The Mechanisms Through Which Conflicts Affects Health Of A Community
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Armed conflict has profound implications for public health, giving rise to a diverse array of multidimensional consequences that can be categorized as either direct or indirect. The conflict effects have a broad pattern, starting from direct war-related morbidity and mortality caused by utilization of fire arms and explosives during conflict to indirect consequences due to the interruption of the delivery of preventive and curative health services. The conflict also causes a breakdown in the health system by causing destruction of health infrastructure, fleeing of health workers and shortage of medication, together with insecurity and lack of transportation, which greatly affect the provision and utilization of health services. [1]
During war and violent conflicts throughout 2023, with the continuation of Russia's invasion of Ukraine, the latest war between Israel and Hamas, war in Sudan and Yamen and political violence elsewhere in the world, reportedly more than 170,000 lives have so far been lost.
In addition, the conflict also indirectly deteriorated the health of the population by disruption of food and clean water supplies. Furthermore, conflict-related insecurity and a lack of free movement also reduced the provision and utilization of health services, with patients hesitating to seek healthcare due to concerns about their safety or potential targeting when traveling to healthcare facilities. Despite these significant consequences, the health impact of conflict is still poorly addressed due to the breakdown of health information systems, particularly civil registration systems that record events and causes of death. Additionally, available information might has also been politicized and intentionally misrepresented. For this reason, the WHO has already passed a resolution in 2012 that calls for leadership in documenting evidence of attacks against health workers, facilities, and patients in armed conflict settings. There have been numerous reports of destruction and atrocities against health systems and civilians during various ongoing armed conflicts worldwide but, most of the reports have relied on press reports of eyewitness accounts, journalists, humanitarian agencies and official announcements of combatants. There are several mechanisms through which the conflict affects the community’s health, such as conflict related causalities, famine and food shortage, displacement, insecurity, and lack of health services etc. [1]
Amid violence and insecurity, the health condition of the community is greatly compromised during the conflict. This is exemplified by a high number of both violent related and disease related morbidities and mortality in the community. This can be understood as part of a broader pattern impact of conflict where direct killing of civilians by armed personals, artilleries and armed drones’ shelling become the distinguishing feature of several recent armed conflicts. The conflict also causes tremendous consequences to health of the community in indirect ways including, the lack of electric and clean water supplies, which result in influx and outbreak of communicable diseases of. Similarly, the conflict inflicted famine and food insecurity results in an increased number of individuals and children affected by malnutrition.
These consequences are mainly evidenced in susceptible individuals including; chronic patients, elders, pregnant mothers and children. The conflict also affects the health of the community by inflicting collapse in the health system, causing closure and looting of health facilities, displacement of health workers and disruption of the supply chain. This greatly limits the community’s access to and utilization of health services. There are now reports of systematically targeted attacks or bombings of health-care facilities, which unfortunately, are an all-too-common occurrences in many conflict zones and have become a troubling trend in recent warfare. The conflict not only disrupts public health services but also causes a great breakdown in the private health system, causing forceful closure of many private clinics and pharmacies. Conflict disrupts the provision of many health promotion and preventive services including immunization. Furthermore, the huge destruction caused to health facilities, would take many years and effort to reestablish and reorganize; jeopardizing long term community health. [2]
Salient Mechanism Of Conflict Causing Casualties
The morbidity and mortality rates are substantially affected by following direct conflict-related and disease-related factors, painting a grim picture of the health situation during the conflict:[3]
· Famine And Food Insecurity: The conflict indirectly affects community health by destroying supply chains and social support structures causing famine and food insecurity, which leads to hunger and malnutrition. This coupled with shortage of clean water and electricity creates a fertile ground for the spread of infectious diseases such as malaria, typhoid, dysentery, and respiratory infections, which amplifies the morbidity and mortality, associated with the conflict.
· Displacement Of The Population: Conflict related violence and instability cause displacement of the population, which also greatly affects community health. Because most adults and family members usually flee the area for fear of being targeted and forcefully recruited by the militants, the elders and people in need are left without supportive and caring persons.
· Insecurity And Violence: In conflict settings, the lack of protection from government and civil institutions results in a high level of sexual violence, with soldiers and civilians using rape to humiliate and spread fear among the community.
· Lack Of Health Services: Moreover, due to a lack of functional health services provision, and associated medication shortages, patients are forced taking inappropriate and lower-quality medications, unprescribed and expired medications.
