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Medicine, Conflict and Survival
ISSN: 1362-3699 (Print) 1743-9396 (Online) Journal homepage: http://www.tandfonline.com/loi/fmcs20
Health in fragile and post-conflict states: a review
of current understanding and challenges ahead
Rohini J. Haar & Leonard S. Rubenstein
To cite this article: Rohini J. Haar & Leonard S. Rubenstein (2012) Health in fragile and post-
conflict states: a review of current understanding and challenges ahead, Medicine, Conflict and
Survival, 28:4, 289-316, DOI: 10.1080/13623699.2012.743311
To link to this article: http://dx.doi.org/10.1080/13623699.2012.743311
Published online: 20 Dec 2012.
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REVIEW ARTICLE
Health in fragile and post-conflict states: a review of current
understanding and challenges ahead
Rohini J. Haar
a,b
* and Leonard S. Rubenstein
c
a
St Luke’s–Roosevelt Department of Emergency Medicine, New York, USA;
b
Columbia
University, College of Physicians and Surgeons, New York, USA;
c
Center for Public
Health and Human Rights, Johns Hopkins Bloomberg School of Public Health,
Baltimore, USA
(Accepted 9 October 2012)
Health systems face enormous challenges in fragile and post-conflict states.
This paper will review recent literature to better understand how, within a
context of economic volatility, political instability, infrastructural collapse
and human resource scarcity, population health deteriorates and requires
significant attention and resources to rebuild. Classifications of fragile and
post-conflict states differ among organizations and reviewing the basic con-
sensus as well as differences will assist in clarifying how organizations use
these terms and how statistics on these nations come about. Of particular
interest is the increase in local conflicts within states that may not affect
national mortality and morbidity but pose heavy burdens on regional popu-
lations. Recent research on sexual and reproductive health, children’s
health and mental health within fragile and post-conflict states highlights
the effects of healthcare systems and their breakdown on communities. We
propose a research agenda to further explore knowledge gaps concerning
health in fragile and post-conflict states.
Keywords: health; medicine; fragile; post-conflict; state; mental health;
sexual and reproductive health; children’s health; conflict state
Introduction: fragile and post-conflict states
Countries that have experienced conflict or political instability face enormous
challenges in recovery. Economic, political, and social structures may have
deteriorated, and lack of physical and human resources make reconstruction
difficult. The health of the population is nevertheless of particular concern to
governments, development agencies, humanitarian organizations and communi-
ties. Stabilizing political structures and government legitimacy will have posi-
tive effects on health systems while conversely reconstruction and
improvement of health infrastructure may have the potential of significantly
*Corresponding author. Email: jrohini@gmail.com
Medicine, Conflict and Survival
Vol. 28, No. 4, October–December 2012, 289–316
ISSN 1362-3699 print/ISSN 1743-9396 online
Ó2012 Taylor & Francis
http://dx.doi.org/10.1080/13623699.2012.743311
http://www.tandfonline.com
improving the governance and political stability of a state. This paper provides
an overview of current literature and addresses the relevance and definition of
fragile and post-conflict states as well as current evidence on the effects of
conflict and fragility on health. It is not a systematic or comprehensive review
of studies conducted but rather a framework to examine the range of work
currently done in fragile and post-conflict states.
Fragile states
The concept of a ‘fragile state’has particular relevance for health in today’s
world for two primary reasons: improving development of health systems and
seeking greater securities. First, fragile states have some of the worst outcomes
in terms of the Millennium Development Goals (MDGs) as well as other
global health statistics (DFID 2005). Numerous studies reveal that post-conflict
and fragile states, or particular regions within states that experience conflict or
instability, have decreased life expectancy, maternal survival, vaccination status
and survival outcomes as compared to their regional and income-ranked
counterparts (Debarati and D’Aoust 2010, WHO 2011). Second, though the
evidence remains limited, concerns exist that because they are unstable, fragile
states may pose security risks both for their own populations and to regional
and global security and that focused assistance to fragile states can stabilize
countries and help prevent future conflict.
Yet there exists no consensus definition of a ‘fragile state’. Though there is
agreement that some states are fragile (e.g., Somalia), applying this term to
others is more controversial (e.g., Cambodia). Further debate exists about the
rank or level of a fragile state, i.e., whether it is declining into fragility,
languishing in fragility, or stabilizing after a volatile period. The importance of
the baseline development index of the country, whether it is a middle- or high-
income country or a low-income one, and its geopolitical and strategic
position, also affects its impact on the global level.
