Health and ConflictA review of the links

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Fafo-report 2009:20 ISBN 978-82-7422-678-4 ISSN 0801-6143 Order no. 20110 P.O.Box 2947 Tøyen

N-0608 Oslo

www.fafo.no/english/

Jon Pedersen Health and Conflict

Are more civilians than soldiers killed in war? Are women especially targeted? Will health effects of war linger on after the war has ended? Can health be used as a bridge to peace?

The report reviews the state of knowledge on these and many other issues related to the interrelations between health and conflict.

Health and Conflict

A review of the links

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Jon Pedersen

Health and Conflict

A review of the links

Fafo-report 2009:20

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ISBN 978-82-7422-678-4 ISSN 0801-6143

Cover photo: © Hartmut Schwarzbach / Argus / Samfoto Cover design: Fafo Information office

Printed in Norway by: Allkopi AS

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Introduction

The four horsemen of the Apocalypse – Pestilence, Famine, War and Death – working together for the demise of humanity illustrate the in many ways obvious connection between health and armed conflict. The purpose of this review of the field of conflict and health is to elucidate what research has shown about how the four horsemen work together: how pestilence, famine and death interact with war. Another focus is how working to stop one of the horsemen in his tracks can help hinder the others: can struggling against disease and famine build peace?

Obvious connections, yes, but ideally, a knowledge based policy framework within health and conflict would entail a solid foundation of how public health phenomena are associated with war and conflict; their prevalence and incidence; the ways in which positive or negative outcomes are produced; as well as the costs of alternative policies.

As this review will make clear, we are far from that state. In fact one of the most frequent phrases in this paper is some variant of “it is difficult to show”.

One of the methodological problems is that it in many situations are neither that easy, nor that fruitful, to distinguish between the pre-conflict, conflict, and post conflict phase. This is also a profound practical problem in peace and reconciliation work, as well as a tragedy for those that experience war. Granted, the level of violence is high during the actual conflict, but pre conflict levels of violence, destabilization of communities etc may also be very high, as may those of post conflict settings. Therefore, health effects of violence may not easily be traced to the conflict, because the lack of development and the overall levels of instability and insecurity in the “non conflict”

situations are more than enough to cause the health effects associated with conflict.

Moreover, interventions thought of as ‘conflict interventions’ may be just as relevant in post conflict situations.

It is prudent to admit at the outset that the review of the literature poses more ques- tions than it answers. Researchers and practitioners have spent large efforts on bringing topics on the agenda of security concerns: civilian deaths, gender based violence, HIV/

AIDS, the use of health as a bridge to peace to mention but a few. Agenda setting often involves pushing a case hard, bringing to bear arguments that are possibly true, but that have not really been researched thoroughly. It is fair to say that the literature now reflects a broad, perhaps even comprehensive, range of issues that have to be confronted and dealt with. Nevertheless, the absolute and relative importance of each issue remains elusive, and in many cases even causal links and mechanisms are far from clear.

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The review starts out by considering what one may call the standard causal direction, namely how and how much conflict leads to deterioration of health. It then goes on to explore the relatively meager literature on the reverse causality, i.e. if and how health may lead to or reduce conflict. The paper then moves on to considering whether health can be used in deliberate efforts to create peace, and if so, if specific types of actions are particularly useful. An important aspect of using health as a bridge for peace is who should build the bridge. Thus, for example, should military actors contribute, or should it be a uniquely civilian project?

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The standard causal direction: conflict leads to deterioration of health

Deterioration of health, both because of direct causalities from conflict, and indirect effects through breakdown in service provision and health infrastructure is the most obvious link between conflict and health. Still, the precise character of the link is far from clear.

Mortality

Mortality from conflict is one of the most used indicators of conflict severity. It is the obvious health consequence of conflict, but far from the only one. Data on death from conflict have been used for several purposes in policy circles:

A measure of severity of human rights abuse;

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A tool for advocacy, either political or in order to raise funds

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A tool for guiding interventions

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Typical examples of using death counts as measure of the severity of human rights abuses are analysis of the number of deaths during the Khmer Rouge regime in Cambodia;

the deaths caused by the Balkan wars and the deaths in Darfur.

Examples of death counts as a tool for advocacy can be found in the papers published in the Lancet on mortality from the war in Iraq following the 2003 American led invasion (Burnham, Lafta, Doocy, & Roberts, 2006; Roberts, Lafta, Garfield, Khudhaini,

& Burnham, 2004) or mortality resulting from the war in the Democratic Republic of the Congo (Roberts L., 2000).

Using death counts as a tool for interventions is common in conjunction with humanitarian operations in complex emergencies and other crisis. Conventionally, a level of mortality corresponding to Crude Death Rate of 1 death per 10,000 population per day is seen as constituting a humanitarian crisis(Howe & Devereux, 2004;

SMART Initiative, 2008). Alternatively, calculating a number of ‘excess death’, i.e.

deaths that would not have happened in the absence of conflict, may be tried. That is the approach used in the calculation of number of deaths from the conflict of the

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Democratic Republic of the Congo, where the estimated death rate is in fact lower than the ‘crisis level’ just cited.

Death rates at a more detailed level may also be informative for specific types of interventions. Thus, high violence related death rates indicate the need for physical trauma related interventions, such as surgery, blood transfusion etc. In contrast, high child mortality rates without high violence related death rates would indicate interventions directed to children (Guha-Sapir & Degomme, 2005)

The rather extensive debate surrounding mortality estimates from the post-2003 invasion period in Iraq illuminates several problems surrounding the estimation of mortality in crisis situations. Data from different sources from Iraq diverge significantly (Burkle, et al., 2008). Similar observations can be made about mortality estimates from the Democratic Republic of the Congo, and Darfur.

The methodological issues surrounding mortality may be divided into the following concerns:

The reliability of news report based estimation. For example, Iraq Body Count

• provides daily figures for violence related mortality in Iraq based on compilation of news sources. The figures are substantially lower than some, but not all, survey based estimates.

Proper field work procedures. The charge has been made, especially regarding the

• fieldwork leading to the estimates of high mortality in Iraq, that adherence to field work procedures were less than perfect(Spagat, Forthcoming).

Sampling issues, in particular whether relatively small scale cluster surveys are

• adequate.

Technical estimation issues, in particular whether to use demographic correction

• techniques to correct for known biases in the data. For example, the WHO/Min- istry of Health survey of mortality in Iraq did correct, other surveys did not (Iraq Family Health Survey Study Group, 2008).

Underestimation of infant and child mortality because of use of methods not de-

• signed for estimation of infant and child mortality.

Choice of counter-factual. When estimating surplus or ‘excess’ deaths from wars,

• some stipulation of what the mortality would have been in the absence of war is needed(Murray, King, Lopez, Tomijima, & Krug, 2002). A particularly important example is the estimation of excess deaths from the wars in the Democratic Republic of the Congo, where the authors of the studies have assumed a relatively low death rate as a reference value.

