems have expanded in recent years. Volcano monitoring systems have enabled timely evacuations and are credited with averting disasters in Iceland, Chile, and elsewhere. Following the 2004 Indian Ocean tsunami, the UN launched a multi-hazard International Early Warning Programme, building on existing tsunami warning systems. But these systems are not perfect. Despite Japan’s sophisticated tsunami warning technology, scientists underestimated the potential impact of the March 2011 tsunami waves (which left 20,000 people dead or missing and caused hundreds of billions of dollars of damage), in part because the magnitude of the undersea Tohoku earthquake (9.0) was unprecedented.

In sum, preparedness efforts interact with ongoing prevention and existing societal conditions. As we shall see next, surveillance systems for hunger and famine that monitor rainfall, crop production, and market prices, and map priority zones, can contribute to preparedness for groups vulnerable to hunger. But these constitute only part of the story.

Key Question:

• • Why and how are famine and food aid political issues?

Though typically instigated by flooding, drought, or soil depletion/desertification—generating crop failure—famines are not sudden ecological disasters but rooted in political and economic circumstances linked to lack of land tenure, lack of democracy, poverty and indebtedness, war, and forced displacement. Precursor to famine is food insecurity, experienced daily by hundreds of millions of people whose nutritional intake is limited by problems of availability, access, quality, utilization, or stability over time. Chronic food insecurity generates vulnerability to hunger and famine as well as illness or death. Transitory food insecurity can lead to acute malnutrition, wasting, and illness, and chronic food shortages can cause micronutrient deficiency diseases, stunting in children, and increased mortality.

As discussed in chapter 7, central to food security is food sovereignty, that is, autonomy of decisions around production and consumption of food, contextualized socio-culturally. Food sovereignty addresses the political and economic underpinnings of much food insecurity, from land grabbing and land degradation to maldistribution, and inappropriate, unsustainable, and inequitable food production—involving monoculture, overcropping, and the use of damaging pesticides, fertilizers, and seeds. These problems, in turn, derive from agribusiness and export-oriented pressures, corruption, inadequate infrastructure, and oppression of poor, rural populations. Importantly, ensuring food security requires that people be fed, regardless (p.342) of the source or kind of food, whereas food sovereignty also addresses long-term prevention in the context of local farming and preferences. For this reason, international responses to famine and food insecurity often aggravate lack of food sovereignty, creating dependence on foreign food supplies and impeding return to local production.

Root Causes of Famines and Hunger

Approximately 800 million people are chronically malnourished (though actual numbers of people experiencing hunger may exceed 2 billion), with recent increases to almost 230 million people in sub-Saharan Africa alone (UN 2015b; FAO, IFAD, and WFP 2014). A range of places in Africa and Asia have faced extreme food crises or famines in recent years, including various countries across the Sahel (Devereux and Berge 2000; FAO 2015) and in Southern Africa, where 40 million people faced food insecurity in 2016 due to drought (UNOCHA 2016a). In North Korea, a combination of unsustainable agricultural practices, loss of food sources, rising global food prices, floods, internal displacement, conflict and delays around food aid, and poor government planning resulted in up to 3 million deaths in the late 1990s (Noland, Robinson, and Wang 2001). In Somalia, over 250,000 people died in a 2011–2012 famine amid rising costs of food imports, drought, internal conflict and terrorism, and large-scale internal displacement (Maxwell and Fitzpatrick 2012).

Sparsely settled Niger, with the world’s lowest HDI ranking and subject to recurring famines, exemplifies how famine can unfold. A 2005 food crisis left 2.5 million people food insecure and over 15% of children suffering from moderate to severe acute malnutrition. Food scarcity was blamed on locusts and drought, yet the 2004 crop yield was only 9% lower than previous years. A deeper analysis points to the Niger government’s adherence to free market economics: it eliminated key regulations of the import-oriented cereal market, leading to large price fluctuations amid currency devaluation, new taxes on foodstuffs, and little attention to food relief (Cornia and Deotti 2015). Incredibly, Niger exported food during this time of food deficits. By 2010 more than seven million people were affected by food shortages (IFRC 2011b), exacerbated by an influx of refugees fleeing terrorism in Mali and Nigeria. Although the Niger government called for help more swiftly in 2010 than in 2005, enabling a better coordinated and effective response, the underlying causes of famine persist.

In southeast Africa, landlocked and subsistence-farming-based Malawi has experienced years of cyclical food shortages, with a 2001–2002 famine causing up to 1,000 deaths and severe food shortages. After the 2005 harvest ranked as the worst on record, with almost 5 million of the country’s 12 million people requiring emergency food aid, Malawi’s President Bingu wa Mutharika vowed not to let it happen again. For years the World Bank pressured small countries to eliminate fertilizer subsidies (while many HICs continue to heavily subsidize their own farming industries; see chapter 9). Breaking with these recommendations, the president increased fertilizer subsidies in 2004–2005, enabling widespread soil enrichment among smallholders (Dugger 2007). The subsidies had a notable impact: small farmers increased their yields, and Malawi generated a food surplus, though it exported grain even as it continued imports (Chirwa and Dorward 2013). However, after a few years Malawi again faced crisis due to rising food and agricultural input prices, insufficient rain, currency devaluation and inflation, a general economic downturn, and the same president’s corrupt and autocratic turn. In 2012 more than 11% of the population (1.6 million people) experienced severe food shortages (UN Africa Renewal 2015).

Politics of Food Aid

The World Food Programme (WFP) is the UN’s food relief agency, the largest humanitarian organization of its kind. It is entirely reliant on annual food and cash pledges plus emergency appeals. Despite recognizing the causes of hunger to include such socio-political factors as poverty, war and human displacement, and unstable food prices (WFP 2015), WFP’s ability to address these underlying issues is constrained by tied donations from governments, corporations, and individuals.

Informing the political act of declaring a famine and WFP’s decision to act, the Famine Early Warning Systems Network monitors food security in 36 countries. According to the UN, only extreme (p.343) instances of food insecurity should prompt declaration of a famine. The criteria are: 20% or more of households facing extreme food shortages with a limited ability to cope; acute malnutrition rates over 30%; and death rates exceeding two people per day per 10,000 people (UN News Centre 2011a). With governmental consent, the food aid system kicks into action. The UN can declare famines if governments fail to do so, as happened in Somalia in 2011 (UN News Centre 2011b).

Most large bilateral aid agencies are involved in food aid, which comprises the largest proportion (25%–30%) of humanitarian assistance (Harvey et al. 2010). The WFP and UN Food and Agricultural Organization (FAO) provide emergency food assistance, daily food programs, and technical assistance in food and agricultural production and distribution. These and other agencies deliver food aid to the most vulnerable groups, but this approach neglects groups less vulnerable but still in need.

While food aid may be needed at particular moments, recipient countries are often worse off after receiving food donations. In addition to displacing local production and jeopardizing the livelihoods of local farmers, food aid is linked to dumping, crowding out of other exporters, transnational companies using their donations to capture new markets, and profiteering (Kripke 2005). Most countries give food aid in grant form rather than tied to donor agri-industry, but the majority of US food aid is “monetized” (i.e., sold in recipient countries to generate cash)—almost 70% in 2009—though this proportion is now declining (Clapp 2012). The United States has been the only country to “sell” food aid to recipients through concessional financing or export credit guarantees (Kripke 2005).

Food aid can create dependence, especially when not accompanied by sustainable agricultural support: for example, in 2008, the United States donated US$460 million to Ethiopia for food aid, but just US$7 million for agricultural development (Perry 2008). Additionally, food aid may be requisitioned by particular political factions or coopted by military forces: in Somalia, al-Shabab militants extort a US$20,000 security fee from WFP every 6 months (Nunn and Qian 2014).

