This analysis summarizes and reflects on the following research: Goli, S., Mavisakalyan, A., Rammohan, A., & Vu, L. (2022). Exposure to conflict and child health outcomes: Evidence from a large multi-country study. Conflict and Health, 16(1), 1-17.
- Across 52 developing countries, children exposed to armed conflict score significantly lower on key measures of childhood health (weight-for-age, height-for-age, and immunization status) than children who are not exposed to armed conflict.
- More severe armed conflicts result in lower childhood health measures.
- The authors call for the “strengthen[ing] [of] health systems in conflict exposed areas.”
Key Insight for Informing Practice
- Policy interventions for improving healthcare for civilians in war can take place at the local/national and international level—but the most critical intervention is to end and prevent war.
To what extent does living in armed conflict affect the health of children? Srinivas Goli, Astghik Mavisakalyan, Anu Rammohan, and Loan Vu quantify the decline in specific measures of children’s health caused by living in conflict-affected areas. It is already well documented that children living in war zones have adverse health outcomes due to a variety of reasons––disruptions in the supply of food or medicine; lack of access to health care, vaccines, or proper sanitation; outbreak of infectious diseases; or adversities faced by their caregivers like loss of income, mental health crises, injury, or even death. This research makes a unique contribution by “focusing on different types of conflicts, and several child health measures across a large group of countries,” using individual-level data rather than country-level data. This enables the authors to compare “children living in the same region of a same country” with different exposure to armed conflict over time, revealing more nuanced statistical results on war’s effect on children’s health.
The authors use data on “590,488 pre-school age children (i.e. in utero to age 5) across 52 countries over the period of 1997 to 2018,” from health surveys and geo-referenced conflict data from the Uppsala Conflict Data Program, to derive exact measures in the declines of key health indicators for children living in conflict areas. Specifically, they select the indicators of children’s weight-for-age (WAZ) and height-for-age (HAZ), which indirectly measure access to adequate nutrition and sanitation: “underweight (WAZ) is determined by short-term energy balance and is therefore an indicator of acute undernutrition, while stunting (HAZ) is determined by an inadequate energy balance over time and indicates chronic malnourishment.” Additionally, they include measures on the rate of childhood immunizations—a critical dimension of healthcare for children that typically suffers under conflict conditions. They also control for various socio-economic and demographic characteristics that may also influence HAZ, WAZ, and immunization rates.
Overall, the authors find significant declines in HAZ, WAZ, and immunization rates among children exposed to armed conflict. The average HAZ and WAZ of children exposed to armed conflict are both lower than those of children not exposed to armed conflict, while full immunization rates are five percentage points lower among children exposed to armed conflict. The negative effect on HAZ is particularly concerning—the probability of a child exposed to armed conflict being stunted ranges from one to three percentage points below the HAZ score of children not exposed to armed conflict. When considering type of conflict and conflict severity, the authors find strong, negative relationships across all measures. Children exposed to at least one act of violence at the province level have lower than average HAZ and WAZ scores. WAZ scores decline across all types of armed conflict, but state-based conflict (meaning, armed conflict including at least one government entity) results in a sharper decline. As for immunization rates, children “exposed to at least one conflict event are 1.3 percentage points less likely to be fully immunized” compared to children without conflict exposure. The severity of a conflict influences whether children receive all recommended vaccinations—the more severe the conflict, the greater the “decrease in the probability of a child being fully immunized.”
The decline in health among children exposed to armed conflict, and in particular the high rate of stunting, are causes for alarm for the authors. They conclude by calling for the “strengthen[ing] [of] health systems in conflict exposed areas.” Understanding that “the destruction of health systems, infrastructure, and disruption to services” during armed conflict contribute to poor health outcomes, the authors call for policy interventions that “ensure that even during conflict periods, some maternal and child health services [are] maintained.”
The decline in multiple measures of childhood health is among the many realities that demonstrate the insanity of war. Here, the authors call for policy interventions aimed at maintaining maternal and child health services during armed conflict. Considering practicalities on the ground, how could peace and medical practitioners/policy makers strengthen health systems in times of war?
Policy interventions can take place at two systems levels—the local/national level or the international level—and include activities like direct humanitarian assistance, monitoring and reporting, advocacy, and strengthening international legal frameworks. At the local/national level, interventions can be targeted at “scaling up” local health care. For example, in Bangladesh, a UN-funded midwifery program sought “to grow a workforce of well-trained and well-supported midwives” to provide maternal healthcare to Rohingya refugees when access to other medical personnel or facilities was limited. In addition, global non-governmental organizations, like Doctors Without Borders or the International Committee of the Red Cross, provide direct medical assistance to areas affected by violent conflict.
At the international level, international institutions and global civil society organizations monitor, report on, and advocate for healthcare and medical personnel in conflict. International legal frameworks—like the Geneva Conventions—prohibit attacks on medical personnel and facilities, meaning that international human rights courts and war crime tribunals could pursue legal action against perpetrators of violence. In 2016, the UN Security Council passed Resolution 2286 to address “attacks on health services in armed conflict” and called on UN member states to prevent attacks and hold perpetrators accountable. The World Health Organization also maintains a surveillance system for attacks on health care dashboard.
The devastating reality is that healthcare workers and facilities are nonetheless still often the targets of violence in war. For example, Physicians for Human Rights—a global non-governmental organization—has documented at least 601 attacks on medical facilities during the Syrian civil war alone. Doctors and other medical practitioners from conflict-affected areas report being subject to violent attacks, arbitrary arrest, and torture. As of today, targeted attacks against medical facilities and personnel continue, as seen in the wars in Ukraine and Yemen.
When facilities are bombed or medical personnel are subject to attacks, the impact felt on civilian populations is compounded: injured, sick, or pregnant people are cut off from immediate, life-saving care. None of the policy interventions reviewed here are a replacement for the destruction of a regional hospital or the imprisonment of trusted, local medical experts. Without question, the most critical policy intervention to improve access to healthcare is ending and preventing war. Policy interventions aimed at improving healthcare in conflict areas should therefore be tied to calls for immediate ceasefires and negotiated settlements, along with a broader range of peacebuilding activities.
- How can peace and medical practitioners/policy makers strengthen health systems in times of war?
Sussman, A. L. (2022, October 12). Ending violence against health care in conflict. Hopkins Bloomberg. Retrieved January 18, 2023, from https://magazine.jhsph.edu/2022/ending-violence-against-health-care-conflict
Rubenstein, L. (2021). Perilous medicine: The struggle to protect health care from the violence of war. Columbia University Press.
Peace Science Digest. (2019, May). When countries increase their military budgets, they decrease public health spending. Retrieved January 18, 2023, from https://warpreventioninitiative.org/peace-science-digest/when-countries-increase-their-military-budgets-they-decrease-public-health-spending/
PRIO. (2018). How does organized violence affect the chances of giving birth at a health facility? Local evidence from sub-Saharan Africa. Retrieved January 18, 2023, from https://legacy.prio.org/utility/DownloadFile.ashx?id=1626&type=publicationfile
Cohen, Y. (2018, August 27). Too little too late: Violence disrupts maternal health care in conflict settings. New Security Beat. Retrieved January 18, 2023, from https://www.newsecuritybeat.org/2018/08/late-violence-disrupts-maternal-health-care-conflict-settings/
Doctors Without Borders: https://www.doctorswithoutborders.org
International Committee of the Red Cross: https://www.icrc.org
Physicians for Human Rights: https://phr.org
World Health Organization: https://www.who.int
Keywords: managing conflicts without violence, war, healthcare, childhood health, armed conflict
Photo credit: World Bank Photo Collection