Extrapolation and synthesis from sources with limited geographic coverage.

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Because of the technical difficulties surrounding mortality estimation many of ques-

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An important issue is the balance between military and civilian deaths and the development of the character of war. According to an oft cited statement:

“In World War I only 5 percent of all casualties were civilians; in World War II that number was 50 percent; and in the conflicts through the 1990s civilians constituted up to 90 percent or more of those killed” (Chesterman, 2002)

Nevertheless, civilian deaths from recent armed conflict, when plotted across time, show an extremely variable picture, with no obvious trend (Eck & Hultman, 2007), and when compared with battle deaths they do not appear to make up 90 percent of the total deaths. Some conflicts have very high proportion of civilian deaths, such as Rwanda, and some have comparatively low, such as the conflict between Eritrea and Ethiopia. Singling out World War I and World War II, and comparing with Rwanda, is actually singling out three very special cases (Newman, 2004). If one, for example, adds the Armenian genocide of 1915–1917 into the picture; or the German Herero war of 1904; the comparison would look quite different as both of these were conflicts were extermination of civilians was an aim. Thus, even though frequently cited in both the academic and policy debate (e.g. (United Nations, 1996; United Nations General Assembly, 2006)), the idea that current wars are particularly new or especially cruel

may simply be painting a too rosy picture of old wars.

As a corollary of the ‘new war’ argument often the addition is made that the deaths are predominantly women and children. The evidence for the gender distribution is not compelling. In a mathematical sense the statement about predominance of women and children is of course correct, women and children make up 60–80 percent of the population depending on its age distribution, and therefore if death rates were equal between men, women and children, men would account for fewer deaths. However, death rates are not equal, but not necessarily higher for women and children.

It seems relatively clear that in terms of direct deaths from war men are heavily overrepresented when considered globally (Murray, King, Lopez, Tomijima, & Krug, 2002). The Vietnam War mainly killed men aged 15–29 years on the Vietnamese side, especially during the years of most intense fighting. While the young men had ten times higher mortality rate than normal, women had 1.5 times the rate (Merli, 2000). In recent wars, such as that of Iraq, the pattern of much higher male mortality compared to that of women is also quite clear (Burnham, Lafta, Doocy, & Roberts, 2006; Iraq Family Health Survey Study Group, 2008; COSIT, 2007) .

One of the more irritating tendencies in the literature is to portray the results in a way that indicates that women and children are seen as the most affected, even when the data shows something else:

“Nearly half of those killed and the vast majority of those who had disappeared were women and children. Our survey results thus confirm reports that civilians

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were often direct victims of the war in Angola. “(Grein, Checchi, Escribà, Tamrat,

& Karunakara, 2003)

In reality a simple calculation based on the data published in the survey indicates that the risk that a man had to become a victim was 3 times as high as that of a woman or child. Moreover, since the study was one of camps for former UNITA fighters and their families, one may assume that the men in question could be termed combatants.

One relatively clear finding when one compares modern and pre modern armies, is that disease, a major killer of soldiers before, now has ceased to be very important. Thus, in the American Civil War about 660,000 soldiers died in total, of these two thirds died from infectious disease. This was actually an improvement compared to some previous wars: the Allies’ ratio of disease deaths to combat deaths in the Crimean war was 3 to 1; in the Mexican-American war 7 to 1 and for British forces in the Napoleonic wars 8 to 1 (Sartin, 1993). Similarly, about as many American soldiers died in the 1918 Flu pandemic as from combat during World War I. In contrast, and at the very other end of the scale, infectious disease was spectacularly absent among American soldiers during operation Desert Shield and Desert Storm (Hyams, Hanson, Wignall, Escamilla,

& Oldfield, 1995). Undoubtedly disease mortality for, say, both government soldiers and rebels during the civil in Sierra Leone was considerably higher than for American troops in Iraq, but today even the most destitute armed group probably has access to some effective health care.

The level of indirect mortality from wars, i.e. that caused by malnutrition and disease is difficult to have very firm views about, especially when considering adult mortality. First, it is difficult to estimate, and second as noted above, it is difficult to decide on the counter factual, i.e. what the mortality would have been in the absence of war. Careful study appears to indicate that the age and gender patterns are in fact quite complex (see e.g. (Curlin, Chen, & Hussain, 1976)). Studies of famine mortality, whether related to war or not, indicate that female mortality from famine often is somewhat lower than that of men, as illustrated by the Japanese Tenpō famine of 1830, or the various European famines during World War II (Jannetta, 1992).

Few studies exist of the mortality in the wake of war, i.e. deaths caused by the effects of reduced national wealth and household income; reduced health investments during war; destruction of public health services and health related infrastructure;

and psychological stress. One study of adult mortality following wars finds a number of interesting conclusions. Among these is that lingering effects of wars may be quite substantial, often more so than the immediate effects. Moreover, consistent with what has been discussed above, males are more exposed to direct effects, while female mortality is increases mainly over time. An important policy correlate of this is that all actions that may serve to reduce the effects of war, including even short lived cease fires, may reduce long term mortality (Li & Wen, 2005).

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In addition to lingering effects of war on mortality due to fundamentally social factors, there are also biological processes involved. When pregnant women are exposed to nutritional and other environmental stress the result is that the phenotype of the fetus is affected. This so called ‘developmental plasticity’ unfortunately results in increased mortality later in life principally through increased risk of coronary heart disease, stroke, hypertension and diabetes (Barker, 2004). Pregnant women who are currently malnourished because of war will give birth to children who in their adult life will face a higher risk of mortality than what they would have if there had not been a war going on when they were in their mothers’ womb(Painter, Roseboom, & Bleker, 2005).

Apart from the long term effect on adult mortality, there are also short term and middle term effects of maternal malnutrition. Nutritional stress in the womb is associated with low birth weight, and low birth weight is associated with increased mortality of the children, especially neonatal. Children with low birth weight also have higher risk of stunting, chronic disease and have poorer neurodevelopmental outcomes than other children (Allen & Gillespie, 2001)

There seems to be little doubt that infant and child mortality are associated with war and conflict. For example, most of the African countries currently embroiled in conflicts, or that have recently been so, also have very high levels of infant and child mortality. However, many of the states where the association between war and high child mortality seem evident, are also states that had extremely high infant and child mortality levels before they became war zones (Guha–Sapir & van Panhuis, 2003).

