New ways to measure the effects of armed conflict in civilian population
Authors: Ayesha Kadir, Daniel Martinez Garcia, Florencia Romero
Journal: The Lancet Global Health (2019)

The short-term and long-term effects of armed conflict on the health of women and children are poorly understood. Public health infrastructure is often underfunded or destroyed during conflict and health facilities are actively targeted by combatants. The resulting barriers in access to health care and data collection pose substantial challenges to our understanding of how and to what degree conflict affects civilian health and mortality.1Kadir A Shenoda S Goldhagen J Effects of armed conflict on child health and development: a systematic review.PLoS One. 2019; 14e0210071Crossref PubMed Scopus (60) Google Scholar Even estimates of mortality directly due to combat remain problematic, since they are based primarily on reports from combating parties, news media, and non-governmental organisations.2Uppsala Conflict Data ProgramMethodology. Uppsala Universitet: Department of Peace and Conflict Research, 2018https://www.pcr.uu.se/research/ucdp/methodology/Date accessed: September 18, 2019Google Scholar The scarcity of data on women of childbearing age in conflict settings is mirrored by the scarcity of data on child health (appendix p 1).1Kadir A Shenoda S Goldhagen J Effects of armed conflict on child health and development: a systematic review.PLoS One. 2019; 14e0210071Crossref PubMed Scopus (60) Google Scholar The study by Zachary Wagner and colleagues3Wagner Z Heft-Neal S Wise P et al.Women and children living in areas of armed conflict in Africa: a geospatial analysis of mortality and orphanhood.Lancet Glob Health. 2019; (published online Oct 24)https://doi.org/10.1016/S2214-109X(19)30407-3Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar in The Lancet Global Health3Wagner Z Heft-Neal S Wise P et al.Women and children living in areas of armed conflict in Africa: a geospatial analysis of mortality and orphanhood.Lancet Glob Health. 2019; (published online Oct 24)https://doi.org/10.1016/S2214-109X(19)30407-3Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar sheds light on the overall scale of health and social effects of armed conflict on civilian populations in Africa and identifies some of the complexities in how these effects ultimately manifest. By comparing Demographic and Health Survey (DHS) data with conflict location and intensity, Wagner and colleagues were able to provide estimates of mortality in women of childbearing age and the likelihood of a child losing one or both parents on the basis of proximity to conflict and conflict intensity (from the Uppsala Conflict Data Program database). The methods are one concrete example of how existing data, such as those from DHS and the Uppsala Conflict Data Program database, can be used to examine population health in conflict settings. The study findings provide evidence of the so-called collateral damage of armed conflict. They also provide evidence on some nuances in the way conflict affects health. Mortality was more pronounced for non-maternal causes of death, suggesting that additional factors beyond barriers in access to maternity care led to death in women of childbearing age. Further, education and wealth were associated with lower probability of orphanhood, suggesting that poverty and social inequities compound the risk of a child living near conflict zone losing a parent. Contextual factors play an important role in shaping the way conflict affects a given population and they also shape the way in which interventions can be developed and carried out. For example, Iraq was previously a middle-income country with a functioning health system until two decades ago, when war, international sanctions, and civil unrest contributed to a substantial deterioration of the health system.4Cetorelli V Shabila NP Expansion of health facilities in Iraq a decade after the US-led invasion, 2003-2012.Confl Health. 2014; 8: 16Crossref PubMed Scopus (18) Google Scholar The health-seeking behaviour of the population is in keeping with the prewar standard, when specialised care, technologically advanced diagnostics and treatment, and frequent prescribing of medication and infant formula were widespread. Delivering health care in postconflict Iraq, using well known preventive strategies such as antenatal visits and promotion of breastfeeding, is challenged by a lack of acceptance by the population.5UNICEFIraq 2018 Multiple Index Cluster Survey (MICS 6) briefing.https://www.unicef.org/iraq/reports/2018-multiple-indicator-cluster-survey-mics6-briefingDate: 2018Date accessed: October 21, 2019Google Scholar Protracted conflict and limited capacity of the health sector in the Democratic Republic of the Congo has created major gaps in access to care, particularly for reproductive health and maternal and child health services. However, security issues continue to limit access for humanitarian actors, resulting in limited care and substantial gaps in data on short-term and long-term health outcomes even for those patients who receive care. The end result is a limited ability to understand the evolving health needs of the population or to deliver interventions for known and prioritised health needs.6Nic Carthaigh N De Gryse B Esmati AS et al.Patients struggle to access effective health care due to ongoing violence, distance, costs and health service performance in Afghanistan.Int Health. 