1. Bang, A. T. and Bang, R. A. Diagnosis of causes of childhood deaths in developing countries by verbal autopsy: suggested criteria. The SEARCH Team. Bull World Health Organ. 1992; 70(4): 499-507.
Keywords: Autopsy: *methods/ *Cause of Death/ Child, Preschool/ Data Collection: methods/ *Developing Countries/ Human/ India/ Infant/ Infant, Newborn/ Interviews/ Pilot Projects/ Reproducibility of Results/ Support, Non-U.S. Gov't.
Abstract: In the absence of medical certification of deaths in developing countries, lay reporting and verbal autopsy have emerged as useful alternative methods for collecting data on causes of death. Of these, verbal autopsy offers advantages and is widely used in field studies and child survival programmes. However, because uniform and valid criteria for the diagnosis of common causes of death are lacking, comparison of the results of different studies becomes meaningless. This article proposes such a set of criteria for the cause of death among neonates and for those aged 1-59 months. The criteria are based on the findings of earlier validation studies, a Delphi survey and the experience gained from performing 1000 verbal autopsies in Gadchiroli, India. The emergence of such standardized criteria of causes of death should be of immense value for health planning, monitoring and evaluation purposes and for interregional comparisons.

2. Brookings Institution; UNHCR, and OAU. Internal displacement in Africa. Report of a workshop held in Addis Ababa, Ethiopia 19-20 October 1998.
Notes: Abstract written by Tulane University.
Abstract: This report is the result of a workshop entitled Internal displacement in Africa. The workshop served as a forum in which leading practitioners and policymakers could discuss the extent of the problem of internal displacement in Africa and collaboratively draw conclusions about recommended measures for appropriate response to the problem. The workshop report focuses specifically on the role of different level government bodies and non-governmental organizations in preventing and ameliorating the problem of internal displacement, with particular attention also given to the protection of human rights, special considerations for displaced women and children, and inter-organizational coordination.

3. Centers for Disease Control and Prevention. Morbidity and mortality surveillance in Rwandan refugees--Burundi and Zaire, 1994. MMWR Morb Mortal Wkly Rep. 1996 Feb 9; 45(5): 104-7.
Keywords: Burundi: epidemiology/ Democratic Republic of the Congo: epidemiology/ Health Status/ Human/ *Morbidity/ *Mortality/ Refugees: *statistics & numerical data/ Rwanda: ethnology
Abstract: In April 1994, resumption of a longstanding conflict between the Hutus and Tutsis--the two major ethnic groups in the central African countries of Burundi and Zaire--resulted in civil war and mass genocide in Rwanda. An estimated 63,000 (primarily Tutsi) refugees subsequently moved from Rwanda into northern Burundi, and 500,000 refugees fled to Tanzania (Figure 1). In early July 1994, as armed strife subsided, many Tutsis returned home to Rwanda, and an estimated 1 million Rwandan Hutus fled to Zaire, and 170,000 fled to Burundi. To monitor the health status of the refugees, the Office of the United Nations High Commissioner for Refugees (UNHCR) and nongovernmental organizations (NGOs) working in refugee camps in both countries established systems for rapid surveillance of morbidity and mortality. This report presents the findings of these systems during May-September 1994 (the period of the most intensive population migration) and indicates that mortality was high among refugees in camps in both countries.

4. Centers for Disease Control and Prevention. Population-based mortality assessment--Baidoa and Afgoi, Somalia, 1992. MMWR Morb Mortal Wkly Rep. 1992 Dec 11; 41(49): 913-7.
Keywords: Adolescence/ Adult/ Aged/ Cause of Death/ Child/ Child, Preschool/ Human/ Infant/ Infant, Newborn/ Middle Age/ *Mortality/ Pilot Projects/ Population Surveillance/ Somalia: epidemiology/ Starvation/ Urban Population
Abstract: Since 1990, Somalia has been the site of an intense civil war that has disrupted health-care services and food delivery to a substantial part of the country. A regional drought, in combination with the ongoing civil disturbances, has further resulted in widespread famine. Multiple international government and nongovernment aid agencies are involved in the relief effort for Somalia. However, security problems in most areas of Somalia have prevented recent, systematic population-based assessments of the health and nutritional status of local Somali populations for use in directing relief efforts. To characterize the mortality of various Somali populations and to provide data on major population centers outside of the capital (Mogadishu), CDC, in collaboration with the United Nations Children's Fund (UNICEF) and the U.S. Agency for International Development, conducted a survey (1) of urban populations in a central region of Somalia (Figure 1). This report describes two pilot assessments performed during November 20-25 and December 5-6, 1992, in the towns of Baidoa and Afgoi.

5. Centers for Disease Control and Prevention. Public health consequences of acute displacement of Iraqi citizens-- March-May 1991. MMWR Morb Mortal Wkly Rep. 1991 Jul 5; 40(26): 443-7.
Keywords: Acute Disease/ Child/ Child, Preschool/ Human/ Iraq/ *Morbidity/ *Mortality/ Nutrition Disorders: epidemiology/ Population Surveillance/ *Refugees/ Relief Work/ Turkey: epidemiology
Abstract: In late March 1991, following military and civil strife in Iraq, approximately 400,000 ethnic Kurds and other Iraqi minority groups sought refuge in rugged mountains on the border of Iraq and Turkey; an additional estimated 1.3 million Iraqi refugees fled to Iran. In contrast to groups affected in other recent refugee emergencies, a large proportion of this displaced population comprised educated urban dwellers. This report describes the major public health consequences of this population displacement and international relief efforts directed toward these problems.

