So-called “excess” mortality is typically the most dramatic outcome of complex emergencies and natural disasters, and humanitarian and disaster relief operations have traditionally and rightly been tasked with reducing or averting it to the extent possible. As a result of the attention that has been given to this over the course of the last two decades, major inroads have been made with respect to understanding the dynamics of excess mortality in crisis situations and in identifying the interventions best suited to those situations. Thus, although averting excess mortality continues to be a constant challenge for relief workers, the knowledge that has been acquired is making the problem all the more amenable to intervention.
Over the years, mortality data have also become valuable indicators of the impact of focused health interventions such as emergency vaccination and feeding as well as the impact of more general operations such as organized evacuation. The donor and the relief community have thus seen fit to refer to mortality statistics in determining the “natural history” of emergencies and in identifying the type, scope, and duration of the assistance required. In much the same way, changing patterns of mortality have been increasingly used as descriptors of impending natural disasters such as famine, and man-made ones such as conflict and ethnic cleansing.
Using mortality data as indicators of past, existing, or forthcoming disasters, and by extension, of the need for relief interventions, nevertheless presents a number of conceptual and methodological challenges.
Some of these have become more evident as a result of recent crises in different parts of the world, and the papers in this volume are particularly valuable in drawing our attention to the issues involved.
Any discussion on the use of health statistics, for example, must consider the perennial question of denominator data and the difficulties that are almost inevitably encountered in obtaining these in the context of complex emergencies and natural disasters. Knowing what the risks are and who is really “at risk” are questions that have long plagued the assessment of complex emergencies and natural disasters and their health impact.
There are no easy solutions to this, especially where national health and other statistics prior to and certainly during crises have been poorly kept, tampered with, or damaged, or are simply not accessible. The papers discussed here reflect these difficulties and rightly raise them as limiting factors in any discussion of mortality in the context of emergencies and disasters. More attention clearly needs to be given to accessing denominator data from countries where the perceived likelihood of complex emergencies and natural disasters is high. It is also important that more attention is given to defining the risk factors and events that are likely to be of concern in crisis situations so that planning for data needs can occur early on. Burkholder et al., for example, refers to “war-related deaths” and highlights the question of what are war-related deaths. Are they the deaths that result from war injuries? Are deaths associated with “unintentional” injuries and exposure that occur during flight from persecution and accidents en route to safe havens to be included? And what about deaths that occur as a result of lack of access to health care services and medication? Shall we include the deaths among the elderly and others who “give up” the will to live in these situations? And what of the suicides that so often occur but also go unmeasured? If the latter are to be included, and surely the case must be made for this, then the concept of war-related deaths takes on a whole new scope and importance.
In the same way, it is important that we try to distinguish between mortality in the location of the crisis (e.g., primarily intentional and unintentional injuries and homicide), mortality during uprooting and forced movement (e.g., primarily “natural” causes, unintentional and intentional injuries), and mortality during resettlement (e.g., primarily “natural” causes and unintentional injuries).
Robinson et al.'s data suggest that in the case of North Korea the movement of people was not associated with mortality either as a prompting event or as an associated impact. In the case of Kosovo, on the other hand, at least two and possibly three very different pictures emerged. Mortality, or the fear of it, was a major prompting event, as it often is in situations of ethnic cleansing. There is also evidence that mortality peaked
around the time the international community took retaliatory measures, and here a confusing image of intentional and unintentional injuries, homicide and genocide will no doubt prove difficult to unravel for a variety of reasons, some of which are discussed below.
The International Centre for Migration and Health (ICMH) also found considerable anecdotal information to the effect that deaths en route to Albania and Macedonia were relatively high among the elderly and newborn infants in the context of complicated pregnancies and deliveries in hostile physical environments where there was little qualified care. By contrast, mortality in refugee camps in Albania and Macedonia was relatively low, pointing not only to the adequacy of the relief operations by national receiving governments and external organizations, but also to the fact that most refugees were probably relatively healthy at the time the exodus began.
Here we are reminded of how each emergency or natural disaster deserves to be approached as a unique event. For while there may be many shared characteristics and processes, it is in the uniqueness of each event that the challenge of planning and implementing relief lies. Unfortunately, some of the relief organizations responding to the Kosovo crisis built operations on experiences gained in other parts of the world where mortality related to malnutrition, infectious diseases, waterborne infections, and unhealthy environmental conditions has traditionally been the problem. In the case of refugees in Albania and Macedonia, however, the problem quickly became more one of chronic diseases whose management called for a different category of support and medical supplies, a fact which, just as during the war in Bosnia, often caught relief organizations unprepared.
