Stressors, more stressors, and blaming the victim in wartime

Those people who dedicate their lives to addressing stressors among displaced populations are frequently faced with an uncomfortable truth: people under a lot of stress sometimes create more problems for themselves. This is a well-observed phenomenon across populations, and is generally known as “stress generation.” As regards trauma work, there is good research to show that the best predictor of future trauma is past trauma. For those of you not well-versed in stress generation, see Constance Hammen’s reflection on her career researching stress generation among depressed individuals in the Journal of Clinical Psychology.

The uncomfortable part of all this is that it can move quickly into “blaming the victim” (particularly as it pertains to trauma). If a combat veteran presents with PTSD and marital conflict due to the irritability and anger that is a part of the PTSD diagnosis, it can be very difficult not to get really frustrated with that vet’s anger and sink into “it’s your own damn fault” despite our initial sympathy. An automobile accident survivor has a higher likelihood of getting into another automobile accident than someone who hasn’t been in an automobile accident because the survivors tend to be extra cautious following their first accident, drive more slowly at the wrong times, get distracted by other drivers, etc.; if these things cause an accident, who is responsible?

When it comes to refugees, blaming the victim may result in less critical aid from the international community and stigma upon resettlement. And yet it’s clear to anyone who’s worked in refugee camps that a stressed population is a difficult population is difficult to work with. Indeed, one of the impetuses behind bringing psychosocial interventions into humanitarian aid is the danger that stressed refugees can pose to aid workers. There are numerous reports of refugees striking out against aid workers for small irregularities in aid distribution or changes in policies. (I should add that their are also striking reports of other refugees coming to the aid of aid workers.)

So how do we reconcile stress generation with our discomfort? Well, first by reminding ourselves that the first order of health provision is not morality. (I’ve harped on that before, and you probably don’t need to read it again here.)

Second, by looking further into stress generation research so we know what we’re talking about. In this literature, folks like Hammen make the distinction between “dependent, interpersonal” stressors and “independent, fateful” stressors. It turns out that research with people with mental health diagnoses have (on average) more stress-dependent events than people without mental health diagnoses, but have the same number of independent events. Dependent events are almost uniformly interpersonal in nature — and therefore plausibly related to how one would act towards others if really stressed. Independent events may be interpersonal, but their core feature is their fateful nature — they are not affected by how someone is acting.

How does the dependent-independent dichotomy map on to the typology of conflict-related stressors proposed in the last entry in this blog? Well, it’s pretty clear that mental health problems aren’t to blame for people being attacked or cause them to end up in unstable resettlement contexts — this is the “direct war exposure potentially traumatic events (PTEs)” category. For “collateral” and “other PTEs” (which, as I think through them may not be as distinguishable as they first seemed), the picture is less clear, and that some of these stressors are related to “being stressed” means that education campaigns surrounding the affects of stress (at the very least) are important. “Social ecological stressors” are clearly set off by displacement, but the breakdown of community institutions may be exacerbated by interpersonal problems. This is why the “social” in “psychosocial intervention” has always struck me as the more important of the two traditions. “Daily hassles” are likewise split between those problems that are outside of the control of the individual (e.g., a military checkpoint) and those that are exacerbated (unemotional reactions to hearing of abuse of loved ones). So perhaps the dependent-independent dichotomy is a second axis that runs through the typology proposed a few days ago. (Again, comments encouraged here.)

Important to remember through all of this is that all of these stressors are precipitated by an initial event — the event that was the cause of displacement. It would be difficult to argue that displacement events were dependent stressors. And yet many subsequent stressors, be they mild or traumatic, are dependent to some degree. In order to address these, humanitarian aid workers must remember the latter, and the former; they are equally important.

Article addendum: Stressors during wartime

The April 2010 issue of the American Journal of Orthopsychiatry includes an article comparing the effects of war-related trauma on mental health to effects of the “current stressors” one finds in refugee camps. I’m the first author on this article, and so I’m going to take the privileges afforded by that role and be somewhat critical of the work here.