6. Centers for Disease Control and Prevention. Mortality among newly arrived Mozambican refugees: Zimbabwe and Malawi. MMWR. 1993; 42(24): 468-469, 475-477.
Notes: Abstract written by Tulane University.
Abstract: This article summarizes a CDC assessment of mortality among Mozambican refugees in Zimbabwe and Malawi. The findings show a high crude mortality rate of 3.5/10,000 population per day in Chambuta during August 1-20,1992 and a crude mortality rate averaging from 1.0 to 3.6/10,0000 population per day from January through September 1992 in Lisungwe. Diarrhea, dehydration, malnutrition and measles were responsible for approximately three quarters of all deaths in both areas. A cost analysis for prevention effectiveness was computed to assess the development of programs to prevent deaths associated with measles and diarrheal disease in Chambuta and Lisungwe. The cost of preventing 86 of the 113 measles deaths occurring in Chambuta between June and July 1992 would have been approximately $37 per death. The cost of providing an appropriate latrine to each household in Lisungwe from January to August would have cost approximately $1004 for each death prevented and $38 for each episode of diarrhea averted. Recommendations from these findings conclude that measures for accelerating measles vaccination efforts and providing appropriate latrines for households as well as adequate supplies of soap, water, and buckets should be taken in these populations.

7. Chandramohan, D.; Maude, G. H.; Rodrigues, L. C., and Hayes, R. J. Verbal autopsies for adult deaths: issues in their development and validation. Int J Epidemiol. 1994 Apr; 23(2): 213-22.
Keywords: Adolescence/ Adult/ Aged/ Autopsy: *methods/ *Cause of Death/ Child/ Child, Preschool/ *Developing Countries/ Female/ Human/ Infant/ Male/ Middle Age/ *Mortality/ Patient Care Team/ Support, Non-U.S. Gov't
Abstract: BACKGROUND. The verbal autopsy appears to be an attractive technique for the assessment of causes of adult death in settings where the proportion of people who die while under medical care is low. Verbal autopsies have been used extensively to assess causes of childhood deaths. The existing experience in verbal autopsies for adult deaths is limited mainly to maternal deaths. This paper aims to highlight the critical issues in verbal autopsies to assess causes of adult death, which need further research. METHODS. This paper reviews the methods of verbal autopsy used in 35 published studies and discusses issues in the development of verbal autopsies, including mortality classification, design of questionnaires, interviewers, respondents, recall periods, procedures for deriving a diagnosis and the recording of single versus multiple causes of death. It also discusses issues in the validation of verbal autopsies, including the choice of reference diagnosis and the required sample size. RESULTS. The methodological approaches used in verbal autopsy studies have varied widely. Very few studies of the validity of verbal autopsies have been conducted. In these studies, the reported sensitivity and specificity varied widely between different causes of death and between studies. CONCLUSIONS. The information available is inadequate to draw firm conclusions on preferred methodological approaches for verbal autopsies for adult deaths. Before these tools are used more widely for adult deaths, further research is required to compare alternative methods and to evaluate the validity of this tool in a range of settings.

8. Chandramohan, D.; Maude, G. H.; Rodrigues, L. C., and Hayes, R. J. Verbal autopsies for adult deaths: their development and validation in a multicentre study. Trop Med Int Health. 1998 Jun; 3(6): 436-46.
Keywords: Adult/ Africa/ Aged/ Algorithms/ Autopsy: *methods/ *Cause of Death/ Human/ Middle Age/ Reproducibility of Results/ Sensitivity and Specificity/ Support, Non-U.S. Gov't
Abstract: BACKGROUND: Verbal autopsy (VA) has been widely used to ascertain causes of child deaths, but little is known about the usefulness of VA for adult deaths. This paper describes the process used to develop a VA tool for adult deaths and the results of a multicentre validation of this tool. METHODS: A mortality classification was developed by including causes of death that might be arrived at by VAs and causes that are responsive to public health interventions. An algorithm was designed for each cause in the classification, based on classifying symptoms into essential, supportive and differential. A structured questionnaire designed to elicit information on these symptoms was developed in English translated into the local languages. The tool was validated on deaths occurring at hospitals in Tanzania (315 deaths), Ethiopia (249) and Ghana (232). Hospital records of all adult deaths occurring at the study hospitals from June 1993 to April 1995 were collected prospectively. Non-medical interviewers with at least 12 years of formal education conducted VA interviews. Causes of death were diagnosed by a panel of physicians and by a computerized algorithm. The validity of the VA was assessed by comparing the VA diagnoses with hospital diagnoses. RESULTS: Specificity of VAs by physicians fell below 95% only for acute febrile illness (AFI) and TB/AIDS. Sensitivity and positive predictive value (PPV), however, varied widely both across the sites and between causes. Sensitivity was > 75% for tetanus, rabies, direct maternal causes, injuries and TB/AIDS and ranged between 60% and 74% for diarrhoea, acute abdominal conditions and AFI. The PPV was > 75% for tetanus, rabies, hepatitis and injuries and ranged between 60 and 74% for meningitis, AFI, TB/AIDS and direct maternal causes. When the communicable diseases were combined in a single group, the sensitivity was 82%, specificity 78% and PPV 85%. For the group of noncommunicable diseases the corresponding sensitivity, specificity and PPV were 71%, 87% and 67%, respectively. Use of an algorithm resulted in lower sensitivity, specificity and PPV than the VAs by physician. CONCLUSION: VAs by a panel of physicians performed better than an opinion-based algorithm. The validity of VA diagnosis was highest for AFI, direct maternal causes, TB/AIDS, tetanus, rabies and injuries.

