Intended for healthcare professionals

Clinical Review Fortnightly review

Lessons learnt and future expectations of complex emergencies

BMJ 1999; 319 doi: (Published 14 August 1999) Cite this as: BMJ 1999;319:422
  1. Frederick M Burkle Jr, director (
  1. Center of Excellence in Disaster Medicine and Humanitarian Assistance (WHO Collaborating Center), University of Hawaii, John A Burns School of Medicine, Honolulu, HI 96826, USA

    Where civil blood makes civil hands unclean.—Shakespeare, Romeo and Juliet, 1597

    Complex emergencies today represent the ultimate pathway of state disruption Zwi says that recent conflicts such as those in northern Iraq, Somalia, Rwanda, Angola, the former Yugoslavia, and the province of Kosovo should be interpreted as complex political disasters where “the capacity to sustain livelihood and life is threatened primarily by political factors, and in particular, by high levels of violence.”1 Although each of the over 38 major conflicts that have occurred in this decade since the end of the cold war is unique, all share similar characteristics (box). Most blatant is that they represent catastrophic public health emergencies in which over 70% of the victims are civilians, primarily children and adolescents

    These mainly internal crises are popularly referred to as complex emergencies. The complexity refers to the multifacted responses initiated by the international community and further complicated by the lack of protection normally afforded by international treaties, covenants, and the United Nations Charter during conventional wars.

    Characteristics of complex emergencies

    • Administrative, economic, and political social decay and collapse

    • High levels of violence

    • Cultures, ethnic groups, religious groups at risk of extinction

    • Catastrophic public health emergencies

    • Vulnerable populations at greatest risk

    • Primarily internal wars with major violations of Geneva Conventions and Universal Declaration of Human Rights

    • Increased competition for resources between conflicting groups

    • Increased migration as refugees or internally displaced populations

    • Long lasting and widespread

    Health resources, both civilian (those provided by United Nations agencies, the International Committee and Federation of the Red Cross/Red Crescent, and many non-governmental organisations) and military, have played a major part in the emergency response, recovery, and rehabilitation phases of complex emergencies. In the process health providers have made major advances in assessment, management, education, training, and research,25 and they remain among the …

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