Natural disasters and political woes continue to affect health and safety around the world. Facing new health threats such as HIV/AIDS and avian flu, Cambodians are fighting to recover from the destruction wrought by decades-old political violence. In the Democratic Republic of Congo, beleaguered citizens survive despite chronic crisis and instability. South Africa, recovering during the last 14 years from the divisive violence of apartheid, unearthed a different kind of hatred and violence. Famine once again threatens North Korea, a country long ostracized by the international community because of its leaders' politics. Indians mourned the deaths of more than 150 people in a stampede, while millions were displaced in floods in Bihar. In the Caribbean, 3 successive blasts from tropical storms and hurricanes battered Haiti and Cuba, leaving hundreds dead.

RECOVERY IN CAMBODIA

Cambodia's recovery from the violent Khmer Rouge reign that killed one-fourth of the population has been slow and difficult. This fragile democracy must manage not only economic and political recovery but also persistent threats from landmines and the new crises of HIV and avian influenza.1 With the murder of most of the educated individuals in the country under the Khmer Rouge, Cambodia has been left with a vacuum of skilled health care providers who are capable of addressing these challenges.

The prevalence of HIV/AIDS in Cambodia is one of Asia's highest. Recent efforts to expand HIV/AIDS programs have been boosted by Cambodia's inclusion in President Bush's Emergency Plan for AIDS Relief. In 2007, US$19 million helped with HIV/AIDS treatment, prevention, and care services.2 Efforts are ongoing to reach the most affected subgroups, such as injection drug users and commercial sex workers, and services are being expanded for prevention of mother-to-child transmission.

Legacies of the 1970s and 1980s civil war, an estimated 4 to 6 million landmines remain buried in the countryside.3 According to the United Nations (UN) Electronic Mine Information Network, a national survey in 2002 found that almost half of all Cambodian villages are affected by landmines.3 Poorer people seeking affordable land are driven to mine-contaminated areas that have not been reached by demining activities. One-third of the estimated 40,000 to 60,000 casualties are children. Decontamination activities by the Mines Advisory Group and numerous local and international agencies are ongoing, but covering the worst-affected areas alone could take years.4

Avian flu also threatens the overburdened health system. Seven fatal human cases of H5N1 avian influenza have been reported in Cambodia, the last case in April 2007.5 Economic constraints and an understaffed public health sector limit Cambodia's ability to cope with the avian influenza threat. Impoverished peoples rely heavily on their poultry stocks for survival. In partnership with the UN Food and Agriculture Organization, the Cambodian government has launched awareness and education campaigns in the most at-risk areas bordering Thailand and Vietnam.6

Finally, putting the past to rest is a painful and arduous task. The Cambodia Special Tribunal, backed by the UN with Cambodian and international judges, is in session to try leaders of the Khmer Rouge for war crimes. The tribunal may last 3 years or more.1 At the same time, Cambodia is looking forward, tackling economic growth, health sector development, and corruption control. Continued international support is necessary for a successful and stable recovery.

SEXUAL VIOLENCE IN THE DEMOCRATIC REPUBLIC OF CONGO

Sexual violence and fighting between rebel, militia, and government forces continue in North Kivu province, despite a peace agreement signed in January 2008 among key actors in the 5-year conflict.7 A report by the Congo Advocacy Coalition cited 2000 cases of rape in June in North Kivu province alone. International media attention during the past few months has highlighted rape and sexual violence as weapons of war, but attacks have not ebbed. Despite increased international and local resources devoted to identifying and helping victims of sexual violence, the number of women affected will grow unless the violence stops. UN estimates place the number of women raped in the Democratic Republic of Congo during the years of the conflict at more than 40,000.8

The rapes are particularly brutal. Women are beaten and sometimes shot by gangs of rebels and militants. Fistulas between the urinary, intestinal, and genital tracts are common and sometimes life-threatening. Sexually transmitted diseases, chief among them HIV/AIDS, are also a threat. Often, survivors of sexual violence are ostracized by their families and communities and forced to flee, perpetuating the psychosocial trauma of the attacks themselves. Families are fragmented when women are driven from their homes. Identification of victims is complicated by far-reaching stigma, and current statistics of the number of women affected may be gross underestimates.

Relief activities include education and training of local counselors by organizations such as the International Committee of the Red Cross in coordination with local relief agencies, and free medical care for rape victims at Panzi Hospital in Bukavu, North Kivu province.9, 10 A UN human rights team in the region in July 2008 investigated mass rapes and violence.11 Even so, Oxfam America, working in North Kivu, voiced concerns that sexual violence “has begun to corrode the core of traditional communities,” with few consequences for perpetrators and a long road to justice for victims.12

UN and donor agencies are funneling resources into North Kivu for relief and rehabilitation for victims of sexual violence, who are a fraction of those affected by chronic violence in the region.13 Prospects for the conflict's resolution are not optimistic, despite the presence of UN peacekeepers and internationally mediated talks between the key actors.

