UNDPKO Civilian Police Division Draft Training Module, June 2005 Community Conflict Resolution.
Civilian health: the new target of conflict
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1228 THE LANCET • Vol 360 • October 19, 2002 • www.thelancet.com
FEATURE
Civilian health: the new target of conflict
The biggest problem for health-care personnel in a conflict situa-
tion is not knowing where and in whatform the enemy will strike. The UKand USA have just spent vast sums ofmoney on 60 million and 250 millionsmallpox vaccines, respectively. But,such responses are simple ones to avery complex issue: “we are respond-ing to the fear of an attack rather thanthe reality”, said Vivienne Nathanson,at the Royal Society of Medicine’smeeting on the effect of waron civilian health on Oct 10(London, UK).
According to the WorldMedical Association, morethan 50 bacteria, viruses, ortoxins have been identifiedthat could potentially beused in an attack, and atpresent, vaccines are avail-able for only 12 or 13 ofthese agents. Smallpox is notthe only threat. “The bestpublic-health planning in theworld would not preventdamage from biologicalweapons, but only amelioratethe effects”, commentedNathanson, “but what is really neces-sary is stockpiling of vaccines anddrugs, and updating doctors andother health workers on recognition of‘tropical’ diseases so that they are pre-pared to consider obscure agents andunlikely diagnoses”.
To plan a response, you need toknow who will be affected most.“Since World War II, there have beenmore than 190 conflicts, and morethan 90% of the casualties have beencivilians”, noted Derek Summerfield(South London and Maudsley NHSTrust, London, UK). During conflict,people, communities, and health serv-ices become vulnerable; vector anddisease control programmes, training,resource allocation, and sanitation areusually impeded, infrastructure isdemolished, and health systems breakdown. Since the conflict inAfghanistan started in 2001, mostAfghan hospitals have totally col-lapsed. Electricity supplies are lim-ited, and health care therefore stops atnight. And not just the infrastructureis targeted. “Figures from major hos-pitals in Northern Ireland show thatthere were more than 500 assaultsagainst hospital staff in 2000, andthere were many more occasions onwhich they were verbally abused.According to official statistics, attackson paramedics have doubled over thepast year”, noted Niall Martin, Royal
Army Medical Corps, NorthernIreland.
Most wars happen in poor coun-tries, and the people most affected inthese countries are those in margin-alised populations, such as theKurdish people in Iraq. Within mar-ginalised populations, the most vul-nerable are the very old, the veryyoung, and the already frail becausethey are unable to move away fromthe site of conflict, to gather the
essentials needed to survive, or todefend themselves. Women and chil-dren are jointly vulnerable: “If amother is killed or disabled, so too, inall probability, are her children”,noted Gill Hinselwood (MedicalFoundation for the Care of Victims ofTorture, London, UK). Furthermore,children are deliberately used as sol-diers because they are “easy to controland manipulate, agile and quick tolearn, cheap and expendable, andbecause soldiers find it harder to fireat a child”, said Sarah Uppard, emer-gencies adviser for separated children,Save the Children, UK. And thisexploitation is not just in poor ordeveloping countries. In the “Cost ofthe Troubles” cross-sectional surveyof school children in Belfast,Northern Ireland, in 2002, more thanhalf the children interviewed hadrioted at least once, and about a thirdhad seen someone seriously assaultedor killed.
Special planning is needed to assistthese vulnerable people during andafter conflict. “Much focus has beenplaced on individual counselling andtrauma work, since funds are easier toacquire for such interventions than forrebuilding social structures”, notedSummerfield. But, providing healthcare and counselling for these peopledoes not help if their basic needs arenot met.
Not only do you need to know whowill be affected most, you also need toknow how people are most likely to beaffected. “Conflict has several hiddencosts”, commented James Ryan, sur-geon at University College London,“which often don’t become evidentuntil several years after the war—andany funding—has ended”. Civiliansand soldiers alike can be injured bylarge chunks of shrapnel, causingmassive tissue loss. Their wounds
seemed to have healed aftertreatment, but many developsepsis and chronicosteomyelitis several yearslater, observed Ryan. Theseconditions are exacerbatednot only by non-ideal cir-cumstances—doctors whoare exhausted dealing withwounds and conditions theymay never have come acrossbefore, surgery done whileunder fire, poor conditions,and delayed treatment—butalso by starvation, malnutri-tion, and poverty, which arethemselves associated withconflict. By the time these
effects become evident, funding haslong since dried up.
But by far the biggest consequenceof conflict is the burden of communi-cable diseases. In just 32 months,during 1998–2001, in the DemocraticRepublic of Congo, 2·5 million morepeople are estimated to have diedthan would have been expected. 350000 died from fighting, the other 86%died from disease and malnutrition.Egbert Sondorp, (London School ofHygiene and Tropical Medicine,London, UK) commented that “it iseasy to focus on epidemics, and rela-tively easy to find funding to combatthem, but it is not epidemics thatcause the most deaths”. Most peopledie as a result of illnesses endemic totheir countries, such as respiratorydiseases, diarrhoea, malaria, and mal-nutrition, which have been exacer-bated by conflict. These illnesses donot receive the attention and fundingthey need.
So what can be done? Sondorpnoted that “lots more research isneeded: there are very few data on theburden of war or on the effectivenessof health interventions”, and calledfor a “more focused role of the health-care community combating the mainburden of communicable disease incomplex emergencies”.
Anna York
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More focus needed from the health community
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