Civilian health: the new target of conflict
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For personal use. Only reproduce with permission from The Lancet Publishing Group. 1228 THE LANCET • Vol 360 • October 19, 2002 • www.thelancet.com FEATURE Civilian health: the new target of conflict T he biggest problem for health- care personnel in a conflict situa- tion is not knowing where and in what form the enemy will strike. The UK and USA have just spent vast sums of money on 60 million and 250 million smallpox vaccines, respectively. But, such responses are simple ones to a very complex issue: “we are respond- ing to the fear of an attack rather than the reality”, said Vivienne Nathanson, at the Royal Society of Medicine’s meeting on the effect of war on civilian health on Oct 10 (London, UK). According to the World Medical Association, more than 50 bacteria, viruses, or toxins have been identified that could potentially be used in an attack, and at present, vaccines are avail- able for only 12 or 13 of these agents. Smallpox is not the only threat. “The best public-health planning in the world would not prevent damage from biological weapons, but only ameliorate the effects”, commented Nathanson, “but what is really neces- sary is stockpiling of vaccines and drugs, and updating doctors and other health workers on recognition of ‘tropical’ diseases so that they are pre- pared to consider obscure agents and unlikely diagnoses”. To plan a response, you need to know who will be affected most. “Since World War II, there have been more than 190 conflicts, and more than 90% of the casualties have been civilians”, noted Derek Summerfield (South London and Maudsley NHS Trust, London, UK). During conflict, people, communities, and health serv- ices become vulnerable; vector and disease control programmes, training, resource allocation, and sanitation are usually impeded, infrastructure is demolished, and health systems break down. Since the conflict in Afghanistan started in 2001, most Afghan hospitals have totally col- lapsed. Electricity supplies are lim- ited, and health care therefore stops at night. And not just the infrastructure is targeted. “Figures from major hos- pitals in Northern Ireland show that there were more than 500 assaults against hospital staff in 2000, and there were many more occasions on which they were verbally abused. According to official statistics, attacks on paramedics have doubled over the past year”, noted Niall Martin, Royal Army Medical Corps, Northern Ireland. Most wars happen in poor coun- tries, and the people most affected in these countries are those in margin- alised populations, such as the Kurdish people in Iraq. Within mar- ginalised populations, the most vul- nerable are the very old, the very young, and the already frail because they are unable to move away from the site of conflict, to gather the essentials needed to survive, or to defend themselves. Women and chil- dren are jointly vulnerable: “If a mother is killed or disabled, so too, in all probability, are her children”, noted Gill Hinselwood (Medical Foundation for the Care of Victims of Torture, London, UK). Furthermore, children are deliberately used as sol- diers because they are “easy to control and manipulate, agile and quick to learn, cheap and expendable, and because soldiers find it harder to fire at a child”, said Sarah Uppard, emer- gencies adviser for separated children, Save the Children, UK. And this exploitation is not just in poor or developing countries. In the “Cost of the Troubles” cross-sectional survey of school children in Belfast, Northern Ireland, in 2002, more than half the children interviewed had rioted at least once, and about a third had seen someone seriously assaulted or killed. Special planning is needed to assist these vulnerable people during and after conflict. “Much focus has been placed on individual counselling and trauma work, since funds are easier to acquire for such interventions than for rebuilding social structures”, noted Summerfield. But, providing health care and counselling for these people does not help if their basic needs are not met. Not only do you need to know who will be affected most, you also need to know how people are most likely to be affected. “Conflict has several hidden costs”, commented James Ryan, sur- geon at University College London, “which often don’t become evident until several years after the war—and any funding—has ended”. Civilians and soldiers alike can be injured by large chunks of shrapnel, causing massive tissue loss. Their wounds seemed to have healed after treatment, but many develop sepsis and chronic osteomyelitis several years later, observed Ryan. These conditions are exacerbated not only by non-ideal cir- cumstances—doctors who are exhausted dealing with wounds and conditions they may never have come across before, surgery done while under fire, poor conditions, and delayed treatment—but also by starvation, malnutri- tion, and poverty, which are themselves associated with conflict. By the time these effects become evident, funding has long since dried up. But by far the biggest consequence of conflict is the burden of communi- cable diseases. In just 32 months, during 1998–2001, in the Democratic Republic of Congo, 2·5 million more people are estimated to have died than would have been expected. 350 000 died from fighting, the other 86% died from disease and malnutrition. Egbert Sondorp, (London School of Hygiene and Tropical Medicine, London, UK) commented that “it is easy to focus on epidemics, and rela- tively easy to find funding to combat them, but it is not epidemics that cause the most deaths”. Most people die as a result of illnesses endemic to their countries, such as respiratory diseases, diarrhoea, malaria, and mal- nutrition, which have been exacer- bated by conflict. These illnesses do not receive the attention and funding they need. So what can be done? Sondorp noted that “lots more research is needed: there are very few data on the burden of war or on the effectiveness of health interventions”, and called for a “more focused role of the health- care community combating the main burden of communicable disease in complex emergencies”. Anna York Panos Pictures More focus needed from the health community Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Transcript of Civilian health: the new target of conflict
For personal use. Only reproduce with permission from The Lancet Publishing Group.
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
Pano
s Pi
ctur
es
More focus needed from the health community
Rights were not granted to include thisimage in electronic media. Please
refer to the printed journal.