Despite the lack of consensus, exploring the definition of a ‘fragile state’
used by various agencies helps to uncover the motivations for donor interest
and humanitarian programming, as well as the strategic implications of state
fragility. Though many of the commonly agreed upon states are categorized as
fragile under many definitions, there are some interesting differences among
them. The Organization for Economic Co-operation and Development (OECD)
and the Development Co-operation Directorate (DCD-DAC) recently defined
fragile states on the basis that such states lack capacity against two criteria: (1)
legitimacy of the government; and (2) effectiveness of state mechanisms to
carry out governmental functions. A fragile state, according to this definition,
is ‘unable to perform basic functions [like] maintaining security, enabling eco-
nomic development and ensuring the essential needs of the population are met’
(OECD 2008). By this definition, these states are not just poor or corrupt; they
are essentially incapable of accomplishing their basic objectives as a state. The
290 R.J. Haar and L.S. Rubenstein
World Bank has replaced its label of ‘Low-Income-Countries-Under-Stress’
(LICUS) with the term ‘Fragile States’. In its definition, used by many donor
agencies, fragile states are ‘characterized by weak policies, institutions, and
governance’(Carvalho 2006). The income level and Country Policy and Insti-
tutional Assessment (CPIA) rating assist in classifying a country into one of
three subgroups: ‘severe’,‘core’,or‘marginal’. Utilizing this definition, there
were 33 countries or regions classified by the World Bank as severe or core
fragile states in 2011 (World Bank 2011a). Elsewhere, UNDP has an unofficial
composite list of fragile countries that utilizes Food and Agricultural Organiza-
tion and World Bank indicators (Cammack et al. 2006). USAID refers to frag-
ile states generally as ‘failing’,‘failed’or ‘recovering’states because ‘in
USAID’s view, it is more important to understand how far and quickly a
country is moving from or towards stability than it is to categorize a state as
failed or not’(Cammack et al. 2006, p. 88).
Conflict and post-conflict states
Many fragile states, due to violence, political instability, and civil or interna-
tional conflict, also fall into the category of ‘conflict’or ‘post-conflict states’.
Though again no single definition exists, there are numerous indicators to
define which countries (or regions within countries) can be categorized in these
terms and a variety of definitions are used by different agencies.
The Heidelberg Institute for International Conflict Research (HIIK), a lead-
ing institution in work on conflict and post-conflict states, stresses the difficulty
in categorizing states as ‘conflict states,’‘post-conflict states’or a broader cate-
gory. HIIK generally defines conflict, as ‘the clashing of interests over national
values of some duration and magnitude between at least two parties that are
determined to pursue their interests and achieve their goals’(Heidelberg Insti-
tute for International Conflict Research 2010, p.88), which included 135 coun-
tries in 2009 alone. Violent and non-violent conflict, as well as sub-national
conflict are further segmented in the Heidelberg approach into grades of inten-
sity: 1for dispute, 2for non-violent crises such as verbal pressure and eco-
nomic sanctions, 3for violent crisis that is sporadic by at least one party, 4for
a limited war where force is used repeatedly in an organized way and 5as war
where ‘violent force is used with a certain continuity in an organized and sys-
temic way’with extensive measures and possibly resulting in massive destruc-
tion over long duration (Heidelberg Institute for International Conflict Research
2010, p.88). In one example of the complexity of conflict definitions, of the
six wars (intensity level 5) that were in progress in 2008, four (Afghanistan,
Somalia, Iraq and Pakistan) continued in the following year but the remaining
two (Mexico among the drug cartels and Sudan in Darfur) transitioned to ‘lim-
ited war’(4) rather than ‘war’(5) in 2009. HIIK then identifies four new wars
from 2009 that did not continue into 2010, including Sri Lanka, Israel/Pales-
tine, Yemen, and Pakistan among Taliban and tribal militias, that are now
Medicine, Conflict and Survival 291
considered post-conflict regions but still in a ‘state of crisis’(Heidelberg Insti-
tute for International Conflict Research 2010). Though many of the crises and
wars included would not qualify the state as a whole as fragile (as the conflict
is regional or local), this analysis of conflict, crises and wars highlights the
dynamic nature of state stability.
A new analysis for UNESCO utilizes the Uppsala Conflict Data Program
(UCDP) dataset over 20 years to expose the role of factors such as the identity of
actors (state or non-state) and the magnitude of conflict (number of deaths, nutri-
tional status, property destruction) to create an operational definition of post-con-
flict states (Strand and Dahl 2010). Though identifying comparables is
important, even these precise definitions can be confounded by the reality of
complex conflicts. For instance, is a militia a state actor if it receives funding
from the state? Are deaths counted as battle deaths only or do they include total
excess mortality during the war’s period, whether from violence or starvation? In
many places with poor data collection, identifying the numbers dead or the actors
in the conflict may be difficult. And finally, how does one identify the effect of
the conflict on the state? In some places, a small conflict could severely disrupt
the function of the state and in other places a larger or even longer conflict could
make less of an impact despite increased mortality and destruction. Using a defi-
nition of 1000 battle-related deaths over the past 10 years, Strand et al. create a
list of 22 conflict states with four more non-state or extra-definitional conflicts
(Strand and Dahl 2010). Dahl et al. identify 11 countries as post-conflict. These
nations –Angola, Eritrea, Guinea, Indonesia, Ivory Coast, Liberia, Myanmar,
Rwanda, Sierra Leone, United States of America, and Yugoslavia (Serbia) –all
had a conflict that produced more than 1000 battle-related deaths in the 1999–
2008 period but less than 200 deaths in 2006, 2007 or 2008. Despite this more
rigorous definition, each state has very different needs and general assessments
would be misleading, as the inclusion of the United States indicates.
