Discussion

It may not be surprising that epidemics with mortality occur more frequently during large-scale complex emergencies. A historical analysis demonstrated a very significant dose-response relationship between the incidence of leishmaniasis and levels of conflict and political terror. Further analysis indicates that this association is through a process of population displacement and health system deterioration. Important factors are population movement of non-immune persons to endemic areas, or infected people moving to non-endemic areas where vector is present. Moreover, population displacement is generally associated with crowding, poor housing and sanitation, immune-compromised health status, and increased human-vector interactions. Several case presentations from different conflict contexts (South Sudan, Somalia, Iraq, Syria, Afghanistan, Pakistan, Colombia) are demonstrating the impact of conflict on the incidence of visceral and cutaneous leishmaniasis, and the emergence of leishmaniasis in new areas. The specific mechanisms leading to disruption of health services, increased disease transmission, and disruption of control activities are explained.