The article is based around the idea that there are lots of things that happen during wartime that cause emotional and cognitive distress in addition to armed conflict. In order to decide what to do about distress in displacement camps, one should consider these non-conflict stressors. In the paper, we measured war-related traumas (or “potentially traumatic events” to be more precise) separate from other “camp stressors” and examined which was more highly associated with the psychological problems of posttraumatic stress disorder, depression, and two local idioms of distress (local ways of discussing emotional problems). We found that war trauma and camp stressors among Darfur refugees were both related to all four psychological problems, and in several cases the number of camp stressors was actually more strongly associated with these than the number of war traumas. We went on to find that camp stressors partially mediated the effects of war trauma on most psychological problems. We concluded that humanitarian aid agencies interested in addressing general distress in camps thus had empirical support for interventions that target everyday camp stressors, in addition to popular war-related and trauma-focused interventions (which are already empirically-supported for displaced persons with posttraumatic distress).

Since the manuscript was accepted (fall of 2009) I have had a number of opportunities to think about the variability within this category of “current stressors.” Critical to this was the opportunity to co-author an editorial on trauma-focused versus psychosocial perspectives in humanitarian aid with my friend and sometimes collaborator Ken Miller, who is really the pioneer in this work (look up his stuff on Afghanistan and Sri Lanka for examples). Something has always bothered me about the category “current stressors” and a common criticism is that we are throwing a lot of different types of stressors — with different effects — into the same conceptual bag. So, I’d like to propose — really by way of proposing a starting point, not answering the problem outright — a typology of stressors that are critical to consider in studying the psychological consequences of armed conflict and displacement.

1. Direct war exposure potentially traumatic events (PTEs): Direct (both personally experienced and witnessed) exposure to the violence and destruction of war. Examples include (but are in no way limited to) direct attacks by military (or paramilitary) personnel, being pursued by these forces, bombing, and exposure to mines.

2. Collateral PTEs: Direct exposure to trauma collateral to war (i.e., coming about because of war) but not comprising an act of war itself. This may include abuse by non-military persons during flight (e.g., criminals or fellow refugees), attacks by locals in the displacement context, abuse by peacekeeping forces, and motor vehicle accidents occurring during flight.

3. Other PTEs: Non-war-related traumatic events that increase during wartime. It has been noted that all forms of violence increase during wartime (e.g., see the work of James Garbarino for particularly articulate illustrations), whether because of stress on the perpetrators of these events or degraded safety of settings which allow these events to occur more frequently. Examples include domestic violence, child abuse, and attacks by dangerous animals (e.g., poisonous snakes are evidently a big problem in some refugee camps in Sri Lanka).

4. Social ecological stressors: War-related degradation of social institutions (both formal and informal). Examples are destruction of schools and subsequent lack of educational opportunity, diminished health care, loss of social support networks, religious institutions, war-induced poverty, and famine. It may be difficult to distinguish some of these from preexisting conditions (e.g., the difference between war-induced and preexisting poverty may be minimal in some cases).

5. Daily hassles: Daily hassles are those seemingly minor problems of daily life that either come to exist or increase in intensity in wartime. These have shown to be strongly related to mental health problems in non-war contexts, even moreso than stressful major life events. These may include checkpoints along a commute, regular questioning by military or police, mild forms of humiliation (e.g., degradation by authorities, bribes), needing multiple forms of documentation in order to complete simple tasks, long wait times in order to get basic resources (e.g., food distribution at refugee camps), and hearing complaints about such daily hassles from loved ones. All involve some persistent inconvenience or stressor that is not physically abusive or threatening. Some daily hassles may at times come close to collateral trauma (e.g., regular questioning that involves strip searches).

It is important to note that for individuals exposed to the different types of stressors delineated above, differences may seem phenomenologically trivial. Stressors related to direct attacks, harassment and abuse during flight, and loss of social networks may be part and parcel of a single, undelineated narrative of war. Moreover, for many these categories may not be readily distinguishable from non-war-related stressors. War-induced poverty may be seen as an extension of preexisting poverty, increases in domestic abuse may be experienced as an extension of pre-war abusive relationships, and bribes paid to police during wartime may have the same effect as bribes during peacetime. In order to study the effect of conflict, researchers should conduct work that estimates the change in prevalence, incidence, and effect on outcomes of these phenomena over time (i.e., pre-conflict to conflict).

Let me reiterate that these are only a first pass at types of stressors, and I welcome all comments. Next: The sticky problem of stress generation among displaced populations.

37 year-old refugee crisis comes to an end

Where do refugees go after the crises that made them refugees leaves the headlines? The options are: go home, get resettled to a wealthier country, stay in the camps.