· Disruption Of Health System: The poor health condition of the community is exacerbated by the health system’s disruption, which range from the partial or complete shutdown of medical institutions to shortage of health workers and medical supplies. The complex and multifaceted way through which the conflict affects the health system have been described as; closure of health facilities, shortage of medication and supplies, displacement of health professionals, insecurity and lack of free movement, and overtaking of health facilities by combatant. [4]
· Closure Of Health Facilities: The conflict causes closure of most of the health facilities in the area; only few hospitals and some health centers provide quality health care services. This is caused by fear of being targeted, displacement of health professionals and shortage of supplies. The closure of the facilities also places an enormous burden on the functioning institutions. But their ability to provide services is usually hindered by shortage of medical professionals and medications. As a result, they are merely able supporting those with emergency. Not only does the conflict disrupt public healthcare facilities, but it also affects the private healthcare system. Private clinics, pharmacies, and laboratories are forced to close which exacerbate the problem.
· Displacement Of Health Workers: The armed conflicts also result in the forceful displacement of health workers, with many fleeing the area due to security concerns
· Shortage Of Medication And Supplies: The conflict causes disruption in the supply networks of health facilities, leading to widespread looting of medical supplies, and scarcity of pharmaceuticals. This shortage of medication limits people’s access to essential healthcare services, especially for those with severe disease. This can result in delayed or inadequate treatment, increased morbidity and mortality rates, and a decline in overall health outcomes.
· Insecurity And Lack Of Transportation: In addition to the shortage of professionals and supplies, the widespread instability and lack of transportation cats a significant impact on health provision and utilization, affecting both the health workers and patients. Even if they become ill, they will not go to health institutions. Going to health facilities becomes difficult; there used to be a security check everywhere. Furthermore, the absence of electricity and the restriction of movement at night further complicates the issue. Consequently, healthcare services could only be accessed during day time. Health providers also face an enormous challenge in going to health facilities, because travel at night is very unsafe, with harassment, assault, or extortion by armed persons at roadblocks a common phenomenon.
· Overtaking Of Health Facilities By Combatants: Some health facilities are also forced to use their limited medications and supplies for treating the wounded fighters. When the fighting becomes intense, they bring their injured fighters to the hospital and use it as a shelter to protect themselves from drone strikes. They also turn it into a military camp. Although the conflict usually impacts nearly all segments of the community, vulnerable individuals, including those with chronic disease, pregnant mothers, and children, experience greater suffering due to the absence of routine care and follow-ups.
· Conflict and Emerging Infectious Diseases: Conflict situations are characterized by war or civil strife in a country or area within a country. Affected populations may experience defined periods of violence (weeks to months), ongoing or recurrent insecurity in a protracted conflict (years to decades), or long-term consequences of a previous (usually prolonged) war.
· Inadequate Surveillance And Response Systems - Emerging Infectious Diseases: Detection and control of emerging infectious diseases in conflict situations are major challenges due to multiple risk factors known to enhance emergence and transmission of infectious diseases. These include: inadequate surveillance and response systems, destroyed infrastructure, collapsed health systems and disruption of disease control programs, and infection control practices even more inadequate than those in resource-poor settings, as well as ongoing insecurity and poor coordination among humanitarian agencies. Disease emergence is influenced by ecologic and environmental changes (e.g., agriculture, deforestation, droughts, floods), human demographics and behavior (e.g., population migration, urbanization, international trade and travel), technology and industry, microbial adaptation, and breakdown in public health measures.
Conflict may lead to the displacement of large populations into temporary settlements or camps with overcrowding and rudimentary shelters, inadequate safe water and sanitation, and increased exposure to disease vectors during the acute phase of the emergency. These populations may be more vulnerable to infection and disease because of high levels of undernutrition or malnutrition, low vaccine coverage, or long-term stress. Long-term consequences of civil war can affect entire countries because of chronic lack of investment in health, education, and public works. These conditions, which are encountered during or after war and conflict, favor emergence of infectious diseases. [5]
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Risk Factors Enhancing Disease Emergence and Transmission in Conflict Situations: [6]
· Population Displacement and Environmental Conditions: Armed conflict situations in any country leads to massive population displacement and deterioration in living conditions. So, water/food borne and some infectious diseases outbreaks ensue like, malaria, lassa fever, cholera, typhoid, measles, hepatitis etc. In some conflict-ridden countries like Africa, surveillance has been poor and the extent of any outbreak is unknown. However, numbers of new cases related to the conflict are unavailable. Emergence of these infectious diseases is probably related to the poor condition of dwellings and storage of grain rations in nonsecure canvas sacks, which attracts rodents. Similarly, unsanitary environmental conditions lead to the proliferation of rats in postwar countries and result in a tularemia outbreak among the displaced population.
