WRITING SAMPLE:
CHAPTER 1
FOR ONE DOES NOT CREATE A HUMAN SOCIETY ON MOUNDS OF CORPSES – LOUIS LECOIN
INTRODUCTION
According to the Correlates of War data project, 76 wars were initiated
between 1990 and 2007 of which 67 were intrastate, or civil conflicts (Ghosn et al,
2004).1 Since 1935, approximately 25 million people have been killed in civil
conflicts, the majority of which have taken place in developing countries (Farrell
and Schmitt, 2012). This staggering number does not take into account the millions
more whose health has been affected by civil war in a myriad of immediate and
lasting ways. Forced displacement, destruction of integral health services and food
sources, and the breakdown of state functionality can have long-term effects for the
progress of a developing country and all its inhabitants thus extending the
destruction wrought by pervasive and systematic violence far beyond the signing of
peace accords.
1 This research uses the Uppsala Conflict Data Project definition of intrastate conflict: “a conflict between a government and a non-governmental party [within a sovereign territory], with no [direct] interference from other countries” (Uppsala Conflict Data Program “Definitions”, 2014). Note that civil/intrastate war/conflict are used interchangeably throughout this work.
Conflict is motivated by a number of different factors that can be separated
into greed-motivated or criminal wars (wars that are motivated against a
government primarily for financial gain) or grievance-motivated or ethnolinguistic
wars (wars that are motivated by dominance of one ethnic, religious, or linguistic
group over another, usually involving a territorial component) (Ballentine, 2003).2
This research looks at these different war motivations within civil conflicts and their
short- and long-term effects on population health.3
Population health4 in war-torn countries is worse than in similar countries
unaffected by war. Access to basic health services can be interrupted for a multitude
of reasons, leading to a decrease in standards of care and an increase in
communicable and treatable diseases and injuries. The burden of communicable
diseases is highest in low income and politically unstable countries – those most
prone to civil conflict (The World Health Organization, 2005) – and is exacerbated
by conflict. Vaccination rates drop precipitously during times of conflict as a result
of disruption of services (GAVI, 2013), leading to an increase in otherwise
2 Given the interrelationships between war type and conflict motivation that is explained in more detail later in this chapter and in chapter two, the term greed-motivated wars will be used interchangeably with criminalistic or criminally motivated wars throughout this work. Grievance-motivated wars will be used interchangeably with ethnolinguistic wars. 3 Because of the effect of GDP on health and the lack of civil conflict within OECD countries, this research only looks at non-OECD countries in the analysis of health and civil conflict. This is consistent with other works in conflict and world politics (Anderson & Poullier, 1999; Kanavos & Mossialos, 1999; Heshmate, 2001; Collier, 2012). 4 Population health is defined by Kindig and Stoddard (2003) as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group… the field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two.” This relates to the basic health quality and general health level of a population within a country or within a particular group.
preventable deaths in children under the age of five (The World Health
Organization, 2010).
Infrastructure destruction tends to be the main target in civil conflicts and is
used in an effort to undermine state functionality (Collier, 1999). Even when the
intentional targeting of civilians is not evident, widespread infrastructure
destruction has an extensive effect on the ability of a government to provide basic
necessities and services to the population (Collier, 1999; Murdoch and Sandler,
2002, 2004; Hoeffler and Reynal-Querol, 2003; Kang and Meernik, 2005).
The lack of adequate health facilities, supplies, and monitoring can lead to
increases in mortality from injury and disease (Ugalde, 2000; Ghobarah, et. al.,
2003). Forced migration into refugee and internally displaced persons camps also
causes an increase in non-combat mortality. A study done of the Tigrayan refugee
population in East Sudan and Cambodian refugees in Thailand in 1984/1985
showed a non-combat mortality rate of 14 to 24 per 1,000 refugees per month
(Toole, Nieburg and Waldman, 1988). This was far higher than the mortality rate of
civilians outside the refugee camps. The destruction of population health wrought
today can have long-term effects on the growth capabilities of a developing society.
THE CURRENT STATE OF WAR AND HEALTH
Both intra- and interstate wars have decreased since the end of the Cold War,
but intrastate, or civil wars are still prevalent. As shown in Figure 1, the number of
active wars was highest in the early 1990s, directly after the fall of the Soviet Union.
