APPENDIX: FIVE ILLUSTRATIONS OF UNCERTAINTY: MORTALITY IN AFGHANISTAN, BOSNIA, NORTH KOREA, RWANDA, AND SIERRA LEONE
This appendix presents short narratives of five countries that have experienced recent conflict, in which data on mortality are difficult to ascertain. They are included as a kind of rough overview on how general estimates of mortality are generated in emergencies, rather than a scientific study of mortality estimation in these settings. This is done in order to give readers a sense of the real difficulties of data collection and analyzing the many different estimates that are produced in situations involving conflict and forced migration. Five cases are presented:
Afghanistan in the 1980s and 1990s,
Bosnia-Herzegovina during the period of civil conflict, 1992-1995,
North Korea during its famine crisis of 1995-1998,
Rwanda during the year of genocide in 1994, and
Sierra Leone from 1992 to 1998.
In each case, evidence is culled from a variety of sources, including interviews, published literature, news wires, and firsthand observations. In many cases, the data provide only indirect, circumstantial, or limited views of the mortality pattern, and at times the data were drawn from points in time outside the periods of interest. Each case begins with a brief discussion of the situation, followed by evidence for and conclusions about the estimates of excess mortality. Finally, there is a review of mortality risk factors in each setting. Figure 1-9 shows the range of estimates of excess mortality for each of these five complex emergencies.
Afghanistan has suffered cyclical conflict, displacement, massacres, food insecurity, epidemics, collapsed health services, and earthquakes since the 1970s. During this period, virtually no international aid organizations have been able to observe conditions in much of the country, although groups like International Medical Corps (IMC), CARE, and Save the Children have had periodic access to Kabul and the eastern districts. Afghanistan's reported population of 24.8 million is therefore very difficult to confirm, and in any case, millions of Afghan citizens continue to
live in Iran or in refugee camps in Pakistan, where many of them fled during the conflict with the Soviet Union that began in 1979.
Evidence of Mortality
The war in Kabul in 1993 reportedly led to 23,000 deaths, and fighting in the north during the mid- and late 1990s led to numerous massacres and disappearances. Indiscriminate shelling during 1994 and the first three months of 1995 killed 13,000 people, injured 50,000, and left the city without water or electricity (Cohen, 1996). In 1993, Mé decins Sans Frontières (MSF) conducted a retrospective, population-based, household survey of 600 families in Kabul and found a crude mortality rate between 0.5 and 1.0. Mortality was highest among those who had lived in Kabul for a long time and was usually due to gunshot wound. For children, however, deaths were due to measles, diarrhea, and acute respiratory tract infections (Gessner, 1994).
Refugee Camps in Pakistan
Media coverage during the conflict with the Soviet Union characterized the refugees as poor, desperate, hungry, and ill. Due to political stakes and the media coverage, most Westerners believed that the refugees were living in terrible conditions.
Upon review, however, there was never any substantial excess mortality in the camps. One relief coordinator for Oxfam (a nongovernmental organization) reported that “The refugee camps themselves were relatively free of any of the problems inside Afghanistan itself. Also, as time went on, Afghans in the North-West Frontier Province began quite rapidly to find employment; there was very little evidence of malnutrition in the camps” (Bennett, 1999). In some camps, however, child mortality was high, particularly in the southern refugee camps, in Queta Province, due to the failure to immunize the children (Boss et al., 1986).
Estimates of Excess Mortality
The last 20 or more years have been a period of political and social disintegration characterized by ongoing mass migration, arms trade, and rule of law at gunpoint. An entire generation has grown up in Afghanistan knowing nothing but conflict; there is no clear baseline mortality rate and no discrete event or disaster period to contrast to other periods. Many sources refer to relatively high numbers of casualties (Sliwinski, 1988; Khalidi, 1991). Wallensteen and Sollenberg (1998) report yearly estimates of casualty figures in the annual surveys of conflict. But total excess mortality is unknown; it could lie anywhere between 200,000 and 2 million.