Nevertheless, cross national research indicates, unsurprisingly, that increased child mortality is associated with the incidence of wars, as well as their duration. A perhaps surprising finding is that an increase in the ratio of military to population tends to reduce infant mortality. One explanation that has been put forward is that countries that maintain large military forces also maintain infrastructure. This is a conclusion that is supported by the fact that access to safe water is strongly correlated with reduced child mortality, and that inclusion of an indicator for safe water reduces the strength of the military link in the modeling (Carlton–Ford, Hamil, & Houston, 2000). An alternative or complementary hypothesis could be that wars that are being fought with relatively small military forces are wars that to a great extent involve civilians.

The fact that infant and child mortality are difficult to estimate in conflict zones leads to uncertainty or agnosticism about how one should treat a few specific cases, such as Somalia and Afghanistan. Recent surveys indicate that child mortality have been decreasing in both countries (DEVINFO, 2008). At face value this is puzzling.

While Afghanistan might conceivable have reduced its mortality rates since the invasion, because of increased access to health care, the data suggests that post invasion gains are a continuation of pre invasion downward trends. The Somalia data also seem to indicate that child mortality may be decreasing during conflict. If this is the case, it would be useful to discern the mechanisms. One possibility is diffusion of knowledge

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to women about child care practices that reduce mortality. Nevertheless, a very real possibility is that the data are just bad.

The literature suggests that many of the characteristics that affect the infant and child mortality during war are relatively slow to change: women’s education, income per capita or access to safe water. That Iraqi child mortality should have increased rapidly after the 1991 bombing of the country now seems disproved, as recent surveys carried out in Iraq are unable to substantiate the claim (Iraq Family Health Survey Study Group, 2008; COSIT/UNDP, 2004; COSIT, 2007) and instead indicate an arrest of Iraq’s steady trend of decreasing child mortality before the first Gulf war.

Nevertheless, an exception to the generalization above is that rapid forced displacement is most likely a cause for rapid increases in infant and child mortality in many situations. Again, although often mentioned (United Nations, 1996), this is not extremely well substantiated, but, for example, the CE-DAT database of surveys of mortality and nutrition in complex emergencies indicates that this is the case (CRED, 2008). There are also scattered reports of disease outbreaks in refugee camps (e.g. C.

Djeddah, 1988) . However, good studies of morbidity and mortality conditions in refugee camps seem to be lacking, although there are a large number of surveys made by NGOs as part of their operational fact gathering. In one review the authors explicitly warns against taking for granted stereotyped notions of mortality trends among refugees and internally displaced (Guha-Sapir, Gijsbert van Panhuis, Degomme, & Teran, 2005). A similar cautious sentiment is echoed in a review of HIV/AIDS prevalence among refugees (Spiegel, et al., 2007).

Gender differences in infant and child mortality as a result of war remain a rather unexplored territory. It seems likely that gender differences in infant and child mortality caused by war reflect and perhaps be exacerbated by factors that produce such differences during times of peace. However, it is also the case that some of the important correlates of infant and child mortality that are affected by war – lack of sanitation or safe drinking water, lack of access to birth with qualified care or mother’s education – may affect male and female children equally, and thus not result in gender differences in mortality one way or the other.

Good gender disaggregated statistics for infant and child mortality for complex emergencies and war situations are hard to come by. The large number of surveys carried out in complex emergencies by NGOs as well as research organizations using SMART type methodologies provide rather poor estimates of under five mortality because neonatal mortality is under estimated; because of large uncertainty due to sampling;

and also because research protocols are not sufficiently stringent. Demographic and Health Surveys and Multiple Indicator Cluster Surveys provide much better estimates, and have in many cases coverage of war zones, but even for those there are problems associated with disaggregation by gender.

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Morbidity

There is a fair argument that it is more useful to have information about disease patterns in a crisis or war than about the mortality, because by addressing disease one can do something for those that are still alive, while by addressing mortality one is simply documenting. However, in practical terms the difference for policy use may not be that great, because the knowledge generated from both morbidity and mortality studies is more often used for constructing general conceptualizations about conflict, rather than assisting with the particular situation that generates the knowledge. That being said, an aim should be to be able to use locally derived knowledge more efficiently in the situations that generated it.

That disease accounts for a large amount of mortality in wars is quite clear, but it contributes to human suffering also when not lethal. It is well documented that disease follows wars (Smallman-Raynor & Cliff, 2004), but it may sometimes be debated if the disease is a concomitant or coincident factor of war. Thus, was the influenza epidemic of 1918 directly related to the war? Some medical historians argue that it was (Byerly, 2005), while others would say that it was coincidental. Regardless, since the disease seems to have been especially virulent among young adults, having many young men together in military camps at least contributed to both spread and the mortality. The smallpox and measles that wiped out the native population of America in the course of the Spanish conquests would probably have been devastating even in the absence of war.

However, it is not difficult to find cases where disease appears as indirect consequence of war. Even though Palestinian refugees in general have experienced an improvement in infectious disease prevalence since 1948, episodes of intensified conflict, such as the Lebanese conflict of 1975–90 resulted in increased morbidity (Smallman-Raynor & Cliff, 2004, p. 289).

Cholera is perhaps the disease that are most frequently associated with war, after it emerged from South Asia during the 1817–23 pandemic. It is regularly reported, and it has broken out, for example, in Iraq following the 2003 invasion (for one of many reports see for example (WHO, 2007)).

In a careful analysis of cholera during the American-Philippines war of 1902–04 Smallman-Raynor and Cliff make two observations regarding the spread of the disease:

first, that the basic pathways that the disease spread was the same during war and peace;

and second, that the speed by which it spread was increased by the mass population movements that followed the war (Smallman-Raynor & Cliff, 2000). The last observation is certainly general, as war is associated with increased concentration and mixing of populations. The first is very relevant if it has general application, at it indicates that peacetime knowledge of disease pathways in a location also can be employed for wartime disease control.

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Wars are associated with a fairly specific set of infectious diseases. Diarrhea, measles, and acute respiratory tract infections are common among those displaced from current wars (Smallman-Raynor & Cliff, 2004, p. 297). In general it is well known how to control the diseases in question, even in wartime; the problem is access and preserva- tion of health infrastructure.

HIV/AIDS has in recent years been put forward as a disease particularly associated with war and complex emergencies (Khaw, Salama, Burkholder, & Dondero, 2000) (Bergenstrøm, 2003). This may seem reasonable. Wars are often associated with practices that are likely to spread HIV/AIDS, such drug abuse, rape, unprotected sex, unsafe blood transfusion etc. (Hankins, Friedman, Zafar, & Strathdeee, 2002). Nev- ertheless, the evidence that such potential factors actually result in higher incidence of HIV infection in war zones than elsewhere of is far from clear cut (Spiegel P., 2004;

Spiegel, et al., 2007). One reason is that conflict may be associated with factors that both increase or decrease the risk of HIV transmission (Mock, et al., 2004)

Liberia, Sierra Leone, Côte d’Ivoire, Eritrea/Ethiopia and Sudan all have relatively low HIV prevalence rates, while peaceful Botswana and Malawi have high ones. A recent survey shows that war-torn Democratic Republic of the Congo have an average HIV prevalence among those aged 15–49 years of ‘only’ 1.3 percent, but with women having 1.8 times as high prevalence as that of men (Ministère du Plan and Macro International, 2008). Of course, some not so peaceful African states have high HIV prevalence, but taken together the evidence appears to point more to a geographic pattern of Great-Lakes and the south of Africa rather than a war-peace dimension.