The UN estimates that at the end of 2008 (the last year there are reliable numbers for at the moment) there were 15.2 million refugees in the world (a refugee here is a person who has fled across a border because of political violence). Eighty percent of these refugees, or about 12.2 million, lived in camps or urban areas in neighboring countries in the developing world (e.g., the 1.8 million Afghans in Pakistan).

Some refugees go home. How many? In 2008, 600,000 refugees went home; 600,000 / 15.2 million = 4%. This was the lowest number since 2004, suggesting that going home is less and less an option.

What about all the refugees resettled in wealthy Western nations? In 2008, 121,000 were proposed for resettlement to wealthier nations (US, Canada, and Western Europe, primarily), or 0.8% of all refugees at the time.  Only 67,000 of these were actually resettled, about 0.4%.

So, most refugees remain in camps and foreign cities for very long periods of time as refugees. Surely there must be some other plan. Well, recently UNHCR has been proposing a policy of “local integration.” Local integration means what it sounds like  — making refugees part of the local economy and society of the region in which they live, with full citizenship rights and privileges, and no more refugee aid. The involves getting local governments to accept that refugees they have played host to for years are there to stay, and getting the refugees themselves to accept that they cannot receive aid forever. This long-term solution is usually pretty long-term. In Chad, the UNHCR started encouraging local integration for refugees from the Central African Republic who had been there for 1o years.

One of the oldest refugee populations are Burundians in Tanzania. Burundi is now infamous for ethnic conflict in 1994 (similar to neighboring Rwanda’s), but many Burundians in Tanzania are there because they fled from massacres in 1972. In other words, these Burundians have been sitting in camps for 37 years. This week, Refugees International reported that last month Tanzania gave citizenship to 162,000 of these Burundians. This is a welcome and generous move by Tanzania, a country that has been host to several large refugee populations — the price of being a peaceful place in a dangerous neighborhood.

(162,000: That’s 1% fewer refugees, for those of you counting.)

Afo de kurnaŋa, Hadjer Hadid: Massalit literacy developing in eastern Chad

My coverage of disappearing languages in New York City made it all the way to Hadjer Hadid — which is, incidentally, my favorite place in Chad, hands down. It seems that currently there is a project on the ground to develop a written form of Massalit in Roman script. Eunice Kua of SIL International is working on the Massalit Language Development Project in the refugee camps of Bredjing and Treguine (Bredjing is the largest Darfur refugee camp, with approximately 30,000 residents, Treguine with about a half to two-thirds that). She reports:

You may be interested to know that there is a written form for Massalit, though the orthography is still a work-in-progress (and will probably be for the next few years, as people sort out how they want to spell things, etc! We’re working on a dictionary, but it takes time).

I am working in mother tongue literacy project with refugees in Bredjing and Treguine in eastern Chad – in fact, I should right now be preparing for this afternoon’s session of a refresher teacher training course for teaching the Massalit primer rather than writing emails.

I don’t think that we would have been able to help you much in terms of the survey, as Massalit right now is written in Roman script (when the written form was being developed years ago, the Massalit people consulted chose Roman over Arabic script, and recently when the literacy project was getting started, those who were consulted then reaffirmed this decision and continue to reaffirm it, tho’ we have expressed doubts from time to time). Your interviewers probably read Arabic script fluently but would have trouble reading Roman script… your friend’s solution is probably the way to go for now…

In response to my query about the languages of the other major ethnic groups from Darfur, Fur and Zaghawa, she writes:

There is indeed written Fur, but Zaghawa is ‘very much at the beginning stages’, also in Roman script, from what I understand.

Her comment on the preference of a Roman script is notable because many Massalit do study Arabic in Koranic schools. I have also heard that there are some written versions using Arabic script developed in Darfur, but these have not been codified.

Eunice also sent little language lesson. Here’s “Good morning” in Massalit:

Afo de kurnaŋa (the ŋ represents the sound of the ’ng’ in singer)

Non-written languages and refugee research

Often one of the biggest challenges in working with displaced populations is speaking to them. This is because most of the people who have the resources to undertake these activities are from Europe and North America and speak English or French, and most displaced populations do not. In addition, as many displaced populations are ethnic minority groups, they often speak languages for which there are a very limited number of interpreters available. The poverty and resulting lower education levels that is often common among groups that have been discriminated against makes good interpreters even harder to find. In other words, with many displaced populations you are often limited to the most rudimentary of communication.