Mortality Risk Factors
Mortality risk factors in Afghanistan include landmines, communicable diseases, food insecurity, and natural disasters.
Afghanistan is one of the more heavily mined countries in the world, with ongoing risk from one landmine per person and over 10,000 landmine victims (Lindenberg, 1999). In some areas, it is likely that a high proportion of deaths is attributable to landmines. However, most landmine injury surveillance comes from hospital reporting, which underestimates those persons killed immediately by the blast (McDiarmid, 1995; Andersson et al., 1995; Coupland, 1991). Landmine injuries tend to affect men more than women, and adolescents and young adults more than other age groups.
Communicable diseases account for most of the excess mortality in
areas outside of immediate combat zones. Among children seen in a Kabul hospital, half of all deaths were related to diarrhea, and two-thirds of all patients seen were malnourished (Choudhry et al., 1989). A recent report from Jalalabad finds that roughly half of hospital cases are related in one way or another to either malaria or typhoid (Pilsczek, 1996).
In 1987, the main concern of humanitarian aid agencies in Afghanistan was food security, especially given large projected returns of refugees to central and southern provinces. However, there are very few data on food insecurity inside Afghanistan.
In addition to these other factors, Afghanistan has high excess mortality due to natural disasters. One of two earthquakes that occurred in 1998 resulted in 5,000 deaths (Ivker, 1990; International Federation of the Red Cross and Red Crescent Societies, 1999).
In spring 1992, Serbian forces attacked Sarajevo, and thus began a war for Bosnia-Herzegovina, which had a population of approximately 4.5 million. During the war, roughly 3 million people became refugees; estimates of internally displaced persons inside Bosnia were around 1.2 million. The Serbs laid siege to Sarajevo, cut it off from outside contact, and began bombing and sniping at civilians in 1993.
Evidence of Mortality
Some sample surveys have shown episodes of high mortality from various causes, mostly killing: a survey by MSF-Netherlands in April 1993 found a crude mortality rate of 2.3. The event causing the largest excess mortality of the Bosnia crisis took place in Srebrenica in 1995, when an estimated 7,300 to 8,000 men (out of an overall civilian population of 40,000) were captured, disappeared, and murdered. While the event itself was widely discussed, the true number of missing men has not been precisely estimated. These deaths were not combat-related: they were executions, for which the principal risk factor was being an adult Muslim male resident of the city.
The International Committee for the Red Cross (ICRC) established a database of persons reported missing to help disrupted families. Of the 20,000 persons on the list, several hundred have been found, but it is widely believed that most of the 20,000 who remain missing are dead. The Bosnia State Commission on Missing Persons estimates that 28,000 are missing.
Forensics research has been extremely valuable in reconstructing patterns of adult mortality in Bosnia. Between 1995 and 1998, approximately
400 mass graves were identified, each holding between 3 and 300 dead bodies. Various groups working on exhumations are collaborating with the efforts to trace missing persons, including Physicians for Human Rights, a U.S. nongovernmental organization (NGO), and the International Crimes Tribunal for Yugoslavia (ICTY). It is difficult to estimate the true number of mass graves, but there is reason to believe that there may be as many as 600.
Estimates of Excess Mortality
Total excess mortality from diseases, urban massacres, disappearances, and battles adds up to about 60,000 to 80,000 deaths, yet estimates of 150,000 to 200,000 deaths have been given credence by some policy makers (Médecins Sans Frontières, 1995). These high estimates are based on the assumption that non-Muslim deaths totaled no more than 10,000, which may be a questionable premise.
The high-end estimate of 200,000 originates from the Bosnian government itself and was taken up by other groups, such as the United Nations High Commissioner for Refugees (UNHCR), in order to draw world attention to Bosnia. In late 1993, the United Nations estimated that some 230,000 persons were either dead or missing (Minear et al., 1994). Some government analysts also estimated very high mortality: in November 1995, the U.S. Central Intelligence Agency estimated 156,000 civilian deaths (Borden and Caplan, 1996). George Kenney, an U.S. Department of State official involved in the Bosnia crisis, has challenged these estimates. Kenney argued that mortality was substantially lower, based on Red Cross and other international agency estimates (Kenney, 1995). NGO aid workers, the U.S. Centers for Disease Control, and the Stockholm International Peace Research Institute generally support his figure of 25,000 to 60,000. Within the U.S. Department of Defense, there is disagreement about the best estimate, but it ranges from 70,000 to 95,000, which is closer to Kenney's original 1995 estimate.