The lack of an apparent immutable association between HIV/AIDS and wars does not mean, however, that one should be complacent about a HIV/AIDS war link, and ignore it. Very high HIV prevalence in national armies has been reported. There is evidence of links between military recruitment and the spread of HIV/AIDS in particular countries. In Uganda, it appears that in the initial phases of the epidemic soldiers from the North carried the virus from the south where the disease was spreading unnoticed in the late 1970s and early 1980s(Smallman-Raynor & Cliff, 1991). Thus rather than ignoring the problem, or positing it as a general feature of all war situations, the best strategy is probably to try to understand the epidemiology and relevant mechanisms of transmission in each situation.

HIV/AIDS is perhaps the disease that in recent years have been associated in the minds of policy makers with the spread of diseases from conflict areas. But HIV/

AIDS is just one example. Conflict zones may serve as a reservoir for diseases that may then spread outside of the area. The Afghanistan conflict, for example, has lead to the spread of malaria to surrounding countries together with refugees, and during the Soviet occupation also with returning soldiers to the Soviet Union. It probably also has increased drug-resistance of the malaria parasite (Wallace, et al., 2002).

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Another disease related aspect of war is reduction of vaccination coverage. While it is obvious that immunization campaigns may be difficult to conduct in war zones, reduced immunization may spread outside of the conflict area. For example, one study documents that vaccination coverage in Vienna and Klagenfurt was below the level required for general immunity, partly as a result of influx of refugees and migrants from former Yugoslavia (Waldhoer, Haidinger, Vutuc, Haschke, & Plank, 1997).

Poliomyelitis and its eradication illustrate the fact that the specific nature of a disease is important for how diseases relate to war and conflict. Smallpox was eradicated despite the fact that many countries of the world were engaged in prolonged conflicts as the eradication was underway. Poliomyelitis has proved much more difficult to deal with in conflict zones than smallpox was, because surveillance over extended periods is required; because transmission takes place differently; and because immunization demands repeated doses for each patient. Thus, poliomyelitis eradication requires a health system that functions at a higher level than what was the case for smallpox eradication (Henderson, 2002). Measles have turned out to spread easily in refugee camps, most likely because the conflict may bring together a sufficient number of un- vaccinated children to make the disease become epidemic. It is therefore important to immunize against in refugee camps(Brown, Guerin, Legros, Paquet, Pécoul, & Moren, 2008), not only to protect refugees but also avoid larger outbreaks.

Malnutrition

Most likely famine has been a corollary of war since wars started. Measurement of child malnutrition belongs to the standard toolkit used by many humanitarian organizations to measure the severity of crisis (SMART Initiative, 2008).

Famine occurs in conjunction with war for many reasons: because soldiers eat the food that should have gone to other members of the population, because the security situation makes it impossible to work and to produce and procure food; because of mass displacement; because the population is forcibly relocated; because food is exported from the area; because of breakdown in transport and because of inflation associated with war.

Some argue that the open war is not even necessary to create child hunger. Thus it has been demonstrated using cross national data, that militarization as such, i.e. that the military controls a large portion of a society’s resources, in addition to war, gender inequity and lack of political rights contribute to child hunger, as measured by acute malnutrition (Jenkins, Scanlan, & Peterson, 2007)

Populations embroiled in war actually do quite a lot to avoid famine. A striking finding from several studies is the fact that economic activity, often quite creative, continues during the course of the war (Pedersen, 2007).

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Functional impairment

Even if people are not killed outright they may be maimed for life as a result of war.

While many who are wounded in fighting recover without lasting functional impairment, many do not. There appears to be very little research that indicates what the proportion of debilitating injuries to deaths is, although there are a number of population based surveys that attempt to measure disability in populations affected by war.

However, definitions on disability vary, in one report it is said, for example:

“There are no national statistics available in Cambodia; however, it is thought that 2–3% of the population of Cambodia is disabled, making the per capita rate of disability one of the highest in the world” (FAO, 1997)

In fact, compared to other disability surveys, the rate reported in the quote must be considered very low, and probably represents severe underreporting, especially of minor disabilities.

Mines, unexploded ordnance and other explosive remnants of war also cause mortality and disability long after the wars have ended. One study from Afghanistan based on interviews in communities finds men (65 percent of victims) much more exposed to death and injury from explosive remnants than women (13 percent) or children (22 percent) (Benini & Moulton, 2004). Another study of victims of explosive remnants of war in Afghanistan admitted to health care found 46 percent children, and 51 percent men(Bilukha, Brennan, & Woodruff, 2003). One would assume that both gender and age pattern of exposure would be totally dependent on culturally defined activity patterns.

Psychological effects

Wars do not only kill and create physical wounds, but also affects the psyche. According to one source, psychiatric casualties were twice as frequent as somatic during the first world war, and made up 33 percent in the second(Armfield, 1994).

The literature on psychological effects of war and exposure to violence can be divided into two main groups. One holds that war creates severe psychological trauma that are quite generalized and widespread in the population. The other hold that while it is true that war exposes people to severe psychological stress, this does not for the majority result in traumas that the individual cannot deal with, either alone or with the help of close family and friends. Thus, it is important not to reframe normal distress as psychological problems (Summerfield, 2000). There is a substantial body of studies that support the first position, and a smaller, but significant body that sup-

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A large body of literature describes high prevalence of post traumatic distress syndrome following wars. For example, in as study of four settings it was found that in random samples of the population in selected districts exposed to violence aged 16 years and above 37.4% in Algeria, 28.4% in Cambodia, 15.8% in Ethiopia, and 17.8% in Gaza had post traumatic stress (Jong, et al., 2001). Other studies report even higher preva- lences: In a review of the countries in the Eastern Mediterranean Region the authors found that 43 percent of the population within the 22 countries had post traumatic stress disorder, with a range from 20 to 73 percent. Other ailments, such as major depression, had even higher prevalence (Ghosh, Mohit, & Murthy, 2004). Follow up studies of refugees indicates that post traumatic stress from violence last for several years (Mollica, Sarajlic, Chernoff, Lavelle, Vukovic, & Massagli, 2001).

There are, however, other studies that appear to flatly contradict figures such as those cited above. A comparison between Northern Ireland and other parts of the UK, finds that people in Northern Ireland does not score significantly worse than people elsewhere in the UK when it comes to psychiatric morbidity. The authors suggest that this may be related to coping mechanisms and tight cohesion in local communities(Murphy & Lloyd, 2007).