The International Development Association (IDA) at the World Bank
defines ‘post-conflict countries’as: (i) a country that has suffered from a severe
and long-lasting conflict, which has led to inactivity of the borrower for an
extended period of time; (ii) a country that has experienced a short, but highly
intensive, conflict leading to a disruption of IDA involvement; and (iii) a
newly sovereign state that has emerged through the violent break-up of a for-
mer sovereign entity (World Bank 2011a). A conflict or post-conflict country
may be difficult to clearly define, but an operational definition can assist in
creating consensus understandings.
A compilation from numerous lists of fragile and post-conflict states
(Table 1) indicates that 67 states qualify as fragile and 78 qualify as post-con-
flict when including all states labeled under the various definitions. Table 1
highlights the states that fall under at least three definitions of ‘fragile’or
‘post-conflict’: the Xs on the left hand side of the table identify those states
that are ‘fragile’under at least 3 definitions (44 states out of the 67 considered
‘fragile’under one or more definition); the Xs on the far right-hand side of the
292 R.J. Haar and L.S. Rubenstein
Table 1. Fragile and post-conflict states: an analysis of definition
Fragile state under
three or more
definitions
OECD
2010
(1)
World Bank fragile
situations FY 2011
(2)
LICUS from
World Bank
(3)
DFID
(4)
UNDP
Composite (not
official) (5)
Human
Development
Report (6)
Post-conflict
UNESCO
(7)
In-conflict
UNESCO
(7)
CRISE
2009
(8)
UN Peacekeeping
Missions since 2005
(9)
UNDPs
(10)
Post-Conflict State under
three or more definitions
X Afghanistan X X X X X X X X X–present X Afghanistan X
Algeria X X Algeria
X Angola X X X X X X X X X Angola X
Azerbaijan X X X X Azerbaijan
Bahrain X Bahrain
Bangladesh X X Bangladesh
Belarus X Belarus
Benin XBenin
Bhutan X Bhutan
Bosnia and
Herzegovina
XX Bosnia and Herzegovina
Burkina Faso X Burkina Faso
X Burundi X X X X X X X X–2007 X Burundi X
X Cambodia X X X X X X Cambodia
X Cameroon X X X X X Cameroon
X Central African
Republic
XX X XX X X X X–2010 Central African Republic X
X Chad X X X X X X X X X Chad X
China X China
Columbia X Columbia
X Comoros X X X Comoros
X Congo, DR X X X X X X X X X–2010 X Congo, DR X
X Congo, Republic of X X X X X X X X Congo, Republic of
X Cote d’Ivoire X X X X X X X X X–present X Cote d’Ivoire X
Croatia X Croatia
Cuba X Cuba
Cyprus X–present Cyprus
X Djibouti X X X Djibouti
Dominica X Dominica
El Salvador X El Salvador
Equatorial Guinea X X X Equatorial Guinea
X Eritrea X X X X X X X X X–2008 X Eritrea X
(Continued)
Medicine, Conflict and Survival 293
Table 1. (Continued).
Fragile state under
three or more
definitions
OECD
2010
(1)
World Bank fragile
situations FY 2011
(2)
LICUS from
World Bank
(3)
DFID
(4)
UNDP
Composite (not
official) (5)
Human
Development
Report (6)
Post-conflict
UNESCO
(7)
In-conflict
UNESCO
(7)
CRISE
2009
(8)
UN Peacekeeping
Missions since 2005
(9)
UNDPs
(10)
Post-Conflict State under
three or more definitions
X Ethiopia X X X X X X X–2008 X Ethiopia X
Gabon XGabon
X Gambia, The X X X X Gambia, The
Georgia X X X Georgia
X Guinea X X X X X X X Guinea
X Guinea Bissau X X X X X X X Guinea Bissau
Guatemala X Guatemala
Guyana X X X Guyana
X Haiti X X X X X X–2011 X Haiti
India XX–present India X
X Indonesia X X X X X Indonesia
Iraq X X X Iraq
Israel XXX–present Israel X
X Kenya X X X Kenya
X Kiribati X X X Kiribati
Korea, Dem
Republic
XX Korea, Dem Republic
Kosovo X X–present X Kosovo
Kuwait X Kuwait
X Lao, PDR X X X X X Lao, PDR
Lebanon X–present X Lebanon
Lesotho XLesotho
X Liberia X X X X X X X X X–present X Liberia X
Libya X Libya
Madagascar X Madagascar
Malawi XMalawi
X Mali X X X X X Mali
Mauritania X X Mauritania
Mozambique X Mozambique
X Myanmar/Burma X X X X X X Myanmar/Burma
Namibia X Namibia
X Nepal X X X X X X X Nepal X
Nicaragua X Nicaragua
(Continued)
294 R.J. Haar and L.S. Rubenstein
X Niger X X X X X X Niger
X Nigeria X X X X X X–non-
state
X Nigeria
Oman X Oman
X Pakistan X X X X X–present Pakistan
Palestinian
Administration
XX X–present Palestinian Administration
X Papua New Guinea X X X X Papua New Guinea
Philippines X X Philippines
Qatar X Qatar
Russia X X Russia
X Rwanda X X X X X X X Rwanda X
X Sao Tome and
Principe
XX X Sao Tome and Principe
Saudi Arabia X Saudi Arabia
X Senegal X X X Senegal
X Sierra Leone X X X X X X X X X–2005 X Sierra Leone X
X Solomon Islands X X X X X Solomon Islands
X Somalia X X X X X X X X Somalia X
South Sudan X X South Sudan
Sri Lanka X X Sri Lanka
X Sudan, The X X X X X X X X Sudan, The
Swaziland X Swaziland
Syria XX–present Syria
X Tajikistan X X X X X Tajikistan
Tanzania XTanzania
Thailand X Thailand
X Timor Leste X X X X X–present X Timor Leste X
X Togo X X X X X X Togo
Tonga X Tonga
Turkey X Turkey
Turkmenistan X Turkmenistan
X Uganda X X X X X X Uganda
United Arab
Emirates
X United Arab Emirates
X United States of America
(Continued)
Medicine, Conflict and Survival 295
Table 1. (Continued).