9. Cosgrave, J. Refugee density and dependence: practical implications of camp size. Disasters. 1996 Sep; 20(3): 261-70.
Keywords: Adult/ *Dependency (Psychology)/ Food Supply/ Health Resources/ Health Services Needs and Demand/ Human/ Infant/ Infant Mortality/ Models, Economic/ *Population Density/ Refugees: *psychology: *statistics & numerical data/ Relief Work: *organization & administration/ Water Supply
Abstract: Different refugee camps may have widely differing morbidity and mortality rates. Some of these differences are ascribed to environmental factors. This paper reviews the key issues relating to one environmental factor: the size of the refugee camp, and provides a tentative theoretical framework for examining the effect of camp size on refugees. This effect may not be considered because aid workers chronically underestimate the value of the refugees' contribution to their own survival. Large camps settle great numbers of refugees to the hinterland of the camp and limit their access to resources available there. This may increase refugee dependency and vulnerability. There is some slight evidence from the analysis of data provided by Mercer (1992) that child mortality rates (aged 0-4 years) are positively correlated with camp size (as inferred from child populations). If other factors allow, it might be wise for camp planners to try to limit camps to a size, which allows refugees reasonable access to local resources.

10. Coupland, R. M. and Meddings, D. R. Mortality associated with use of weapons in armed conflicts, wartime atrocities, and civilian mass shootings: literature review. BMJ. 1999 Aug 14; 319(7207): 407-10.
Keywords: Civil Disorders: *statistics & numerical data/ Homicide: *statistics & numerical data/ Human/ *War/ Wounds, Gunshot: *mortality
Abstract: OBJECTIVE: To determine the implications of variation in mortality associated with use of weapons in different contexts. DESIGN: Literature review. SETTINGS: Armed conflicts and civilian mass shootings, 1929-96. MAIN OUTCOME MEASURE: Mortality from wounds. RESULTS: During the fighting of war the number of people wounded is at least twice the number killed and may be 13 times as high; this ratio of the number wounded to the number killed results from the impact of a weapon system on human beings in the particular context of war. When firearms are used against people who are immobilized, in a confined space, or unable to defend themselves the wounded to killed ratio has been lower than 1 or even 0. CONCLUSIONS: Mortality from firearms depends not only on the technology of the weapon or its ammunition but also on the context in which it is used. The increased mortality resulting from the use of firearms in situations other than war requires a complex interaction of factors explicable in terms of wound ballistics and the psychology of the user. Understanding these factors has implications for recognition of war crimes. In addition, the lethality of conventional weapons may be increased if combatants are disabled by the new non-lethal weapons beforehand; this possibility requires careful legal examination within the framework of the Geneva Conventions.

11. Cutts, F. T.; Dos Santos, C.; Novoa, A.; David, P.; Macassa, G., and Soares, A. C. Child and maternal mortality during a period of conflict in Beira City, Mozambique. Int J Epidemiol. 1996 Apr; 25(2): 349-56.
Keywords: Adult/ Case-Control Studies/ Child/ Cluster Analysis/ *Developing Countries/ Female/ Human/ Infant/ *Infant Mortality: trends/ Male/ *Maternal Mortality: trends/ Middle Age/ Mozambique: epidemiology/ Odds Ratio/ Population Surveillance/ Risk Factors/ Support, Non-U.S. Gov't/ *Urban Health/ *War
Abstract: BACKGROUND. Child mortality rates have been declining in most developing countries. We studied child and maternal mortality risk factors for child mortality in Beira city in July 1993, after a decade of conflict in Mozambique. METHODS. A community-based cluster sample survey of 4609 women of childbearing age was conducted. Indirect techniques were used to estimate child mortality ('children ever born' method and Preceding Birth Techniques (PBT) and maternal mortality (sisterhood method). Deaths among the most recent born child, born since July 1990, were classified as cases (n = 106), and two controls, matched by age and cluster, were selected per case. RESULTS. Indirect estimates of the probability of dying from birth to age 5 (deaths before age 5 years, (5) q (0) per 1000) decreased from 246 in 1977/8 to 212 in 1988/9. The PBT estimate of 1990/91 was 154 (95 percent confidence interval [CI]: 124-184), but recent deaths may have been underreported. Lack of beds in the household (odds ratio [OR] = 2.0, 95 percent CI: 1.1-3.8), absence of the father (OR = 2.4, 95 percent CI: 1.2-4.8), low paternal educational level (OR = 2.1, 95 percent CI: 0.8- 5.4), young maternal age (OR = 2.0, 95 percent CI: 1.0-3.7), self- reported maternal illness (OR = 2.4, 95 percent CI: 1.2-4.9), and home delivery of the child (OR = 2.3, 95 percent CI: 1.2-4.5) were associated with increased mortality, but the sensitivity of risk factors was low. Estimated maternal mortality was 410/100 000 live births with a reference date of 1982. CONCLUSIONS. Child mortality decreased slowly over the 1980s in Beira despite poor living conditions caused by the indirect effects of the war. Coverage of health services increased over this period. The appropriateness of a risk approach to maternal-child-health care needs further evaluation.