For the United States the provision of food aid is as much a political decision as a humanitarian one. US food production, though privately owned and operated, is heavily government-subsidized, in part through food aid. This system allows private interests to profit from the production, procurement, packaging, transport, and distribution of food aid, and via the sale of food surpluses. The US government requests bids from a limited list of prequalified companies, and arranges for transport on US-flagged ships. The bidding process results in expenses that are higher than market costs, with a handful of transnational companies benefiting—from 2004 to 2007, more than half of Food for Peace’s food aid came from just four corporations: Archer Daniels Midland, Bunge, Cargill (which control the US wheat industry, together with Louis Dreyfus), and Cal Western Packaging (Clapp 2012).

There are growing efforts to reform the food aid system. In 2007 the NGO CARE took the bold step of refusing US government support (US$45 million per year) to deliver food aid, claiming that US programs risked harming the very people they purported to help. CARE held that not only was purchasing food at local markets more efficient, but it helped sustain local farmers, many of them women (CARE 2013). The shakeup in food aid has also led to increasing challenges to monetization, emergence of new donors beyond HICs, food aid being gradually untied from donor country industries, and greater local and regional food procurement, which can shorten arrival time by 70 to 100 days (Elliott and McKitterick 2013). These changes have repercussions not only in the context of ecological disasters but also under war conditions, for CHEs, and in refugee camps.

Key Questions:

• • What is the impact of militarism and war on public health?

• • Why should nuclear, chemical, and biological weapons be banned?

As we have seen, the political economy context substantially shapes the susceptibility to, responses around, and health outcomes of disasters. Yet its (p.344) explanatory resonance in “human-manufactured” crises, most notably wars, is even more profound (the health toll of other kinds of “human-made” crises, such as environmental disasters and climate change, are discussed in chapter 10).

Figure 8-1: World military expenditures, 2005–2015 (constant 2014 US$ billion).

Data Source: SIPRI Military Expenditure Database 2015, https://www.sipri.org/databases/milex.

In the course of human history, more so now than ever, wars have been an integral part of the political economy of societies. The causes of war are complex, relating to local and far larger struggles linked to ethnic and class conflicts, longstanding animosities, corruption, repression, and colonial legacies of exploitation and oppression; war is often inflamed when abundant resources are controlled by a few.

Development, manufacturing, and sale of arms, maintenance of military forces and capabilities—together constituting the “military-industrial complex”—and mobilization of the population for military goals and policies take up a large portion of nations’ resources, diverting attention and money from other societal needs around income security, education, and health equity. In the last century, wars became a preferred solution to a range of social, political, and economic issues (both local and global), and militarism—the subordination of the ideals or practices of a nation’s government or of its civil society to military goals and policies—became a dominant ideology of modern societies.

Albeit with variations among major spenders (Figure 8-1), military expenditures have risen in both absolute and real terms since 1996, following a short-lived “peace dividend” after the Cold War. In 2015, world military expenditures amounted to an estimated US$1.8 trillion, 2.5% of global GDP. The United States is overwhelmingly the largest actor, contributing 34% of world military spending in 2015, with over US$15 trillion in military expenditures since the end of World War II (SIPRI 2015).

Weapons manufacture and sales are concentrated in the hands of a small group of powerful countries. Between 2004 and 2011 the five permanent members of the UN Security Council (China, France, the Russian Federation, the United Kingdom, and the United States) produced and sold 85% of the world’s arms (Global Issues 2013).

World expenditures on weapons research exceeds the combined spending on developing new energy technology, increasing agricultural productivity, and controlling pollutants. Some military discoveries spill over into the civilian sector, including the development of the Internet, antimalarial insecticides, drones, and advances (p.345) in surgery and field medicine. But not only does militarism lead to huge expenditures on the development, production, and testing of nuclear and conventional weapons, the enormous sums going to financial and human resources for military services diverts from social investments in improving the quality of life.

Moreover, promotion of violence as an acceptable way to resolve conflicts contributes to increased violence worldwide (Levy and Sidel 2008). Newer technologies such as unmanned drones heighten tensions and generate civilian casualties even without declaration of war (Kolsy 2015). Countries marked by militarism, for instance the United States, Honduras, Afghanistan, and South Africa, also tend to have the highest rates of gun violence (Geneva Declaration 2015). In such settings, the political forces advocating gun ownership may garner such power that they can paralyze efforts to limit access to guns or even study the consequences of gun use. For example, since 1996 the US Congress has refused to fund the Centers for Disease Control and Prevention to carry out research on gun violence as a public health issue (Kellermann and Rivara 2013). Militarized societies normalize police violence and fragment communities, especially in contexts of poverty and discrimination. In (p.346) Baltimore, USA, poor African-American neighborhoods have experienced decades of social disinvestment while being “hyper-targeted” by the police force’s “war on drugs,” together contributing to high stress rates and poor health (Gomez 2016). (For more on drug wars see Box 8-2.)

Although militarism is not identical to war, it is war’s precursor and companion, readying societies logistically, technically, practically, politically, psychologically, socially, and economically. The effects of militarism are particularly detrimental in LMICs. Every yuan, real, and rand that goes to armed forces and weapons means neglect or underfunding of nutrition, housing, education, and health services. Arms spending can destabilize governments, as during the destructive civil wars in Liberia and Sierra Leone through the 1990s, in which the harvesting of raw diamonds subsidized the weapons used in the fighting, in turn fueling further conflict. Wars are also ecologically devastating and a windfall for weapons contractors and arms manufacturers.

Militarism’s immense burden on civilians is even evidenced in approaches framed as alternatives to militarism. Sanctions and embargoes have been used by high-income powerful nations to impose penalties on countries whose foreign and domestic policies they oppose. Embargoes were once considered a “safe” way to punish a country’s leadership, but research shows they have serious effects on the health and well-being of the most disadvantaged populations (Thoms and Ron 2007). Before the first Gulf War in 1991, embargo-related shortages of food and the deterioration of infrastructure significantly increased infant and child mortality in Iraq (Garfield and Daponte 2000). Ultimately, the impact of sanctions was greatest not on leaders, but on those least able to bear the burden.

Perhaps most importantly, the deep integration and normalization of war into the world’s political and economic order has blurred the traditional line between military personnel and civilians, making (p.347) the latter a “legitimate” target for military actions. The 20th century was the deadliest on record, with an estimated 45 million combat casualties. Yet civilian losses were three times higher, reaching a staggering 146 million people. The civilian toll now comprises 80% to 90% of war-related deaths (Roberts 2010).

Since the end of World War II, at least 30 million people have died in 250 armed conflicts, often driven by the interests of international arms producers and traders (Mahmudi-Azer 2011). War’s indirect effects on civilians include population displacement, loss of social services, unstable food sources, destruction of infrastructure, and the long-term impact of leftover landmines (Wiist et al. 2014) (Box 8-3).

Nuclear, Chemical, and Biological Weapons

The industrialization of war during the 20th century led to the development of new kinds of armaments—chemical, biological, and nuclear weapons of mass destruction (WMD). During World War I, military, political, and corporate leaders in the major warring nations, particularly Germany, developed chemical weapons (CW) (e.g., mustard gas and chlorine) that were responsible for the deaths of thousands of soldiers (Box 8-4). Various countries also sponsored research on biological weapons (BW). Revulsion against the use of CW provided impetus for the Geneva Protocols of 1925 banning the use of chemical and biological weapons (CBW) in warfare. However, the Geneva Protocols did not prohibit the development, production, stockpiling, and transport of such armaments, and between the two world wars, major military powers utilized this loophole to develop CBW programs.

