Long after fighting has ended the consequences of conflict lingers on. War and violence impact negatively on public health for years after most of the humanitarians packed up and left, show commonly used health indicators such as child mortality.

– There is a critical lack of data. Public health seems to be seriously and negatively affected at least 10 years after fighting has stopped. As many war-torn societies relapse into conflict every 10 years, this lingering impact on health in a post-conflict society is seldom documented – nobody is financing that kind of documentation. Physical and psychological traumas, disability and loss of years of schooling are some of the indirect consequences that have never been accounted for. It seems nobody wants to know, says Professor Morten Sodemann from the University of Southern Denmark.

Sarah Cliffe – one of the main authors of the 2011 World Development Report on Conflict, Security and Development confirms that this seems to be the case. She has worked for 20 years in countries emerging from war. And sees the shortcomings of the interventions from the International Community.

– We’re rather good at delivering health services quickly in areas such as child vaccination and managing hospitals – relatively simple non-political areas. But – improving health outcomes is dependent both on institutional stress and on other factors such as people’s level of income and their access to water. So if we look at the struggle to improve infant and maternal mortality it’s how to build capacity in all of those areas in countries that have lacked it during decades of conflict, says Sarah Cliffe.

Data deficiency

Data on death and disability are scarce – during the war as well as after. Lack of research makes it extremely difficult to assess the situation and to make comparisons to the time before the violence. Many of the figures reported are at best – not very precise. And thus the effort by the International Community to alleviate the suffering and to support the lives of the population can’t always be the best possible – neither during the war or after.

The numbers of civilian deaths as a direct and indirect result of war in the Democratic Republic of Congo (DRC) are truly staggering – we just don’t know many. The 2009/2010 issue of the Human Security Report seriously challenges the conventional wisdom, i.e. the estimate from 2008 by the International Rescue Committee that 5.4 million people have died as a consequence of the fighting in DRC.

Estimates differ by millions depending on how the calculation is done. But the figure of 5.4 million is grossly overestimated according to the report. It stems from five retrospective mortality surveys – from some of the worst affected areas and then extrapolated to the whole area. But that kind of war only affects small parts of a country. Furthermore in DRC you don’t have reliable data of the health situation before the war, which of course makes it difficult to calculate the excess war death tolls. The report points out that the starting point, the baseline, was set too low – which of course results in more people considered dead because of the violence.

On the other hand, child mortality has been falling all over the world for decades – during most wars as well. If you measure child mortality in a prolonged war as the one in DRC against a fixed starting level – your estimate of how many civilians have died because of the war will be too low. In DRC the report concludes the figure might be as low as 860.000 or as high as almost 3 million. We don’t know.

Getting it right

Counting the dead is a highly politicized issue in each and every conflict – combatants try to market each their version of the casualties, everyone with a stake in the outcome of the conflict try to convince international decision makers that the picture they paint is right, humanitarian organizations make assessments to attract funding and the media choose the best, often the most dramatic story. The international fights over the number of casualties in Iraq, in Darfur, in Afghanistan, in Libya, in Syria are clear examples of that. So getting it right during the war is extremely difficult – but immediately after the war it’s almost impossible to have exact data on the public health.

Donors are reluctant to invest heavily in expensive health systems in countries coming out of war and do not prioritize data collection and research. As soon as the focus shifts to other hotspots, so does the money and nobody has an interest in highlighting the post-conflict consequences – not even when they are gruesome. Clear examples of that are – Iraq, Darfur, Afghanistan, Libya and even Syria. All of those are still experiencing a high level of violence and little interest from the various actors in documenting how bad the situation is.

The information is important – not only data on mortality and morbidity but also the underlying reasons. The diagnose has to be right to prescribe the right cure no matter whether the patient is a person, a community, a health system or a war-torn country.

Many contemporary armed conflicts take place in areas in which you don’t even know the most basic data on public health before violence break out. During the war efforts to reduce civilian mortality and morbidity is a major component of the relief effort – disease control, nutrition, emergency medical or surgical interventions, reproductive health and maternal care, sanitation services etc. Most of the information will typically be collected by humanitarian agencies. They are also the ones in charge of assessing the situation and deciding what to do. But the effort may be hampered by lack of knowledge of the local situation among the agencies trying to help. And when the fighting stops funds tend to dry out.

