Chapter 90 Global Crimes, Incarceration, and Quarantine
Most physicians and medical personnel practice in relatively safe and stable environments, although some health care providers have chosen to work in conflict settings that involve some degree of political instability and personal danger. To health care workers interested in working internationally, remote climates may seem inherently dangerous, but the opposite is often the case. For example, a rural setting in Sudan may be remote and relatively austere, but is likely to be safe and secure; alternatively, working in the inner city of Nairobi, Kenya, may be much more dangerous.
Traveling and working in conflict areas or regions with significant political volatility requires a far more detailed understanding of the unique attributes of conflict areas. Judging whether a certain geographic region is dangerous requires significant knowledge of that area’s unique political, economic, social, and cultural context. It is important to realize the relative risk of travel itself as well as the likely causes of morbidity and mortality among travelers. The most frequent killers of travelers are cardiovascular disease and accidental injuries (most commonly motor vehicle accidents). As this chapter reviews the unique risks to workers in hostile geopolitical environments, conflict settings, and war zones, it is important to keep in mind the more predictable risks of accidents and underlying health issues in travelers, in order to plan and deploy mitigation strategies.
There is very good evidence that health care workers and humanitarians working in areas of modern conflict around the world have a significantly elevated risk of being killed or injured as a result of violent causes. One needs to determine the degree of risk that accompanies spending time in any particular locale. Determination of the degree of danger is a complex and dynamic process, and cannot be adequately ascertained solely from media reports or U.S. State Department travel advisories. The risk of an adverse event while traveling is closely linked to the traveler’s behaviors and abilities to adapt to the shifting political and security environment in regions that may be inherently dangerous as a result of military presence, differing ethnicities, and political volatility.
Certain locations frequented by civilian travelers and international workers are known to be more dangerous than others. Modern conflict over the last two decades has increasingly victimized civilians and nonwarring parties, including women and children. International workers and local and foreign staff of humanitarian agencies have been increasingly targeted for crime and other hostile activities. The conduct of war has changed considerably during the last decades in the following ways:
Some regions, in a general sense, are more dangerous than others. In his quirky, entertaining, and occasionally controversial website, The World’s Most Dangerous Places, author Robert Young Pelton offers a list of some of the world’s most difficult destinations.12 Box 90-1 lists these with a four-star grading system that addresses their “dangerousness.” In some instances, I have changed the rankings on the basis of the current political climate.
BOX 90-1 Dangerous Destinations
Escalation of ethnic and intrastate conflicts during the early 1990s after the conclusion of the Cold War led to a significant increase in civilian nongovernmental organization involvement in active conflict settings. The number and size of these organizations grew significantly during this period (Figure 90-1). They employed a large number of civilian health professionals in areas of active conflict, including the former Yugoslavia, the Great Lakes region of Africa, Somalia, and West Africa. Civilian medical and public health personnel found themselves working in settings with active combatants, migratory populations, international military forces, and large-scale humanitarian needs.
During the post 9/11 era, as wars in Afghanistan and Iraq continue, it has become increasingly difficult for Western workers to travel in several regions that are dominated by persons who are ideologically opposed to Western involvement. Although the dynamics of this change are complicated and beyond the scope of this chapter, the net result is that an American traveling in the Palestinian territories, Lebanon, Iran, Pakistan, and Afghanistan must consider these risks very carefully, understand local political nuances, and take the appropriate safety precautions.
Intentional targeting of civilian aid workers and erosion of neutrality exemplify major changes in the recognition of the neutrality of Western aid organizations. Analysis of 382 aid worker deaths from 1985 to 1998 revealed the alarming fact that most of these deaths (68%) were intentional and the result of aggravated assault and murder as compared with the most commonly accepted risks of motor vehicle accidents, which comprised the second leading cause of death (17%) among these individuals.15 Countries noted to be a significant risk to aid workers include Angola, Sudan, Rwanda, Afghanistan, Democratic Republic of Congo, Somalia, Burundi, the former Yugoslavia, and regions in the Middle East, including Iraq.
There remain several regions that are quite restrictive with regard to the numbers and types of travelers that are allowed into their countries. Some of the most controlled areas include North Korea and Burma, with increasing restrictions applying to travel in Eritrea, Sudan (especially outside Khartoum), Chad, Zimbabwe, and several former Soviet states. Travel restrictions remain in effect (often for obtuse reasons) in Cuba and Iran; travel to these regions may require special arrangements.
Working in settings of active conflict or social disruption caused by political instability creates high-risk situations that require a deep understanding of regional politics and local people of influence. In many of these settings, travelers encounter informal militia, banditry, and obstructed access. It is essential to become familiar with the range of possible threats before encountering them (Figure 90-2).