BW programs expanded during World War II, with the United States, Japan, and Great Britain weaponizing anthrax and other pathologic organisms, and culturing microorganisms and insect vectors. Japan performed grisly experiments with biological agents on captured prisoners of war and civilians, and used chemical agents freely in the Manchurian war from 1937 to 1945. In addition, Japanese airplanes dropped various infectious agents, including plague bacteria, on numerous Chinese cities, with reported outbreaks of disease among the civilian population.

By far the world’s most deadly and egregious use of CW was by the Nazis during World War II: upwards of 1 million Jews plus at least 100,000 others were gassed using Zyklon B in concentration camps; and more than 1.7 million Jews, 90,000 people with disabilities, over 4,000 Roma, and untold numbers (probably in the millions) of Soviet prisoners of war and Soviet civilians were killed in stationary chambers and vans with carbon monoxide.²

Since then, intentional military use of CBW has involved: napalm deployed in wars in Korea (1950–1953) and, especially, Vietnam (1955/61–1975), where it caused widespread destruction of foliage and infrastructure and innumerable deaths from horrible burns (Neer 2013); mustard and nerve gas, used in the 1980s Iran–Iraq war (Ali 2001); and, according to the Organisation for the Prohibition of Chemical Weapons, use of chlorine and other poisonous gases in the ongoing war in Syria (2011–present), killing up to 1,500 people. There has also been isolated CBW use for terrorizing purposes, such as in the 1995 Tokyo subway sarin attacks. Although not included in the international conventions, tear gas and pepper spray, causing severe eye, lung, and mucous membrane irritation (and unknown long-term effects) are routinely deployed by police forces around the world against public protesters.

During World War II, the United States developed the world’s first nuclear weapon—the atomic bomb. Its use against Japan in August 1945 is the only instance of nuclear weapons directed at civilian or military populations. The bombs, dropped on Hiroshima and Nagasaki, killed 118,000 people and injured 30,000 in the first year alone, with 95% of casualties occurring within a 1.3 mile radius of the explosions, and up to 300,000 deaths overall (Yokoro and Kamada 1997). The bombs caused the near complete destruction of the physical infrastructure and populations of the two cities and generated long-term health effects of radiation and deep psychological trauma among survivors. Delayed effects included fetal deaths in 1946, elevated rates of leukemia in the 1950s, thyroid cancer in the 1960s, and breast and lung cancer in the 1970s.

Within a few years, the Soviets also developed nuclear weapons, leading the Cold War rivals to produce tens of thousands of nuclear warheads. Over time the horizontal proliferation of nuclear weapons (p.348) programs has expanded beyond a core group of states (United States, Russia, the United Kingdom, France, and China) to include India, Pakistan, North Korea, and Israel (undeclared). South Africa, Ukraine, Belarus, and Kazakhstan have acceded to the Nuclear Non-Proliferation Treaty and no longer have weapons, and Iran agreed in 2015 to make its nuclear program exclusively peaceful.

Collective agreements to control WMD are one way of preventing their health hazards. A 1975 Biological Weapons Convention (BWC), calling for the elimination of all biological weapons programs, currently has 173 parties, with 14 UN member states having neither signed nor ratified the convention (UNOG 2015). Originally proposed by the United States to keep states without nuclear weapons from developing BW programs, the United States ensured the BWC would allow stockpiled biological agents for “defensive” purposes, such as vaccines and countermeasures. In 2001 the US government (p.349) spurned a tentative global accord on a more vigorous BWC, due to pressure from the US pharmaceutical industry regarding loss of proprietary information, and US desire to expand its own “biodefense” programs in potential violation of the BWC. But in 2011, the US administration agreed to the terms of the seventh BWC review conference (The White House Office of the Press Secretary 2011).

Similar concerns about CW, underscored by their use during the Iran–Iraq war, led to the ratification and entry-into-force of the Chemical Weapons Convention (CWC) in 1997, with 190 parties. Enforcement of the CWC has been constrained by inadequate funding for inspections. Of note, while Syria acceded to the CWC in 2013 following international pressure, it was since found to have used CW, highlighting the difficulty of enforcing such treaties. Moreover, technical challenges surrounding the safe destruction of stockpiles have delayed elimination of the vast and dangerously deteriorating CW arsenals of the United States and Russia. Neither country met the CWC’s 2012 deadline for stockpile destruction, and both received extensions. The United States now projects a 2023 completion date, and Russia a 2020 date (Arms Control Association 2014). Iraq has also missed its 2012 deadline for destruction of its small stockpile.

Most daunting are global efforts to control and end the dangerous and ever-costly nuclear arms race, on which US spending alone amounted to US$7.5 trillion (in 2005 dollars) from 1940 to 2005 (Cirincione 2005). Huge volumes of toxic and radioactive waste generated by global nuclear weapons manufacture has poisoned countless workers and communities, threatening public and environmental health for future generations (see chapter 10).

The Nuclear Non-Proliferation Treaty of 1968, to which all but five nations are signatories, commits nuclear weapons states to move speedily through disarmament and the eventual elimination of their nuclear weapons stockpiles. Toward this end, the 1996 Comprehensive Test Ban Treaty (CTBT), still not ratified by 32 countries including the United States, would end all nuclear weapons testing. The Nobel prize-winning activist medical group International Physicians for the Prevention of Nuclear War was instrumental in finalizing the CTBT. There is renewed attention to creating a Nuclear Weapons Convention, supported by the United Nations and the International Committee of the Red Cross (ICRC), to extend the principles of the CWC and BWC to the nuclear realm, given the “catastrophic humanitarian consequences of any use of nuclear weapons” (Maurer 2015).

Terrorism and Public Health

On September 11, 2001, two hijacked planes crashed into the twin World Trade Center (WTC) towers in New York City. The buildings quickly collapsed due to enormous fires, trapping several thousand office workers unable to escape. The hijackers crashed a third airliner into US Department of Defense headquarters, and a fourth plane, also heading to Washington, D.C., plunged into a field after passengers battled the hijackers. In addition to the 19 hijackers, 2,997 people died, comprising office workers, airline passengers, and rescue workers.

The 9/11 attacks caused the single largest loss of civilian life from a coordinated act of terrorism. New York City’s Department of Health mobilized a month-long emergency response, then shifted to worker-injury prevention and surveillance, bioterrorism surveillance, environmental health monitoring and cleanup, and ensuring food and water safety, rodent and vector control, and related public education (Holtz et al. 2003).

Immediately following the attacks, nearly 10% of Manhattan residents showed signs of acute traumatic stress and other mental health problems (Galea et al. 2002). Thousands of tons of WTC debris containing high levels of toxins, including known carcinogens (dioxins, cadmium), have led to a range of illnesses. Several thousand emergency responders have either retired on disability or experienced chronic health problems as a result of their exposure at the scene (Yip et al. 2016). The longer term effects are being monitored through a 20-year registry of over 70,000 people (Brackbill et al. 2006).

Although the long-term psychological and carcinogenic consequences of 9/11 remain significant, the US-led “war on terrorism” has generated far larger consequences globally, with terror begetting more terror in an escalating cycle. The war waged on al-Qaeda (the Jihadist group responsible for 9/11) and on Iraq and Afghanistan has not only caused massive civilian mortality and destruction, it also helped spawn the more decentralized Wahhabi Sunni (p.350) group Daesh (which calls itself ISIS, also referred to as Islamic State group). Daesh operates on an ever more diffuse and deadly scale involving extremist factions in multiple countries throughout the region and beyond, affecting, directly and indirectly, much of the world. This situation of seemingly intractable complexity has been facilitated and worsened by the West’s militarized approach, which ignores extremism’s social, political, and historical roots, from imperial exploitation to nefarious Cold War and commodity-driven calculations and alliances.