– After the elections in 2013 donors seem to have ticked off Mali as a success story and have moved on, says UN deputy representative to Mali, David Gressly. As of May the UN appeal for 2014 has failed to attract any pledges for health, sanitation or water. Even if it’s considered extremely important to help the newly installed government deliver services to the northern, rebellious part of the country. Previous peace agreements have failed – in part because the northern population has been marginalized by the national political system in the south.

The long road

On average it takes 40 years for a poor fragile state to advance to a level of a middle income country – to grow from a level of Somalia or South Sudan to Ghana, according to Sarah Cliffe. Some countries make an easier and faster transition, some a much slower. But the populations of states experiencing severe instability or of states unable to meet the basic functions of governance as well as of those embroiled in conflict make up one-sixth of the world’s population and suffer from far poorer health than the populations in other states at comparable stages of development – according to the US Institute of Peace.

Again – donors are reluctant to engage in long term investments like thorough research and health systems in fragile and post-conflict states. They often point to the risk of losing the investment due to renewed conflict or corruption. Thus the people most in need may be cut off from most aid except from stabilizing military interventions and emergency aid like food.

Post-conflict states are typically to be counted among the most fragile. The population faces problems caused by the conflict as well as all the challenges of being a poor citizen in a poor country.

People may be traumatized by the violence and they atrocities they have experienced – they may have seen close relatives die or have been hurt or abused themselves. And they may be living in areas that remain unstable.

Memories and bad experiences are not left behind when people take refuge far away from home. The psychological impact of war is immense – most common are symptoms of PTSD, depression and anxiety  – such as anger, despair, isolation, distrust and paranoia. Research at the Danish Migrant Health Clinic shows that new and lesser traumas can activate PTSD and result in physical reactions and crippling loss of language, cognitive and working skills – many years after the first traumatic experience.

People may be or have been displaced. They may have been maimed, disabled, raped, enslaved, kidnapped, trafficked or forced to fight. They may have lost their livelihood, the ability to sustain themselves, to work. They may have lost access to essential medicines or to all kinds of health services. They face risk from infectious disease and malnutrition as well as ongoing violence.

Health services may have been disrupted, hospital buildings ruined and stripped off anything of value – like the hospital in Monrovia during the Liberian civil war. Not a window frame or a single wire was left. Health workers may have fled the area or they may have found more lucrative employment with the international community. A surgeon in Jalalabad in Afghanistan earns at least 10 times his usual wage by working as a driver. Or the health workers may not have the skills needed for coping with the post-conflict situation.

The government may have more pressing items than health on its agenda, the state of the economy is likely to be unstable. Investments in health systems do not come cheap and will often depend heavily on donor funding. The post-conflict countries may see an influx of donors immediately after the fighting stops and may take advantage of the financial injections. But – as American Public Health Association points out – donors come with their own agendas and priorities and they may not be in line with the recipient government’s. Weak new or interim authorities may find it difficult to control the direction of donor financing. And donor funding cannot be relied upon.

The well documented case of Guinea-Bissau

It has been reported many places that the civilian population typically bear the brunt of war, suffering from direct and indirect effects of the fighting.  Again estimates vary wildly even if health analysts and practitioners has grown much better at describing how mortality and morbidity differ across population groups and areas and over time.

– The poorer and the more fragile a region, the less we know, says Professor Ib Bygbjerg from Copenhagen University. He points out that even in regions considered well documented it may not be possible to know the exact cause of death.

One such place is Guinea-Bissau. When war broke out in 1998, the Guinean-Danish Bandim Health project had been closely surveying the health in part of the capital for 20 years and kept on doing it throughout the war and after. According to the health project some interventions worked very well. Actually the researchers observed a decline in case fatality among hospitalized children which most likely stems from a better availability of drugs funded by humanitarian aid and was made possible because the staff stayed at the hospital.  The special vitamin A supplement and the nutrition program had possive effects.  But where food aid was delivered it did not show in health indicators.