My most problematic encounter with this issue was in Chad, trying to document conflict history and consequences among Darfur refugees. Most of the refugees we were working with were fluent in Massalit, a tribal language with no systematic written form. I needed to design a structured survey so that refugees we hired to carry out the survey could document things that had happened to their community members and the consequences in a systematic way (i.e., everyone had to ask the same questions). So how do you write an unwritten language? Well, I didn’t know, so I had the interview questions first translated into Arabic (then translated back into English to check the equivalency), then did a lot of training (in Arabic) with the people who would be conducting the interview — all of whom spoke Arabic and Massalit. The interviewers then had to interpret from the written Arabic to Massalit when they conducted the interviews. Messy? You bet. But how else could we have done this?

Later, my friend and sometimes co-conspirator Ken Miller had an answer for me. For his doctoral dissertation, he worked in Mexico with Mayan refugees from Guatemala. The Mayan dialect most of them spoke had no written form. What he did was to record someone speaking the questions in that dialect and take the tape and tape recorder into the field (he used cassette tapes at the time — Ken got his PhD a little while ago). He would then play the recording for the participants in the field, and all of them could then answer the same questions, not some slightly different interpretations of each question (as was almost certainly the case in my chad research).

Another answer is presented in today’s New York Times: create your own written form of the language in question. It turns out that for Massalit, this is being done… right here in New York City… at New York University… where I work. New York City, like other large US cities, is apparently something of a linguistic treasure trove for linguists interested in disappearing languages. A couple years ago Daniel Kaufman, an adjunct professor of linguistics at the City University of New York and NYU, established the Urban Field Station for Linguistic Research. He has recruited and recorded speakers of several disappearing languages in New York, including one man from Indonesia who appears to be the sole remaining speaker of his language.

He has also recruited Daowd I. Salih, 45, a refugee from Darfur who lives in New Jersey and is a personal care assistant at a home for the elderly, to teach Massalit, a tribal language, to a linguistic class at New York University. They are meticulously creating a Massalit lexicography to codify grammar, definitions and pronunciations.

“Language is identity,” said Mr. Salih, who has been in the United States for a decade. “So many African tribes in Darfur lost their languages. This is the land of opportunity, so these students can help us write this language instead of losing it.”

The lesson? You don’t have to go too far to get good language help. Start with the diaspora of the groups you think you will encounter.

Read the rest of the article and view the accompanying video here.

The war next door, and the US’s newest refugee population

Refugees made the front page of the Sunday New York Times this morning, and above the fold at that; but you might be surprised to learn the origin of the US’s fastest growing refugee population: Mexico. Drug wars in the northern state of Juárez along the border with Texas are sending thousands fleeing north.

In El Paso alone, the police estimate that at least 30,000 Mexicans have moved across the border in the past two years because of the violence in Juárez and the river towns to the southeast. So many people have left El Porvenir and nearby Guadalupe Bravos that the two resemble ghost towns, former residents say.

Similar to Colombia in the 1980s and 1990s, drug-related violence in Mexico has displaced thousands; unlike Colombia, many displaced Mexicans are seeking shelter outside of their country. Although a few incidents of drug-related violence have occurred on the US side of the Rio Grande, Texan border towns like El Paso and Fort Hancock remain remarkably peaceful. This combined with regional family ties and a long history of border crossings (and borders crossing; Texas to California and north to Oregon and Wyoming were, after all, part of Mexico for 300 years before they were part of the US) make fleeing north an obvious choice.

The Times article, written by James C. McKinley, Jr., presents several cases that will sound familiar to anyone who has worked with war-affected populations. New arrivals report sleep disturbances (and being able to get some sleep for the first time in weeks), pervasive anxiety symptoms, and that their children only play one repetitive macabre game, in this case called “sicarios” — hitmen.

So, are we welcoming Mexican forced migrants with open arms?

“This is an emergency situation, a war,” said Jorge Luis Aguirre, a journalist who himself has asked for asylum after his life was threatened in 2008 in Ciudad Juárez. “It’s a question of life and death for these people.”

But few Mexicans are granted asylum. Over the last three federal fiscal years, immigration judges heard 9,317 requests across the country, and granted only 183.

Fort Hancock has had a surge in applications in March and April, officials said. All told the number of people asking for asylum at ports of entry along the border alone has climbed steadily, to 338 for the federal fiscal year ended last October, from 179 two years before.