Mortality Risk Factors
The main risk factors have been exposure to battle conditions and gunshots (Centers for Disease Control and Prevention, 1993). Violent trauma accounted for 15 percent of total morbidity, 56 percent of total mortality, and affected two-thirds of the civilian population.
By and large, communicable diseases, chronic diseases, and malnutrition did not cause substantial numbers of deaths, although simply being in a hospital may have been correlated with mortality, since hospitals were bombed during intense fighting in the town of Mostar (Horton,
1999). When Serbs shelled the Gorazde hospital in April 1994, 700 were reported killed (Cohen, 1998).
The availability of field hospitals appears to make a large difference in the survival of the battle-wounded in settings like Bosnia (Maricevic and Erceg, 1997). Approximately 4,000 trauma and surgical cases were seen during the first 10 months of war in Zenica. While Bosnia had qualified surgical personnel, the limiting factors were more often lack of power supply in the hospitals, new equipment, and drugs (Pretto et al., 1994).
The main mortality risk factor in Sarajevo was going to the river to obtain water for household use, because of the danger of getting caught in sniper fire. Despite efforts by international humanitarian agencies, internally displaced persons received inadequate protection. One observer has argued that the creation of exclusion zones could have reduced mortality (Cuny, 1996:209):
In Bosnia, the imposition of a total exclusion zone for heavy weapons around the besieged capital of Sarajevo in February 1994 had the potential for ending the war. The Serbs were ordered to either withdraw their weapons or place them in designated weapons collection points within the zone. Any heavy weapon firing inside the zone would be subject to air strikes by NATO. The imposition of the zone dramatically altered the strategic picture by denying the Serbs the ability to capture the capital. Had similar zones been placed around other Bosnian cities, the fighting might have ended.
North Korea (the Democratic People's Republic of Korea) has been isolated since the fall of the Soviet Union and therefore very vulnerable during times of crisis. Between 1992 and 1995, government food ration distributions were drastically curtailed to citizens in the northeastern provinces. In 1995, after 23 inches of rain fell during 10 days in July and August, North Korea declared a disaster and appealed for international food aid while it repaired its damaged agriculture and infrastructure. This was an unusual shift for the government, which had previously resisted admission of need or failure. A year later, a drought hit the country, leading to an even greater need for foreign aid.
The peak of North Korea's famine appears to have been in late 1996 and early 1997, and international food aid grew during those years, peaking in 1998. It appeared to save large numbers of lives. International aid, including over a million tons of food from China, and several million tons of food from the World Food Program and the United States, permitted new observers to enter North Korea for the first time in decades.
Evidence of Mortality
Mortality estimates in North Korea are prone to many potential biases, including:
Observational bias related to lack of access to the population by independent authorities and international aid workers;
Observational bias related to the intrinsic invisibility of high-risk individuals: many manifestations of poverty, malnutrition and related mortality tend to be hidden;
Observational bias related to the areas where aid workers work: this can also lead to over-reporting because of biases on the part of aid workers;
Time-frame validity: this may be due to mis-reporting of dates by individuals or purposeful mis-reporting of dates by governments;
Construct validity: it is difficult to define deaths due only to famine because of intervening factors;
Reporting bias for political reasons: this may be mis-reporting by the government, by civilians, or by refugees; or
Sampling bias because of the use of data from refugees from North Korea: refugees who have fled North Korea are more likely to be fleeing from situations in which crisis is more intense, the risk of death is higher, and, statistically, more deaths have occurred.
