Returning to the account of the cholera epidemic in Goma with which we began, it is important to emphasize that the circumstances in which that drama unfolded were not the only determinant of the unconscionably high mortality that was experienced. As discussed, cholera is a disease for which case-fatality ratios should not exceed 2-3 percent. The fact is that, in addition to the virulence of the outbreak, the physically challenging environment, and the traumatized population that had fled to Goma out of fear of retribution for the genocidal actions in which many of them had been at least peripherally engaged, fewer refugees might have died if relief workers had been more experienced in treating cholera specifically, and in working in complex emergencies more generally (Goma Epidemiology Group, 1995). Few health workers forge a career in humanitarian assistance, and many, despite the best of intentions and the generosity of spirit that they bring to strange and difficult situations, are unfamiliar with the basic approaches to health-care delivery in complex emergencies that have been forged since the debacle in Goma (Sphere Project, 2004). Recently there have been calls for further professionalization of health care in emergency settings, and in the future a medical specialization in this field may be developed.

Still, humanitarian workers are never responsible for the conflict and the accompanying violence that are the root causes of increased morbidity and mortality in emergency settings. Their job is to do what they can, in environments that are in many ways the "emergency rooms of international health," to provide the equivalent of first aid and to try to limit the impact of communicable diseases on the population, not to prevent them from claiming an excessive toll. The real cause of what are sometimes extraordinarily high rates of morbidity and mortality from common conditions like pneumonia, diarrhea, malaria, and measles in complex emergencies are not the bacteria, viruses, or parasites that might be identified in a laboratory, or even the fact that many of those engaged in providing assistance may be unfamiliar with the best ways with which to deal with these conditions. Instead, the underlying cause is armed conflict, which creates an environment of unspeakable violence that leads to forced migration, difficult access to available health services, and a besieged and beleaguered population that it is hard to reach and difficult to serve.

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