With much of the last twenty years spent preventing illegal immigration from Mexico, it is of course not surprising that immigration authorities would find asylum claims by all Mexicans suspect. But with the recent recession in the US, cross border immigration has decreased to some of the lowest levels in years. The refugees from the Mexican borderlands are not coming for economic reasons, they are running for their lives.

They are being met in this country by a harsh anti-immigrant and anti-Mexican climate. Not far to the west, the Arizona legislature has passed the most stringent immigration enforcement law in the US, one that asks and allows local police to determine whether someone is in US illegally using “reasonable suspicion” alone. Although police chiefs and civil libertarians (as well as immigrant advocacy groups) have spoken out against the bill, Governor Jan Brewer is expected to sign it into law within the next few weeks.

Pedicures in Haitian tent cities

We usually think of displacement as an economically disempowering phenomenon. The residents flee from war or natural disasters with just the shirts on their backs, arrive in a new place without much in the way of orientation. How could anyone make any kind of money?

Last night on PBS’ News Hour, Adam Davidson of planet money presented a piece on the surprising economy of a displacement camp in Haiti. Evidently, the transformation from “collection of tents” to a real, functioning “tent city” has begun. There are evidently many good examples. Pedicures, for instance:

At the beginning, it was the basics, food, water, clothes. Then business expanded beyond the essentials. A week after the earthquake, Yoleen Samard went to her old salon, which had collapsed entirely, and rescued whatever beauty products she could. She brought them back.

Her husband cleaned out a space in their tent, and now she’s in business.

These customers, both 18 years old, say they can convince their parents to pay for a pedicure about every two weeks.

I once talked to a refugee kid from the Central African Republic living in a camp in southern Chad and asked him if he could do anything to make money. “I rent DVD’s.” Somebody had a DVD player and a generator, they sold tickets… so they needed someone to rent DVD’s.

None of this should make anyone think that displaced persons aren’t in desperate shape. But don’t assume that everybody’s just sitting around either. As I’m not an economist, I don’t know of any good research on what makes for relative success in displacement camps and what makes for “just sitting around,” but it seems to me a promising area of study for those interested in aid programming.

Pedicures in Haitian tent cities

We usually think of displacement as an economically disempowering phenomenon. The residents flee from war or natural disasters with just the shirts on their backs, arrive in a new place without much in the way of orientation. How could anyone make any kind of money?

Last night on PBS’ News Hour, Adam Davidson of planet money presented a piece on the surprising economy of a displacement camp in Haiti. Evidently, the transformation from “collection of tents” to a real, functioning “tent city” has begun. There are evidently many good examples. Pedicures, for instance:

At the beginning, it was the basics, food, water, clothes. Then business expanded beyond the essentials. A week after the earthquake, Yoleen Samard went to her old salon, which had collapsed entirely, and rescued whatever beauty products she could. She brought them back.

Her husband cleaned out a space in their tent, and now she’s in business.

These customers, both 18 years old, say they can convince their parents to pay for a pedicure about every two weeks.

I once talked to a refugee kid from the Central African Republic living in a camp in southern Chad and asked him if he could do anything to make money. “I rent DVD’s.” Somebody had a DVD player and a generator, they sold tickets… so they needed someone to rent DVD’s.

None of this should make anyone think that displaced persons aren’t in desperate shape. But also don’t make the assumption that everybody’s just sitting around either. As I’m not an economist, I don’t know of any good research on what makes for relative success in displacement camps and what makes for “just sitting around,” but it seems to me a promising area of study for those interested in aid programming.

Richer refugees living in cities? A review of refugee trends presented in the Lancet

The Lancet’s special issue on Violent Conflict and Health (featured in the last three posts in this blog) includes required reading for refugee professionals examining trends in health-care needs among conflict-affected populations. The article, “Health-care needs of people affected by conflict: Future trend and changing frameworks,” is a collaborative effort between researchers at the UN High Commissioner for Refugees, the London School of Hygiene and Tropical Medicine, and the International Rescue Commission.

Recent trends include an increase in internally-displaced persons and a decrease in refugees — essentially due to an increase in intrastate conflicts. The concept of refugees fleeing across borders to escape wars between armies is old hat. Much more likely now is the armed conflict that happens within regions of countries, leading primarily to internal displacement. The best example of this is in a nation not often thought of in the refugee cannon. Currently, this country in home to the largest displaced population in the world… Give up? Colombia.

Two trends cited by the paper are worth thinking about a little bit: (1) the urbanization of refugees and (2) higher baseline development index of refugees’ countries of origin.