In contrast, research from Croatia suggests that integration into local communities does not necessarily reduce post traumatic distress; it may in fact exacerbate it, possibly because the social system itself has been stressed(Kunovich & Hodson, 1999). Others how the experience is channeled into emotion is totally culture bound, and describes how Somalis reconstruct the experience in terms of kin and other group conflicts and individually as anger rather than distress (Zarowsky, 2000).

There has been a particular interest in the psychological effects of war and violence on children. For example, a study from the West Bank and Gaza Strip finds that 27.1 of boys in 9–11 grade suffers post traumatic distress, while 31.2 percent of girls do (Abdeen, Qasrawi, Nabi, & Shaheen, 2008).

In one study of the families of holocaust victims and Arabs dislocated from their native homes in 1948 it was found that the initial trauma led to psychological distress to be transmitted not only to the children, but also to the grand children (Lev–Wiesel, 2007).

As for adults, the results for children are far from clear. In a review of a range of studies from a wide variety of settings, but in particularly from Palestine (Sagi-Schwartz, 2008) concludes that although negative effects on children are clearly found, their extent and depth vary considerably. The variability is partly due to how distress is measures, but also appears to be related to the context of the child – in terms of family and community cohesion for example. Thus, children are surprisingly resilient. In the case of the Gaza Strip another review concludes similarly with respect to resilience, but puts more emphasis on the cases where it fails (Qouta, Punamäki, & Sarraj, 2008).

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A sub field within the literature is that of the psychological effects of child soldier’s experiences. It is to a large extent structured along the same lines as the overall debate, namely with respect to trauma versus resilience. The ‘standard’ interpretation would be that child soldiers develop trauma, get used to violence and will be prone to use violence when they grow up. They may therefore be a threat to a future peaceful society (United Nations, 1996) see also (West, 2000) for references to this perspective. The alternative interpretation is that child soldiers in fact are quite resilient, and that the war experience not necessarily weakens them compared to other groups (Boyden, 1994) (West, 2000). It is difficult to have firm conclusions, not the least because selection effects are enormous: we only observe the children that survive, and aid workers only see a minority in rehabilitation camps. Therefore conclusions are likely to be biased (Pedersen & Sommerfelt, 2007).

A particular problem in determining the extent to which people experience serious post traumatic stress is how to develop scales of measurement that are both comparable and culturally adapted. Several studies address the problem, some concluding that the whole notion of post traumatic stress disorder may be misguided if it is interpreted as a human universal response to the experience of violent events (Zarowsky, 2000).

In such a view, valid cross cultural scales are impossible to develop. Other, less radical approaches hold that while post traumatic stress disorder is the underlying response, the expression in particular settings may vary, and cross cultural scales have to take that fact into account (Shoeb, Weinstein, & Mollica, 2007).

One criticism of the emphasis on psychological trauma is that such emphasis makes war-affected populations seem psychologically dysfunctional and that such populations therefore are lacking the capacity for self-government without external help. (Pupavac, 2004) That is not to argue that wars are not psychologically stressful, but rather that the way of conceptualizing such stress disenfranchises people from the ability to govern their own lives.

The psychological traumas associated with war have different origins: some are associated with war itself, i.e. results of the direct experience of fighting. Those are deplorable, but are not necessarily the results of breaches of international law. However, a large part of the traumas are results of such breaches: sexual and gender based violence during war; terrorizing of civilian populations; or torture. On this background some authors have argued, in line with the old saying the prevention is better than cure, and that the focus should be on avoiding the transgressions (Fisher, 2002). The realism of such approaches may be questioned, but given the near complete lack of capacity for provision of help on an individual bases people affected by psychological distress following wars, curative approaches are not particularly realistic either.

One approach to alleviating the plight of those with psychological afflictions from war has been outlined:

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“In post-conflict situations there are six levels of interventions needed:

first, increasing resilience; second, making the family the focus for effective support; third, encouraging community solidarity and traditional methods of support; fourth, using the media in mental health promotion; fifth, the integration of mental health skills of caring for the population with general services; and sixth, focusing on long- rather than short-term measures.”

(Ghosh, Mohit, & Murthy, 2004)

While the exact content of such measures may be questioned, not the least in light of the discussion of the various research findings above, the approach has the merit of focusing on what is possible, namely addressing potentially large numbers of afflicted collectively.

Sexual and gender based violence

A particular gruesome association between war and health is rape and other forms of sexual and gender based violence. There are at least two main mechanisms by which war may increase sexual and gender based violence that are relevant for peace building:

Rape committed by combatants, usually with victims of the opposing group.

1.

Trafficking of human beings to and from war theaters 2.

There is a large number of examples of both forms of sexual violence, but it is difficult to determine the levels, trends and what the specific association between war and sexual and gender based violence is. To give an example, one source hold that 215,000–

257,000 women and girls may have been subject to sexual violence during the conflict in Sierra Leone (Denov, 2006). This would (roughly) correspond to about 10–15 percent of the female population aged 10 years and above. Another source says that 50% of the women experienced sexual violence during the conflict (Jansen, 2006).

In a review Woods documents that wartime rape and sexual violence varies tremen- dously across wars and the following description is to a large extent, but not exclusively, based on her work (Woods, 2006).

It is often contended that rape is used as a weapon of war. It is strongly suggested by the patterns of rape and violence that the belligerents employed rape as a weapon of war in former Yugoslavia, with the intention of humiliating and shaming opposing groups. In Sierra Leone, in contrast, while rape and other forms of sexual violence appear to have been very widespread, and were carried out by all groups, it is not clear if there were any strategy behind it (Woods, 2006). Thus, one need to be clear about

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what is meant by “rape as a weapon of war” – it cannot be just any rape carried out by soldiers in wartime.

The rapes and sexual violence against civilians in the eastern Democratic Republic of the Congo is also a case where it is often contended that rape is used as a weapon of war (Amnesty International, 2004). Rape in the Democratic Republic of the Congo appears to have endemic proportions (Wakabi, 2008) and have been intermittently reported in the press for several years. Doctors without Borders (MSF-USA) reported in 2006 that while they had treated 270 women for injuries relating to rape in 2004 in North Kivu, this was the average monthly figure for 2006(Doctor Without Bor- ders USA, 2006). However, although the rapes certainly are terrorizing the civilian population, it is not made clear what the strategy behind the use is, and if it indeed is considered by the soldiers as a weapon.

In the Second World War, rapes perpetrated by the Soviet army was very frequent in some areas and periods (such as during the occupation of Berlin), and much less frequent in others. The same goes for German troops. British and American troops apparently raped French women after the invasion of Normandy (Bourke, 2006).