Estimates of Excess Mortality
Estimates of mortality due to famine in North Korea come from a number of sources. The government of South Korea recently estimated that 2 million North Koreans have died due to the crisis. The North Korean government's official estimates are that 220,000 deaths have occurred.
One recent study indicates that mortality peaked in 1997, with a crude mortality rate of 56.0 deaths per 1,000 population per year. The average rate over three years (1995 to 1997) was 43.0 (Robinson et al., 1999). This research is the strongest evidence to date of confirmed mortality in North Korea, although it represents only one geographic portion of the country. Since 20 deaths per 1,000 per year would be normal for a country like North Korea, a three-year average rate of 43 implies excess mortality of about 23 per 1,000 during this period, or net 69 deaths per 1,000 population. If this is representative of about one-third of North Korea's total population, this would translate to approximately 450,000 excess deaths.
Over the last two years, World Vision and the Korean community in the United States have publicized interviews conducted by Buddhist monks of refugees fleeing North Korea into South Korea, coming up with
estimates of closer to 3 million deaths. These groups may have political motives for overestimating mortality, however.
Another key report is by former U.S. disaster coordinator Andrew Natsios (1999). Applying the mortality rates derived by Robinson et al. (1999) to the general population, he concludes that roughly 2.4 million people died. This high-end estimate is apparently based on an arbitrary extrapolation, however, and may be very unrealistic.
Mortality Risk Factors
The clearest cause of mortality in famines is wasting malnutrition, and this is certainly the case in North Korea. In 1998, the European Union, the World Food Programme (WFP), the United Nations Children 's Fund (UNICEF), and Save the Children, working with UNHCR, estimated food insecurity malnutrition in North Korea. Their surveys, conducted at the end of the famine, found moderate levels of malnutrition that would not lead to high future mortality rates (16 percent moderately or severely malnourished) (European Union et al., 1998). They also suggest that death rates had not been very high until then.
According to Natsios (1999), mortality was lower among many small farmers who cultivated secret gardens, strategically pre-harvesting some grain crops for surreptitious grain stores to help their families survive. The only other groups with direct availability to crops are the military, who have become involved both in monitoring and in helping with agricultural production.
Extrapolating from similar crises in other countries, it is highly likely that excess mortality is disproportionately higher for young children, especially girls, the elderly, those working in service professions (outside the government and the military), and those living in remote areas and northern provinces.
After years of simmering tensions between Hutu and Tutsi ethnic groups, Rwanda erupted in the early 1990s, when civil conflict flared after Tutsi army incursions from Uganda, leading to the displacement of 900,000 people due to the 1993 fighting. In 1994, the worst genocide in recent times took place, followed by retribution killings of civilians, by excess mortality in refugee camps related to poor health, and ongoing battles with internally displaced persons inside Rwanda. The largest share of excess mortality, however, was due to the systematic campaign of ethnic cleansing by the ruling Hutu government prior to April 1994.
Evidence of Mortality
The killings in Rwanda took place across the country all at once, but the lines of population displacement proceeded in a wave following the progress of the Tutsi forces, who streamed southward from Uganda. Most of the deaths from the crisis occurred in a short span of 10 weeks in 1994, and most resulted from one-on-one attacks by Hutu villagers against their neighbors, most often with machetes (Prunier, 1995). ICRC and MSF estimated during the early phases of the genocide that 200,000 were killed in the first three to four weeks. The estimated number of deaths after six weeks was 500,000 (Weiss, 1999). However, these estimates are highly speculative.
In the Camps
Very high excess mortality occurred in the Rwandan refugee camps, but only briefly and only in one area: 35,000 in approximately one week in July 1994 in the camps based around Goma, due to cholera. During the first month, approximately 50,000 died in North Kivu (Goma Epidemiology Group, 1995). And 40,000 deaths were reported by the gravediggers. Later, when these same refugees were forcibly returned to Rwanda in 1996, there was another cholera outbreak affecting 10,000, with only 46 deaths (Brown et al., 1996).