In addition to terrorism linked to the wars the United States launched in Afghanistan (2001–present, with up to 100,000 casualties) (Crawford 2015) and Iraq, spilling into Syria (see ahead for both), in recent years there have been repeated Daesh-inspired group bombings and automatic weapon and vehicle assaults in Belgium, France, Germany, and elsewhere across Europe, in Turkey, Indonesia, Lebanon, Iraq, of a Russian airliner, among other incidents, each causing up to hundreds of casualties and generating military counter-attacks with huge death tolls among civilians and medical facilities, and in turn sparking Daesh retaliation. Other conflicts, such as between Pakistan and India (dating from imperial Britain’s exit from India and its 1947 partition, which uprooted some 15 million people and led to the deaths of up to 1 million), Russia and Chechnya, Palestine and Israel, and civil wars in Lebanon, Libya, and Algeria, have also seen multiple deadly terrorist acts in recent decades.

Terrorism is not new, but it has accelerated since 9/11, with no country (outside direct war zones) more affected than Pakistan. From 2003 until mid-2016, over 21,000 Pakistani civilians died from terrorist attacks, involving hundreds of bombings, suicide attacks, and railway assaults (Institute for Conflict Management 2016). HICs are highly concerned about terrorism strikes within their borders, propagating a culture of fear and heightened militarism, but only 5% of the estimated 107,000 terrorist fatalities from 2000 through 2014 occurred in OECD countries. In 2013, 82% of the almost 18,000 deaths from terrorist attacks occurred in Iraq, Afghanistan, Pakistan, Nigeria, and Syria. Iraq, bearing the heaviest brunt of terrorism that year, had 2,492 incidents.

In sub-Saharan Africa, the Somalia-based militant Islamist group al-Shabab has carried out deadly attacks in Kenya and Uganda. In Mali, al-Qaeda terrorized the country’s north and took over the storied city of Timbuktu in 2013, swiftly eliciting French bombing and ever more attacks and hostage-takings, even as Mali’s pleas for debt relief and social development to address deep impoverishment were long spurned by Western donors and bankers (Prashad 2015). Meanwhile, Boko Haram, resurgent since 2009, has terrorized parts of Nigeria and Cameroon through frequent deadly attacks affecting thousands of people, the abduction and rape of hundreds of women and schoolgirls, and kidnappings of business leaders, police officers, and soldiers, in seeking to create a “pure” Islamic state in Nigeria’s north (Institute for Economics and Peace 2014).

The impact of these events reverberates widely for those directly affected, for those living in circumstances of danger and anxiety, and for much of humanity living under conditions of heightened militarism, uncertainty, and increasing violations of human rights. Yet beyond the reported number of casualties, little is known about the long-term effects of terrorism on health in “non-Western” settings: the security concerns of Western powers privilege the suffering of their “innocent” populations over comparable horrific realities among much larger numbers of affected “innocents” in “counter-terrorism” target countries. All suffering merits public health attention, but the global health community has an important role to play in ensuring equity in care and research on the health effects of terrorism across the world.

The “war on terror” has harmed public health in other ways. In 2013, the CIA allegedly organized a fake vaccination campaign as part of its hunt for al-Qaeda leader Osama bin Laden in Abbottabad, Pakistan, recruiting (or duping) Pakistani physician Shakil Afridi (imprisoned by Pakistani authorities) to go door-to-door offering hepatitis B vaccinations. Purportedly the campaign’s real goal was to collect DNA evidence from bin Laden’s offspring to identify his presence (Mullaney and Hassan 2015). True or not, once uncovered this story destroyed trust in vaccination campaigns in the area, particularly jeopardizing polio vaccination efforts: in the years following the deception, 78 vaccination workers were killed by militants accusing the eradication program of espionage (Agence France-Presse 2015). In 2013, Deans of 12 prominent US schools of public health wrote an outraged letter to US President (p.351) Obama decrying the use of vaccination programs for intelligence purposes.

Figure 8-2: Trend of global displacement and proportion of world population displaced, 1996–2015.

Source: UNHCR (2016).

Key Questions:

• • Where are the recent “hot spots” for refugees and internally displaced persons (IDPs)?

• • Why are their numbers growing?

Together with the toll of death, illness, and injury, militarism and wars lead to massive displacement within and beyond borders. According to the United Nations High Commissioner for Refugees (UNHCR), the UN agency charged with the protection of “populations of concern,” in 2015 there were 65.3 million people forcibly displaced around the world, a number that has been rising steadily since 2000 (Figure 8-2). The total number of displaced persons consists of refugees (21.3 million, including 5.2 million Palestine refugees), IDPs (40.8 million), and asylum-seekers (3.2 million) (UNHCR 2016a).

Although refugee numbers declined from the early 1990s until recently due to fewer armed conflicts and several large repatriations, such as the return home of displaced Guatemalans from Mexico, Liberians from Ghana, and Hutus to Rwanda, since 2010 the total number of refugees has soared again (UNHCR 2016a).

In 2015 alone, there were 12.4 million newly displaced individuals (including 8.6 million IDPs, the highest number on record [Figure 8-3], and 1.8 million refugees), quadrupling the number of newly displaced persons in just 4 years (UNHCR 2016a) (Table 8-1). This worst year for displacement since World War II has created a “post-apocalyptic” situation in camps, major receiving communities, and along routes of flight (Feffer 2015). The largest recent surge of refugees and IDPs stems from the war in Syria that risks engulfing the entire Levant. The Syrian war is itself linked to the protracted Iraq War (and “Coalition of the Willing” occupation). It has involved continuing use of drones and airstrikes—against Daesh among other targets—by the United States, France, United (p.352) (p.353) Kingdom, and other NATO countries, as well as Russia, the Syrian government, and certain Gulf States. Since 2011, almost 5 million Syrian refugees have fled to Turkey, Jordan, Lebanon, and other countries, with 6.6 million internally displaced (UNHCR 2016a), living in crowded settlements with water and electricity shortages, and limited health services (Bashour 2015). Turkey is now the biggest host of refugees (2.5 million), followed by Pakistan (1.6 million), Lebanon (1.1 million), and Iran (~1 million) (UNHCR 2016a). This is why Asia is currently the site of the world’s largest “population of concern” (Table 8-2).

Figure 8-3: Map of complex humanitarian emergencies causing internal displacement, 2015.

Source: UNHCR (2016).

A large proportion of UNHCR’s “populations of concern” are young people (over 50% are under 18 years old, with many under age 5). Dubbed the “year of fear,” 2015 became the most dangerous year for children since 1945 (Tisdall 2015). Children and adolescents, especially unaccompanied children who have been separated from families during war or refugee flight, are extremely vulnerable to forced labor, abuse and violence, recruitment into armed groups, sexual exploitation, HIV, and trafficking (with children constituting one third of trafficked persons). Refugee and displaced children are often denied access to education, basic assistance, and asylum (UNODC 2014a).

Unfolding Refugee Situations and HIC Negligence

Refugee and IDP crises are proliferating in multiple parts of the world simultaneously. Since 2012 the Central African Republic (CAR) has been in turmoil, lacking a functional government, and facing ongoing civil conflict. Almost one million people (one fifth of the population) are refugees or IDPs (UNHCR 2016a), and virtually all of the country’s children have witnessed violence and fear for their lives (Jones 2015). Both the African Union and the United Nations have deployed peacekeepers to CAR but humanitarian (p.354) organizations are being denied access to parts of the country by local militias (UN 2015a).

Meanwhile, though most attention to the military conflict in eastern Ukraine has focused on political dimensions, there has been a rapid swelling of over 1.3 million asylum-seekers to Russia, Belarus, Moldova, Poland, Hungary, and Romania (UNHCR 2016c) and 1.5 million IDPs within Ukraine (UNHCR 2015b).