The urbanization of refugees refers to those people who flee their country and settle in cities rather than in refugee camps. You can think of Somalis in Nairobi (Kenya) and  Zimbabweans in Johannesburg (South Africa). Here’s a chart from the article showing the trend in the growth of urban refugees, 1996-2008. The aqua bar at the bottom is the number of refugees in camps, the next bar (is that khaki?) is the urban population, and the olive bar is the number in rural areas.

Where Refugees Live

Note the jump in the middle bar between 2005 and 2006 on to 2007. What major refugee crisis was coming to head these years? Well, the second largest refugee population in the world (1.9 million last I checked) was from Iraq, and many many many of those are in Damascus, Syria, and Amman, Jordan. So, the urbanization of refugees is certainly a trend in terms of numbers, but this chart doesn’t really tell us much beyond the fact that the Iraq War resulted in a large urban refugee population in neighboring countries. As Iraqis return home (as many have been doing for a year or so now) we shall see whether the urbanization trend is as strong as this article contends.

My guess is that urbanization of refugees is increasing, but that if you removed Iraqi refugees from these data, urbanization would be increasing at a lot slower rate than it appears here (perhaps at the rate urbanization is increasing in general). In any case increasing urbanization of refugees means that aid groups need to shift their strategies for needs assessment and service delivery; a group of refugees that is living dispersed throughout a city is much harder to find and help than a group living enclosed within the well-defined confines of a camp.

Contrast this with the trend examining the increasing baseline development index of refugee “sending countries” (i.e., the socioeconomic status of places where refugees flee has been increasing over time). Here the authors used the “human development index,” or HDI, presented in the chart below. The blue bar indicates refugees from “low human development” countries, the khaki from “medium and high development” countries.

HDI of Refugee Sending Countries

Here too we should think about how Iraq fits into this trend, as Iraq was a relatively well-developed country until recently. Note the general annual decrease of the blue bars from 1993 to 2008; here it looks like there was a trend before the emergence of the Iraqi refugee crisis, and so these data seem to present a more reliable trend than urbanization.

Note here that the HDI is a measure of countries, not people. This matters becasue it’s often the poorest who become refugees. For instance, Sudan has a moderate HDI (lots of oil, decent roads in the north), so the destitute farming refugees from Darfur or the rural cattle herders from the South would be evidence of this trend. It’s not the case that refugees are getting richer, only that the nations they flee from are richer. Indeed, there may be evidence in there somewhere for the hypothesis that an increasing income gap between richer and poorer is an important predictor in modern refugee-producing conflicts.

Death in Darfur: 20% violence, 80% diarrhea

The latest Lancet is a special issue on Violent Conflict and Health, and includes articles on the connections between political violence and domestic violence, surgery in conflict settings, and a review of mortality surveys from the Darfur conflict.

Darfur has produced more numbers than most conflicts of its nature. Numbers of the dead are at the core of the debate between so-called Darfur advocacy groups (SaveDarfur being the largest) and skeptics who have argued that claims of genocide are grossly oversold and get in the way of facilitating lasting solutions (Mahmood Mamdani being the most prominent of these). The article in the Lancet, by epidemiologists at the Catholic University of Louvain (that’s in Belgium), takes the 12 biggest studies of deaths in Darfur, statistically smushes them together, divides their findings into six time periods between February 2003 and December 2008 according to political events, and then divides deaths into those directly attributable to violence and those attributable to illness.

Although I usually find epidemiology to be a profoundly boring enterprise (although a nonetheless critical one), the data here are remarkably illuminating. The period September 2003 to March 2004 represented the height of violence with a mortality rates due to violence of 2.5 per 10,000, but following this time these rates fell dramatically to 0.3 (April to December of 2004) and then to less than 0.1 since then. Deaths in Darfur continued during this time of course, but the majority were due to diarrhea, not violence. The authors estimate that between 2003 and 2008, a full 80% of all deaths were due to illness among those displaced by the conflict. In other words, this crisis has been 20% violence, the the vast majority of which was done by mid-2004. For the past six years (or really five years in the data reviewed), the problem has been diarrhea.

As stark as these numbers are, this ultimately means that Darfur followed the common pattern of violent internal conflicts: Initial massacres were followed by massive displacement and the loss of protective health systems, and the problems of displacement ultimately affected the well-being of the population more than the direct experiences of violence.