Fragile state under
three or more
definitions
OECD
2010
(1)
World Bank fragile
situations FY 2011
(2)
LICUS from
World Bank
(3)
DFID
(4)
UNDP
Composite (not
official) (5)
Human
Development
Report (6)
Post-conflict
UNESCO
(7)
In-conflict
UNESCO
(7)
CRISE
2009
(8)
UN Peacekeeping
Missions since 2005
(9)
UNDPs
(10)
Post-Conflict State under
three or more definitions
United States of
America
X Uzbekistan X X X X Uzbekistan
Vanuatu X X Vanuatu
Vietnam X Vietnam
Western Sahara X X–present Western Sahara
X Yemen, Republic of X X X X Yemen, Republic of
Yugoslavia X Yugoslavia
Zambia X X Zambia
X Zimbabwe X X X X X X Zimbabwe
67 Total # fragile states
on any list
78 total post-conflict states 78
44 44 states listed under
3 or more definitions
17 states listed as post-
conflict under 3 or more
definitions
17
7 states on 3 or more lists of BOTH fragile and post-conflict states
Sources: (1) OECD, 2010. Resource flows to fragile and conflict-affected states. Paris: OECD Publishing; World Bank, 2011. World Development Report: con-
flict, security and development. harmonized list of fragile situations. World Bank; (3) S. Carvalho, 2006. Engaging with fragile states. An IEG review of World
Bank support to low-income countries under stress. World Bank; (4) N. Chapman and C. Vaillant, February 2010. Synthesis of country programme evaluations
conducted in fragile states. Department for International Development, ITAD; (5) R. Muggah, T. Sisk, E. Piza-Lopez, J. Salmon, and P. Keuleers, 2012.Gover-
nance for peace. Securing the social contract. United Nations Development Programme. United Nations Publications; (6) United Nations, 2011. Human devel-
opment report.”United Nations Development Programme. United Nations Publications; (7) H. Strand and M. Dahl, 2010. Defining conflict-affected countries.
The hidden crisis: armed conflict and education. Background paper prepared for the Education for All Global Monitoring Report 2011. UNESCO; (8) A. Langer,
F. Stewart, and R. Venugopal, 2011. Horizontal inequalities and post-conflict development. Oxford, UK: Palgrave Macmillan, Centre for Research on Inquality,
Human Security and Ethnicity (CRISE); (9) United Nations peacekeeping, online, https://www.un.org/en/peacekeeping (accessed 13 November 2012); (10) J.
Oriorhenuan and F. Stewart, 2008. Crisis prevention and recovery report 2008. Post-conflict economic recovery. Enabling local ingenuity. United Nations Devel-
opment Programme. Bureau for Crisis Prevention and Recovery.
296 R.J. Haar and L.S. Rubenstein
table identify those states that are considered ‘post-conflict’under at least three
definitions (17 out of the 78 considered ‘post-conflict’under one or more defi-
nition). Though the lists are not homogenous, comparing them may help create
a more unified understanding of fragile and post-conflict states with practical
implications for policy and research.
Current knowledge about conflict and fragility and its impact on health
However defined, evidence shows that low-income fragile and post-conflict
states generally lag significantly behind other low-income countries on the
MDGs and other economic indicators.
The 1.5 billion people who live in countries affected by organized violence,
defined by political violence or high levels of homicide, are twice as likely to be
undernourished, 1.5 times as likely to be impoverished, and their children are
three times as likely to be out of school. (World Bank 2011a)
Alarmingly, ‘no low income fragile or conflict-affected country has yet
achieved a single Millennium Development Goal’(World Bank 2011b, p.5). A
BMJ study reviewing World Health Survey data estimated that 378,000 violent
war deaths occurred annually from 1985–1994 (Obermeyer et al. 2008).
Analysis of WHO demographic data has shown that:
…the additional burden of death and disability incurred in 1999 alone, from the
indirect and lingering effects of civil wars in the years 1991–1997, was nearly
double the number incurred directly and immediately from all wars in 1999.
(Ghobarah et al. 2003; see also Slim 2008)
Lack of health services and health workers contribute to the civilian casualties
of war.
