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Friends of MSF Essay Competition 2009-10 | Category 1: ‘Medical and Practical ---------------------------------------------------------------------------------------------------------------------------------------------------

What is the impact of war on public health? Helen Casey Introduction War has a large impact on all areas of life. Interruption of normal services leads to an impact on the health and needs of a population, these changes then impact on public health. Since 2002 there have been around 30 active conflicts annually; most of these are intrastate conflicts1 therefore globally their impact can be small however locally, in neighbouring countries, a large effect can be felt. Main Issues During War One of the biggest impacts of war on public health is that existing infrastructure, programmes and surveillance are invariably destroyed or put on hold. Successful programmes need adequate and long term funding to be most effective but a country in a civil war tends to produce less, and collect less revenue, then funds tend to be directed away from healthcare into other areas.2,3 A study conducted in El Salvador looked at recurrent costs and public health. Before the civil war ambitious building projects had created many new facilities, however with the onset of war the health budget started shrinking as money was diverted to war efforts. To compound this problem healthcare budgets were being based on historical data, meaning facilities were still being built even though there was no money to finance the running costs. Therefore although money was being spent it was not directly targeted at the right areas so healthcare provisions suffered.2 This shows how constant surveillance and up to date information about the state and needs of a country are important to provide effective public health measures, war disrupts this chain leading to a breakdown between the services being funded and the needs of the population. 1


Another example of a breakdown of funding and civil war is from Sudan and Uganda,3 this example is based on a report looking at finances related to the conflict in these countries. First agriculture and trade were disrupted, leading to a decrease in revenues collected then the amount of money available to the government decreased and military budgets increased meaning the amount spent on healthcare dropped significantly. Many hospitals were taken over by armies or destroyed, meaning the halt of existing healthcare programmes and immediate access to care. The problem then increased as people displaced by war and famine came together in refugee camps. With poor sanitation, high rates of malnutrition and little access to vaccinations it left a population highly susceptible to the spread of communicable diseases.3 This shows how the effects of the breakdown of the networks mentioned above eventually lead to a rise in disease in the population which could have been prevented if adequate public health measures had been in place. During the war in Bosnia and Herzegovina there were two outbreaks of typhoid fever in neighbouring Croatia, one in a group of refugees and one in a group of soldiers. 22 cases were recorded as part of the outbreaks (overall 57 cases were recorded during the war); in the three years before the war began the number of cases recorded was 12. This shows that the effects of poor sanitation and an unsafe water supply and the movement of populations can contribute to an increase in infective disease.4 The epidemic was brought under control by an active search for symptomatic cases, rectal swabbing looking for asymptomatic individuals and treatment.4 All these measures required the knowledge of authorities that an outbreak existed so they could use the information to target resources, showing the importance of surveillance. War tends to disrupt surveillance, in Bosnia the WHO (World Health Organisation) helped restart surveillance, allowing humanitarian aid to be targeted at appropriate areas.5

This shows how supporting those attempting to carry out health

surveillance during war is important to public health as only with accurate data can limited resources be targeted effectively.5 A civil war can also have a political impact on public health. In Angola a study looked at the effect of ethnolinguistic group and region on levels of immunisation and malnutrition in children. It used data from a cross-sectional survey so it only represented a snap-shot of the population, however this was taken into account when drawing conclusions. It showed that regions with the highest levels of malnutrition and lowest levels of immunisation correlated with the areas of the most ferocious fighting. These tended to be the areas of the country which had the longest areas of control by the opposition.

Although no evidence of

discrimination by the government was found this meant that for long periods of time there was no access by governmental organisations (such as health and food aid) to the areas.6

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All of the examples above show that war can affect and disrupt all areas of public health from funding to surveillance to implementation and most importantly it changes the population involved. This means after a war has ended recognising these changes becomes even more important. After War War continues to have an impact on public health even after the cessation of violence as the prevalence and incidence of diseases may have changed due to the effects of war. For instance a study in Luanda, Angola, looked at HIV rates in pregnant women and women going to family planning services from a deprived area of the city (therefore thought to represent the most vulnerable groups); it found that there was a statistically significant difference in the prevalence of HIV in countries at war to those at peace with countries at war having lower rates of infection even thought there were no active prevention programmes. Two possible causative factors are restricted travel limiting spread and interruption of medical services (preventing spread by contaminated needles), however no actual causation was shown.7 This is an example of a health advantage after war which a successful public health strategy could hopefully maintain.3,4 Often though there is no infrastructure or money to put these strategies in place so the opportunity is lost. Although lack of funding and destruction of services can be a huge problem it also provides opportunities to redesign and improve healthcare. In Nicaragua a civil war meant that health budgets and services had to be used more effectively; therefore at the end of the war the system was more successful at managing resources and prioritising treatment.8

