B Harrell-Bond

Cernea

Davis

Harrell-Bond

M Boelaert

Sapir

Van Damme

W Van Damme

W Van Lerberghe

English

Van Damme, W

Boelaert, M

Van Lerberghe, W

Harrell-Bond, B

MSF Field Research

THE LANCET
correctly cites as odds ratio of 1·15, but the confidence
intervals were wide enough to extend well below unity (95%
CI 0·69–1·93). Further, the point estimate from matched
analysis was 1·01/100 Bq m
3, not 1·02 (the CIs cited were
correct).
Anssi Auvinen
Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MA 20892,
USA
1 Auvinen A. Mäkeläinen I, Hakama M. Indoor radon and risk of lung
cancer: a nested case-control study in Finland. J Natl Cancer Inst 1996;
88: 966–72.
2 Rowe P. Finnish study shows low risk from home radon exposure.
Lancet 1996; 348: 257.
What should be done in acute emergencies?
SIR—Davis (Sept 28, p 868)
1 convincingly challenges the
assumption that children under age 5 years can be singled
out as the most vulnerable group during acute emergencies
and that, as a result, emergency public health interventions
can be reduced to a standard package of child survival
measures. We have witnessed in refugee camps how such
focused strategies channelled a disproportionate share of
scarce resources towards inefficient intensive feeding
programmes for under-5s, in situations in which drinking
water was lacking and diarrhoea rampant. In a highly absurd
instance a 5-year-old marasmic child, not belonging to the
target group of under-5s, was excluded from supplementary
feeding.
Age is often not the most important determinant of
vulnerability—social factors are. Members of disrupted
families (eg, female-headed households
2 and unaccompanied
minors) often suffer disproportionately, irrespective of age.
That these result often from an adult death, be it before,
during, or after flight, only adds to the arguments put
forward by Davis.
1 His focus is on emergency public health
measures when survival is at stake, because of extreme
crowding, lack of drinking water, basic shelter, and food.
However, if the response to an emergency is adequate, then
the situation can be brought under control within weeks,
rather than months; and mass population displacement does
not always result in a serious health crisis, especially when
severe overcrowding can be avoided.
3 Nevertheless,
displacement-inducing situations tend to be long. The three
case studies presented by Davis
1 are still unresolved more
than 2 years after their onset, and similar situations have
rarely found a solution in less than a decade.
3 Most of the
world’s refugees and displacees are thus not facing an acute
emergency. Most are living under conditions which could be
qualified as chronic instability, be it in refugee camps, or as
self-settled migrants. In these chronic situations, problems of
displacement through flight are similar to those faced by
those uprooted by development. The impoverishment can be
understood through eight crucial dimensions: landlessness;
joblessness; homelessness; marginalisation; increased
morbidity and mortality; food insecurity; loss of access to
common property assets; and social disarticulations.
4
The type of assistance needed is not always well-known,
but refugees usually have resilience and develop their own
coping strategies. When their strategies for survival require
mobility, external assistance—which demands they remain in
one place—often undermines their ability to cope. As a
consequence, many refugees and displacees choose not to be
assisted and flee the protection granted by the aid-umbrella.
5
In such situations targeting under-5s is probably even more
counterproductive than in the emergency phase.
Understanding people’s own coping mechanisms in
unstable situations, and developing appropriate measures to
Vol 348 • December 14, 1996 1663
support them, is as important as focusing on emergency
public health interventions. The task of preserving and
reconstructing livelihoods in complex and unstable situations
should be tackled as soon as the real emergency is over.
W Van Damme, M Boelaert, W Van Lerberghe, *B Harrell-Bond
*Department of Public Health, Institute of Tropical Medicine, Antwerp 2000,
Belgium; and Refugee Studies Programme, Oxford University, Oxford, UK
1 Davis AP. Targeting the vulnerable in emergency situations: who is
vulnerable? Lancet 1996; 348: 868–71.
2 Sapir DG. Natural and man-made disasters: the vulnerability of
women-headed households and children without families. World Health
Stat Q 1993; 46: 227–33.
3 Van Damme W. Do refugees belong in camps? Experiences from
Goma and Guinea. Lancet 1995; 346: 360–62.
4 Cernea MM. Understanding and preventing impoverishment from
displacement: reflections on the state of knowledge. J Refugee Studies
1995; 8: 245–64.
5 Harrell-Bond B. An alternative to refugee camps: pitch the tents.
Washington: The New Republic; September 1994: 15–19.
Smoke in the face, diet, and harm to the
heart
SIR—Hopkins’ Sept 7 news report
1 of coronary heart disease
incidence in non-smokers exposed to tobacco smoke from
their spouses is incomplete. The authors of the study
2 she
cites concluded that their results were consistent with earlier
reports that never-smokers currently exposed to
environmental tobacco smoke have about 20% higher
coronary heart disease mortality. However, the cited authors
noted: “Our data do not show consistent dose response
trends and are possibly subject to confounding by
unmeasured risk factors”. Hopkins does not mention these
last two important conclusions. The following is an example
of one confounding risk factor.
Numerous epidemiological studies since 1939 have
reported that smokers tend to have low plasma
concentrations of vitamin C and -carotene. Smokers also
tend to consume lower quantities of fruit and vegetables, and
they have higher intakes of saturated animal fat than non-
smokers; both these dietary patterns are risk factors for
coronary heart disease. The very small increased relative risks
reported by Steenland and colleagues
2 (1·22, 1·10) could
equally be due to smoke-exposed non-smokers sharing the
same higher risk diet as the smoking partner. This hypothesis
is supported by five studies which include significant dose
response trends reporting an inverse relation between spousal
smoke exposure and intake of -carotene or fruit and
vegetables.
3,4 In another study of 4018 spouse pairs, the -
carotene intake of the wives was significantly correlated with
that of the husbands (r=0·46, p0·0001).
5 Steenland and
colleagues reported
2 that there is no increased risk of
coronary heart disease with exposure to tobacco smoke in the
workplace and other settings; in such settings there would be
no confounding by a common diet. In general, the extent of
workplace exposure is likely to be greater than the extent of
spousal exposure.
K W E Denson
Thame Thrombosis and Haemostasis Research Foundation, Chinnor Road, Thame,
Oxfordshire OX9 3NY, UK
1 Hopkins KD. Smoke in the face is harmful to the heart. Lancet 1996;
348: 673.
2 Steenland K, Thun M, Lally C, Heath C Jr. Environmental tobacco
smoke and coronary heart disease in the American Cancer Society
CPS-II cohort. Circulation 1996; 94: 622–28.
3 Le Marchard L, Wilkens LR, Hankin JH, Haley NJ. Dietary patterns
of female non-smokers with and without exposure to environmental
tobacco smoke. Cancer Causes Control 1991; 3: 11–16.

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