Japanese troops carried out large scale rape as in Nanjing. Apparently, one reason to establish the so-called “comfort-women” system where women was forced to serve in brothels for Japanese soldiers was to avoid the indignation of the local populations in response to more direct forms of rape.

In the Israeli/Palestinian conflict rapes are virtually unknown. That is also the case with the Sri Lankan conflict: while there are some reports of rapes carried out by government forces, there is no indication of strategy, and there appears to be no reports of transgressions by rebel forces. Similarly government forces carried out a limited number of rapes during the first years of the conflict in El Salvador, while rebel forces did not.

There is little regularity in who is targeted according to age, whether men are also raped or sexually assaulted; or socio-economic characteristics. Rapes may be carried out publicly, in detention camps, or in homes. In some conflicts all parties commit rape, in others only one does. Sometimes combatants respond with rapes on their own when members of their constituency are raped, sometimes that does not happen. In some conflicts rapes are carried out by disciplined troops, sometimes it is rather the opposite. Sometimes, but perhaps not all that often, rape is used as an explicit weapon of war (Woods, 2006).

Because of the variation in character and frequency of war time rape and sexual violence, as well as the large lacunae in knowledge positing generalized explanations or policy interventions based on simple explanations of why rape occurs are not likely to bring us anywhere. There seems to be little evidence for the contention that “the nature of war has changed” and that women’s bodies have become a battlefield in war

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as argued by some writers (Jansen, 2006). Their bodies have always been so, but to varying extent in different wars.

In a review of the literature up to the late 1990s Skjelsbæk delineates three sets of conceptualizations that attempt to explain why victims are raped and sexually assaulted during war. One conceptualization considers all women living in a war zone and finds the explanation in a militaristic masculinity. Another focuses on targeted women and consider the sexual violence as a means to attack the ethnic, political or other group of the victim. The third, preferred by Skjelsbæk, consider that the victim is feminized while the perpetrator are masculinized through the sexual violence (Skjelsbæk, 2001).

All of the explanations suffer from the problem that it is difficult to see how they can deal with the fact the incidence and character of sexual violence is so varied.

Woods points out a few areas of research that would help both our understanding and policy formulation of rape and war. One is simply documenting the variation. A second area is understanding the cases where rape and sexual violence is relatively infre- quent, such as Sri Lanka and Israel/Palestine. What factors leads to the lack of sexual violence in these cases? A third area is understanding the small group dynamics of sexual violence in war. The reason for the latter focus is the observation that much unaccept- able violence are carried out by normal people in small groups (e.g. soldiers patrolling together, platoons) during war, and that to understand how the interaction (Barnett, 2004) within the group and its relation to command structures may be fruitful.

Domestic violence

Several authors hold that domestic violence increase as a corollary of armed conflict.

UNHCR states unequivocally:

“War magnifies the everyday injustices that many women live with in peacetime . During periods of armed conflict, all forms of violence increase, particularly violence against women and girls” (UNHCR, 2006).

For example, in the case of the West Bank and Gaza, some reports hold that levels of domestic violence have increased during the second Intifada (Human Rights Watch, 2006). Other conflicts have also been linked to increases or high levels of domestic violence. Sri Lanka is also cited as a case either in general (Paudel, 2007) or in the specific instance of refugee camps (Rajasingham-Senanayake, 2004). The level of domestic violence caused by the war in South-Sudan has been described as ‘appalling’

(Jok, 1999). In Tanzania, Human Rights Watch reported extensive domestic violence against refugee women (Human Rights Watch, 2000), and implicitly reports an in-

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crease due to the situation of the refugees. The organization made similar findings in Nepal ((Human Rights Watch, 2003).

Various explanations have been put forward for the apparent finding that domestic violence increases during armed conflict. One is that, within the context of a nationalist struggle, men come to see sex as a just reward for the danger they face in the fight (Jok, 1999). Another is the ‘militarization’ hypothesis, namely that men adopt strategies

and tactics of military nature in order to control their partners, because their military experience predispose them towards such methods (Adelman, 2003). Linked to this may be men’s insecurity, and their use of partner battering to preclude that women can, or dare to, seek out other partners (Jok, 1999). Yet another is what one might call a failed masculinity hypothesis, namely that men who fail to live up to masculine ideals of control and authority compensate by dominating their partners through violence.

Other explanations, such as that of violence in refugee camps, points to contextual issues such as strained domestic situation because of lack of resources, and lack of extended kin and neighbor networks that can serve to reduce violence (Human Rights Watch, 2000).

Nevertheless, whether domestic violence increases during conflict is far from clear cut. The most obvious problem with the current state of knowledge is that there does not appear to exist much data that credibly links armed conflict with domestic violence.

Conversely, there is not much data that can disprove such a link. While one paper cites Israel as the case per excellence of militarized domestic violence (Adelman, 2003) another paper points out that the level of domestic violence in Israel is similar to that of the United States, and put forward the hypothesis that the lack of association with overall levels of violence and war may be due to families caring for each other in times of societal violent conflict (Eisikovits, Winstok, & Fishman, 2004). A problem here is knowing whether the level in the United States is actually high or low, compared to societies around the world, and if the methods of measurement in Israel and the United States are comparable.

While comparisons in levels of domestic violence are difficult between societies, there is little data that may be used to show the development of domestic violence before, under and after conflict. To be sure, in the case of refugee camps, the inhabit- ants may mention their situation of being a refugee as a reason for domestic violence (Carlson, 2005), but that does not really tell us whether this actually results in increased incidence. In fact, the evidence from refugee settings are mostly case stories, and do not document incidence in a way that allow for comparison. Domestic violence can be very noticeable in refugee camp settings, while it may be more hidden to external observers in non refugee camp settings. That observation, of course, is not an argument against working for reduction of all forms of gender based violence in refugee camps.

While it may not be clear that domestic violence is more or less frequent in refugee

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camps than elsewhere, what is quite convincing in the literature is that domestic and other forms of gender based violence are widespread in many camps.

At least one author, in the West Bank and Gaza case, holds that the international human rights focus on domestic violence in the West Bank and Gaza overemphasizes the problem of domestic violence; ignores the wider framework of everyday violence towards Palestinian women as a result of the Israeli occupation; and finally ignores the efforts of Palestinian women’s organizations to deal with the issue (Johnson, 2008). In a similar vein, using the example of Sri Lanka, (Rajasingham-Senanayake, 2004) argues that the victimization approach to women and armed conflict tends to overlook the empowerment that also may occur in parallel with the conflict.

Deterioration of health systems

That health systems deteriorate as a consequence of war is perhaps a truism. The mechanisms are diverse: Investments in health suffer because resources are diverted for military use. Hospitals and health centers may be destroyed by fighting, or the infrastructure that serves them such as water and electricity supply might be damaged or destroyed. Key health personnel may flee, or be directly targeted. Sensitive supply chains, such as cold chains for vaccines may be impossible or difficult to maintain.