In 2011, the Uppsala Conflict Data Program recognized twenty-seven active
intrastate wars with over 25 annual war-related casualties per year (UCDP, 2013).
This was an increase from twenty-two in 2010. Though many of these conflicts are
considered to be “low intensity wars” (over 25 but fewer than 1,000 war-related
casualties per annum), the lack of settled peace agreements could interrupt the
normal functioning of the state.
Figure 1: Global Trends in Armed Conflicts 1946-2011 [intrastate wars are titled ‘societal warfare’ in this graph] (Center for Systemic Peace, 2013)
Figure 2 illustrates the interrelationship between gross domestic product
(GDP), state fragility,5 and the likelihood of conflict. The majority of these conflicts
took place in Africa and Asia, with a smaller proportion in the Middle East. Most of
5 The OECD defines a fragile state as “a state with weak capacity to carry out the basic state functions of governing a population and its territory and that lacks the ability or political will to develop mutually constructive and reinforcing relations with society.” (Organization for Economic Cooperation and Development “Conflict and Fragility”, 2014)
these countries are considered to be “developing”6 (The International Statistical
Institute, 2013).
Figure 2: The State Fragility Index (Center for Systemic Peace, 2011)
The health prospects within low income, fragile countries also vary
significantly from their higher income and more stable counterparts. Figure 3
displays the environmental burden of disease as calculated by the World Health
Organization in 2005. Communicable disease burden is still highest in the
developing world, particularly Africa. Vaccination rates for preventable diseases
vary from region to region, and may be greatly affected by disruption of services,
which are ubiquitous during conflict (GAVI, 2013). According to The World Health
Organization, between 2000 and 2010 58% of deaths in children under the age of
five were caused by infectious diseases such as pneumonia, diarrheal disease, and
6 Developing countries are defined as countries with a GNI of US$ 11,905 and less in 2010. (World Bank “How we Classify Countries”, 2014)
malaria (figure 4). War also affects the other common causes of child and infant
death such as pre-term birth complications and injuries (The World Health
Organization “Causes of Death Among Children Aged Under Five Years”, 2010).
Figure 3: Environmental burden of disease throughout the world (The World Health Organization “Environmental Burden of Disease Globally”, 2005)
Figure 4: Causes of mortality among children aged under five years (The World Health Organization “Causes of child mortality for the year 2010”, 2010)
Why is improved and stable population health so integral in post-conflict
developing countries? The economic effects of war influence current and future
growth, which can translate directly into a lack of resources for basic human
necessities, like health care supplies and workforce (Hoeffler and Reynal-Querol,
2003; Iqbal, 2006). This can have a direct effect on the future development of a
society. Research on the relationship between health and economic growth show
that healthy populations are more productive, and improvements in the adult
survival rate within developing countries lead to improved GDP growth rates and
higher rates of usable human capital7 (Spurr, 1983; Feachem, 1992; Strauss and
Thomas, 1998; Bhargava, 2001). Scholars working from the Solow growth model of
human capital (1956) found that the effects of health on growth are most
pronounced in developing societies (Knowles and Owen, 1995, 1997; Rivera and
Currais, 1999). These effects also seem to be cyclical – as development and GDP
improve, general population health tends to improve as well (Preston, 1976).
The inverse in these findings reveal that worse population health leads to
lower productivity and stunted GDP growth (Feachem, 1992). A 1996 study by
Murray and Lopez found that 0.6 disability adjusted life years8 (DALYs) per capita
7 Human capital is defined as “a measure of the economic value of an employee's skill set. This measure builds on the basic production input of labor measure where all labor is thought to be equal. The concept of human capital recognizes that not all labor is equal and that the quality of employees can be improved by investing in them. The education, experience and abilities of an employee have an economic value for employers and for the economy as a whole” (Investopedia “Human Capital”, 2014). 8 According to the World Health Organization, a DALY “can be thought of as one lost year of "healthy" life. The sum of these DALYs across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability” (World Health Organization “Metrics: Disability Adjusted Life Years, 2014).
were lost due to premature mortality and years lived with disability in sub-Saharan
Africa (Murray and Lopez, 1995).9 These years lost in the “working age” population
can add up to a loss in economic and societal productivity. The infrastructure
destruction that is inherent to war can exacerbate the already tenuous balance of
population health and economic growth within a developing country.