The highest death rate for a defined sub-population was among refugee children who matriculated into centers of care for unaccompanied minors (who were assumed to be mostly orphans, but were at least dislocated from their families). Their mortality was up to 80 times above baseline (Dowell et al., 1995).
Estimates of Excess Mortality
The UN has estimated that 800,000 died. But the most recent report of Human Rights Watch (HRW) argues that this estimate is high because it includes non-genocide causes (Des Forges, 1999). HRW estimates range from 500,000 to 600,000 genocide-specific mortality. Africa Rights (an NGO) estimates that the genocide totaled 750,000 deaths in Rwanda, based on strong evidence of mass executions, but this estimate may be biased by the personal interest of the authors (Omaar and de Waal, 1994). When one adds in all the collateral deaths related to the complex emergency, however, the total excess mortality for the period is around 750,000.
Mortality Risk Factors
Rwanda was a very complex emergency with many mortality risks. Most of the deaths occurred in three sub-populations:
Tutsi civilians residing in Rwanda, particularly those in the north and public officials;
Resident Hutus who were not part of the Interhamwe (the Hutu militia group who massacred Tutsis) but were suspect of allegiance to the Forces Armées Rwandaises (FAR), the former Rwandan army, in mid-1994, when retribution killings occurred, and in 1995, when internally displaced persons were subject to intolerance; and
Refugees in North Kivu who were subject to a combination of shigella, cholera, dehydration, and malnutrition.
Civil conflict began in Sierra Leone in 1991 and has been heavily influenced by spillover from the ongoing conflict in Liberia. In general, the war has pitted the democratic government against Revolutionary Unity Front (RUF) rebels, backed by Charles Taylor's militia in Liberia. The course of recent events has been greatly determined by the military intervention of West African peacekeeping troops (ECOMOG). However, despite a supposed peace agreement that the elected government of Sierra Leone and rebels signed in 1999, fighting continues and the situation has not improved.
Evidence of Mortality
The conflict in Sierra Leone began in 1991. By the time of the 1992 coup d'etat, there were outbreaks of pertussis (whooping cough) and measles, and floods destroyed food crops. By the mid-1990s, half a million persons were displaced. Approximately 700,000 of Sierra Leone's population of 5 million are believed to have been internally displaced, particularly during 1998-1999, and 440,000 refugees have crossed the borders into Guinea and Liberia.
Prior to the hostilities, Sierra Leone already had the highest mortality rates in the world. Until recently, few NGOs had a presence in Sierra Leone, Africare being an exception. Today NGOs in Sierra Leone have unusually good coordination, and data is well shared. So estimates of mortality from the capital and major IDP areas (5,000-10,000 deaths) are fairly robust. Data from the hinterland and refugee camps, however,
must be surmised. Estimates range from 20,000 to 50,000 additional deaths during the 1990s.
Estimates of Excess Mortality
Much of the killing, terrorism, and mortality secondary to forced displacement is unseen and, therefore, unrecorded and underestimated. The U.S. Office of Foreign Disaster Assistance (OFDA) has said it is impossible to make any estimates of mortality, reflecting the large gaps in information about most of the affected population. Nevertheless, its official situation report states that fighting in the 1990s has claimed at least 20,000 lives (Office of Foreign Disaster Assistance, 1999). Because this figure is not based on any review of the primary health care problems that followed the state collapse, forced migration, malnutrition, and economic damage, it is probably substantially inaccurate and an underestimate.
Multiple reports indicate that in three weeks in 1999, 5,000 people were killed in and around Freetown (United Nations Office for the Coordination of Humanitarian Affairs, 1999b). Thousands of civilians have been abducted in the movement of armies, and hundreds of children are missing and presumed to be abducted. It is hard to know what to infer from this type of disappearance data. As early as 1996, analysts believed that the war had already led to 25,000 deaths (Reno, 1998). So the true cumulative excess mortality rate could be at least 35,000 by now.