12. Davis, A. P. Targeting the vulnerable in emergency situations: who is vulnerable? Lancet. 1996 Sep 28; 348(9031): 868-71.
Keywords: Adolescence/ Adult/ Age Factors/ Child/ Child, Preschool/ Cross-Sectional Studies/ *Delivery of Health Care/ Democratic Republic of the Congo: epidemiology/ Diarrhea: mortality/ Female/ Human/ Male/ Nutrition Disorders: mortality/ *Refugees/ *Relief Work/ Risk Factors/ Rwanda: ethnology/ Sudan: ethnology/ Support, Non-U.S. Gov't/ Tanzania: epidemiology/ Uganda: epidemiology.
Notes: COMMENTS: Comment in: Lancet 1996 Sep 28; 348(9031): 840
COMMENTS: Comment in: Lancet 1996 Dec 14; 348(9042): 1663
Abstract: BACKGROUND: Emergencies such as wars and natural disasters increase the vulnerability of affected populations and expose these populations to risks such as disease, violence, and hunger. Emergency public health interventions aim to mitigate these effects by providing basic minimum requirements, reducing vulnerability, and reducing exposure to risk. Targeted services are generally aimed at children under 5. Mortality rates among young children are higher than the crude mortality rate (CMR) among the whole population in emergency settings, so attention is focused on this age group. However, even under normal conditions mortality is higher in young children. This analysis compared the relative risk of death for young children with that for older children and adults under normal conditions and in emergency settings. METHODS: Mortality data from refugee camps set up in response to three different emergencies were examined. Baseline mortality rates in the refugees' countries of origin were calculated from published data. Relative risks between normal and emergency conditions were calculated and compared. FINDINGS: Mortality rates were higher among children under 5 than among older children and adults both under normal circumstances and in the emergency setting in camps in Tanzania, Uganda, and Zaire. However, the relative risk for under-5 versus over-5 mortality was smaller under emergency conditions than under normal circumstances. Thus, children over 5 and adults are disproportionately more affected by exposure to emergency risks than are younger children. INTERPRETATION: If the objective of intervention, to reduce mortality, is to be achieved, the population over the age of 5 cannot be ignored. Emergency public health needs to develop specific tools to investigate risk in other age groups (as well as children under 5), to identify causes, and to design programmes to address such needs.

15. Gordenker, L. Early warning of disastrous population movement. International Migration Review. 1986; 20(2): 171-189.
Abstract: This article undertakes the analyzation of existing and potential early warning facilities in man-made disasters, which induce forced movement of people. It sets out some possible forms of early warning and the organizational options connected with them. It concludes that a model form of organization, combining some existing facilities and some modest new organization, could provide early warning, although the function would operate in a difficult and delicate political atmosphere that cannot be avoided.

16. Hansch, S. The demography of vulnerability: Somalia in the 1990s. Unpublished paper presented for the National Academy of Sciences workshop on Mortality Patterns in Complex Emergencies; Washington, D.C., 18 November 1999, National Research Council.
Notes: "This paper derives much of its insights and data from research conducted by a team of Steve Hansch, Charlie Teller, Scott Lillibridge, Michael Toole, John Prendergast, and Grace Egeland in 1994, as published in the 1995 CDC/RPG report Lives Lost, Lives Saved, Excess Mortality and the Impact of Health Interventions in the Somali Emergency."
Abstract: This working paper discusses the background of the Somalian refugee crisis in the 1990’s, and the humanitarian interventions that took place in the country. The paper details methods used for measuring mortality in a large population-inhabited area, defines patterns of risk, and identifies missed opportunities to saves lives in Somalia. It stresses that relief agencies collecting data must better document their sampling strategy, population, population size, and date, and that better sharing and synthesis of this data will inform resource deployment and planning. In addition, relief agencies should employ tools that measure the level of need in large portions of the country where basic observations, rapid assessments, and other data collection are not conducted. The author concludes that current methods for understanding the demography of a crisis are inadequate for dealing with large-area emergencies. Methods of data collecting and inference need to be developed that can address conditions where rural populations are unregistered, uncounted, migratory, and likely to be mobile in response to aid."