It is known that war leads to poor health, and poor health leads to stunted
growth within a society. What is unclear is if and how dissimilar types of wars affect
health differently. Because of the ever-present threat of intrastate conflict, we
should explore whether diverse war motivations lead to poor health in both the
present and the future of a country. If war type does have a differing effect on
population health, we should attempt to discern why those variations are present.
This understanding may help policymakers approach post-conflict reconstruction
and rehabilitation in a targeted manner, focusing on the specific reconstruction
needs within a particular country. This in turn should allow more meaningful and
comprehensive structural changes post-conflict, leaving to improvements in the
health sector and beyond.
THEORY
There are a number of qualitative and quantitative studies demonstrating
that the presence of war has adverse effects on population health. Destruction of
9 An update to this work was published in 2013. Though the authors found that the percentage of burden of disease had shifted, communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden in sub-Saharan Africa (Murray et. al., 2013).
infrastructure, loss of funding for healthcare, disruption of food supply, and
heightened susceptibility to infectious diseases are common during war, regardless
of the motivations behind the conflict (Ugalde et al., 2000; Ghobarah, et. al., 2003;
Levy and Sidel, 2008). The quantitative analyses in chapter three support and
reinforce this relationship. What is not clear is how different types of war may affect
health.
There are no standard theories with which to approach the problem of war
type and the effects on health, but using theories of conflict and health from multiple
academic fields, I have synthesized a theory to approach the effect of war type on
population health in the short- and long-term:
(1) Wars in general are detrimental to population health in the short-term,
regardless of the type.
(2) Criminally motivated conflicts, typified by government incompatibility10,
may have a different effect on particular areas that affect health than
ethnolinguistic conflicts (such as the stealing of supplies versus
infrastructure targeting, respectively), but in the short-term, all conflict will
affect population health equally.
(3) While all conflicts will have immediate ill effects on population health,
ethnolinguistic conflicts with a territorial component will have more long-
term effects, due to conflict length, historical disparities, the nature of
segregation, and purposeful and endemic access denial for marginalized
groups before, during, and after conflict.
10 UCDP defines “government incompatibility” as an “incompatibility concerning type of political system, the replacement of the central government or the change of its composition or policies” (Uppsala Conflict Data Program “Definitions”, 2014).
To explain this synthesized theory, we first consider the political, economic,
and territorial aspects of war motivation by exploring the greed/grievance conflict
literature along with the literature that considers ethnic and territorial conflict
components. Subsequently, we will combine the above theories with theories of
health and human rights to create an integrated theory explaining the effects of war
type on population health.
First, we examine the greed vs. grievance theory of civil conflict. Greed- or
criminally-motivated conflicts are usually carried out by a small group of rebels or
bandits that use government incompatibility11 as a cover story for their criminal
motivations (Alesina and Perotti, 1996; Konrad and Skaperdas, 1998; Grossman,
1999; Duffield, 2000; Keen, 2000). In these cases, rebels are willing to use
destructive force if they will receive some immediate payoff (Collier and Hoeffler,
2002; Mkandawire, 2002).
In terms of the effects on health, these types of wars produce immediate
health issues, rather than long-term ones. Attacking healthcare facilities, workers,
and supplies is exogenous to the motivations for the conflict. These attacks are only
done for the immediate payoff in terms of resale value of supplies or medications,
for the purpose of using the goods for their own benefit, or in direct retaliation
towards particular individuals, rather than as a way of affecting an entire segment of
the population (Grossman, 1999; Collier and Hoeffler, 2002). Fighters on both sides
may attack healthcare access as a way of hindering the other’s capabilities in the
11 Government incompatibility refers to the dissatisfaction with the rebel group over the type of government, the particular leaders, or standard policies or laws enforced by the government (Uppsala Conflict Data Program “Definitions”, 2014).
present, but not to cause lasting destruction for society at large or despair for a
particular ethnic or religious group.
These attacks produce detrimental outcomes in the short-term, but do not
tend to have systemic, long-term effects.12 The eleven-year civil war in Sierra Leone
saw many atrocities on the part of both rebels and government forces directly
related the quest for control over the lucrative diamond mines within the country.
During the fighting, hospitals, aid facilities and humanitarian workers were attacked
for their stores of, or access to drugs and medical supplies (Smillie et. al., 2000;
Klare, 2001). Since the conclusion of the conflict in 2002, the country has seen the
“second fastest improvements in the world on the UN Human Development Index”
(Africa Governance Initiative “Sierra Leone”, 2014). The criminally motivated
conflict of the 1990s did little to stem growth after the conclusion of the war.