Two other ongoing humanitarian crises, involving large numbers of refugees fleeing war, oppression, and dire economic conditions and making perilous journeys to seek asylum, demonstrate that many HIC governments have a tendency to raise alarms only when their own borders are breached. In recent years millions of political and economic refugees from Syria, Afghanistan, Iraq, Eritrea, Somalia, Nigeria, Gambia, and elsewhere in Africa and the Middle East have made their way to Libya (where civil war has both reduced employment opportunities and facilitated human smuggling) and crossed the Mediterranean Sea in flimsy boats to seek asylum in Europe. In 2015 alone, over 1 million people made the crossing and nearly 3,800 died or went missing. By September 2016, over 310,000 more people had made the trip, with more than 3,600 dead or missing (UNHCR 2016b). Those continuing to make this risky passage, many young and educated professionals, face crowded conditions, violence, and precarious prospects, while those left behind are disproportionately elderly and poor (Morabia and Benjamin 2015). Migrants and asylum-seekers also face tremendous mental health distress, a problem poorly addressed by recipient countries (MSF 2016).

Italy and, especially, Greece are the main frontline recipients of these migrants, many of whom hope to reach Northern Europe via increasingly reluctant Eastern European countries. Though Germany registered over 1 million asylum-seekers in 2015 and Sweden accepted hundreds of thousands (the highest per capita in Europe), the situation remains contentious (European Council on Foreign Relations 2016). Among controversial responses are plans to send migrants rejected by European countries back to Turkey. Failing to provide a collective humanitarian response, the EU is focusing on forestalling migrants at sea and fighting human traffickers, with pledges to provide financial support to sending countries (Casinge 2015). North America, by contrast, has welcomed few Syrian refugees, though in late 2015 Canada began resettling almost 30,000 refugees.

Another crisis concerns the Rohingya, a persecuted Muslim ethnic group totaling over 800,000 people and considered stateless, who are fleeing Myanmar and Bangladesh to Indonesia, Thailand, and Malaysia (Parnini 2013). Conflict in 2012 left hundreds dead and 140,000 homeless. An estimated 100,000 Rohingya have faced exploitation by ruthless smugglers (UNHCR 2015a). Thousands of refugees were stranded at sea, with surrounding governments slow to act. In 2015 Australian politicians (p.355) rejected asylees outright, claiming a war on human smugglers (Iltis 2015).

In recent years the number of environmental/climate refugees (not documented by UNHCR) has also mounted, stemming from the complex interplay among economic forces, human settlement patterns, and ecological change (see chapter 10). For example, international demand for timber leads to excess logging and loss of forest cover, increasing flood magnitude along rivers and causing dislocation of entire communities from their homes. In 2011 almost 15 million people were internally displaced due to water disasters, largely in Asia. It is estimated that by 2050 there could be 200 million environmental migrants (Warner et al. 2009).

Refugees and IDPs experience high rates of human rights violations such as exploitative working conditions, sometimes lasting for decades, as in the case of Palestinians (Giacaman 2015) (see ahead). Their vulnerability, due to displacement from known surroundings, makes their rights to food, housing, and medical care all the more pressing. Threats to refugee rights range from abuse in the hands of foreign authorities to theft, assault, domestic violence, child abuse, rape, and human trafficking.

Key Questions:

• • How does a CHE differ from other types of crises and disasters?

• • What are the political economy of health dimensions of CHEs?

• • What specific threats are faced by women and children during CHEs?

Protracted military conflicts frequently deteriorate into CHEs, which involve “total or considerable breakdown of authority resulting from internal or external conflict,” leading to severe health and social consequences and requiring “an international response that goes beyond the mandate or capacity of any single agency” (IFRC 2011a). CHEs can last for years or even decades, as happened in Sudan, Somalia, and the Democratic Republic of Congo (DRC), contributing to huge numbers of IDPs (Centre for Research on the Epidemiology of Disasters 2013).

It is important to note that while the standard CHE definition describes visible circumstances, it omits key dimensions related to the history of colonialism and ongoing imperialism, asymmetric political and economic power, and social relations that determine who is affected and in what ways. Most recent CHEs arise from civil wars connected to failure in the political and diplomatic arena, yet many of these “internal” conflicts are spurred by competition among and between local and external forces for land or valuable natural resources such as gold, diamonds, or coltan. Such economic interests often become conflated with and heighten ethnic, regional, and class divisions, with civilians recruited and manipulated on behalf of foreign interests into killing, terrorizing, and pillaging entire communities in order to ensure access to resources (Mining Watch Canada 2003).

As with famines, declaring a CHE can be fraught with dilemmas, because it opens the door to UN presence and, increasingly, military intervention. An initial technical indicator of a humanitarian emergency is a doubling of the crude mortality rate (CMR; see chapter 5). Where prior data are not available, the baseline CMR is assumed to be one death per 10,000 people per day, so 2 or more deaths per 10,000 per day is deemed a humanitarian emergency (Sphere Project 2011b). Such quantitative indicators, even when based on incomplete data, allow for comparisons of different emergencies and for monitoring trends within an emergency. A CHE goes beyond a humanitarian emergency, typically involving political and/or sectarian violence, breakdown of social cohesion, disease outbreaks, severe food insecurity, and large-scale population displacement.

The contemporary concern with humanitarian emergencies arose in the context of the 1967–1970 conflict in Biafra, Nigeria. Following Nigerian independence from Britain, the Igbo people sought to secede from the colonially constructed state. Turmoil turned into civil war, resulting in the death of up to three million people (Uzokwe 2003), mostly due to hunger and disease generated by mass displacement and impeded food distribution (Noji and Toole 1997). Responses to this conflict, including the founding of MSF (see ahead), spurred the beginnings of a more outspoken and systematic (public (p.356) health) approach to such crises. Other instances of prolonged civil strife, food shortages, and significant population dislocation shaping humanitarian responses include: Bangladesh’s 1971 liberation war from Pakistan atop the devastation of Cyclone Bhola (with 300,000–500,000 deaths and over 4 million people displaced); the US bombings of hundreds of thousands of Cambodians followed by the 1975–1979 Khmer Rouge terror that led millions of refugees to flee to Thailand (Haas 1991); and the millions of Afghans who fled to Pakistan during the 1979–1989 Soviet-Afghan war.

Particularly horrific, the Rwandan genocide illustrates the sheer dimensions of a CHE and its inseparability from the political economy context. In April 1994, long-festering inter-ethnic tensions, largely deriving from colonial hierarchies, spiraled out of control, and the Interahamwe militia and Rwandan Armed Forces launched a 100-day massacre of approximately 1 million people—mostly Tutsis as well as moderate Hutu sympathizers—in their homes, places of worship, and hiding places in forests and marshes. Roughly 11% of the population, including 85% of all Tutsis in Rwanda, were exterminated, with half a million injured and hundreds of thousands of women and girls raped. The “unimaginable carnage” was essentially ignored by the United States, which did not consider it of immediate national interest. The UN meekly ceded to the Security Council’s refusal to recognize the genocide and sabotaged its own peacekeeping force (Orbinski 2009). Belgium and France, former colonial powers with ongoing strategic and business interests in Rwanda, have been accused of complicity, with France secretly sending arms to the Rwandan government (Dallaire and Beardsley 2004).