17. Hansch, S. (Virtual Research Associates). Mortality levels in humanitarian emergencies. Unpublished paper presented at the workshop on Mortality Patterns in Complex Emergencies; Washington, D.C., 18 November 1999, National Research Council.
Notes: Abstract written by Tulane University.
Abstract: This report on mortality levels in humanitarian emergencies provides a synthesis of rates of mortality in situations of complex emergencies. In conceptualizing death as an important indicator for the effectiveness of humanitarian aid, assessing the risk of a population and the severity of the emergency, this report reviews evidence about mortality in situations of protracted crises. In compiling this report, data about mortality in humanitarian emergencies has been collected from primary published sources and is outlined here with situation specific country summaries. The approach of this report has allowed for identification and synthesis of a large amount of published literature on mortality trends and cause-specific mortality rates in crisis situations. The study begins with review of country specific cases and then proceeds to discuss notable trends in causes of death in emergency situations. Recommendations for areas of further mortality research in the context of complex emergencies are also included.

18. Hansch, S. and Waldman, R. The evolution of mortality patterns in complex emergencies. Paper prepared for the National Academy of Sciences workshop on Mortality Patterns in Complex Emergencies; Washington, D.C., 18 November 1999, National Research Council.
Notes: Abstract quoted in part from introduction to paper.
Abstract: This paper discusses the patterns of excess mortality seen in a range of humanitarian crises, including complex emergencies and natural disasters. It concludes that "humanitarian organizations need to move beyond the current practice of exclusive fixation on excess mortality, and begin to find standardized methods for tracking other relevant aspects of crises-long-term psycho-social impairment, lost physical growth, brain growth, or education, social distrust, populations relegated to camps for many years, and physical disabilities due to violence."

19. Hill, A. G. and Macrae, S. Measuring childhood mortality levels: a new approach. United Social Statistics Bulletin. 1985; 8(2): 1-14.
Notes: Abstract is quoted from summary to article.
Abstract: "This brief review sketches the outline of a variety of techniques currently available to produce reasonably accurate estimates of mortality in childhood when registration data are deficient. Each method has its strengths and its weaknesses, which must be recognized before data collection begins. In many instances, combinations of one or more of the methods described above will offer the best hope of fixing the level and trend in infant and child mortality in the period of an intervention. The new clinic-based method of measuring mortality before age two is simple and appears to be practicable in the field. Despite its biases and other limitations, it will be useful in estimating short-term changes in mortality since some of the factors responsible for bias will not alter very much over short periods. Neither the lengths of the birth intervals nor the coverage of the health care system will alter very suddenly even when interventions are under way. Since it is simple to begin the collection of the necessary information (indeed, in some instances, the data may already be recorded), those in charge of clinic and hospital records are encouraged to try the technique in as many cases as possible. Sharing of experience with the collection and analysis of the data from different sorts of communities in Africa should help us all to develop and improve this and similar techniques in the future."

20. Kayongo-Male, D. African refugee migration: a model and research agenda. Humboldt Journal of Social Relations. 1989; 15(2): 133-156.
Abstract: This article elaborates upon the problems of the refugee crisis in Africa. With around 4 million refugees, heavily concentrated in particular African nations like Sudan and Somalia, the impacts on the host country can be severe. A model, dealing with the process of refugee migration, with particular reference to impact s on host countries, is developed. Negative impacts include military attacks on communities in the host country. One positive impact is the increase in the number of development-type projects, which go beyond the mandate of the UN High Commissioner for Refuges. A tentative research agenda on African refugee migration is put forward.

21. Legros, D.; Paquet, C., and Nabeth, P. (Epicentre). The evolution of mortality among Rwandan refugees in Zaire between 1994 and 1997. Unpublished paper presented for the National Academy of Sciences workshop on Mortality Patterns in Complex Emergencies; Washington D.C., 18 November 1999, National Research Council.
Notes: Abstract written by Tulane University.
Abstract: This paper gives an overview of the history of the Rwandan refugee situation, their living conditions, and the health issues that they faced. It discusses the measurement of mortality rates during the Goma influx, and in the Tingi Tingi, the Ubundu-Kisangani railways, and the Congo Brazzaville camps. The paper states that mortality rates are the most useful health indicators for assessing emergency situations and monitoring intervention programs. In the case of the Rwandan refugees in Zaire, mortality rates were measured using an on-going surveillance system and retrospective surveys. The authors conclude that surveillance systems should be undertaken from the beginning of an emergency situation, but the only objective of the surveillance should be to assess trends. Retrospective surveys run the risk of not being representative of the overall situation and should be conducted when surveillance data are unavailable. The validity of the questionnaires and sampling techniques used in these surveys has never been evaluated, and their interpretation must be done with caution.

22. Mendonca, M. G. Demographic-sanitary indicators in Mozambique. Genus. 1982; 38(1-2): 199-208.
Notes: Abstract is quoted from introduction to article.
Abstract: "In August 1979, the National Department of Statistics carried out a pilot census in one District of the country and in some wards of the capital, city of Maputo, in preparation for the National Population Census to be held in August 1980, the first since Independence, proclaimed in June 1975.
The Ministry of Health conducted the analysis of the forms filled in during the census trials, in order to study some demographic indicators, especially infant mortality."