Grievance motivated wars, on the other hand, are concerned with long-term
capabilities and the effect of attacks on the capabilities of the other side. Grievance
motivated wars tend to be of an ethnic, linguistic, or religious nature, and may have
a territorial component, where rebels are fighting for access to or secession of their
traditional homeland (Reynal-Querol, 2002). Scholars have found that in cases of
long-term discrimination, ethnolinguistic minorities will reach a level of suffering in
which they choose to fight back against the government (Ngaruko and Nkurunziza,
2005). These types of wars tend to have deep-seated, historic connotation in which
the “reasons” for war are passed down through generations, and the “enemy” is
12 The author wants to insure the reader that she is aware that even in criminally motivated wars where ethnic or religious hatred or oppression is not the overall motivating factor, the effects of war can be widespread and horrifying, regardless of their long-term effects.
anyone with a connection to that group, whether they participate in the war or not
(Stavenhagen, 1996).
In these types of wars healthcare services, providers, and supplies are not
only seen as an immediate resource for rebels, but also as a way to weaken
opponents and those who support them. Limiting basic health services can be used
as a strategy to weaken the enemy and force supporters to withdraw their support
for fear of losing access to care. This was the case in the former Yugoslavia where
hospitals known for serving enemy combatants were targeted by government
forces, and non-Serbian minorities were allowed only second-rate or no healthcare
due only to their ethnic affiliation. The support for rebel fighters lost strength as
civilians began to suffer due to widespread restrictions (Buwa and Vuori, 2006).
Population health effects will be prolonged in cases of ethnolinguistic grievance
conflicts because both enemy combatants and entire segments of the civilian
population are denied access to acceptable healthcare.
Territorial conflicts tend to be ethnolinguistic or grievance motivated, and
can aggravate the discriminatory aspects of such conflicts (Yiftachel, 1996, 2006;
Diehl, 1999; Newman, 2006). According to Kubo (2011), territorial secession
conflicts and ethnic grievance go hand-in-hand so frequently that they have become
synonymous (see also Denny and Walter, 2014). These cases have a stronger long-
term effect on health because an entire group considered to be the enemy and they
tend to be isolated and segregated within a distinct area. Poor health infrastructure
and limited access for these groups and areas are likely entrenched in the structures
of society (Cederman and Girardin, 2007; Weidmann, 2009; Wimmer, Cederman
and Min, 2009).
Healthcare services and resources in secessionist or segregated areas may be
inferior or they may be cut off altogether producing poor health outcomes that
continue long after the bullets stop flying (Ghobarah et. al., 2004). This was the case
in Sri Lanka where healthcare quality in the northern Tamil areas was significantly
worse, even during times of peace, and health resources and non-profit healthcare
organizations were prohibited from entering the area during times of heightened
conflict. Though population health and access have improved in the north since the
cessation of violence, they are still behind their southern and western Sinhalese
neighbors after years of restricted access (Reilley et. al., 2002; Nagai, et. al., 2007).
Territorially motivated ethnic conflicts also tend to last longer, with a mean
of approximately 14-years versus eight for criminal, non-secession conflicts (Denny
and Walter, 2014). This is the result of bargaining and settlement problems inherent
in ethnic and territorial conflicts (Hassner, 2003; Goddard, 2006; Toft, 2006). Ethnic
groups may have historical or cultural ties to a region that they are unwilling to part
with regardless of the rising costs. Even if a mutually agreeable settlement can be
reached, the group may remain isolated having to rebuild health infrastructure from
the ground up, without the support system provided by an established government.
As shown above, theories of war and health from various fields can be
combined to support the research question explored in this work: how does war type
effect population health? This question is examined and broken into corresponding
hypotheses below, and investigated with quantitative and qualitative techniques in
the remaining chapters.
