Richard Garfield

Background: Armed conflicts include declared cross-border and internal wars and political, ethnic, and religious hostilities. The number of conflicts worldwide and their level of intensity have varied widely during the last 5 decades. Tracking conflicts throughout this period has focused predominantly on the number of individuals killed or displaced from these hostilities through count-based estimation systems, or establishing rates of excess mortality from demographic surveys. This report focuses on people living in areas with conflict by applying an estimated level of conflict intensity to data on the population of each territory with hostilities during 1946 to 2007.Methods: Data from the Uppsala Conflict Data Program/Peace Research Institute Oslo (UCDP/PRIO) Armed Conflict project database on 324 conflicts of any type in countries with populations greater than 500 000 were combined with conflict-intensity estimates from the Center for Systemic Peace and population data from the US Census Bureau International Data Base.Results: More than half a billion people lived in conflict-affected areas in 2007. An increasing proportion of those affected by conflict lived in early postconflict areas, where hostilities were judged or declared during the last 5 years. In the past 2 decades, the average intensity of conflict among those living in areas with a current conflict has gradually declined.Conclusions: A burgeoning population lives in areas where conflict has recently ended, yet most of the world's large-scale medical responses to emergencies focus on high-intensity conflicts. Effective emergency and reconstruction activities in the health sector will depend on reorganizing services to increasingly focus on and transition to low-level and postconflict environments.(Disaster Med Public Health Preparedness. 2012;6:241–246)

The Darfur region of Sudan has been an intense focus of humanitarian concern since rebellions began there early in 2003. In 2004, the US Secretary of State declared that conflict in Darfur represented genocide. Since 2003, many sample surveys and various mortality estimates for Darfur have been made. Nonetheless, confusion and controversy surrounding mortality levels and trends have continued. For this project, results were reviewed from the highest quality field surveys on mortality in Darfur conducted between 2003 and 2008. Trend analysis demonstrated a dramatic decline in mortality over time in Darfur. By 2005, mortality levels had fallen below emergency levels and have continued to decline. Deaths directly due violence have declined as a proportion of all of the deaths in Darfur. Declining mortality in Darfur was not associated with other proximate improvements in well-being, such as improved nutrition. Without large-scale, humanitarian intervention, continuing high rates of mortality due to violence likely would have occurred. If mortality had continued at the high rate documented in 2004, by January 2009, there would have been 330,000 additional deaths. With the humanitarian assistance provided through the United Nations and non-governmental organizations, these people are alive today. A focus on excess deaths among non-combatants may draw attention away from other needs, such as establishing better security, improving service delivery to the displaced, and advocating for internally displaced persons to be reached today and to re-establish their lives and livelihoods tomorrow.

The accurate interpretation of mortality surveys in humanitarian crises is useful for both public health responses and security responses. Recent examples suggest that few medical personnel and researchers can accurately interpret the validity of a mortality survey in these settings. Using an example of a mortality survey from the Democratic Republic of Congo (DRC), we demonstrate important methodological considerations that readers should keep in mind when reading a mortality survey to determine the validity of the study and the applicability of the findings to their settings.

The ability to monitor assistance, define humanitarian needs, and approach equity in the distribution of assistance has lagged behind the world’s growing commitment to responding to humanitarian emergencies. This article highlights relevant data sources to elucidate elements of an operational definition of humanitarian need. New and refined measures are proposed to assist in assessing the level of need among affected populations. An original measure that combines data on conflict and disasters to summarize the cumulative magnitude of 4 types of humanitarian threats is presented. (Disaster Med Public Health Preparedness. 2007;1:110–116)

There has been little systematic analysis of casualty data from the Iraq invasion and postinvasion conflict since 2003. Here we combine well known sources on military casualties and little known or understood sources on non-combatant mortality to identify major trends and impacts. This conflict is unique in many ways. It is associated with high risk of death to previously little affected groups ? female and older adult soldiers. From the early days of combat, the conflict has resulted in a relatively high rate of death among soldiers, reversing a long term trend toward declining mortality among U.S. troops. Despite a high survival rate among those with serious injuries, it is the first conflict for which most deaths occurred after the end of major hostilities. Deaths among non-combatant groups are much higher, and have resulted in far more confusion regarding actual mortality rates. This is not surprising; in few of the major conflicts or humanitarian crisis have epidemiologic estimates been made. It is shown that pre-invasion projections regarding civilian casualties were uniformly mistaken regarding the major risks and risk levels to be faced. More research is needed to improve and standardize approaches to identifying mortality risk to major population groups.