23. Reed, H.; Haaga, J., and Keely, C. (Committee on Population National Research Council). The demography of forced migration: summary of a workshop. Washington, DC: National Academy Press; 1998.
Notes: Abstract written by Tulane University.
Abstract: Normal demography data collection processes cannot always be applied to situations of forced migration. Program assistance to refugees and internally displaced persons requires an understanding of the specific context of the forced migration and the types of population shifts occurring. The collection of demographic data in situations of forced migration is challenged by methodological difficulties. Given the context of rapidly shifting populations and unstable political conditions, estimations of the patterns of migration and numbers of forced migrants present logistical obstacles for standard methods.
In an effort to address these concerns, the Committee on Population of the National Research Council organized a workshop entitled "The Demography of Forced Migration" in November 1997. The workshop was held in Washington, D.C. and provided a forum for discussing issues surrounding the collection of demographic data on refugees and internally displaced persons. This report includes a summary of the background papers prepared for the workshop, the presentations, and the discussions of the meeting. The report addresses the following demography issues in situations of forced migration: general population estimates, population compositions and vital rates, and future research possibilities.

24. Robinson, W. C.; Lee, M. K.; Hill, K., and Burnham, G. M. Mortality in North Korean migrant households: a retrospective study. Lancet. 1999 Jul 24; 354(9175): 291-5.
Keywords: Adolescence/ Adult/ Aged/ Birth Rate/ Child/ Child, Preschool/ China: epidemiology/ Family Characteristics/ Female/ Human/ Infant/ Korea: ethnology/ Male/ Middle Age/ *Mortality/ Questionnaires/ Retrospective Studies/ Support, Non-U.S. Gov't/ Transients and Migrants: *statistics & numerical data
Abstract: BACKGROUND: A deteriorating economy, coupled with a series of natural disasters in 1995-97, led to a severe food crisis in North Korea. Although the country has received substantial international aid since 1996, demographic assessments of crisis impact have been limited. We assessed mortality trends in North Korea since 1995. METHODS: At 15 randomly selected sites in China, 440 North Korean adult migrants were interviewed during July-September, 1998. Respondents were asked about births, deaths, and migration patterns in their households between mid- 1994 and mid-1998, and about household food sources. The respondents also provided basic demographic information about the households of their relatives. We compared mortality rates from migrant households with data from the 1993 census and with data about households of non- migrant relatives. FINDINGS: Households that included a recent migrant to China showed increasing mortality: crude death rates rose from 28.9 per 1000 in 1995, to 45.6 per 1000 in 1996, and to 56.0 per 1000 in 1997 (p=0.0001), with a 3-year average rate of 42.8 per 1000. The crude 3-year birth rate was 11.0 per 1000. Average household size declined from 4.0 at the beginning of 1995 to 3.4 at the end of 1997 (p=0.0002). Among 259 households of non-migrant relatives, the crude death rate was 43.2 per 1000 and the crude birth rate was 8.8 per 1000. In these households, the 3-year trend of increasing mortality was significant (p=0.001), as was the decline in average household size from 4.3 at the beginning of 1995 to 3.7 at the end of 1997 (p=0.0001). INTERPRETATION: Among North Korean households that include a recent migrant to China, mortality has increased and household size has declined since 1995. This trend raises concern about the state of the general population, at least in the province of North Hamkyong, from where most of the migrants originated.

25. Schmeidl, S. Exploring the causes of forced migration: a pooled time-series analysis, 1971-1990. Social Science Quarterly. 1997; 78(2): 284-308. Abstract: Objective: This paper (1) develops a theoretical model of refugee migration that builds on existing research in early warning and preventative diplomacy, and (2) empirically tests this model in order to assess the role played by generalized structural factors in the formation of forced migration. Methods: I regress the number of refugees on several political, economic, and intervening variables, using pooled time-series analysis over twenty-year period (1971-1990) Refugee data come from the United Nations High Commissioner for Refugees (UNHCR) and the U.S. Committee for Refugees (USCR). Results: The results suggest that, first, measures of institutional human rights violations have weaker predictive power than do measures of generalized violence. Second civil wars with foreign military interventions are more important in producing large refugee populations and prolonged migrations than are civil wars without outside influence. Third, ethnic rebellion is important as a cause of small refugee migrations, but cannot significantly predict mass exodus. Finally, economic and intervening variables have little impact of predicting refugee migration. Conclusions: These findings contradict the argument that economic hardship is a very important cause of refugee migration. In addition, they support the argument that the level and type of violence determine the likelihood and size of refugee displacement.

26. Sharp, T. W.; Yip, R., and Malone, J. D. U.S. military forces and emergency international humanitarian assistance: Observations from three recent missions. JAMA. 1994; 272(5): 386-390.
Notes: Abstract quoted from introduction.
Abstract: "The purposes of this article are to examine recent military relief operations in Kurdistan, Bangladesh, and Somalia; describe advantages and limitations of using US armed forces for emergency international assistance; and propose recommendations for increasing the effectiveness of military forces in future operations. Although the use of the armed forces for humanitarian assistance involves many complex issues, our focus is on the provision of appropriate and effective medical and public health services. The observations in this article are derived from the personal experiences of the authors in these missions, interviews with key military and civilian participants, and a review of the literature".