High rates of malnutrition have been found in northern districts, now that international agencies have access to these populations (United Nations Office for the Coordination of Humanitarian Affairs, 1999a). Many of the estimates of mortality are inferential, however, based on expected levels of childhood mortality given high rates of malnutrition and diarrhea.
Mortality Risk Factors
Most of the excess mortality is related to malnutrition, diarrhea, and communicable diseases. Much of the country had good immunization coverage in the past, and there was an apparent general reduction in vaccine-preventable diseases as well as diarrheal and respiratory diseases between the 1970s and early 1990s (Hodges and Williams, 1998).
One health risk that emerged in 1998 in Sierra Leone was limb amputation, perpetrated by rebels as a tactic of terror and retribution. Tens of thousands of persons have had arms or hands cut off, and no studies have yet estimated the case fatality rate from these injuries, which is likely to be substantial.
The presence or absence of aid agencies also appears to play a large role in which groups of people suffer excess mortality. Some of the largest IDP camps benefit from good public health programs by international NGOs. Where aid agencies had access, they had success in containing a measles epidemic (e.g., in the towns of Bo and Blama in early 1999).
As in other emergencies (i.e., Somalia and Ethiopia) the effectiveness of international aid to mitigate excess mortality in Sierra Leone appears to be cumulative—that is, it is better during the later stages than during the early stages, when risk of death was highest. Only now are aid agencies able to set up camps and access populations in need.
Andersson, N. , C. Palha da Sousa , and S. Paredes 1995 Social cost of land mines in four countries: Afghanistan, Bosnia, Cambodia and Mozambique . British Medical Journal 311 : 718-721 .
Bennett, J. 1999 Personal communication .
Borden, A. , and R. Caplan 1996 The former Yugoslavia: The war and the peace process . P. 203 in SIPRI Yearbook 1996 . Oxford, UK : Oxford University Press .
Boss, L. , E.W. Brink , and T. Dondero 1986 Infant mortality and childhood nutritional status among Afghan refugees in Pakistan . International Journal of Epidemiology 16(4) : 556-560 .
Brown, V. , B. Reilley , M. Ferrir , and S. Manoncourt 1996 Cholera outbreak during massive influx of Rwandan returnees in November, 1996 . Lancet 349(9046) : 212 .
Centers for Disease Control and Prevention 1993 Status of public health in Bosnia and Herzegovina . Morbidity and Mortality Weekly Report 973 : 979-982 .
Choudhry, V. , I. Fazal , G. Aram , M. Choudhry , L.S. Arya , and M.S. Torpeki 1989 Pattern of preventable diseases in Afghanistan: Suggestions to reduce the morbidity and mortality at IGICH . Indian Pediatrics 26(7) : 654-659 .
Cohen, M. 1996 Afghanistan: Abandoned to Violence, Drugs, Hunger, Disease and Death . Maryland : Bread for the World .
Cohen, R. 1998 Hearts Grown Brutal: Sagas of Sarajevo . New York : Random House .
Coupland, R. 1991 Injuries from antipersonnel mines: The experience of the International Committee of the Red Cross . British Medical Journal 303 : 1509-1512 .
Cuny, F.C. 1996 Refugees, displaced persons and the United Nations system . Pp. 187-211 in R. Caynes , and R. Williamson , US Foreign Policy and the United Nations System . New York : WW Norton .
Des Forges, A. 1999 Leave None to Tell the Story: Genocide in Rwanda . New York : Human Rights Watch .
Dowell, S. , A. Toko , C. Sita , R. Piarroux , A. Duerr , and B. Woodruff 1995 Health and nutrition in centers for unaccompanied children: Experience from the 1994 Rwandan refugee crisis . Journal of the American Medical Association 273 : 1802-1806 .
European Union , World Food Programme , and United Nations Children's Fund 1998 Nutrition Survey of the Democratic People's Republic of Korea . Geneva : European Union, World Food Programme, and UNICEF .
Gessner, B. 1994 Mortality rates, causes of death, and health status among displaced and resident populations of Kabul, Afghanistan . Journal of the American Medical Association 272 : 382-385 .