So in

peacetime with better funding it was in a good position to capitalise on this. However longterm services like psychiatric and rehabilitation care were neglected during the war and with large numbers being left disabled and with psychiatric problems the development of these services is key to success.8 This example shows a positive effect war can have on public health which can then be utilised to improve the health of a population although the changing needs of a population after the end of conflict need to be included. Developing appropriate strategies and implementing them after war is key to the improvement of public health (as seen in the example from Nicaragua above).8 However this relies on accurate information about the population. A situation illustrating this point was Liberia at the end of the civil war from 1989-1996.9

The prevalence of malaria in Liberia

ranged from 28% to 80% (figures from Ministry of health reports 2000). In the national control policy chloroquine was the first-line drug used, however the amount of chloroquineresistant malaria had increased from previously recorded figures (previously 5% - 38%). This is based on a literature review of studies on malaria in Liberia so includes accurate and 3


up-to-date data (again showing the importance of surveillance). This meant that to improve public health a new strategy needed to be implemented to change the treatment given.10 Without surveillance being carried out no-one will be aware of the need for new strategies. Impact on surrounding areas It is important to recognise that war also affects the public health of countries in the surrounding area. An example already given was the outbreaks of typhoid in Croatia caused by the movement of people from endemic areas to areas where there were previously low levels leading to a change in public health (as stated above).4 Another case is an outbreak of malaria in Oman in a previously malaria-free area. Dhofar reported an outbreak of malaria and over the course of the study 65 cases were recorded. They occurred in two waves, the first made up of mainly Somali immigrants (fleeing from civil war) and the second of Omani citizens.

The study concludes that it is likely that the Somali immigrants increased the

infective reservoir in Dhofar to a high enough level to sustain transmission to the Omani population once the rainy season began, however this is only a theory and needs further research. This shows how widely the effects of war can be felt on public health.11 It also highlights how important it is to implement public health strategies for refugees fleeing conflict; in this case screening and treatment of malaria in refugees while costly initially may then have prevented the spread to the Omani population. Conclusion The impact of war on public health can be long-standing and far reaching. During a war there are many new challenges faced by doctors responsible for public health however the impact does not stop after war. When fighting ceases not only do public health measures have to be reinstated but they also have to be changed to reflect differences in health among the population.

The effect of war on the wider world can also not be ignored as the

implications of large movements of a population to public health is great and can be felt far from the original conflict. References 1. Harbom L (ed.). Number of conflicts in the world no longer declining [online]. Oslo: Uppsala

Universitet;

27/12/2007.

Available

from:

http://info.uu.se/press.nsf/pm/number.of.idF52.html (accessed 2009/3/12). 2. Fielder JL. Recurrent cost and public health care delivery: the other war in El Salvador. Social Science & Medicine. 1987; 25 (8): 867-874.

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3. Dodge CP. Health implications of war in Uganda and Sudan. Social Science & Medicine. 1990; 31 (6): 691-698. 4. Bradaric N et al. Two outbreaks of typhoid fever related to the war in Bosnia and Herzegovina. European Journal of Epidemiology. 1996; 12: 409-412. 5. Weinberg J and Simmonds S. Public health, Epidemiology and War. Social Science & Medicine. 1995; 40 (12): 1663-1669. 6. Agadjanian V and Prata N. Civil war and child health: regional and ethnic dimensions of child immunization and malnutrition in Angola. Social Science & Medicine. 2003; 56: 2515-2527. 7. Strand RT et al. Unexpected low prevalence of HIV among fertile women in Luanda, Angola. Does war prevent the spread of HIV? International Journal of STD & AIDS. 2007; 18: 467-471. 8. Garfield RM. War-related changes in health and health services in Nicaragua. Social Science & Medicine. 1989; 28 (7): 669-676. 9. Global Security. Liberia First Civil War 1989-1996 [online]. Globalsecurity.org; 27/4/2005.

Available from:

http://www.globalsecurity.org/military/world/war/liberia-

1989.htm (accessed 2009/3/10). 10. Massaquoi MBF and Kennedy SB. Evaluation of chloroquine as a potent anti-malarial drug: issues of public health policy and healthcare delivery in post-war Liberia. Journal of Evaluation in Clinical Practice. 2003; 9 (1): 83-87. 11. Baomar AT and Mohamed AG. Malaria outbreak in a malaria-free region in Oman 1998: unknown impact of civil war in Africa. Public Health. 2000; 114: 480-483.

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What is the impact of war on Public Health? - Helen Casey