Although differing definitions and methodologies make it hard to general-
ize about the impact of fragility and conflict on mortality, health and health
systems, several analyses found that in fragile and conflict-affected states
studied, population health worsens during and after conflict (Garfield and
Neugut 1991, Levy and Sidel 2007, Zwi and Ugalde 1991). Increases in infec-
tious diseases, malnutrition, lack of access to emergency care and lack of other
resources can potentially lead to decreased life-expectancy (Roberts et al.
2004, Coghlan et al. 2006b, Degomme and Guha-Sapir 2010).
Evidence in the field of health systems in fragile and post-conflict states is
emerging that suggests that fragile and post-conflict states suffer from poorer
health than their neighbors and experience difficulty transitioning into stable
health systems. Table 2 compares health indicators in ‘Fragile States’(by the
World Health Organization definition) to non-fragile states in similar economic
status or geographical regions. In nearly all indicators, populations in fragile
states are worse off than their counterparts in non-fragile states, including the
Medicine, Conflict and Survival 297
percentage of births attended by a skilled health personnel, measles
immunization coverage among 1-year-olds, percentage of underweight children
under 5-years-old, total fertility rate, life expectancy, neonatal mortality rate
and maternal mortality rate.
Several conflict states, including Kosovo, Liberia, Chechnya, and
Mozambique, underwent destruction or severe damage to health facilities that
reached up to 80% (Cliff and Noormahomed 1988, Physicians for Human
Rights 2001, 2009). A study in Cote d’Ivoire found that the number of
healthcare providers in the war affected regions were dramatically lower than
pre-war levels and was associated with a collapse of infrastructure and health
services for HIV/AIDS related services (Betsi et al. 2006). The poorest coun-
tries, with decreased baseline health service capacity, and even further
decreased capacity after a conflict, have the highest ratios of non-combat
related deaths (Garfield 2008). However, though several studies indicate that
there are significant decreases in life-expectancy and worsening health indica-
tors post-conflict and other studies illustrate the loss of infrastructure and
emigration of health workers from conflict area, the mechanisms of causality
between war and ill-health are yet to be firmly established.
The impact of local and regional conflicts on health
Some more recent studies suggest that health indicators may not be as dramati-
cally affected by modern conflicts as previously thought. The Human Security
Report (HSR) from 2010 argues that ‘nationwide mortality rates actually fall
during most wars,’primarily because local conflicts do not dramatically change
the general trend in the improvement of health indicators worldwide. The HSR
states that ‘of the 52 countries that experienced war in the period from 1970 to
2008, only 8 countries (or 15 percent) experienced any increase in the Under-5
Mortality Ratios during wartime’(Human Security Report Project 2010). This
may be a product of targeting particular demographic groups, the regionaliza-
tion of conflict within a state, or inability to obtain quality health data in con-
flict zones.
In a background paper to the 2011 World development report on ‘Conflict,
security and development’, the World Bank shows that though conflict can
dramatically affect the health of populations directly involved in the violence,
the entire country may not suffer the aftermath equally (Debarati and D’Aoust
2010). Particularly in conflicts that are more locally focused, targeted groups
within populations may be significantly more affected than the population as a
whole. An analysis of the demographic patterns of mortality in Cambodia and
Rwanda post-conflict show that violent deaths were concentrated in males aged
20- to 40-years-old (Heuveline 1998, Walque and Verwimp 2009). As the
population ages, this demographic shift of fewer men continues, creating a
population pyramid that has far fewer men than women and potentially
affecting social behavior and fertility as well as economic stability.
298 R.J. Haar and L.S. Rubenstein
Local factors in smaller conflicts may also be hidden by broader national
data. A comparison of mortality rates between provincial and national regions
within conflict settings reveals that provincial data is often dramatically differ-
ent from national aggregates (Debarati and D’Aoust 2010, CE-DAT 2010). In
Sri Lanka, for example, a recent survey of key informants, healthcare providers
and inhabitants found that the war torn Northern Province had dramatically
lower numbers of physicians and midwives as well as a higher maternal
mortality than neighboring provinces (Nagai et al. 2007).
Finally, national statistics may be inconsistent with local surveys reporting
poor health indicators because of the nature of statistical reporting systems.
Because national reporting may select for populations in more secure environ-
ments and with less disruption of assessment mechanisms, proportionally fewer
conflict-affected populations may be surveyed (CE-DAT 2010, Debarati and
D’Aoust 2010). Regional surveys in Kenya, Congo, Somalia and Ethiopia, for
instance, show that particular regions are less surveyed than others, creating
‘black-holes’that could alter national data. Additionally, generalized country
statistics may not fully assess the breakdown in healthcare delivery in particu-
lar isolated populations such as IDPs and refugees, who usually have worse
health status and may live in camps outside the reach of country data.
The impact of conflict on mental health
There is a growing body of evidence regarding the toll of conflict on the mental
and psychological health of populations. Recent research on inter-state and civil
conflicts, and on various populations including civilians, soldiers, refugees and
specific vulnerable groups such as the elderly, children or women, find increased
incidence and prevalence of mental health disorders during and well after the
conflicts studied (Summerfield 2000, Krippner and McIntyre 2003, Murthy and
Lakshminarayana 2006). Much of the recent evidence comes from the Balkans.