The breakdown of the Albanian communist regime provides a case in point. Al- though one not directly related to armed conflict, Albania represent a case where the public health system steadily deteriorated. This lead to a decrease in efficient immunization against poliomyelitis during the 1980s, but this did not lead initially to outbreaks because the very limited population movements limited exposure to the disease. With the 1991 change of regime, and the subsequent radically increased mobility of the population, Albania saw an epidemic of poliomyelitis in 1996 which also spread to Kosovo and Greece (Prevots, 1998) .

How health systems in concrete instances are affected by war is, again, difficult to come by. Iraq is probably the best described recent case. The Iraq Living Conditions Survey documents the extent to which health infrastructure was damaged by the war, and also how particular practices, such as the treatment of diarrhea with oral rehydra- tion therapies was interrupted (COSIT, 2007). While the effects of socio-economic adaptation to war, both from the local population and in terms of amelioration policies executed by the international community, has been little studied, some authors hold that the organization of society becomes such that the rational management of public services, including health provision, becomes very difficult (Pedersen, Three wars later: Iraqi living conditions, 2007).

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In some cases, such as the one of the Mozambique civil war, it appears relatively clear that the rebel group (Renamo) directly targeted government health infrastructure (Cammack, 1987) and the 1999 post referendum violence in East Timor also targeted health infrastructure (together with nearly everything else) (Wheeler & Dunne, 2001).

Despite these descriptions systematic treatment of the fate of health infrastructure during war and occupation appears to be lacking.

Long term health effects of weapons

Some weapons have all their effect when they are used, others have effects that linger on. The most obvious such effects are those of nuclear weapons, well known from Hiroshima and Nagasaki, but other, non nuclear weapons are far from innocuous.

Explosive remnants from war have been discussed above. Ill health, especially cancer and birth defects, has been much debated in conjunction with the extensive use of de- pleted uranium in the Kosovo and Iraq conflicts. There are no conclusive studies that show widespread effects (WHO, 2003), but several that indicate that effects may be present although there are no really sound epidemiological studies available (Hindin, Brugge, & Panikkar, 2005).

Agent Orange (2,4-D/2,4,5-T) was extensively used as a defoliant by American forces in Vietnam in order to rob the Vietnamese their jungle cover. Since Agent Orange contains Dioxin as a contaminant from its production, there are good reasons to assume that Agent Orange is responsible for cancers and genetic disorders in Vietnam, as the Vietnamese government indeed has claimed. An Australian NGO holds that about one million Vietnamese suffer disabilities because of the problem (The Vietnamese Victims of Agent Orange Trust, 2008). A consultancy group that have worked extensively on the problem holds that while dioxin levels in the soil in sprayed locations now in general are at background levels, serious problems remain around former American bases where major spills of Agent Orange occurred (Dw- ernychuk, et al., 2006).

US veterans from the Vietnam war receive compensation if they suffer from a number of diseases thought to be caused by Agent Orange, such as diabetes type II or if their children suffer birth defects (especially spina bifida) (Unted States Department of Veterans Affairs, 2008).

Destroyed military equipment, such as armored vehicles of different kinds, represent a potential environmental risk because of the amount of heavy metals used in their armor, but appears to be little studied.

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Research on long term effects of weapons systems that are independent of the various interested parties is very difficult to come by. It is also difficult to design studies that are methodologically sound. Many of the claims of ill health resulting from weapons systems pertain to cancer, and environmental epidemiology with respect to cancer is difficult at the best of times, — it is fiendishly difficult in areas that have been exposed to conflict.

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Reverse causality 1: does ill health contribute to conflict?

Whether ill health leads to conflict is a much more intractable issue than whether conflict leads to ill health. There appears to be an association between poverty and conflict, in the sense that most countries that currently experience violent conflict in their own territory are poor. If this is related to health, or some other aspect of poverty is not clear, and next to impossible to disentangle, as nearly all poor countries also are far down the scale on health indicators.

The mechanisms one would think that would lead to more conflict in societies with low levels of health than in healthy ones would be similar to those that are usually brought forward to explain the apparent link between poverty and conflict. One such is what one could term lack of fulfillment of the social contract between the state and its citizens, i.e. that the state fail to deliver basic social services, among them health.

Another is perceived disparities in access to resources or services, i.e. that one group obtain access to for example health care, while others do not. Closely related to the perceived disparities in resources or access is actual conflict over resources or access.

In the case of health, that would be the case in actively discriminatory systems, such as South Africa before the abolition of apartheid.

There is a large debate on whether such grievances as described above are adequate explanations of conflict. Collier and Hoeffler have generated a large debate within the development literature by focusing on opportunities for engaging in conflict rather than on the motives(Collier & Hoeffler, 1998). Their basic argument is that grievances are very widespread, and often are not associated with violent conflict. Thus, even if violent conflict is more rarely seen in rich societies there are many poor societies that live in peace. While traditional motives/opportunity discussions of conflict in social science tend to focus specifically on the resources for starting and preserving conflict, the Collier Hoeffler hypothesis tends to focus on opportunities as “greed”, i.e. the possibility to control resources that in turn both bring profit and the ability to carry on a conflict.

In this context, if grievances can be seen to be an explanation or part of one, an additional consideration is if health is in any way different from other grievances. For example, if lack of health is worse in terms of its conflict generating capacity than, say, lack of education; or disparities in health vs disparities in education. Awarding health

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a special status in terms conflict generating capacity is, in a way, the flip side of the hypotheses about health as a bridge to peace, as the assumption in that case is often that health is particularly well suited for peace related work because of the importance that people attach to health. There is little research that can elucidate such hypotheses, and the problems associated with formulating such hypotheses in a testable form are also large.

Another link between ill health, poverty and conflict is an indirect one. If we ac- cept that poverty is linked to conflict, and there are, as mentioned, good reasons for thinking that it is, then if ill health is a cause of poverty it will be indirectly linked to conflict. The case for ill health being a direct cause for poverty is quite good. General high frequency of disease leads to reduction of days available for productive work and education, both factors that are related to lack of income. For individual households large outlays for health care because of a sudden illness may tip the household over the brink to poverty. Moreover, epidemics, such as the HIV/AIDS epidemic, Ebola or SARS may seriously disrupt the ordinary functioning of society, thus reducing overall incomes.

More than any other disease HIV /AIDS has been directly linked to security.