After the genocide, with the Tutsis now in power, over 2 million people (mostly Hutus) fled to neighboring countries, especially the DRC (then called Zaire), Burundi, and Tanzania, with another one to two million persons displaced within Rwanda. Goma, in Eastern Congo, received masses of refugees, both perpetrators and victims. The CHE saw renewed killings on both sides and severe outbreaks of cholera and dysentery (Van Damme 1995). After just one month, 50,000 refugees died of these preventable diseases, with one of the highest CHE mortality rates (60 times the baseline) ever documented (Goma Epidemiology Group 1995). With the Interahamwe taking control of many camps, the slaughter continued: UNHCR called Zairian refugee camps a “virtual state of war” (Seybolt 1997). Some NGOs (e.g., MSF) withdrew from certain camps in protest of the misappropriation of humanitarian aid; camps were so unsafe that Zairian forces pulled out a few months after agreeing to provide security. UN agencies provided strategic and operational leadership and organized delivery of goods (albeit with numerous donations not matching needs) for the 200 NGOs on the ground to distribute. Many refugees were forcibly returned to Rwanda after outbreak of war in Congo in 1996; most refugees have left the camps in DRC and elsewhere, but given Rwanda’s extreme poverty and post-genocide context, the challenges of repatriation persist.

Simultaneous to the Rwandan genocide, another set of humanitarian crises garnering inadequate international response was taking place in the Balkans. Following the post-Cold War breakup of Yugoslavia, in the early 1990s the region experienced a series of civil wars that escalated into CHEs. Involving shifting protagonists pandering to extremist nationalism and engaged in “ethnic cleansing”—often with problematic UN, NATO, and EU military and humanitarian participation—the region was engulfed in conflict for over a decade. In Bosnia-Herzegovina, for example, 2.6 million people became refugees in less than 3 months, with Sarajevo under siege for almost 4 years and requiring a protracted airlift. By the time a peace agreement was signed in 1995, between 97,000 and 200,000 were dead, including some 8,000 people in that year’s Srebrenica genocide, and over half the population was displaced (Ahmetasevic 2007; Young 2001). In the Kosovo conflict in the late 1990s, ethnic/racial oppression and violence led to another 12,000 deaths. Throughout, refugees became a target—not only a consequence—of war, with denial of humanitarian assistance used as a weapon (Goodwin 2002). A UN peacekeeping force, UNPROFOR, was meant to enable a humanitarian response, but security problems plagued the 250 relief missions coordinated under UNHCR’s lead (Cutts 1999).

Syria and Yemen serve as tragic contemporary examples of CHEs. After years of expanding armed conflict, upwards of 250,000 Syrian men, women, and children have been killed, with many more seriously wounded and traumatized, and over half (p.357) of the population living in extreme poverty, thousands facing siege and starvation, and nearly 12 million uprooted (UNOCHA 2016b). The deliberate destruction of health facilities has left 13.5 million people in dire need and wholly dependent on humanitarian assistance for survival (UNOCHA 2016b). Strife-ridden Yemen is also facing catastrophe: 21.2 million people rely on humanitarian assistance; hundreds of medical facilities have been shuttered; and millions of children risk dying from pneumonia and diarrhea (UNOCHA Yemen 2016).

CHEs, Public Health, and Mental Health

The health impact of CHEs is greatest where the public health infrastructure is already tenuous, especially when IDPs and refugees arrive into unprepared settings. Countries wracked by war, chronic food insecurity, economic exploitation, political oppression, and net extraction of wealth have limited ability to cope with a massive influx of people. It is precisely these political contexts that have generated the world’s most pressing refugee situations.

The acute, or emergency, phase of the displacement of large numbers of people is usually characterized by the highest morbidity and mortality, most commonly due to diarrheal diseases, acute respiratory infections, and malaria, exacerbated by concomitant acute malnutrition. Diarrheal diseases can account for over 50% of deaths during a CHE’s acute phase, mainly from inadequate quality and quantity of water, substandard sanitation, overcrowding, poor hygiene, and a scarcity of soap. CHE responses typically emphasize clinical care and vaccination campaigns to prevent outbreaks of cholera, measles, and other outbreak-prone diseases, but these efforts cannot compensate for hazardous living conditions.

Increasingly, populations displaced by CHEs seek refuge in towns and cities rather than refugee camps (Crisp, Morris, and Refstie 2012). However, medical care quality and access inside long-established camps are frequently greater and better funded (and have lower mortality) than services for local populations.

Where there is inadequate health infrastructure, CHEs feature poor maternal outcomes and high neonatal death rates (Morof et al. 2014). As well, ongoing health concerns of tuberculosis, malaria, diabetes, HIV, and other diseases require attention just as they do in non-emergency settings (Sphere Project 2011a).

To help address child health under conflict conditions, in the mid-1980s PAHO pioneered the “Health as (a) Bridge for Peace” program in Central America. Amid El Salvador’s civil war, PAHO worked with UNICEF, the Red Cross, and the Catholic Church, among others, to negotiate 1-day, and later 3-day, cease-fires between the government and rebel forces that enabled child immunization against polio, tetanus, diphtheria, and other diseases (de Quadros and Epstein 2002). This approach—involving large-scale social mobilization and the work of thousands of volunteers, health personnel, and guerilla forces as vaccinators during “days of tranquility”—was subsequently adopted by WHO and implemented in Peru, Angola, the DRC, Afghanistan, Croatia, Indonesia, Sri Lanka, and elsewhere.

Mental health is also a leading CHE concern. Most refugees and IDPs exhibit remarkable resiliency, yet the mental health consequences of CHEs can be significant. According to contemporary Western definitions, up to 21% of those who lived through the 1970s Cambodian conflict, for example, experience posttraumatic stress disorder (PTSD) (Mollica et al. 2014). However, applying Western psychiatric understandings and treatment via individualized psychiatric care (e.g., “debriefing”) is problematic: such assessments may lack cultural validation (Ertl et al. 2010) and whether these framings are relevant in war contexts or are ever preferable to local understandings and forms of healing is contested (Bracken, Giller, and Summerfield 2016; Fernando 2014; Summerfield 2000). The social construction of PTSD, for instance, is subject to intense debate in multiple contexts (Akyeampong et al. 2015).

The Inter-Agency Standing Committee that coordinates humanitarian assistance across sectors has developed Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC 2007) to address some of these concerns. In addition to “cultural competence,” listening to communities, and integrating humanitarian mental health care with existing healing services, mental health “first (p.358) aid” includes ensuring basic needs and mobilizing a gamut of social services.

Nevertheless, humanitarian responses alone cannot possibly address the near complete destruction of society and its institutions that occurs with a CHE. Even where a comprehensive mental health plan supports the normalization of everyday life through reestablishment of sociocultural and economic activities, family reunification, and protection from violence (Mollica et al. 2004), restoring tolerance and peaceful coexistence remains a tremendous political challenge. Healing is a profoundly complex matter and can take generations, if not centuries. For example, although two decades later, the unspeakable genocide in Rwanda seems to have given way to a more stable society with attempts at equity-oriented health and social policies, poverty is growing and under the surface there remain high levels of psychological distress that were likely exacerbated by village level truth and reconciliation tribunals (Brounéus 2010).

Gender-Based Violence and Gendered Economic Consequences of CHEs

At least one in five women have experienced gender-based violence (GBV) in CHEs since the 1990s—in Uganda, Liberia, Sierra Leone, Bosnia, Rwanda, the DRC, Darfur, Syria, and elsewhere (Vu et al. 2014). The problem of rape and abuse during war is hardly new. During World War II, Japanese troops abducted between 100,000 and 200,000 Korean, Chinese, Filipina, Indonesian, and Burmese women to serve as “comfort women” (sex slaves) to the Japanese army (Ashford and Huet-Vaughn 1997). Only 10% of these female prisoners survived the war, and few were alive to receive Japan’s formal apologies starting in 1993.

During wartime, public rape is used to terrorize entire communities, forcing flight or submission to captors (Ward and Marsh 2006). During the 1994 Rwandan genocide, Hutu men were urged to rape Tutsi women as an expression of ethnic hatred. The trauma of this humiliation and its long-term psychological effects was magnified for the many women who became pregnant as a result of assault, and/or have suffered from sexually transmitted diseases including HIV (reportedly intentionally spread as further torment) and reproductive health problems.