Bosnian refugees who fled the war in Bosnia and Herzegovina had high rates of
physical disability as well as psychiatric co-morbidity compared to standardized
World Health Organization regional baselines (39% depression, 26% Post-Trau-
matic Stress Disorder [PTSD] in a survey population of 534 adults) (Mollica
et al. 1999). A three-year follow-up of the same population revealed that those
who stayed in the region continued to exhibit increased rates of psychiatric dis-
orders compared to persons who left (Mollica et al. 2001). Similarly, a study of
558 Kosovar Albanian households found that 17% of people over 15-years-old
suffered from PTSD and there was particularly increased risk of disorder in those
over 65-years-old (Lopes Cardozo et al. 2000). A sample of 2976 children aged
9- to 14-years-old revealed increased rates of PTSD and grief reactions directly
correlated to the exposure to traumatic events in Bosnia-Herzegovina in 2002
(Smith et al. 2002). As another example, a survey of 99 Bosnian refugee chil-
dren in Sweden revealed a significant correlation between the experience of trau-
matic events and prolonged psychological issues (Angel et al. 2001). More
Medicine, Conflict and Survival 299
Table 2. Health Indicators in Fragile State Summary.
#
Countries
% of births
attended by a
skilled health
personnel, 2000–
2010 (source:
WHO Health
Statistics 2011)
Measles
immunization
coverage among 1-
year-olds, 2009
(source: WHO
Health Statistics
2011)
Children under 5
years that are
underweight, 2000–
2009 (source: WHO
Health Statistics
2011)
Total fertility
rate (per
woman) 2009
(source: WHO
Health Statistics
2011)
Life expectancy
at birth (years)
2009 (source:
WHO Health
Statistics 2011)
Neonatal mortality
rate per 1000 live
births 2009
(source: WHO
Health Statistics
2011)
Maternal mortality
ratio per 100,000
live births 2008
(source: WHO
Health Statistics
2011)
Fragile states 43 50% 73% 23% (42) 4.5 58.1 33.7 558.0
Global WHO data
All
countries NA 82% NA 2.5 66.0 24.0 260.0
BY INCOME STATUS
Fragile states, low income 27 43%⁄72% 25% 4.8 56.5 35.6 641.6
Non-fragile low income
countries
13 60% 83% 4.4 55.0 36.0 580.0
Fragile states, low middle
income
14 61%⁄⁄ 76% 20% 4.2 60.9 31.1 436.3
Non-fragile lower middle
income countries
40 83% 88% 2.8 66.0 26.0 230.0
Fragile states, upper middle
income
1 89% 67% 8% 2.2 68.0 15.0 38.0
Non-fragile upper middle
income countries
49 97% 91% 4.40% 2.1 68.0 11.0 82.0
Fragile states, high income 1 65% 51% 11% 5.3 53.0 40.0 280.0
Non-fragile high income
countries
48 99% 94% NA 1.7 77.0 4.0 15.0
BY GEOGRAPHICAL
REGION
Fragile states in the African
region
28 54.5 37.8 685.6
Non-fragile states in the
African region
20 69% 82% 16% 3.8 52.0 620.0 36.0
(Continued)
300 R.J. Haar and L.S. Rubenstein
Fragile states in the region of
the Americas
1 62.0 27.0 300.0
Non-fragile states in the
region of the Americas
34 92% 92% 5% 2.3 73.0 66.0 9.0
Fragile states in the South-
East Asian region
4 66.5 26.3 307.5
Non-fragile states in the
South-East Asian region
6 72% 92% 25% 2.3 64.0 240.0 31.0
Fragile states in the European
region
3 68.3 18.7 44.0
Non-fragile states in the
European region
50 100% 94% NA 1.6 71.0 21.0 7.0
Fragile States in Eastern
Mediterranean region
3 59.0 39.3 578.3
Non-fragile states in the
Eastern Mediterranean
region
16 90% 89% 11% 2.7 64.0 320.0 30.0
Fragile states in the Western
Pacific region
4 65.8 21.5 323.3
Non-fragile states in the
Western Pacific region
24 92% 87% NA 2.6 72.0 51.0 11.0
Medicine, Conflict and Survival 301
recently, studies of Kosovar survivors of torture have been followed up long-
term and found to have worsening career outcomes, sleep disorders and suicidal
ideation as well as high prevalence of severe pain and reduced physical fitness
(Wang et al. 2010, 2012).
Studies in Afghanistan provide evidence that mental health suffers
significantly during and after conflict. A 2004 paper in JAMA found that 67%
of 799 civilian respondents in Afghanistan suffered from depression, 72%
suffered from anxiety and 42% from PTSD (Cardozo et al. 2004). Women and
those directly affected by trauma were most significantly affected. In a second
Afghanistan study, 38.5% of 1011 respondents suffered from depression,
51.8% from anxiety and 20.4% from PTSD (Scholte et al. 2004). Although
these studies did not report baseline rates, and such baseline rates of mental
health disorders in a general population vary with the location, these levels
appear far higher than in non-conflict areas worldwide.