A great number of people were displaced and typically hosted and helped by family and friends – according to the evaluation done by Danish researcher Hjalte Tin. Health indicators showed that the host families often were in worse condition than the displaced – especially in the very poor areas. Most of the planned WFP food aid was never delivered. The part that was distributed was only targeted at displaced persons and not at the most vulnerable persons.  By and large people managed by themselves – by sharing and helping each other and thus avoided the usual negative effects by massive food aid – disruptions of local markets and especially undermining local coping ability.

–  In Guinea-Bissau the infusion of certain types of humanitarian aid in the health sector proved very successful. Paying the staff to stay at the hospital and supplying medicines actually resulted in a lower mortality rate during the fighting than before the war broke out. At the same time directing food aid to the IDP’s only showed how far out of touch with local realities the WFP rules were. The families receiving food aid had a lower mortality than the people not eligible for aid, says Professor Morten Sodemann from the University of Southern Denmark.

Health as a peace builder

In Northern Uganda the conflict was long and rural people were forced into living an urbanized life in IDP camps, where many has grown dependent on aid supplies of food e.g. Now they are being resettled in rural areas with poor services. The Gulu University has since 2008 developed a health surveillance system. Preliminary findings suggest issues regarding nutrition, security, gender, generation and land disputes, high levels of human insecurity and post-traumatic stress. The University of Southern Denmark among others has now joined Gulu University to conduct a study of the long and short term effects of more or less controlled displacement in a population now struggling to establish homes and manage on their own after years of war, camp life and WFP food deliveries.

– In general the most important priority for the international support in a post-conflict area is to try to help build confidence between states in their political transitions and their citizens. As part of that helping states gather data for a longer term development plan can be important. But the most important priority generally is to deliver something practical quickly and in the short term, says Sarah Cliffe.

In Northern Uganda most households don’t have the education level or jobs to pull themselves out of poverty or reduce their food insecurity. That’s one of the key messages in the latest Briefing Paper from The Secure Livelihoods Research Consortium – lead by the Feinstein International Center, Tufts University. Furthermore – households that experienced serious crimes during the war are significantly worse off today than other war affected households. Social protection services are rare and are not targeted to those who need it most. Services often go to the better off households

As for basic health services, access to necessary health treatments remain extremely weak. People who have suffered serious crimes during the war have significantly greater difficulties in accessing health services.

Bearing Sarah Cliffes emphasis of confidence building in mind, it’s important to note, that households that were less satisfied with their access to and quality of healthcare, education and water had more negative views of government.

A government that cannot or will not deliver the most basic services to the majority of its citizens – securing their chances of survival – often find it difficult to earn legitimacy. Afghanistan is one blatant example of that. The health care system has become totally dependent on foreign funding and the health care delivery contracted out to NGO’s. The people in the provinces don’t see their government caring about them. Such a country might be more at risk of collapsing back into conflict – which happens to 40 percent of post-conflict states. Governments want a thriving economy, they want security and they want to stay in power, while people want health care, roads, water, schools – and of course – security.

In sum, health programs may be important in the post-conflict setting not because they lower the burden of disease, but because they lower the level of tension within a society and reduce the high-risk conflict recidivism – wrote Professor Paul Collier from Oxford University in 2004.

Internationally there is a growing interest in the role of health systems as social institutions and a growing focus on addressing pre-conflict inequities. But as this article clearly shows – most of the literature relates to the role of donors, the research is primarily done by institutions based in donor countries, the work is financed by the donors. And in this world of limited resources the donors have already turned to the next emergency.

By Kirsten Larsen, Journalist

FURTHER READING:

• Francesco Checchi and Les Roberts: Documenting Mortality in Crises: What Keeps Us from Doing Better? July 2008, available at www.plosmedicine.org
• Livelihoods Research Programme Consortium: Livelihoods, Basic Services, and Social Protection by Feinstein International Center available at fic.tufts.edu
• Paul Collier: Development and Conflict, October 2004, available at www.un.org
• Health Programming in Post-Conflict Fragile States: Review by USAID, prepared by Ron Waldman on behalf of BASICS, June 2006.
• World Bank: World development report 2011 : conflict, security, and development, available at worldbank.org