(United States Institute for Peace, 2001; International Crisis Group, 2001). Such arguments have partly employed a sort of sliding definition of security, inspired by the human security discourse, namely using the concept to cover any threat to the lives of the citizens of a state, rather than in the conventional “national security” sense of the term (see e.g. (Altman, 2003)) . The problem with this use is that any disease, in fact nearly any phenomenon at all, easily can be seen as a security threat. MacLean makes the point that the debate about HIV/AIDS and security is as much about a “securization” of the health concept, rather than about empirical issues (MacLean, 2008). The policy benefit of this securization of the health concept is that it embeds health and health outcomes into the high prestige discourse on security, the downside is that it might easily get lost there, competing with other concerns.

If one does consider the empirical aspects, linking HIV/AIDS to security only constitutes a link between HIV/AIDS and violent conflict if it can be demonstrated that the security threat actually has such consequences, rather than being a problem if violent conflict should occur. Security threats usually taken into account include diminishing of the size of armed forces because of the disease; the disease’s ability to destabilize nations if it becomes very widespread; and the impact of the disease on large, strategically important states such as Russia and China (Feldbaum, Lee, & Patel, 2006).

It might be argued that smaller armed forces do not lead to violent conflict, although a hostile neighbor might seize the chance of an easy win if the armed forces are weakened.

A specific form of impact on armed forces is the potential negative impact on peace keeping forces (United States Institute for Peace, 2001).

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Whether or not HIV/AIDS has the ability to destabilize is not clear, at least at the levels of infection currently seen. At least one author (Altman, 2003) has seen the conflict in Zimbabwe as at least being partially related to the spread of HIV/ADIS, but admits that the link is difficult to demonstrate. Another group of authors argues that in the Zimbabwe we case, AIDS is best thought of as a factor contributing to the overall tension of the society, principally through three mechanisms: decreased life expectancy; erosion of economic strength; and decline in state capacity (Price-Smith

& Daly, 2004). It is possible that ineptly managed HIV/AIDS leads to conflict, as the case of Zimbabwe could indicate, but it is also well within the bounds of the possible to think of other explanations for Zimbabwe’s woes. In fact, some have observed that HIV/AIDS have not led, at least not yet, to crisis in African political systems, partly, they say, because public health has not featured prominently as something African politicians have had to be accountable for, together with the fact that the disease is relatively slow acting (de Waal, 2006).

Others have argued rather speculatively that HIV/AIDS have increased the amount of violence employed by military forces (Bertozzi, 1996), and thereby both increased the risk of transmission and the character of war.

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Reverse causality 2: Can improvement of health lead to reduction of conflict?

Health as a bridge to peace

The “Health as a bridge for peace” approach was developed in the Americas during the 1980s starting with an initiative by the Pan American Health Organization (PAHO).

The initiative had two main purposes, namely to contribute to the peace process in Central America and Panama and to contribute to the eradication of polio(de Quad- ros & Epstein, 2002). In particular, the civil war in El Salvador made a mass vaccination campaign difficult, and the initiative therefore engaged guerilla commanders throughout El Salvador as well as government forces. This, of course, necessitated that the governments accepted that such contacts were made. The initiative managed to negotiate that vaccination could take place during particular truce days. Large efforts were also made to inform the population about the initiative.

The basic framework pioneered in Central America has been copied in a large number of instances, when truce days (or “days of tranquility” as they are often called) have been negotiated.

WHO has adopted “Health as a bridge for peace” as a program in a number of countries such as Mozambique, Croatia, Bosnia, Sri Lanka, and Angola, and views

“Health as bridge for peace” as

“a multidimensional and dynamic concept, based on the integration of peace- building concerns and strategies into health relief and health sector development in post-conflict transitions.” (WHO, 2008)

As the quote above indicates “Health as a bridge for peace” is conceived of as more than a practical way to carry out vaccinations and other health campaigns. Rather, “health as a bridge to peace” entails the assumption is that health may serve as a privileged domain for peace interventions. Since health is high on the list of nearly all people’s real and perceived needs, health interventions may be seen as fundamentally good and constructive by all actors. Dialogue about health interventions may also be expanded to dialogue about peace, since the health dialogue, if properly handled, can create a basis that other dialogues can build on.

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A basic problem or question with “health as a bridge to peace” is (unintentionally) well summed up in de Quadros and Epstein’s paper on the original initiative:

“It is difficult to measure the contribution of polio eradication to the final achieve- ment of peace in that region, but, undoubtedly, the collaboration among all those working in health helped to raise the level of trust among people.” (de Quadros &

Epstein, 2002, p. 26)

To put it crudely, the reality of the link between peace and the vaccination campaign depends on a large number of assumptions that are not demonstrated. The use of the word “undoubtedly” does not constitute proof, and whether an increase in trust took place, and if this purported increase had any relation to the establishment of peace, is unclear. In fact, in the literature on “Health as a bridge to peace” calls for developing better evaluations and evaluation methodologies are common (MacQueen & Santa- Barbara, 2000; Vass, 2001).

It may also be questioned that even if the general population put its health high on the agenda, the warring partners may not. In fact, the belligerents may consider that terrorizing the civilian population is useful, and may therefore consider that improved health is against their interests (Rushton, 2005). In such situations, health initiatives may perversely come to be a bridge to more conflict.

Health may also, perversely, be a bridge to more conflict through providing the belligerents themselves with a resource, namely health. Soldiers are human beings, and need food and medicine just as the civilian population do. Humanitarian aid may therefore just as well serve belligerents as the civilian population, and may therefore make it easier to wage war. While accusations abound in this field, both from NGOs accusing governments, and governments accusing NGOs and other donors, there is little firm evidence. For example, while USAID sums up “Operation Lifeline Sudan” as having averted famine but also prolonged the conflict because of the parties using aid to finance war, days of tranquility to regroup etc (USAID, 2003), others portray the operation in much more positive light (e.g. Taylor-Robinson, 2002). A review of the issue argues that while there are several cases where aid has been used by the belligerents in securing their position or feeding their soldiers, one should also not overemphasize the role played by aid, as the volume in many wars are to small to matter (Shearer, 2000).

Of course, that observation does not make the ethical or practical problems simpler for an aid organization faced with diversion of aid to military purposes.

“Health as a bridge to peace” is not restricted to creating trust and dialogue between conflicting parties. The UK Government health plan “Health is global”, launched September 30, 2008, explicitly addresses “Health as a bridge to peace” by arguing that improved global health is a bridge to increased security and peace and that a way to achieve this is by greater coherence between domestic and international health(HM

Health and ConflictA review of the links

Jon Pedersen Health and Conflict

Health and Conflict

A review of the links

Jon Pedersen

Health and Conflict

A review of the links

Contents

Introduction

The standard causal direction: conflict leads to deterioration of health

Mortality

Morbidity

Malnutrition

Functional impairment

Psychological effects

Sexual and gender based violence

Domestic violence

Deterioration of health systems

Long term health effects of weapons

Reverse causality 1: does ill health contribute to conflict?

Reverse causality 2: Can improvement of health lead to reduction of conflict?

Health as a bridge to peace