Literature from elsewhere, in varying circumstances of conflict, also show
related patterns. Evidence from Cambodia reveals that survivors of war may
have psychiatric symptoms three (Kinzie et al. 1989) to 10 years after conflict
(Mollica et al. 1993, 1998, Boehnlein et al. 2004), particularly among those
who continue to be displaced (Mollica et al. 1993). In Chechnya, two thirds of
256 displaced respondents exhibited symptoms such as depression, insomnia,
anxiety and somatization (De Jong et al. 2007). In Lebanon, ravaged by war
from 1975–1990, mothers and children (Macksoud and Aber 1996, Karam
et al. 1998) and hostages (Saab et al. 2003) exposed to traumatic events and
war showed increased prevalence of mental health disorders, particularly
depression and PTSD. Recent studies in Palestine have found long-term psy-
chological trauma among children exposed to conflict. One study showed that
only 2.5% of children 10- to 19-years-old in a sample from Gaza did not exhi-
bit any PTSD. Of the other 97.5% who did exhibit some PTSD symptoms,
32.7% exhibited severe symptoms requiring psychological intervention (Sarraj
and Qouta 2005). Parents of refugee children in Palestine also reported signifi-
cant rates of general conduct problems (Baker 1990) as well as bedwetting,
poor grades, nightmares and aggressive behavior when compared to non-refu-
gee children (Mousa and Madi 2003). Evidence from Iraq (Gorst-Unsworth
and Goldenberg 1998, Ahmad et al. 2000), Rwanda (Pham et al. 2004), Sri
Lanka (Somasundaram and Sivayokan 1994, Somasundaram and Jamunannan-
tha 2002), Somalia (Odenwald et al. 2007) and South Sudan (Paardekooper
et al. 1999) also shows long-term effects of war on mental health.
The impact of conflict on children’s physical health
Conflict may decrease children’s opportunities for education, expose them to
higher risk of sexual violence, malnutrition and disease, deny them treatment
for medical problems, subject them to recruitment as child soldiers or forced
labor, and create health risks from food insecurity and lower immunization,
302 R.J. Haar and L.S. Rubenstein
hospital access, and parental literacy (Kiros and Hogan 2001). Some studies
have reported increased child mortality in conflict via both violent and non-
violent means (Office of International Affairs, National Research Council
1995, Bellamy 1996). Children may also experience more illness than adults in
similar circumstances (Toole and Waldman 1997, Agadjanian and Prata 2003,
Pearn 2003, Coghlan et al. 2006b, Moss et al. 2006).
The cumulative toll on children in war is enormous. A UNICEF report
estimated that:
…in the last decade more than 2 million children have died, more than 6 million
have been permanently disabled or seriously injured, more than 1 million have
become orphans, and more than 12 million have fled their homes. Child health is
of particular concern in poor countries that have undergone long periods of
armed conflict. In low-income countries, where children are already extremely
vulnerable to disease, malnutrition, and trauma, the onset of conflict increases
death rates by up to 24 times, with adverse effects especially for under-five
children. (UN and UNICEF 1996; see also Machel 1996, UNICEF 2001)
There is growing evidence of the severe disruption to child health and educa-
tion. The EFA Global Monitoring Report reviews the impact of conflict on
children’s educational ability, noting that they are at much higher risk for
school dropout and illiteracy (UNESCO 2010).
Worldwide, 16 of the 42 countries with the highest reported under-five
child mortality rates have suffered from conflict, with neonatal deaths, infec-
tious disease, malnutrition, diarrhea and respiratory infections being the pri-
mary causes of death (Black et al. 2003). It may be that states that have poor
health indicators are more likely to become embroiled in conflict, thereby
worsening their health status even further, but establishing causality in this
context is secondary to understanding that the two are fundamentally related,
particularly in terms of practical implications for stakeholders. Furthermore,
even in low-intensity conflicts, the impact of war on children has been
disastrous. The steady decline in infant mortality in Nicaragua from 120 per
1000 live births in 1978 to 76 per 1000 in 1983, halted during the peak of the
Nicaraguan Resistance and the rate did not decline again until after 1987
(Garfield et al. 1987).
Children with HIV/AIDS start at much higher risk of morbidity and mortal-
ity than other children, which makes them even more vulnerable post-conflict
(Ahman et al. 2000). The peak of the AIDS epidemic in sub-Saharan Africa in
the 1990s correlates with a time of many wars and conflicts, so independent
analysis of why mortality rates did not trend down as they did in much of the
rest of the world is difficult. More recent evidence using multivariate analysis
shows that both the AIDS epidemic and political instability have independently
had a significant impact on the high under-5 mortality rates in sub-Saharan
Africa (McMichael et al. 2004, Garenne and Gakusi 2006, Vreeman et al.
Medicine, Conflict and Survival 303
2009). Personal stories of tragedy abound and are marked by both a systemic
and local breakdown in infrastructure (Husic 2008).
The impact of conflict on sexual and reproductive health
It is well-established that systematic gender-based violence has been used as a
tool of war more and more frequently (Bastik et al. 2007, Cohen 2011,
Peterman et al. 2011). The Human Security Report 2012, however, challenges
some of the conventional wisdom on sexual violence during conflict. It reasons
that while ‘focusing disproportionate attention on the relatively small propor-
tion of countries that are deeply affected by [direct] conflict affected violence’
and presenting men and combatants as the agents of all violence, it ignores the
far more pervasive non-combatant violence, often perpetrated within the home
or extended family (Human Security Report 2012). The report proposes to cre-
ate awareness of this bias (caused by media interest in news-worthy stories and
a drive to secure donor funding) while focusing on realigning policy with
evidence-based analysis.