27. Snow, R. W.; Armstrong, J. R.; Forster, D.; Winstanley, M. T.; Marsh, V. M.; Newton, C. R.; Waruiru, C.; Mwangi, I.; Winstanley, P. A., and Marsh, K. Childhood deaths in Africa: uses and limitations of verbal autopsies. Lancet. 1992 Aug 8; 340(8815): 351-5.
Keywords: *Cause of Death/ Child/ Child, Preschool/ Hospitals, District/ Human/ Infant/ Infant, Newborn/ Interviews: methods: *standards/ Kenya: epidemiology/ Malaria: mortality/ *Mortality/ Patient Admission: statistics & numerical data/ Population Surveillance: methods/ Prevalence/ Prospective Studies/ Sensitivity and Specificity/ Support, Non-U.S. Gov't
Abstract: The verbal autopsy (VA) is an epidemiological tool that is widely used to ascribe causes of death by interviewing bereaved relatives of children who were not under medical supervision at the time of death. This technique was assessed by comparison with a prospective survey of 303 childhood deaths at a district hospital in Kenya where medically confirmed diagnoses were available. VA detected common causes of death with specificities greater than 80%. Sensitivity of the VA technique was greater than 75% for measles, neonatal tetanus, malnutrition, and trauma-related deaths; however, malaria, anemia, acute respiratory-tract infection, gastroenteritis, and meningitis were detected with sensitivities of less than 50%. There may have been unwarranted optimism in the ability of VAs to detect some of the major causes of death, such as malaria, in African children. VA used in malaria-specific intervention trials should be interpreted with caution and only in the light of known sensitivities and specificities.

28. Telford, J.; Gibbons, L., and Van Brabant, K. Counting and identification of beneficiary populations in emergency operations: registration and its alternatives. Relief and rehabilitation network good practice review 5. London: Overseas Development Institute; 1997.
Notes: Abstract is quoted from introduction to report.
Abstract: "Full, formal registration of a beneficiary population has, over recent years increasingly been considered to yield the most reliable set of quantitative and qualitative data on which to base planning and delivery of the different types of protection and assistance which make up a humanitarian assistance programme. However, in light of the rapid onset of many of today’s ‘emergencies’, the size, expense and often controversial nature of registration exercises, this Review argues that, given such constraints, total population registration is but one option for the establishment of reliable figures for the effective delivery of assistance."

29. Toole, M. J.; Nieburg, P., and Waldman, R. J. The association between inadequate rations, undernutrition prevalence, and mortality in refugee camps: case studies of refugee populations in eastern Thailand, 1979-1980, and eastern Sudan, 1984-1985. J Trop Pediatr. 1988 Oct; 34(5):218-24.
Keywords: Food Services/ Human/ International Cooperation/ Nutrition Disorders: *epidemiology: mortality/ *Refugees/ Starvation: *mortality/ Sudan/ Support, U.S. Gov't, P.H.S./ Thailand. Abstract: A review was conducted of nutrition and mortality data collected among Tigrayan refugees in Eastern Sudan (1984-85) and Cambodian refugees in Thailand (1979-80), two populations of comparable size. The Cambodian refugee population showed a rapid decline in mortality rates during the acute phase of the emergency – from 10/1000 per month to less than 1/1000 per month within 1 month. These changes were associated with rapid improvement in nutritional status and the provision of adequate rations soon after the arrival of the refugees in Thailand. By contrast, mortality rates in the Tigrayan refugee population in the late 1984 and 1985 were unusually high (14-24/1000 per month) and prolonged. The high mortality was associated with persistently high prevalence rates of undernutrition (14-50 per cent) among children less than 5 years of age. Inadequate amounts of food (1360-1870 kcal per person per day) were distributed to this population during the first 5 months after their arrival; in addition, a severe measles outbreak in the camps added to the high mortality. The reported high undernutrition prevalence in the Tigrayan refugee camps persisted despite supplementary feeding programmes, for which enrollment and attendance rate among identified undernourished children were low. The close association of mortality with undernutrition leads us to conclude that refugee relief programmes should give highest priority to ensuring the adequate rations are distributed. This requires better anticipation of, and more timely response to, refugee movements by international relief agencies.