RESEARCH QUESTION AND TECHNIQUES
Intrastate conflict is presently more common than inter-state conflict, but
has not been studied to the same extent as conflicts that involve multiple parties,
such as either of the World Wars (Guha-Sapir and Van Panhuis, 2002). This
dissertation combines prior research in the fields of international political economy,
world politics, and global health to explore conflict and post-conflict consequences
of civil war and underlying war motivation on population health while asking the
questions: how does civil war affect population health? Does the “type” of war have
any effect on population health? How long do these effects last? To this end I propose
an analysis of the following intersecting relationships:
Figure 5: Relationship between independent and dependent variables
Figure 5 lays out the variables that are present in all countries at all times
(under economic factors and ‘other factors’) as well as those variables that are
present during times of conflict. These variables weigh on population health to a
varying degree and with varying effect, as explored in chapter three. Using the
framework of variables and relationships laid out above, I will test the following
hypotheses using both quantitative and qualitative research methods:
Hypotheses:
H1a) Civil conflict will have a negative effect on population health (as
measured by infant mortality rate and other population health measures).13
13 In the quantitative analyses presented in chapter three, “short term” or “immediate effects” are shown through quantitative models with no lag or a one-year lag on independent variables (meaning the relationship between the independent variables and dependent variable is either from within the same year, or from one year previous, t-1).
H1b) Civil conflict will have a negative effect on population health in the
long-term.14
H2a) Criminally motivated conflicts typified by government incompatibility
(greed wars) will affect population health differently than ethnolinguistic
conflicts (grievance wars).
H2b) Ethnolinguistic wars with a territorial incompatibility will have a
different effect on population health than ethnolinguistic wars without a
territorial incompatibility.
H2c) The type of war will continue to affect population health differently in
the future.
These hypotheses were explored with a panel data analysis in chapter three,
encompassing a wide number of developing countries over a span of 17 years. The
findings show that the presence of war in general has a severely negative effect on
population health indicators. The effect of war presence stays significant but loses
strength as time passes.
The analyses also show that greed motivated wars tagged have a slightly
worse effect in the present, but the effect dwindles as time passes. Ethnically
motivated wars also have an immediate effect that dwindles. Wars with a territorial
component have an effect on health that grows with time. This corresponds with the
hypotheses, and fits with the theory that the reasons behind attacking healthcare
services and resources have different meanings and goals depending on the “type”
of war. These findings are explored with two case studies in chapter four. With this
14 Long-term effect is shown as through the relationship of the independent variables on the dependent variable either two, three, or five years later in various models.
knowledge we can begin to explore how to best manage post-conflict population
healthcare based on the type of war that was waged.
ORGANIZATION
In the following chapter, I review previous research to shed light on the
effects of conflict on civilian populations using both an international political
economy lens and a public health lens. The relationship between the type of war,
greed versus grievance wars, and the effects of territoriality in war are also
explored. This chapter looks at the differing opinion on the effects of war
motivation, ethnolinguistic versus criminalistic, on the outcomes of civil conflicts,
and the various effects on population health. The chapter then explores the
territorial dimensions of conflict. It also considers the lack of scholarly research into
war motivation and the effects on population health in the short- and long-term.
In chapter three I present empirical analysis of multi-country, multi-year
data to explore the hypotheses stated above. This data is evaluated with quantitative
models using a variety of variables gathered from multiple sources, using the
scholarly research considered in chapter two for assistance and guidance. The
models are presented with no lag and with multiple-year lags on the independent
variables in order to observe the effects of conflict and conflict type on population
health in both the short- and long-term. The models are also presented with a
number of dependent population health proxy-variables in order to better support
the findings.
In chapter four, two case studies, Colombia and Sri Lanka, are presented for
qualitative exploration of the findings from chapter three. The Colombian conflict is
a criminally motivated war of government-incompatibility, while the Sri Lankan
conflict was an ethnically motivated grievance war with a territorial component.
The effects of the type of war on their short and long-term health resources and
general population health match the findings in chapter three, and allow for a more
in-depth look at the effects of war type on population health.
Using the findings from chapter three and four, in chapter five I present the
conclusions to this research as well as recommendations for policy makers to
support improvements in population health both during and after the conclusion of
conflict given the differences in war type and effects, and conclude with the
limitations and further research ideas.
This dissertation attempts to close a gap in the literature by improving on,
combining, and expanding the various disjointed research on health consequences
of war in order to begin on a path towards a coherent theory of population health
after civil conflict. Winston Churchill once said, “healthy citizens are the greatest
asset any country can have.” This dissertation is a first step in understanding how
civil war affects general population health with respect to the motivating factors
behind the conflict, and will be a starting point for better policy making for those
who are most deeply affected after man-made emergency situations, and to allow
for the most positive chances for future development.