Humanitarian crises carry massive human costs. Media exposure may lead to increased advocacy and awareness and strengthen the response of the international community. However, when this does not occur, indifference or neglect may result. Our perceptions of and reactions to large scale human suffering are complex and biased. A deeper analysis of them may allow us to correct flaws in political processes, achieve greater compassion and equity in our global relationships, and ultimately improve the health and wellbeing of those affected by natural disasters and civil strife.

Most of us have sat in our living rooms and watched dramatic television images of large scale human suffering. The emotional response they generate fulfils an important role. It raises collective awareness of the situation and the demand for a tangible political and logistical response from governments and aid agencies.^1,2 However, as this process occurs we unconsciously become part of a wider set of injustices. Across the globe many other crises are occurring, of similar or greater magnitude, but they go largely ignored simply because they do not make it to our television screens. We must understand that our moral response to humanitarian crises is determined as much by the volume of media attention, which is closely related to our own self-interest, as it is by human need.

The recent war in Iraq provides a sobering example. Regardless of your views on war as a political remedy, the human costs were always going to be high. Indeed, the military and aid agencies were primed for a rapid and comprehensive humanitarian response before the first shot was fired.^3,4 Scenes of chaos and desperation at food distributions became commonplace. Stories unfolded about underresourced hospitals, sewage plants disabled by power cuts leading to polluted rivers that were supposed to be water supplies, and looting and lawlessness that followed the conflict. Modern warfare disrupts social infrastructure and costs civilians dearly.

The dramatic footage that humanitarian crises attract is a two-edged sword. Reliance on stereotypes denies us deeper analysis of the social and political complexities of a situation, which are crucial in determining an appropriate response.⁵ Overemphasis of the “crisis phase” neglects the longer term developmental needs of nations.⁶ Shocking scenes may be numbing, leading to “compassion fatigue”. A fatalistic view of events may leave us helpless and disempowered. However, media coverage does at least trigger public debate and is closely correlated with political intervention and assistance. When this is coordinated, culturally sensitive, and founded on evidence based principles, much human suffering can be alleviated.^7,8

History has however taught us that the greatest tragedies may be those we never hear about. In the case of Kosovo, western military intervention was followed by massive expenditure on humanitarian aid. This achieved impressive results: refugee camps were designed and erected by the US military in advance of the exodus, no infectious disease outbreaks were recorded, and the crude mortality rate, a classic indicator of severity, scarcely rose above that of the baseline population.^9,10

It is a shame that such a public health feat could not have occurred simultaneously in Angola, where a polio outbreak, malnutrition rates exceeding 50% in one area, and a daily crude mortality rate well above crisis thresholds^11,12 prompted Médecins sans Frontières to accuse the international community of “near total neglect”.¹³

Such selective attention demonstrates that our decisions are based not purely on the extent of human need but rather on a combination of factors. These include our pre-existing level of awareness and understanding of a particular situation, the degree to which issues of national security or economic interest are at stake, how closely we empathise with affected populations culturally, and the extent to which media imagery and analysis influence our views and spark our conscience.

Confronted with this reality, health professionals may respond in one of two ways: apathy or advocacy. We can despair at the increasing capacity of the media to frame public perceptions and resent the shortcomings of dominant political paradigms; or we can engage more intensively with these sectors to achieve deeper understanding and address inequities in a more balanced fashion.

Recent thinking in the field of public health draws us towards the latter. The definition of health is broadening: no longer just the “absence of disease or infirmity”,¹⁴ health is now considered a “resource for life”.¹⁵ Medical professionals have an increasing mandate to identify and remedy the social and political determinants of health. The emerging role of partnerships and multidisciplinary decision making confirms the value of “cross-pollination” between fields of expertise.¹⁶ As custodians of knowledge and expertise vital to the human condition, we must become more active participants in political processes and improve our coordination with the media.

The criteria for international humanitarian intervention are due for a paradigm shift. The first step in this process is more deeply to understand the factors at work in the global emergency health response. This implies acknowledging its inherent biases and injustices, including media-driven morality and a political process that hampers our ability to identify and prioritise basic human needs. Secondly, what constitutes an appropriate response must be determined; this is a complex question that is being earnestly addressed in international public health circles. Finally, medical professionals must become engaged with the cross-sectoral task of changing practices, not frustrated observers of a flawed process.

So next time you view, at the end of a busy day, television scenes of large scale human suffering, stop and reflect. Allow yourself to be moved, because these are real human lives, but search for the political and social antecedents that transcend the stereotypes. Also search for the injustices that have not made it to your sitting room; they may be even more grave. Raising collective awareness is the first step in achieving a more just world.