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Complex emergencies are situations where “the cause of the emergency as well as the assistance to the afflicted are bound by intense levels of political considerations”.1

1 Coping with Major Emergencies - WHO Strategy and Approaches to Humanitarian Action. Geneva, World Health Organization, 1995 (unpublished document WHO/EHA/95.1; available on request from the Division of Emergency and Humanitarian Action, World Health Organization, 1211 Geneva 27, Switzerland),

Complex emergencies are characterized by varying degrees of instability and even collapse of national authority. This leads to loss of administrative control and to the inability to provide vital services and protection to the civilian population. One main feature of complex emergencies is the actual or potential generalized violence: against human beings, the environment, infrastructures, and property. Violence has a direct impact in terms of deaths, physical and psychological trauma, and disabilities. In conflicts characterized by rapidly shifting zones of combat, civilians often find themselves under crossfire. In many instances they become the primary targets of ethnic cleansing, murder, sexual violence, torture, and mutilation.

The other effects of conflict on public health are mediated by a variety of circumstances that include:

· Population displacement, with concentration in camps, public buildings or other settlements. This causes an increase in the risk of acute respiratory infections, diarrhoea and dysentery, measles and other epidemics. The dependence on food rations entails a parallel and interacting risk of malnutrition and micronutrient deficiencies (see Chapter 7 and Chapter 8).

· The loss of opportunities and instruments of production, food stocks, and purchasing power, usually accompanied by the destruction of the commercial network can result in diffuse food shortages. In an effort to cope, the population may resort to migration, on an even larger scale than that directly caused by violence (see Chapter 8).

· Armed attacks and landmines, in addition to targeting the civilian population, can damage key infrastructures, such as roads, water plants, communications, and even health facilities.

· The general economic crisis brought on by decreased production, loss of capital, and increased military expenditure, can force cuts in the budgets for the social sectors.

· Insecurity and military operations may restrict access to large areas of territory and constrain the delivery of health services, as well as general response and recovery operations.

As a result of population displacement, economic disruption and widespread violence, access to health care and other vital resources decrease just when hazards and vulnerabilities increase. The effects of acute respiratory infection (ARI), diarrhoea, measles, and other epidemics are compounded by the collapse of health services, programmes for immunization, and disease control.

The overall outcome is a generalized increase in the risk of illness and death that extends beyond the immediate area of conflict, and severe, acute, and chronic psychological traumas. All this must be addressed through emergency and long-term interventions.

A final, major consideration is that health needs will increase as soon as the conflict subsides. Cease-fire may be accompanied by such operations as repatriating refugees and demobilizing soldiers, who will need special health programmes in the quartering areas, and demining, which demands special provisions for medical evacuation.

The health infrastructures, weakened by war and economic crisis, will face new demands for curative care, and a major backlog of preventive measures which could not be implemented for long periods (e.g. measles immunization). Population movements will increase greatly, while previously cut-off areas will suddenly become accessible. The health sector will be required to re-establish coverage, since equitable access to services will play a major role in stabilizing the community and contributing to the peace process.