ArticlesWar and mortality in Kosovo, 1998–99: an epidemiological testimony
Introduction
War is one of the critical determinants of the health status of populations in many parts of the world. In terms of loss of disability-adjusted life years (DALYs), war was ranked sixteenth by WHO in the global burden of disease in 1990, and by the year 2020 it is expected to rank in eighth place (www.who.int/eha/emergenc/sue/sld008.htm, accessed April 20, 2000). Although the frequency of civil wars is increasing,1 the direct and indirect effects of war on the civilian population commonly remain poorly documented. In complex emergencies in Rwanda, Iraq, Sierra Leone, Chechnya, and the Balkans, basic measurements such as total number of deaths, mortality rates, causes of death, and risk factors, remain inadequately recorded.1, 2, 3, 4, 5
The proportion of all war casualties that are civilian has increased from about 14% in the First World War to 67% the Second World War, and to 90% in the 1990s.4 The targeting of civilians in modern warfare has become an objective of war. The pattern of human-rights abuses termed “ethnic cleansing” may include individual and mass killings, sporadic or systematic rape, the destruction of civilian residences and institutions, and commonly the violation of medical neutrality. This pattern has been documented previously in the former Yugoslavia, where by late 1994 there were an estimated 150 000 war-related casualties in Bosnia and Herzegovina,2 and it appears to have been repeated in Kosovo in 1998 and 1999.6, 7
Long-standing conflict in Kosovo, a province in the Federal Republic of Yugoslavia, between the majority ethnic Albanian population and the Yugoslav military of primarily Serbian forces, escalated at the end of February 1998. After clashes between Serbian forces and the newly formed Kosovo Liberation Army (KLA), a UN resolution was passed in September 1998 that paved the way for a partial withdrawal of Yugoslav military from Kosovo and the deployment of unarmed observers by the Organization for Security and Cooperation in Europe (OSCE). By the time the aerial bombardment of the former Republic of Yugoslavia led by the North Atlantic Treaty Organisation (NATO) began on March 24, 1999, more than 260 000 people in Kosovo were estimated to be internally displaced and an additional 100 000 people were displaced within the region.8 After an intensification of the “ethnic cleansing” campaign, about 800 000 Kosovar Albanians fled to neighbouring countries such as the former Yugoslav Republic of Macedonia, Albania, and Montenegro, as well as to other countries (www.nnhcr.ch/news/media/kosovo.htm, accessed April 20, 2000). After signing the peace agreement, all of the Serbian forces finally withdrew from Kosovo on June 20, 1999, and the largely spontaneous repatriation of refugees began. By the end of July, more than 770 000 refugees had already returned to Kosovo (www.unhcr.ch/world/euro/fryugo.htm, accessed April 20, 2000).
The large number of civilian deaths was used as a partial justification for the NATO-led intervention. However, debate concerning the number of dead in Kosovo has continued, with wide variation in estimates (www.state.gov/www/global/human_rights/kosovoii/homepage.htm#exe, accessed April 20, 2000).6, 9, 10, 11 We did a systematic population-based survey to determine mortality rates, causes of death, and risk factors among the entire Kosovar Albanian population, including refugees and internally displaced people, from February, 1998, to June, 1999.
The survey was a collaborative effort between the non-governmental organisation International Rescue Committee, the Kosovo Institute of Public Health, the WHO, and the Centers for Disease Control and Prevention.
Section snippets
Methods
We did a two-stage cluster survey in Kosovo between Sept 8, and Sept 17, 1999 with households as the primary sampling unit. The sample size was calculated to achieve a 95% CI of 0·5% around an estimated cumulative incidence of mortality of 1·16% for the study period between February, 1998, and June, 1999. This estimate assumed a doubling of the mean baseline crude mortality rate of 0·31 per 1000 a month (3·72 per 1000 a year) for the period between 1994 and 1996.12, 13 The design effect is the
Results
We completed a standardised questionnaire for 1196 households comprising 8605 people (mean household size included 6·9 individuals). No households refused to participate, although four clusters included only 23 households. We selected villages from 21 of 25 eligible municipalities. Demographic characteristics of the sample population are listed in table 1. The mean age of the sample population was 27·1 years and the average sex ratio was 1·04:1·00 (female:male) in all age-groups.
Of the 105
Discussion
Between February, 1998, and June, 1999, the crude mortality rate (0·72 deaths per 1000 monthly) in Kosovo was 2·3 times higher than the pre-conflict baseline. Mortality rates were highest between the months of March and June 1999, coinciding with the NATO bombing and the intensification of the Serbian campaign of “ethnic cleansing”. The largest increase in the crude mortality rate occurred in April and is of a similar order of magnitude than that reported in previous complex emergencies in the
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