Goma Epidemiology Group 1995 Public health impact of Rwandan refugee crisis: What happened in Goma, Zaire in July 1994? Lancet 345 : 339-343 .
Hodges, M. , and R. Williams 1998 Registered infant and under-five deaths in Freetown, Sierra Leone from 1987-1991 and a comparison with 1969-1979 . West African Journal of Medicine 17(2) : 95-98 .
Horton, R. 1999 Croatia and Bosnia: The imprints of war . Lancet 353(9170) : 2139-2144 .
International Federation of the Red Cross and Red Crescent Societies 1999 World Disasters Report 1999 . Geneva : International Federation of Red Cross and Red Crescent Societies .
Ivker, R. 1990 United Nations launches aid appeal as Afghanistan faces further disaster . Lancet 351(9101) : 508 .
Kenney, G. 1995 The Bosnian calculation . New York Times Magazine . April 23 : 42-43 .
Khalidi, N.A. 1991 Afghanistan: demographic consequences of war, 1978-1987 . Central Asian Survey 10 : 101-126 .
Lindenberg, M. 1999 Complex emergencies and NGOs: The example of CARE . Pp. 211-246 in J. Leaning , S.M. Briggs , and L.C. Chen, eds. Humanitarian Crises: The Medical and Public Health Response . Cambridge, MA : Harvard University Press .
Maricevic, A. , and M. Erceg 1997 War injuries to the extremities . Military Medicine 162(12) : 808-811 .
McDiarmid, J. 1995 Deaths and injuries caused by landmines . Lancet 346(8983) : 1167 .
Médecins Sans Frontières 1995 Bosnia . In Populations in Danger 1995 . Paris : Médecins Sans Frontières .
Minear, L. , J. Clark , R. Cohen , D. Gallagher , I. Guest , and T. Weiss 1994 Humanitarian Action in the Former Yugoslavia: The UN's Role 1991-1993. Occasional Paper #18 . Providence, RI and Washington, DC : Humanitarianism and War Project and the Refugee Policy Group .
Natsios, A. 1999 The Politics of Famine in North Korea . Washington, DC : U.S. Institute of Peace .
Office of Foreign Disaster Assistance 1999 Sierra Leone Complex Emergency Fact Sheet 17 . Washington, DC : U.S. Agency for International Development, Office of Foreign Disaster Assistance .
Omaar, R. , and A. de Waal 1994 Rwanda: Death, Despair and Defiance . London : Africa Rights .
Pilsczek, F. 1996 Visiting doctor's perspective in Afghanistan . Lancet 348(9041) : 1566-1568 .
Pretto, E.A. , M. Begovic , and M. Begovic 1994 Emergency medical services during the siege of Sarajevo, Bosnia and Herzegovina: A preliminary report . Pre-hospital and Disaster Medicine 9(2 Suppl 1) : S39-S45 .
Prunier, G. 1995 The Rwanda Crisis: History of a Genocide . New York : Columbia University Press .
Reno, W. 1998 Warlord Politics and African States . Boulder, Colorado : Lynne Rienner Publishers .
Robinson, C. , M. Lee , K. Hill , and G. Burnham 1999 Mortality in North Korean migrant households: A retrospective study . Lancet 354 : 291-295 .
Sliwinski, M. 1988 The decimation of Afghanistan . Orbis 33(Winter) : 39-56 .
United Nations Office for the Coordination of Humanitarian Affairs . 1999 Mid-Term Review and Revision of United Nations Consolidated Inter-Agency Appeal for Sierra Leone . New York : Office for the Coordination of Humanitarian Affairs .
1999b Integrated Regional Information Network for West Africa . News bulletin .
Wallensteen, P. , and M. Sollenberg 1998 Armed conflicts and regional conflict complexes, 1989-97 . Journal of Peace Research 35(5) : 621-634 .
Weiss, T. 1999 Military-Civilian Interactions: Intervening in Humanitarian Crises . Lanham, MD : Rowman and Littlefield Publishers, Inc.