The population of Burundi has suffered from ongoing civil war since 1993. About one-sixth of the population-or 800,000 people-have been either voluntarily or forcibly displaced by the ongoing conflict. This massive population displacement has exacerbated the spread of disease and malnutrition in many parts of the country. In September 2000, a severe malaria epidemic hit Burundi. Before the epidemic ran its course by the early summer of 2001, more than 3 million cases had been counted in a population of 6.5 million people. The disease reached epidemic proportions in 9 of the country's 16 provinces: in November alone, 720,000 people fell ill countrywide. Between the onset of the epidemic and the end of the crisis in April 2001, MSF treated more than 1,200,000 patients and sprayed more than 30,000 homes in an effort to control the mosquitoes that spread the disease. If the epidemic's direct causes were natural-a deadly mix of parasite-carrying mosquitoes and climatic factors-its indirect causes were man-made. Virtually all vector control was stopped in 1993, the year the country fell into war.
The welfare of thousands of Chechens who have fled the conflict in their homeland for refuge in the neighboring Republic of Ingushetia worsened over the course of 2001. As intense fighting continued inside Chechnya for a third year, attention and sympathy have waned for the estimated 150,000 displaced Chechens currently living in collective centers, with host families, and in tent camps in Ingushetia. Since February 2001, the Russian federal government has insisted that new arrivals from Chechnya, estimated at as many as 500,000 in 2001, are "economic refugees" and ineligible for federal aid. Many of the displaced are living in deplorable conditions because host families have evicted those who can no longer pay rent and shelters are ill-prepared for winter conditions. A recent MSF survey of 440 families living in 70 of the 188 settlements throughout Ingushetia, as well as of 150 families living with Ingush hosts in the city of Malgobeck, found that 80% of the displaced shared latrines with at least 20 other people. In one tent camp in the city of Nazran, more than 430 people shared one latrine. More than 50% of those living in host families had no more than three square meters of space per person-well below international standards for refugees and displaced (3.5-4.5 square meters). More than half of those surveyed living in tent camps inhabited tents that had leaky roofs and holes in the walls-amid harsh winter conditions. The ongoing fighting in Chechnya and the condition of displaced civilians inside Chechnya and in Ingushetia have received scarce attention from the media and the international community in the past year.
In the spring of 2001, China launched a "strike hard" campaign to crack down on "illegal migrants" along the Sino-Korean border. The new policy has worsened the already-precarious situation of as many as hundreds of thousands of North Koreans who have fled to China from their famine-stricken country. Thousands of refugees have been rounded up and forced to return to North Korea where they face possible persecution including interrogation, "reeducation," imprisonment, and even capital punishment. China has increased the fines and prison terms for Chinese and ethnic Koreans who offer assistance to North Korean refugees in China, and inhabitants of the border region have been mobilized to denounce North Koreans and the people sheltering them. North Korean refugees live in constant fear of being caught and forced to return to the oppressive humanitarian conditions in their country. Chinese authorities continue to refuse permission for aid agencies to reach North Korean refugees in the border areas.
Massacres, kidnappings, extortion, and roadblocks are an everyday fact of life in Colombia, particularly in the countryside. Combatants from the government and rebel groups are engaged in an undeclared civil war that has had devastating effects on the civilian population trapped in the middle. Health care centers have been destroyed or lack the medical staff, drugs, and material necessary to offer adequate care. The exodus of displaced people toward cities is ongoing. In the urban areas-so-called "invasion slums"-where the displaced settle, they are again confronted with violence and lack basic services such as health care, clean drinking water, and sanitation facilities. Nearly 2 million people have been pushed from their homes since 1985, with more than 300,000 people displaced in 2000 alone. In isolated villages, acute diarrheal diseases and respiratory infections, malaria, and skin diseases are common, and basic health needs including vaccinations, reproductive health care, and prevention of malaria and dengue fever are rarely addressed. Despite the conflict's impact on the population, the international community has paid scarce attention to the needs of civilians in Colombia; the war is not recognized as such and neighboring states have returned Colombians seeking refuge.
A brutal civil war has been waged in the Democratic Republic of Congo (formerly Zaire) for the past five years. Foreign armies and Congolese armed groups are locked in power struggles that are siphoning off much of the country's vast natural wealth in the process. Caught in the middle are the 53 million Congolese civilians. After decades of government neglect and war, the country's health system is in a state of complete collapse. An estimated 2.5 million Congolese are displaced inside the country, many of them outside the reach of aid workers. Families stripped of their coping mechanisms are more vulnerable to infectious disease and malnutrition. Outbreaks of meningitis, cholera, measles, and malaria are common, and the incidence of sleeping sickness, tuberculosis, and HIV/AIDS is rising rapidly. Hospitals and medical equipment are scarce, and many rural communities are totally without health care. A single Congolese doctor typically serves approximately 25,000 people. One in four children die before reaching the age of five; less than half of the population has access to clean drinking water. Average life expectancy is only 45 years. An epidemiological survey conducted by MSF in 2001 found extremely high mortality rates in areas throughout the country. In Basankusu, an area near the frontline under rebel control, nearly 10% of the global population died over a 12-month period, with the rate climbing to almost 25% for children under five.