· Breakdown in Infection Control: Poor infection control practices in healthcare facilities enable amplification of outbreaks of viral hemorrhagic fevers and other such diseases. Medical settings have been the foci for several outbreaks of Ebola hemorrhagic fever (EHF) in some countries. Compared with other resource-poor settings, conflict situations, because of disrupted health services, may have been more deteriorated due to substandard infection control, insufficient trained staff, nonavailability of an isolation facility; ensuring safe water, sanitation, and waste disposal; and lack of provision of personal protective equipment (PPE), which make EHF containment difficult. Noncompliance of infection control procedures like reuse of needles and syringes and use of multidose vials in healthcare centers due to poor training in safe injection practice enhance outbreak incidences.
· Inadequate Surveillance and Early Warning and Response Systems: Surveillance systems are often weak in conflict situations, which results in delays in detection and reporting of epidemics. Limited laboratory facilities and lack of expertise in specimen collection may delay confirmation of the causative organism. Outbreak investigation and implementation of control measures may be hampered by fighting, impeded access to populations, destroyed infrastructure, limited coverage of healthcare services, poorly trained health staff, and difficult logistics prevent delivery of drugs and thus controlling the impending outbreaks.
· Impeded Access to Populations: In case of any outbreak of diseases, achieving humanitarian access to relevant sites and needy populations becomes difficult because of security problems, which delays travel by response teams for investigation and implementation of control. Access to populations to conduct vaccination campaigns may also be interrupted for months to years during protracted conflict due to long-term inadequacies in cold chain and logistics or ongoing insecurity. Low vaccine coverage can play the major role in reemergence of these infectious diseases in conflict-affected countries and so has also pushed back global eradication targets.
· Development of Drug Resistance: Resistance may develop more rapidly in conflict situations because of inappropriate diagnoses or inappropriate drug regimens and outdated drugs. Treatment compliance may be poor because of purchase of insufficient quantities of drugs, selling or saving of them by patients, or interrupted treatment with sudden displacement or irregular access to healthcare facilities. In addition, private pharmacies, which can flourish in conflict situations because of no regulation, can compound this problem with drugs of unknown quality and acceptance of prescriptions from unqualified prescribers.
· Movement of Refugees and Aid Workers: International spread of infectious diseases from conflict situations may occur through movement of refugees, relief workers, animals, goods, and private sector employees working in mining, oil, logging, or construction industries. The outbreak subsequently spread into neighboring countries because of movement of refugees. Rebuilding and rehabilitation efforts in post-conflict areas have placed aid workers, United Nations peacekeeping forces, and businessmen at risk for contracting these diseases and enable importation of cases to industrialized countries. There is also a hypothetical possibility that aid workers returning from a containment zone of an emerging infectious disease, such as novel pandemic influenza, may introduce the virus causing this pandemic into conflict settings.
Globally the conflict has a multitude of consequences on the health of the community. These consequents are caused by both direct war related causalities and indirect break down in the health system and health supporting structures. The conflicts have caused disruption of health promotive interventions together with lifelong disabilities and posttraumatic disorder which could have a long-term health impact. The coping strategies must be utilized to alleviate the broad consequences of conflict that could be learned to other similar settings to support the resilience of communities affected by conflict. Further efforts should also be made to assess the experience of survivors of violence and its health impact on displaced people to formulate new strategies.
References
1. Morse SS. Factors in the emergence of infectious diseases. Emerg Infect Dis. 1995;1:7–15.
2. Communicable disease profile. Afghanistan and neighbouring countries. Geneva: World Health Organization; 2002. WHO/ CDS/2002.7.
3. Levy BS, Sidel VW. Documenting the effects of armed conflict on population health. Annu Rev Public Health. 2016;37:205–18.
4. No, Protection. No respect: Health Workers and Health Facilities under Attack 2015 and early 2016. Human Rights Watch; 2016.
5. Patel P, Gibson-Fall F, Sullivan R, Irwin R. Documenting Attacks on health workers and facilities in armed conflicts. Bull World Health Organ.
6. Safeguarding Health In Conflict Coalition: Health Workers at Risk Violence Against Health Care.2020, 2017;95(1):79.