30. Toole, M. J. and Waldman, R. J. The public health aspects of complex emergencies and refugee situations. Annu Rev Public Health. 1997; 18:283-312.
Keywords: Cause of Death/ Developing Countries/ Disaster Planning: *organization & administration/ *Emergencies/ Human/ *Public Health Administration/ *Refugees/ Relief Work: *organization & administration/ War
Abstract: Populations affected by armed conflict have experienced severe public health consequences mediated by population displacement, food scarcity, and the collapse of basic health services, giving rise to the term complex humanitarian emergencies. These public health effects have been most severe in underdeveloped countries in Africa, Asia, and Latin America. Refugees and internally displaced persons have experienced high mortality rates during the period immediately following their migration. In Africa, crude mortality rates have been as high as 80 times baseline rates. The most common causes of death have been diarrheal diseases, measles, acute respiratory infections, and malaria. High prevalences of acute malnutrition have contributed to high case fatality rates. In conflict-affected European countries, such as the former Yugoslavia, Georgia, Azerbaijan, and Chechnya, war-related injuries have been the most common cause of death among civilian populations; however, increased incidence of communicable diseases, neonatal health problems, and nutritional deficiencies (especially among the elderly) have been documented. The most effective measures to prevent mortality and morbidity in complex emergencies include protection from violence; the provision of adequate food rations, clean water and sanitation; diarrheal disease control; measles immunization; maternal and child health care, including the case management of common endemic communicable diseases; and selective feeding programs, when indicated.

31. Van Damme, W. Do refugees belong in camps? Experiences from Goma and Guinea. Lancet. 1995; 346:360-362.
Notes: Abstract written by Tulane University.
Abstract: This paper explores options of placing refugees in camps by contrasting the Goma refugee camp experience with the alternative of mixing refugees with the host population, which was common in Guinea. The paper states, "There are hardly any medical reports on refugees living outside camps; however, it is estimated that between 60% and 75% of Africa’s refugees have never lived in camps and have never received international assistance. Sociological and anthropological studies indicate that where refugees could get agricultural land, and were not restricted in movement or access to local employment, they fared better than refugees confined to camps" (362). The author recommends studying coping mechanisms and health-outcomes of freely settled refugees, and the effects of refugees on host populations and on their health services. It is important to compare the cost of maintaining a refugee camp with supporting freely settled refugees, and it is also important to compare large refugee camps to smaller ones. Studies should include the cultural, demographic, agricultural, and political situation, and it should take into account the pace of arrival of the refugees. The paper concludes, " Only by gaining more insight can it be decided when camps are the most appropriate solution, when they can be avoided, and when to accept big rather that small camps" (362).

32. Yip, R. and Sharp, T. W. Acute malnutrition and high childhood mortality related to diarrhea. Lessons from the 1991 Kurdish refugee crisis. JAMA. 1993 Aug 4; 270(5): 587-90.
Keywords: Acute Disease/ Adolescence/ Adult/ Cause of Death/ Child/ Child, Preschool/ Diarrhea: epidemiology/ Diarrhea, Infantile: epidemiology/ *Ethnic Groups: statistics & numerical data/ Human/ Infant/ Infant Mortality/ Infant Nutrition Disorders: epidemiology/ Iraq: ethnology/ Middle Age/ *Morbidity/ *Mortality/ Nutrition Disorders: epidemiology/ Nutrition Surveys/ Nutritional Status/ *Refugees: statistics & numerical data/ Retrospective Studies/ Turkey
Abstract: OBJECTIVE--To determine the extent, major causes, and contributory factors of high rates of morbidity and mortality among children at mountain camps along the Turkey-Iraq border during the 1991 Kurdish refugee crisis. DESIGN--A cross-sectional rapid nutrition survey among children and a retrospective mortality survey covering a 2-month period from the onset of the crisis. POPULATION STUDIED--Households of Kurdish refugees at resettlement camp 1 near Zakho in northern Iraq. MAIN OUTCOME MEASURES--Prevalence of wasting (low weight-for-height) and mean weight-for-height status, prevalence of diarrhea, and crude and age-specific mortality rates. RESULTS--Weight-for-height measurements indicated that children under 2 years of age had suffered significant (P < .001) recent malnutrition. The elevated prevalence of wasting and the reduced mean weight-for-height status in this group indicated generalized weight loss. This weight loss was likely the result of the high rates of diarrhea, which still affected 50% of the younger children at the time of survey. The crude mortality rate for all ages was 8.9 per 1000 per month (expected rate, 0.6 per 1000); two thirds of the deaths occurred among children aged 5 years or younger, and half among infants younger than 1 year. An estimated 12% of all infants died during the first 2 months of the crisis. Most deaths were due to diarrhea, dehydration, and resulting malnutrition. CONCLUSIONS--The high rates of malnutrition and mortality related to diarrhea in infants and younger children of Kurdish refugees took place rapidly despite prompt relief efforts and a previously healthy population. This experience underscores the need for early and aggressive public health management of sanitation, water sources, and diarrhea control programs to augment the traditional focus on food and medical relief during the emergency phase of a refugee crisis.

33. Yusuf, F. Size and sociodemographic characteristics of the Afghan refugee population in Pakistan. J Biosoc Sci. 1990; 22:269-279. Note: Abstract is quoted from summary of report. Abstract: Some recent data are presented on the size and selected sociodemographic characteristics of the Afghan refugee population in Pakistan. Although the official figures show that there were 3.27 million registered Afghan refugees in Pakistan, it is estimated that the actual number may be as high as 3.6 million. There is an excess of females over males, mainly due to war-related activities and excessive casualties particularly among males. While infant and childhood mortality rates are declining and are lower than the levels prevalent in Pakistan, as well as in Afghanistan during the pre-war period, the fertility levels among Afghan refugees seem very high indeed.