2015; 7: 169-175Crossref PubMed Scopus (24) Google Scholar In Mexico, existing disparities in access to health care, in the form of barriers in access to care for native Indians, Afro-Mexicans, and internal migrants has been exacerbated by a surge in international migration. The additional burden in an already weakened national health system has fuelled racist discourse within Mexico and in the neighbouring USA. Further, a substantial proportion of the population is on the move, effectively invisible to health authorities and humanitarian actors. Sexual violence and access to treatment, including emergency contraception and HIV postexposure prophylaxis, is a recognised issue for both women from the local populations, as well as for migrants. Invisibility of the migrant population and the normalisation of violence in the local population has hindered their access to care. Although migrants might be visible during travel in large groups or caravans, they disperse as they approach the Mexico–USA border, some falling under the control of cartels and others actively seeking to remain invisible to avoid danger or deportation. As a result of their invisibility, this population has limited or no access to the available care and our understanding of their health needs and risks remains very poor.7Médecins Sans FrontièresMass arrests drive migrants underground and cut them off from medical care.https://www.msf.org/mass-arrests-drive-migrants-underground-mexicoDate: 2019Date accessed: October 21, 2019Google Scholar, 8Leyva-Flores R Infante C Gutierrez JP Quintino-Perez F Gómez-Saldivar M Torres-Robles C Migrants in transit through Mexico to the US: experiences with violence and related factors, 2009-2015.PLoS One. 2019; 14e0220775Crossref PubMed Scopus (13) Google Scholar, 9UN High Commissioner for RefugeesDisplacement in Central America.https://www.unhcr.org/displacement-in-central-america.htmlDate: 2019Date accessed: October 21, 2019Google Scholar The use of traditional research methods requires a degree of security and infrastructure that cannot be guaranteed in conflict settings. Available data are likely to be fraught with bias, missing data points, double counting, and other errors that might ultimately lead to inaccurate conclusions and misplaced or even potentially harmful interventions. There is a need to develop new, innovative research methods to improve the quality of data and, thereby, improve our understanding of the needs of specific populations, local context, and how it affects health needs and potential interventions. By supporting and collaborating with local networks of health workers, local non-governmental organisations, and international humanitarian organisations, we can improve data collection and develop contextually appropriate interventions. A paper by Meigari and colleagues,10Meiqari L Hoetjes M Baxter L Lenglet A Impact of war on child health in northern Syria: the experience of Médecins Sans Frontières.Eur J Pediatr. 2017; 177: 371-380Crossref PubMed Scopus (20) Google Scholar published in 2017, from Syria, shows that data collection is feasible even in highly intense conflict zones with attacks on health care and sudden closure of health facilities. Technologies such as telecommunications and social media are potentially useful resources, although they pose ethical challenges and security risks that must be carefully considered. The need for better data and more effective, contextually appropriate interventions is clear. It is necessary to develop the methods to achieve this aim. This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on Dec 12, 2019 This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on Dec 12, 2019 We declare no competing interests. Download .pdf (.1 MB) Help with pdf files Supplementary appendix Women and children living in areas of armed conflict in Africa: a geospatial analysis of mortality and orphanhoodAfrican women of childbearing age are at a substantially increased risk of death from nearby high-intensity armed conflicts. Children exposed to conflict are analogously at increased risk of becoming orphans. This work fills gaps in literature on the harmful effects of armed conflict on non-combatants and highlights the need for humanitarian interventions to protect vulnerable populations. Full-Text PDF Open AccessCorrection to Lancet Glob Health 2019; 7: e1585–86Kadir A, Martinez Garcia D, Romero F. New ways to measure the effects of armed conflict in civilian population. Lancet Glob Health 2019; 7: 1585–86—In this Comment, the affiliation for Daniel Martinez Garcia and Florencia Romero was incorrect; the correct affiliation should be Médecins Sans Frontières, Geneva, Switzerland. This correction has been made as of Dec 12, 2019. Full-Text PDF Open AccessKnowledge production in humanitarian crises: beware of the innovation trapKadir and colleagues1 have outlined some of the challenges that affect the ability to accurately quantify the effect of conflict on mortality and health, and associated risk factors. However, they inaccurately suggest that mortality estimates “are based primarily on reports from combating parties, news media, and non-governmental organisations.” This might be the case for the Uppsala Conflict Data Program to which they refer, which draws from the media and reports from non-governmental organisations, as well as a smaller sample of other sources. Full-Text PDF Open Access