VIOLENCE IN SOUTH AFRICA

In late spring 2008, there was increasing violence against foreigners in South Africa, who are blamed for the nation's economic woes. These attacks occurred against the backdrop of a recovery from apartheid that is only 14 years old. Recent violence has driven some people back to the countries from which they fled, fearing for their lives.14 In an ironic turn, asylum seekers fleeing violence and persecution in Zimbabwe returned home rather than risk attack in South Africa. On May 22, 2008, President Thabo Mbeki called up the armed forces to intervene, 10 days after the violence began.15 Although the army and police were able to quell the attacks, questions about their origins linger. Thousands of displaced people have sought refuge outside police stations, and crowded buses and trains leave South Africa bound for their countries of origin.

More than 50 people have been killed, and at least 30,000 have fled their homes and are living in informal camps.16 The true number of displaced immigrants may be as high as 100,000.17 Registration backlogs for asylum seekers and immigrants mean that many people lack papers or carry expired temporary permits.18 Although neither the government nor international agencies have exact figures, several million migrants and asylum seekers from neighboring nations may live in South Africa. During the past 2 decades, Zimbabweans, Malawians, and Mozambicans have fled from their nation's political violence and economic collapse to South Africa.

Poverty is on the rise, amid increasing unemployment, fuel and food prices, and crime. Although violence against immigrants is not novel—Somalis in Cape Town were victimized in the past—the scale of these new attacks is unprecedented. The Mozambique government has arranged transport for limited numbers of migrants seeking to return home, but the remainder live in crowded makeshift camps.14 Reuters reported that aid agencies such as Doctors Without Borders are noting communicable diseases such as diarrhea and respiratory infections in the camps.17

Even though the violence ended in late May, South Africans and immigrants still face displacement, poverty, hunger, and disease. With the 2010 World Cup on the horizon for South Africa, the government's response to the violence is under scrutiny at home and in far corners of the world.

HUNGER IN NORTH KOREA

Up to 6 million people in North Korea are in need of food aid, as the nation faces the threat of famine, arising from combined economic and political stresses.19 The present crisis in North Korea stems from lost harvests, floods in late 2007, and rising global food prices, as well as from changes in outside aid delivery. North Korea is heavily dependent on South Korea and China for food assistance. Recently, however, less aid has arrived from South Korea because the government in Seoul has made policy changes linking food aid to North Korea's abiding by the guidelines of an international nuclear deal.20 Compounding this change, the prices of staple foods such as rice and corn have risen precipitously this year, leaving many hungry.

Humanitarian agencies active in food relief in North Korea have highlighted the urgent need for aid. “The food needs in North Korea right now are extreme and threaten to get worse without immediate attention,” according to George Ward, senior vice president for international programs for World Vision USA.21

To better understand the depth and breadth of the food crisis in North Korea, the UN World Food Programme (WFP) and the Food and Agriculture Organization conducted a Rapid Food Security Assessment in June 2008. They found that three-quarters of families have reduced food intake, that child malnutrition and diarrheal disease rates have risen, and that consumption of nutrient-poor wild foods to supplement poor food availability has increased.22 Jean-Pierre de Margerie, WFP country director for North Korea, has said that the severe hunger the WFP was seeing had been noted in the late 1990s, during a widespread famine.22 Of the population of North Korea, 3% to 5% died during those famine years, although exact numbers are unavailable.23 The hardest hit region then, as now, was the remote northeast.

The WFP seeks donations to ebb the crisis, and has stepped up food deliveries, thanks in part to a US donation of 400,000 metric tons of food aid. An estimated US$500 million is needed for expanded food relief during the next year.24

The humanitarian community hopes the government's pledge to relax restrictions on movements of aid workers will ensure that aid reaches hungry people. Improved monitoring of food distribution is expected subsequent to recent negotiations granting increased access for WFP workers.25

EVENTS IN INDIA

In the far north of India, pilgrims to a temple near Shimla fled as stones along a retaining wall over the temple path fell, causing a human stampede. As people rushed away, 140 were killed, with more than 40 children among the dead. Local hospitals were deluged with victims, and investigations into the cause of the stampede are ongoing. Mass pilgrimages are high risk sites for stampedes, but this incident at Nainadevi temple was the worst seen in recent years.26

Elsewhere, 3 million people were displaced and are vulnerable to hunger and disease outbreaks as a result of the Koshi river dam collapse. The river carved a new path from Nepal to India, flooding fields almost ready for harvest and countless homes. The Indian Air Force has air-dropped food and medicines. Rescue efforts are under way, although some people are staying near their flooded homes, in fear of looting. Aid agencies in the region report that makeshift receiving shelters are poorly supplied and pose risk of disease outbreaks from lack of water and sanitation.27

CARIBBEAN STORMS

Three storms whirled through Haiti in 3 weeks, leaving more than 500 dead in their paths. Hurricane Gustav, Tropical Storm Hanna, and Hurricane Ike caused flooding and widespread damage to homes and crops. Earlier this summer, food shortages caused rioting in the capital of Port-Au-Prince. Now, food stores spoiled or lost in the storms, combined with cash crop damage, threaten to deepen the humanitarian crisis in Haiti, despite the presence and activity of numerous aid agencies.28 Hurricane Ike swept over the eastern half of Cuba before passing briefly out to sea and back to western Cuba, destroying 140,000 buildings.29 Thanks to the successful evacuation of 20% of the population, about 2 million people, the death toll was minimal. In comparison to Haiti, where hundreds died in the 3 storms, Cuba was left with massive structural damage but few deaths.

Author's Disclosures The author reports no conflicts of interest.