The social upheaval of CHEs worsens the everyday injustices many women experience, from systematic bias and discrimination leading to smaller provisions of water, food, and soap, to withholding of food for sex and high rates of intimate partner violence. In refugee settings there are particularly high rates of GBV. Hastily erected camps often ignore the security concerns of women and girls, who may be forced to travel unprotected and walk at night to latrines or in search of food, water, and firewood (Leatherman and Griffin 2014). Without the protection of family and friends, they can become sexual prey for refugees, camp guards, and humanitarian relief workers. Gender-based crimes are heavily stigmatized in most countries and thus underreported (see chapter 7), with many women and girls remaining silent due to shame and fear of being shunned by their communities.

While GBV can be reduced in camps through better planning, training, and allocation of supplies, the longer-term economic consequences of CHEs for women and girls is rarely addressed by humanitarian efforts. CHEs leave large numbers of women solely responsible for their families, debt ridden, and with no access to employment. Although humanitarian agencies are rarely equipped to deal with the lasting effects of CHEs, failure to address the material side of survival (and lack of sensitivity to economic realities) means that the lot of women and communities can be forgotten once the acute phase of a CHE is over.

Effects of Violence and War on Children

Presently, 250 million children live in countries affected by conflicts (UNICEF 2016), with an estimated 15 million children directly caught up in the violence of CAR, Iraq, South Sudan, Palestine, Syria, and Ukraine (UNICEF 2014).

The proliferation of deadly warfare technologies such as landmines and small arms has had dramatic consequences for morbidity and mortality: in conflict zones, for every child who dies from armed attacks, three times as many are left severely wounded. Over the last decade, conflict-related wounds have left approximately 4 million children with disabilities; millions more have experienced war-related psychological distress (Schauer and Elbert 2010).

(p.359) For children, war represents not only acute risk of personal physical and psychological endangerment, but also extreme disruption to normal childhood development, with long-term mental health consequences (Betancourt et al. 2011). In addition to the loss of security, predictability, and the structure of daily life, many children experience infrastructure devastation and family separation; witness atrocities such as rape or killing of friends and family; and directly experience acts of violence, from torture and rape to abduction or forced recruitment as soldiers (UNICEF and United Nations 2009).

An estimated 250,000 “child soldiers” are active in conflicts around the globe. Child soldiers have been used in almost 20 countries, including Afghanistan, Myanmar, CAR, Chad, Colombia, DRC, India, Iraq, Palestine, Philippines, Sierra Leone, Somalia, Sri Lanka, Sudan, Syria, Thailand, and Uganda (Schauer and Elbert 2010). Children conscripted with fighting forces may be forced into combat roles, involved in pillaging villages and mass rapes, or work as porters, cooks, servants, human shields, and sexual slaves (Walk Free Foundation 2014). Child soldiers frequently face torture, forced alcohol and substance use, and persistent psychological threats from their captors (Schauer and Elbert 2010). Abducted girls comprise a significant proportion of child soldiers and can face years of sexual violence, abuse, and unwanted pregnancy (Coulter 2015).

Current and former child soldiers show extremely elevated rates of mental distress, with between one third and almost all affected (Schauer and Elbert 2010). The stigma and discrimination experienced upon returning to their communities further compounds these problems and inhibits reintegration into home communities (Newman 2014).

Ongoing Challenges in Responding to CHEs

While humanitarian aid, often a last resort, may be morally justified, it is not a panacea (Orbinski 2009). Even where need is great, assistance may be limited to a few areas, typically around major hubs, potentially leaving those most vulnerable without assistance. There are further practical questions, particularly in acute conflict settings, regarding treatment of chronic communicable diseases (such as tuberculosis and HIV) whose interruption could exacerbate these conditions (Waldman 2008).

Humanitarian responses have been complicated over the past decade by the UN’s endorsement of the “Responsibility to Protect (R2P)” norm authorizing international military intervention to prevent genocide in contexts where sovereign states are unable or unwilling to protect their populations. Invoked in CHEs marked by pervasive violence, for instance Mali, Northern Nigeria, Somalia, and Syria, R2P is “often misconstrued as a mandate for military action” (Moore 2014). The 2011 NATO military action in Libya, for example, is widely considered in the Majority World to have been an abuse of R2P (Adebajo 2016). Humanitarian organizations remain divided on R2P: while protection of civilians and relief workers is a laudable aim, MSF has argued that militarizing aid constitutes an act of war (and war’s rationalization) in itself and transforms relief efforts into military targets (Weissman 2010).

Even non-militarized CHE responses can cause harm alongside any good. Food drops were used extensively during the 1990s, but their benefits have come into question because centralized distribution of food attracted people to places with poor sanitation where communicable diseases flourished. Food-based interventions that neglect preventive health services, as during the Sudan emergency during the 1990s, can contribute to outbreaks of vaccine-preventable disease such as measles (Deng 2002).

In 2000, a coalition of humanitarian agencies and disaster experts cooperated to produce the Sphere Project Handbook. Proposing a core humanitarian standard, its Charter states that all people in all circumstances have the right to live with dignity and to protection and assistance as described in international humanitarian law, refugee law, and human rights instruments (Sphere Project 2011a). Some NGOs argue that the handbook is too technical and does not place enough emphasis on political solutions and the international community’s obligation to provide protection.

Indeed, despite improvements in guidelines and resources for addressing CHEs and protecting affected populations, CHE responses rarely tackle the underlying structural factors and conditions that make these crises so devastating. On one level this may be understandable. Humanitarian (p.360) organizations and their staffs are trained, organized, and committed to addressing existing suffering and need, not to engage in conflict resolution or advance social and economic policies. But they should at least be aware of the politics of humanitarianism.

Taking a political stance decrying the perpetrators based on evidence at hand is one approach to addressing the underlying causes of CHEs or at least mitigating them once they have started. But this is controversial for groups that wish to maintain “neutrality,” may be dangerous for humanitarian workers and UN peacekeepers, and does not guarantee that the world will listen or respond (Magone, Neuman, and Weissman 2012). For example, Roméo Dallaire, Force Commander for the UN Assistance Mission for Rwanda during the genocide repeatedly requested UN reinforcements before the violence escalated out of control, but was met with a pullback of forces instead (Orbinski 2009).

Case Studies of Conflict, CHEs, and Public Health

Key Questions:

• • What dangers do humanitarian aid workers face when working in conflict zones and how should these be addressed?

• • Why is humanitarianism an insufficient means of addressing emergencies?

Dangers and Dilemmas of Humanitarian Aid

Humanitarian workers face significant dangers when they enter conflict-ridden environments, even if incomparable to the suffering of those they are aiding. Sometimes humanitarian workers are targeted because they work with international peacekeeping or foreign intervention forces. Usually unarmed, they are easy targets, though their presence can also discourage attacks on the displaced. In 2015, there were 148 attacks on 287 humanitarian aid workers (mostly local), resulting in death (109 people), injury (110), and kidnapping (68). Most of these attacks took place in Syria, South Sudan, Afghanistan, Somalia, and Yemen (Humanitarian Outcomes 2016).

Health care facilities are often deliberately attacked to deprive enemy combatants of medical support, to acquire drugs and equipment, and for military advantage, affecting both local and foreign health care workers (ICRC 2011). For instance, between October 2015 and September 2016 there were numerous airstrikes on hospitals in Aleppo, Syria, Kunduz, Afghanistan, and northern Yemen, killing dozens of health workers, patients, and others. As of mid-2016, increasingly frequent assaults had resulted in at least 370 medical facilities being attacked and 750 health care workers killed in Syria alone (Physicians for Human Rights 2016).