At least some of what defines a hostile environment for travelers and health care workers are places with a variety of weaponry. The most common weapon-related threat to international tourists, health care workers, and explorers is a gun in the possession of someone willing to use it for ill gain. Guns are used to protect and intimidate people and to create a threatening environment. Police, military, local militia, security personnel, and civilian gun owners create a dangerous environment for travelers. In a recent review of the impact of small arms assaults on aid workers, Robert Muggah found that more than 220 United Nations civilian staff have died as a result of malicious acts since 1992, and at least 265 have been taken hostage while serving in United Nations operations. This is added to the thousands of assaults on aid workers and foreign travelers in politically insecure areas, which have resulted in hundreds of deaths.17
The most commonly encountered weapons in most conflict areas are personal assault rifles, primarily variations of the Russian-made AK-47 (the name AK-47 refers to “automatic Kalashnikov, 1947,” which is named after its designer Mikhail Kalashnikov and the first year of its production).13 Because of their simplicity, durability, dependability, and ease of creation, variations of the AK-47 constitute more assault rifles throughout the world than all others combined (Figure 90-3). In some regions of the world, an AK-47 can be purchased for as little as $50 to $100. Handguns are also frequently encountered weapons. They are considered close range or self-defensive weapons, and are commonly found among military and “irregular” militias.
(With permission from Chief Mass Communication Specialist Eric A. Clement, U.S. Navy. March 5, 2007.)
Encountering individuals or groups—whether they are members of a formal military or an informal militia—with weapons is a common occurrence. As a civilian working in an unstable setting, protection is accomplished by presenting oneself and one’s organization as civilian and interested in providing impartial assistance. When an individual encounters groups with weapons, it is essential to develop a clear line of communication with an unambiguous message that he or she is civilian, unarmed, and not party to the politics of the setting. It is never recommended that civilians carry a weapon. Carrying a firearm identifies that person as a possible threat and thus removes the perception of neutrality. However, it may be necessary to employ armed guards in certain situations to protect a vehicle, staff member, home, or office. The decision to employ armed guards needs to be made in a local context and by someone with deep local and regional experience.
Travelers to areas that have historically suffered from conflict should be aware of the very real threat of land mines and unexploded ordnance. This is especially the case in regions that are currently stable but have been contested in the recent past. There are 88 nations affected by land mines and unexploded ordnance, and there have been new victims in 71 countries since the turn of the century. Regions notorious for the presence of mines in areas frequented by civilians include Kosovo, Chechnya, China, Jordan, Ukraine, Mozambique, and the Balkans. Eighty-five percent of mine-related casualties occur in Afghanistan, Angola, and Cambodia, although details from Iraq are not accounted for in this figure.7
The biggest producers of the world’s land mines are China, Russia, the United States, Belarus, Ukraine, and Pakistan. Mines are a multibillion-dollar weapons industry. There are more than 350 types of antipersonnel devices produced internationally, from large antitank mines to “toe poppers” and other small devices that are intended to maim rather than kill. In general, mines are designed to injure (not kill), to create terror, and to disrupt military targets by injuring soldiers. They can be detonated by direct pressure, vibration, or trip wires, which results in sending high-velocity projectiles of metal, dirt, and debris into the tissues and bones of victims (Figure 90-4).
(With permission from Nation Defense Days, Esplanade des Invalides, Paris, France, September 24 and 25, 2005.)
Antipersonnel land mines continue to threaten civilians and noncombatants, despite a growing number of conventions intended to ban them. Although there are more than 100 million land mines distributed cross Asia, the Middle East, the Balkans, and South America, land mine production continues unabated by the world’s superpowers. Someone is killed or injured by a land mine every 15 to 20 minutes, and destitute nations like Cambodia struggle with the burden of more than 35,000 amputees.
Land mines represent both an immediate health risk and a delayed threat. More than 110 million land mines have been deployed worldwide. Of the 15,000 victims killed or injured annually, 80% are civilians. The epidemiology of land mine injuries is not known, but case fatality rates are very high. Land-mine injuries pose a major problem for health care providers, who may be poorly equipped to manage the severe penetrating trauma, blast injuries, and consequent infections and gangrene. Trauma from land-mine injuries requires high-level surgical services and can monopolize health care resources.
Another major problem with land mines is that they outlast any conflict, and their removal is difficult and costly. Demining programs exist in 41 nations, but new land mines are being placed in contested areas every day. The reality of land mines is that no one truly knows how many exist or where they are located. This creates significant economic, social, and psychological disruption.
BOX 90-2 Land Mine Types
Dropped by a plane or helicopter, scatter mines are small devices that may or may not explode on impact. These may appear to be innocuous and may even look like toys. They are often the source of devastating injuries to children.
These mines are the size of hockey pucks and designed to be buried close to the surface. They are often made of plastic, with the only metal component being a small pin or spring for the detonator, thereby making them nearly impossible to detect with metal detectors. Produced by China, the United States, and Italy, they cost about a dollar each and can cause immediate amputations and devastating wounds. Larger antipersonnel mines can spray shrapnel over a wider area, thereby injuring or maiming many people.
These include the well-known Claymore mines and mines on sticks that are designed to spray ball bearings or fragments over 50 m (164 feet) or more. Fragmentation mines can be detonated by trip wires and are used to protect perimeters.
These large, plate-sized mines are used to disable and destroy military vehicles, such as tanks or armored personnel carriers. They are detonated by the weight of the vehicle or by remote control. These devices have grown in popularity and complexity during the course of the Iraq war, and variations are responsible for many roadside bombings.