In 2001, an estimated 14 million people died from communicable diseases like tuberculosis, malaria, kala azar, and sleeping sickness, for which there are few effective or affordable medicines. More than 90% of these deaths occurred in the developing world, where many of the drugs currently used to treat these diseases are old and increasingly ineffective due to resistance. Other available drugs are highly toxic or difficult to use in resource-limited settings. For some diseases, no medicines exist. Over the past 25 years, fewer than 1% of the more than 1,300 drugs approved for sale were developed to treat tropical diseases. Research and development of new drugs for these diseases is at a virtual standstill because the millions who need them live in poor countries and do not constitute a profitable market for the pharmaceutical industry. TB kills at least 2 million people each year; yet, the last truly innovative treatment was developed more than 30 years ago. Malaria kills one child every 30 seconds; yet, the high price of newer, more effective drugs contributes to the continued use of old, ineffective medicines, even in places where resistance levels have reached 80 to 90%. The treatment for kala azar was developed 50 years ago and resistance levels have risen to 70% in some regions. Even when effective treatments do exist, they are often priced beyond the reach of those who most need them.
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The 1951 Refugee Convention was reaffirmed in Geneva on its fiftieth anniversary this year, but Doctors Without Borders/Médecins Sans Frontières (MSF) sees evidence of an alarming disregard for the terms of this convention and the protection of refugees worldwide. With growing frequency, those fleeing conflict do not have the opportunity to seek asylum and find safe refuge. Refugees are being contained within national borders and trapped within the violence they are trying to escape. From Afghanistan to Zambia, the rapid growth in the number of internally displaced people is testament to the increasing reluctance of countries to open borders. As wealthy countries refuse to share the financial responsibility for protecting and assisting refugees, poor states that neighbor countries in conflict are less likely to open their borders and to care for people who cross them. Many states interpret the Refugee Convention in the most restrictive manner rather than as a means toward offering genuine protection to those fleeing persecution. There are currently an estimated 21.8 million refugees and 20 to 25 million internally displaced persons worldwide.
Since 1991, Somalia has experienced the complete collapse of its central government, the death or displacement of at least two million people, and a brutal civil war that has destroyed much of the country's public infrastructure and productive capacity. Despite the existence of a transitional national government, the country remains fractured, with various warlords and warring factions in control of various parts of the country. Somalia ranks near the bottom of the United Nations' human development index. The health care system, along with all state services, has collapsed. Most doctors have fled the country, and, apart from staff working with nongovernmental agencies, no doctors or nurses have been trained in Somalia since the outbreak of war. The only available public or free health care is provided by the few humanitarian organizations still working in the country; this is wholly inadequate, though, as large parts of the country remain completely cut-off from humanitarian aid. Diseases such as tuberculosis, cholera, meningitis, and kala azar are rampant. Recent indications show that an estimated 750,000 people, mainly in the southwestern part of the country, are at risk for malnutrition because of an increasingly alarming food shortage brought on by a third consecutive lower-than-normal rainy season and ongoing fighting.
Sri Lanka's 20-year-old civil war has taken the lives of more than 60,000 people and displaced hundreds of thousands. After a lull in the fighting during 2000, attacks and violence increased again in 2001. Every month, civilians are killed, injured, or maimed by landmines, unexploded ordnance, or outbursts of fighting. The psychological impact of the war is profound. A survey conducted by MSF in camps for displaced persons in the northern town of Vavuniya revealed that substantial numbers of people had been directly exposed to the violence of war, either through witnessing or being injured by an act of war, being displaced by the fighting, or losing a loved one. The suicide rate in the camps is nearly 3 times higher (103.5 per 10,000) than in the rest of the community. Overall, Sri Lanka has one of the highest suicide rates in the world. Despite the highly developed health care system that functions in parts of the country, most health professionals have fled the North where clinics and hospitals are in serious disrepair and woefully undersupplied. The breakdown in the health care infrastructure has exacerbated the spread of disease: in the most affected areas, malaria has risen twenty-fold since the beginning of the conflict. One in five children born in the conflict area suffers from low birth weight. Both the Sri Lankan government and the Tamil opposition forces have failed to meet the health care needs of the Sri Lankan people caught in conflict.
West Africa has been experiencing a highly volatile refugee crisis for more than a decade. An ongoing conflict in Sierra Leone has pushed an estimated 330,000 refugees into Guinea over the last 10 years and displaced many others inside Sierra Leone. Civil war in Liberia from 1990 to 1997 forced 235,000 Liberians to flee to Guinea, where more than 100,000 remain today. In early 2001, MSF called attention to the deteriorating situation of hundreds of thousands of mostly Sierra Leonean refugees stuck in a volatile area of Guinea near Gueckedou, or "Parrot's Beak." Without adequate protection or the offer of resettlement to safer areas, large numbers of the refugees fled the area on their own, many returning to unstable areas of Sierra Leone. In the spring of 2001, fighting between government forces and armed groups in northern Liberia's Lofa County-an area fraught with civil war, population movements, and cross-border incursions by armed groups from Guinea and Sierra Leone-prompted the exodus of approximately 150,000 people to the southern part of the country. Since August 2001, there has been an increase in violent clashes between armed groups in and around Lofa County, displacing thousands more to camps in the surrounding counties, including some 8,000 to Jenne Manna in southwest Liberia. Cut off from adequate assistance and trapped between armed groups, displaced persons in Liberia and throughout West Africa are increasingly left with little or no protection or security.