Global Crimes, Incarceration, and Quarantine

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.

Hostile Geopolitical Environments and Political Insecurity

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:

Increasing numbers of violent regional ethnic conflicts. As the Cold War era ended, the new world order quickly gave rise to a variety of ethnic tensions devoid of superpower arbitration. During the 1990s, civil conflicts erupted in the Balkans, Central Asia, the Middle East, and throughout Africa. The world currently has more than 30 countries in the midst of serious armed conflicts.11 Many of these conflicts are intrastate struggles, with many deemed ethnic or religious wars. These conflicts are in contrast to previous international cross-border conflicts launched as proxy wars between the United States, Soviet Union, and other neocolonialists. The net result of modern civil conflict has been massive-scale refugee emergencies and public health disasters as well as an influx of foreign workers. Recent large-scale relief efforts include those in East Timor, Somalia, Sudan, Liberia, Sierra Leone, Guinea, Mozambique, Rwanda, Burundi, Democratic Republic of Congo, Chechnya, Colombia, Honduras, the Former Yugoslav Republics, and northern Iraq. Emerging crises are predicted in several regions in Africa, the Middle East, Northern Caucasus, and Central Asia.4

Civilian casualties. Drafting of the Geneva Convention and adoption of the tenets of international humanitarian law and codes of conduct in war have not stemmed the tide of human rights abuses and deliberate targeting of civilians during the past three decades.5 Civilian casualties resulting from regional conflicts or armed assault have increased as compared with World War II or the Vietnam War or Korean conflict. Today, for every armed combatant killed in a conflict, about 10 civilians die, chiefly from communicable diseases and other preventable illnesses.2 In addition, attacking and controlling civilian populations has been a primary method of securing territory in conflicts, such as in Darfur and the Democratic Republic of the Congo. Civilians and foreigners can be targeted by combatants or used to advance a political or ideologic agenda.15

Reasons for Enhanced Personal Risk in Politically Unstable Regions

Increasing Civilian Nongovernmental Organization Involvement in Unstable Regions

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.


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.

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.

Risk Reduction Strategies for Situations in Which There Are Armed Combatants

When traveling or working in a region that has armed combatants, there are some simple ways to avoid getting into trouble.

Land Mines and Unexploded Ordnance

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

Effects of Land Mines on Populations and Health

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.

Land mine types include those listed in Box 90-2.3

BOX 90-2 Land Mine Types

Sep 7, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Global Crimes, Incarceration, and Quarantine

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