When Mount Nyiragongo erupted in the Democratic Republic of Congo last month it was merely nature's contribution to a public health disaster that has been continuing throughout four years of bloody civil war.
Indeed, aid agencies are already concerned that, with pictures of the lava devastated town of Gomo no longer featuring in daily news bulletins, the world will once again turn a blind eye towards a catastrophe described by the World Health Organization as “one of the greatest humanitarian disasters of all time.”
It is estimated that over 200000 civilians have been killed directly by violence in the republic over the past three years. But this figure pales almost into insignificance when set against the number of deaths caused over the same period by simple, curable diseases.
The WHO estimates that 2.5 million excess deaths occurred in the country between 1998 and 2001. The World Health Report 2000 ranked the expectation of a life in full health in the Congo at 179 out of 191 countries studied. Infant mortality has been reported as high as 370 per 1000, and a maternal mortality of 3000 per 100 000 has been reported in the eastern part of the country.
In 2001 the World Food Programme expressed surprise on finding that in one province malnutrition seemed to be more prevalent among adults than children. They concluded that most of the malnourished children had already died.
Almost all these excess deaths can be attributed to the disruption of health services caused by civil unrest and war.
The recent violence began shortly after the 1997 uprising by Tutsi and other anti-government forces, which, backed by Rwanda, overthrew President Mobutu and renamed Zaire the Democratic Republic of Congo.
Over the next four years a complex civil war, involving soldiers from Rwanda, Uganda, Burundi, Angola, Namibia, and Zimbabwe, split the country into at least three rival territories.
Despite several UN mediated ceasefires the war rages on. Last year the UN claimed that many of the warring parties were deliberately prolonging the conflict in order to plunder the country's plentiful natural resources.
The effect on the civilian population has been devastating. Of the total population of 52 million, at least two million have been displaced within the country, while over 300000 are refugees in other countries.
Health services have all but collapsed, routine vaccination programmes have been discontinued, and the one public health programme to survive—the UN's polio eradication programme—recently came under fire from the International Rescue Committee for consuming too much of the Ministry of Health's time and resources.
However, one ray of hope has recently emerged. In September last year health officials from four rebel controlled areas met with officials from the Kinshasa government's Ministry of Defence, the WHO, Unicef, and a number of non-governmental organisations operating in the republic.
Over the next four days the group developed a package of public health measures designed to operate in war conditions. Although the plan at this stage is little more than a list of minimum services, it does indicate that public health can remain a priority even in a time of war.