There is also a need to highlight the importance of disaggregating mortality, or indeed any health-related data, by at least age, sex, and family status. Not to do so puts into question the usefulness of mortality (and other health) data from the perspective of understanding both the epidemiology of mortality itself and its implications for surviving populations. For especially (but not only) in emergency and disaster situations the death of any individual has the potential to implicate and threaten the health and well being of others in many and profound ways. The precocious rupture of symbiotic relationships between people, particularly within families, can have an immediate impact on the welfare of survivors, be they children, women, the elderly, or indeed men. It is noteworthy, for example, that Robinson et al. found that widows were more vulnerable. And when Burkholder et al. refer to the high mortality rate among the elderly, this was probably due not only to natural attrition in the harsh conditions of forced uprooting and movement, but also to the fact that many were “unaccompanied” and possibly without the help of relatives and close family.
From a more methodological perspective the papers also highlight the realities and shortcomings encountered in enumerating anything, including health events in complex emergencies and natural disasters. For even when events are readily discernible and measurable in principle, the fact remains that from a logistical perspective they often occur in situations from which it is difficult (and at times dangerous) to gather reliable information. The papers also remind us of the fact that while mortality data may be important to relief organizations from the point of view of knowing when, how, and with what to intervene from an international perspective, they are sometimes not seen in the same light from a national point of view.
There are a number of reasons why national partners may view these data differently. In countries where ethnic hostilities and political strife are the cause of excess mortality, information can be politically sensitive and, at best, susceptible to under- or over-reporting. Because they can be indicative of things that are going wrong, mortality data are often defended by countries and interested parties as highly private and confidential. When they are, they also tend to be hidden, tampered with, or purposely skewed. In this regard, Robinson et al. highlight the importance of using creative techniques for generating mortality data while at the same time reminding us of the difficulties involved in developing sensitive and specific methods for doing so. The papers in this volume are an important reminder of how easily mortality data (and mortality itself) can be hidden unless innovative and creative techniques are used to extract and put together relevant images of excess mortality.
Burkholder et al. refer to the difficulties that many external relief groups had in accessing data that had been gathered by national health services in Albania and Macedonia. While this limited access can be criticized, the other reality is that the relationship between external groups and national governments receiving refugees is often so ill defined that governments are not clear as to why health data (or other information) are being requested and how they will be used. In Albania and Macedonia, the lack of a good working relationship between relief organizations and national and local government was already evident in the first week of April 1999. It did not improve significantly for a variety of reasons, some of which were probably preventable. In the case of Macedonia, where large numbers of refugees had been accommodated from the very beginning of the crisis in local communities, the government felt that it was being unduly recognized for what it had done to assist. External groups were arriving and setting up relief operations, often bypassing national and local governments. The authorities were also concerned about the impact refugees would have on local health services and the capacity of those services to respond to both refugees and national populations.
ICMH studies of this phenomenon in other parts of the world have pointed to the relatively cavalier way in which local health systems and authorities are often neglected by relief organizations in both planning and implementing relief operations. Yet no matter how comprehensive relief interventions are, referral of complicated cases always depends on the capacity of local health services to accommodate them. The additional “load” this represents is rarely reflected in the support they get from relief organizations.
In the case of Albania, where the health care system has been underfunded and over-stretched for the past five or so years, local authorities were concerned about their capacity to respond appropriately (although, just as in Macedonia, they did respond well). They were also critical of how little they were invited to participate in some of the relief planning operations that would ultimately have an impact on local services as well. Making access to health-related data difficult to external groups under such circumstances may often be a reaction to how they feel they are being treated.
In the context of the Kosovo crisis, poor coordination and communication between different relief agencies also stood out as a major problem that while not unique to that situation, nevertheless had serious implications for data generation and planning in general. The proliferation of relief agencies and groups often became a challenge as well as a contribution. Some came with different mandates, interests, and degrees of experience and technical sophistication. Their interest in and capacity for gathering health-related data in general and mortality data in particular varied considerably. More importantly, their commitment to sharing data (or even understanding why health data should be pooled) also varied and different methods of data collection were often used and the possibilities of using standardized techniques were typically neglected.
The fact that health-related data are useful in generating support from donors and in reporting back to them on the impact of relief operations also, no doubt, tended to make pooling of information even more of a challenge. Traditionally this has often thrown into question the reliability of data generated by relief groups because of fears that it would be imprecise and either over- or underestimated.
The lack of coordination and pooling of health data also had its implications for the interventions formulated by different groups, and there is no doubt that duplication, contradictions in approaches, over-focusing on some issues and neglecting others occurred as a result. Coordination, or the lack of it, thus stood out as one of the most difficult issues in general, and especially so in the collection of mortality and other health statistics.
Finally, although mortality statistics are of paramount importance in understanding the severity of crisis situations, we must not lose sight of
the fact that they provide only a restricted image of those crises. However, because they do reflect such a visible part of the problem, there is a danger that at times the collection of mortality statistics and activities designed to reduce excess mortality will eclipse other equally salient but less evident concerns. Thus, for example, the issue of psychosocial morbidity, and I would even dare to say, mortality, has been neglected as an issue even though from the point of view of long-term disability and limitations to social reconstruction and recovery, this may be of equally significant importance as physical mortality.