Humanitarian aid workers may also experience mental health effects from working in situations of mass violence. Up to 14% of aid workers in the Kosovo conflict exhibited symptoms of depression and anxiety (Lopes Cardozo et al. 2005). As well, those who document human rights abuses in the field and collect stories of trauma and abuse may experience vicarious or “second-hand” traumatization (Holtz et al. 2002).

In the past, relief organizations maintained control and leadership over CHE responses, adhering to the principle of neutrality. Since the Balkan wars, however, military forces have become increasingly involved in community health and food programs during CHEs. Instead of improving security, increased military engagement potentially worsens it by blurring the line between civilian and military populations, eroding trust, and associating relief organizations with armed forces (Pringle 2008). (p.364) This has been accompanied by a rising corporate penetration of war and disaster relief (Klein 2007). In 2003, NGOs voiced concern regarding the US military’s decision to coordinate relief efforts in Iraq, given the potential to undermine their impartiality; still, many of the largest US and European NGOs were forced to comply with this directive (Burkle and Noji 2004).

The US Pentagon’s ill-conceived foray into the aid business offers a telling illustration. In 2001, amid a bombing campaign in Afghanistan, US warplanes dropped food packages as humanitarian relief. But cluster bombs that were also being dropped had an almost identical appearance to the food canisters. As a result, an unknown number of persons were maimed or killed, with uproar forcing the Pentagon to suspend this practice (Human Rights Watch 2001).

The threats faced by humanitarian workers raise important questions about the role of the military and intelligence/security forces in purveying relief. Humanitarian organizations have traditionally distanced themselves from military forces, except for cooperation around ecological disasters. Yet rapidly deployable military and security forces may be the sole entity able to meet the reconnaissance, evacuation, and supply needs of certain emergency responses (see chapter 4).

In sum, working with military and intelligence forces, even when they provide essential logistical and security support, presents moral dilemmas for relief organizations and imposes substantial risks for both beneficiaries and aid workers, many of whom argue for humanitarian independence or consider the military to be part of the problem.

Whither Humanitarianism?

The human impulse to do good and serve those in need drives much humanitarian work and has attracted many to the global health field in the first place. Both the nobility and the limits of this aim are evident in the story of MSF, one of the most effective and ubiquitous organizations involved in CHE and disaster responses. Founded in 1971 in Paris by 13 doctors and journalists outraged at the inadequate government and ICRC response to the conflict and famine in Biafra, MSF quickly grew to 300—now 30,000—volunteer doctors, nurses, and staff in 28 countries (see chapter 4). MSF’s first mission was to Nicaragua in the aftermath of a 1972 earthquake, and by 1975 it developed a large-scale medical program for Cambodian refugees in Thailand (MSF 2013a). In 1979 the organization fractured: those preferring more formal structure and organization, while retaining a tempered if still powerful principle of “speaking out” against atrocities, remained in MSF; those seeking to serve as practitioners of social justice-oriented “guerrilla medicine” and more outspoken activist witnessing formed Médecins du Monde (Fox 2014). MSF grew far more rapidly and was awarded the Nobel peace prize in 1999.

Questions of neutrality versus bearing witness have troubled the humanitarian field since its beginnings. Legendary founder of modern nursing Florence Nightingale famously warned in the 1860s that the newly founded ICRC’s volunteer medical caregivers for the war wounded and sick would relieve governments of their responsibilities and thus “render war more easy.” In the 20th century, and despite the horrific human impact of conflict in Europe, Asia, and beyond, the ICRC continued its refusal to take a stance against war, in part arguing that this would limit its access to the wounded and suffering on all sides of conflagrations (and thus constrain its institutional utility). In remaining silent while aligning itself with nationalism and militarism—witnessing barbarism without denouncing it—the ICRC sidestepped founder Henri Dunant’s espousal of pacifism (Hutchinson 1996).

In its founding and early forays, MSF sought to resolve such dilemmas (Redfield 2013). Navigating moral legitimacy, neutrality, and speaking out to justify its cause, MSF was expelled from Ethiopia in the 1980s after its French section accused the regime of using famine and food aid to force resettlement (DeChaine 2002). And in Rwanda, MSF’s call for collective action was articulated in its bitter refrain “you can’t stop genocide with doctors” (Bortolotti 2010, p. 282).

Of course, humanitarian aid organizations are circumscribed by their missions and ambits. MSF, for example, notes that notwithstanding their provision of health services in Gaza, they are unable to “… open borders or end violence” in the Palestine-Israel impasse (Whittall 2014). Humanitarian organizations do not serve the same role as diplomats or (p.365) politicians, though they can report and decry violence to authorities.

Can humanitarian aid workers ever play a role in upending or preventing humanitarian emergencies altogether? In other words, can an emergency response be mounted that also deals with underlying causes? One illustration of a missed opportunity can be found in MSF’s response to a severe childhood lead poisoning outbreak in impoverished communities in northern Nigeria in 2010. The outbreak, which resulted in hundreds of child deaths and many more exposed, was linked to the rise of artisanal gold mining (which through the grinding process released large quantities of lead dust), fueled by soaring gold prices, the collapse of subsistence farming, and the economic crisis that began in 2008. In the absence of Nigerian government action, MSF provided chelation therapy in what would be the “world’s first population-level treatment of severe lead poisoning,” and by helping to coordinate environmental remediation and safer mining practices (Pringle 2014b, p. 301). MSF’s efforts were deemed successful because of the drastic reduction in mortality (Thurtle et al. 2014).

But as John Pringle, an MSF responder in the outbreak, argues, in leaving “unjust political structures” untouched, the “humanitarian response may have created apathy by allowing political structures to gloss over a sense of urgency. Years later, MSF, which has failed to speak out on the political determinants of the lead poisoning outbreak, is still spearheading the medical response, and prospects for a generation of severely lead-affected children seem grim” (Pringle 2014b, p. 304).

Little discussed, but with ongoing salience, is how (medical) humanitarianism was historically enmeshed with the colonial enterprise (Paulmann 2016). Humanitarianism continues to be viewed in some contexts as an accomplice to imperialism through its appropriation by warring parties and its own role in perpetuating dependency and charity over solidarity and human rights (Drayton 2013; Klein 2007; Murdoch 2015).

Like all institutions, humanitarian organizations must also focus on their own survival. Unlike the military, which expects casualties as part of its role, humanitarian organizations may (plan to) evacuate aid workers when they face danger (Karunakara and Dollé 2013). On a different note, use of media and storytelling by UN and humanitarian organizations is a key fundraising strategy that may skew public perceptions of conflicts, disasters, and how they can be addressed (DeChaine 2002). Humanitarian assistance in 2015 grew to US$28 billion (3/4 in government contributions, 1/4 private), about half channelled through multilateral organizations, 40% through NGOs and the ICRC, and just 6% via the public sector (Development Initiatives 2016).

In the end, Nightingale’s concern, amplified, may still stand, more than 150 years later. Some even argue that humanitarian aid that does not address the political economy context on some level may serve to legitimize the status quo, alleviating the responsibilities of governments (including current and former imperial powers) to preempt crisis and excusing their mismanagement, nefarious ties with elite interests, and failure to avert harm and conflict from the other powerful entities in the chain of political and societal determination of health: corporate perpetrators of exploitation of people and resources and international financial actors and their national counterparts, who tolerate or encourage tax evasion, capital flight, deregulation, indebtedness, poverty and inequality, disinvestment in infrastructure, unfair trade rules, and so on (Polman 2010).

While humanitarian organizations alone cannot possibly take on such forces, perhaps there remains a special onus on those who engage in action on the ground and respond firsthand to the needs of the poor and downtrodden—a quid pro quo of providing a lens on atrocities and disasters—conferring responsibilities of speaking out and advocating for political and economic accountability. Here we join the small chorus of voices who call for a social justice response for transformative change that complements, and in the long term transcends the need for, emergency humanitarian responses.