Ronald Waldman

The spring of 1994 was a hellish time in the tiny central African country of Rwanda. For four months, following the death in April in a plane crash of the country's President, civil war reigned. The conflict pitted the majority Hutu ethnic group against its rival, the Tutsi. Although violence had erupted between the two on several occasions in the preceding decades, this time the Hutu intentions were frankly genocidal. In an atmosphere of unrelenting propaganda, emotions were stirred to the point that political leaders, military personnel, police, religious authorities, and Rwandans from all walks of life both precipitated and participated in murderous acts that resulted in the deaths of 800,000 people (Powers, 2002).

Amazingly, in late June the Rwanda Patriotic Front, a Tutsi militia trained in Uganda and supported by the government of that country, having crossed the border to Rwanda, penetrated the countryside and drove to and captured the capital Kigali, overthrowing the Hutu authorities and seizing both political and military power. Hutus, in well-founded fear of reprisals and retribution, took flight, and many were able to cross the border to Tanzania in the east, and to then-Zaire (now the Democratic Republic of Congo) to the west. An estimated 500,000800,000 crossed the narrow bridge from the Rwandan town of Gisenyi, a picturesque community on the northern shore of Lake Kivu, to the equally beautiful and, at that time, calm city of Goma, a city that in many ways had closer ties to Rwanda than it did to Kinshasa, the distant capital of Zaire.

The scene in Goma that July, however, was far from idyllic. Relief workers arriving there to provide humanitarian assistance to the massive numbers of poorly housed, underfed, confused, and traumatized refugees during the second week of the month might as well have been entering a house of indescribable horrors. Their first sight, along the two-kilometer stretch of road leading from the small, one-runway airport to the center of town where the United Nations relief agencies were in the process of setting up their offices, was one of dead bodies stacked four and five high along both sides of the road. During the next three weeks, up to 45,000 people - close to 10 percent of the refugee population -died, and the carnage did not stop there (Goma Epidemiology Group, 2005).

What caused these deaths? During the preceding months, the months of genocide, the answer was clear: people died because of man's unspeakable cruelty to man. But in the aftermath of the genocide, when the killing by machete, by bullet, by beating, and by fires set to buildings in which large numbers of people had been forcibly assembled, had stopped, what could have been responsible for carnage of the magnitude seen in Goma?

From the biomedical perspective, the answer is also simple. The refugees were the victims of one of the most virulent epidemics of cholera ever recorded. The Central African Region, especially the area around Lake Kivu, had been a frequent location of cholera epidemics. In fact, a delegation from the World Health Organization had visited Rwanda and other countries in the area, just a few months before the genocide took place, holding consultations with national government officials on how to prepare and respond to cholera cases that were expected to occur during the summer, according to their usual seasonality.

The events that led to the situation in Goma that July, though, rapidly surpassed the capacity of local and national officials to cope. And, although literally thousands of humanitarian workers arrived in the days and weeks following the chaotic settlement of the refugees, the epidemic continued unabated.

The source of the outbreak has never been definitively established, but most experts feel that heavy contamination of the waters of Lake Kivu (from which the refugees obtained most of their water supplies), combined with the abominable sanitary conditions of the area - just as graves could not be dug, neither could latrines - and the progressively debilitated state of the population were responsible. The failure of the humanitarian community to respond effectively, providing neither adequate quantities of safe water nor effective treatment, was also an important factor.

Cholera is a disease that can, but need not, be fatal. The World Health Organization has stated that case-fatality rates can be kept to less than 1 percent. Deaths from cholera are due to the dehydration that results from the rapid loss of copious amounts of fluid and electrolytes due to the breakdown of homeo-static mechanisms in cells that have been poisoned by the toxin of the bacteria, Vibrio cholerae. The illness, however, is self-limiting in time, and the provision of replacement fluid and electrolytes until the cells of the intestinal lining regenerate is sufficient to carry a patient through it. Antibiotics may help reduce the duration of illness, but they are given primarily as a public health measure -reducing the bacterial load in the bowel of an infected individual renders that person less infectious to others.

Accordingly, the treatment of choice for cholera, as for other forms of acute, watery diarrhea, is oral rehydration salts (a formulation of sodium, potassium, chloride, a base compound, and glucose) dissolved in water in concentrations that take maximum advantage of active transport mechanisms that exist in the cells of the intestinal wall and that remain intact in the presence of most diarrheal diseases, including cholera. Oral administration of this formula is as effective as the administration of intravenous fluids and can be done at the household level in most cases, diminishing the need for clinics and hospitals, which are required only for those patients who present with the most severe cases of dehydration and those who are unable to drink rapidly enough to replace their losses.

A strong case can be made for the real cause of death of those 45,000 people in Goma in July 1994 being not cholera, a potential lethal but treatable infection, but the circumstances in which the epidemic occurred. Massive numbers of frightened refugees, gathered in a relatively small area (most refugees were concentrated in one of four refugee camps along the two principal roads that led from Goma toward the east and toward the north) with inadequate sources of unsafe water, non-existent sanitation, a heavily compromised food supply, and sub-standard shelter, were particularly vulnerable to the high fatality rates that have been documented. In sum, the massive number of excess deaths that occurred in Goma can more honestly be attributed not to cholera, but to war.

In today's world, similar circumstances are found only in what have been termed "complex emergencies." Public health experts have proposed various definitions of a complex emergency, but none is completely satisfactory. Some of these include civil strife or war as a defining characteristic, and add to it population displacement and elevated levels of mortality (Burkholder and Toole, 1995). However, if one considers situations that prompted large-scale humanitarian responses, such as the Balkan conflicts of the 1990s and the Timor Leste crisis that followed the referendum for independence from Indonesia in that tiny new country, it might reasonably be concluded that conflict is a more constant feature than an excess number of deaths - which was not a prominent feature of either of those two situations, despite the destruction of most elements of the health system in both settings, and accompanying reductions in the ability of the population to access health-care providers or to utilize health services of any nature.

Another definition focuses more on the impact of a situation on the potential responders than on the affected population. It defines a complex emergency as "a humanitarian crisis in a country, region or society where there is total or considerable breakdown of authority resulting from internal or external conflict and which requires an international response that goes beyond the mandate or capacity of any single agency and/or the ongoing United Nations country programs" (CDC, 2007). Although no definition is sufficiently precise, few would disagree with the statement that complex emergencies take an enormous toll on the societies they affect, and that they require a response that is all too frequently inadequate.

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