Recent trends nonetheless suggest that higher rates of sexual violence do
not always end with the conflict. Increased sexual violence may persist either
directly (for example as continued violence against women) or indirectly as
increased infertility, HIV and other sexually transmitted diseases, anatomical
pathologies like fistulas that cause permanent disability, and social or psycho-
logical consequences that leave women ostracized, deemed unfit for marriage
and society or with long-term psychological trauma (Steiner et al. 2009, John-
son et al. 2010). In other cases, gender-based violence in post-conflict areas
may undergo a transformation into trafficking, prostitution, forced captivity
and other forms of ongoing sexual victimization. The post-conflict state must
deal with this violence, as well as with the poor status of reproductive health,
and a lack of trained medical staff or resources for birth planning and labor.
The creation of new bodies such as UN Women, and of new research into
women’s health, has served to highlight the importance of women’s health in
post-conflict and fragile states (Crosette 2010). Recent literature exposes the
increasing complexities involved in the understanding of sexual and reproduc-
tive health post-conflict and the need to design appropriate interventions. Here
we examine four of the most prominent issues in that literature:
HIV/AIDS in the aftermath of rape and sexual violence
Conflict and war have traditionally been directly linked with the epidemic
spread of HIV/AIDS. The presence of sexually active peacekeeping forces, the
return of potentially infected soldiers and refugees, and the increase in high-
risk behaviors stemming from desperate circumstances and social upheaval
may act to increase the spread of sexually transmitted diseases (Tripodi and
Patel 2004, Becker and Drucker 2008). In South Asia, increased rates of HIV
304 R.J. Haar and L.S. Rubenstein
at the Jammu and Kashmir border, and among Bhutanese and Sri Lankan
refugees, indicate that HIV prevalence may be higher in some fragile and post-
conflict populations (Save the Children, UK 2002, Subramanian 2002). Similar
work in Afghanistan revealed that the opium trade and insurgency lead to
higher odds of HIV infection (Griffin and Khoshnood 2010). However, recent
research projects by the AIDS, Security and Conflict Initiative (ASCI) find
that ‘governance outcomes have been shaped as much by the perception of
HIV/AIDS as a security threat, as the actual impacts of the epidemic’(de Waal
2010, Becker et al. 2008). ASCI research found that the current indices of
fragility at country level did not demonstrate any significant association with
HIV, calling into question the models used for asserting such linkages.
However, at the local government level, ASCI and other evidence suggests that
conventional indicators of conflict, including the definition of when it ends, fail
to capture the social traumas associated with violent disruption and their
implications for HIV. Though there may not be a direct increase in the HIV
incidence post-conflict, the unique characteristics of HIV management and con-
trol in fragile states is important to grasp; these include targeting at-risk
groups, protection, programming strategies, coordination and integration and
monitoring and evaluation (Spiegel 2004).
Trafficking, prostitution and sexual victimization in post-conflict settings
Trafficking of vulnerable girls and women in the aftermath of a conflict
was first noted in Boznia-Herzegovinia in the 1990s. Even UN peacekeepers
have been implicated as consumers for trafficked women and in assisting
the trafficking (Murray 2002). Several studies show that the presence of
peacekeepers may actually create a demand for trafficking (Panagiota 2003,
Skjelsbæk and Barth 2003, Mendelson 2005). Internally displaced persons
(IDPs) and refugees are at particular risk for trafficking for sexual labor
(Ward 2002, United Nations High Commissioner for Refugees 2003). The
legal complexities of IDP and refugee status, particularly within post-conflict
and fragile states, make these populations particularly vulnerable to exploita-
tion (Steinberg 2005). Several case studies from countries as diverse as
Burma (Young and Pyne 2006), Mexico (Acharya 2004) and Tajikistan
(Mirzoyeva 2004) exemplify the concern with exploitation of refugee and
IDP women and girls. The links between organized crime and trafficking in
post-conflict states are also demonstrated in several studies (International
Organization for Migration 1999, Klopcic 2004).
Maternal health and mortality in fragile and post-conflict settings
Effective and stable health services are necessary for maternal and reproductive
health since death peri-partum is most often caused by lack of access to obstet-
ric care (McGinn 2000, Hill et al. 2007). Conflict regions often report the
Medicine, Conflict and Survival 305
worst shortages in trained healthcare providers, disrupting obstetric protocols
and leading to high maternal mortality ratios, particularly within local conflict
zones even within otherwise relatively stable countries (Debarati and D’Aoust
2010, Kruk et al. 2010, WHO 2011). In Liberia, maternal mortality nearly dou-
bled from 578 per 100,000 live births in 1999 to 994 per 100,000 in 2005
(Liberia Institute of Statistics and Geo Information Services [LISGIS] 2008).
Evidence from Afghanistan shows that the maternal mortality ratio increased to
nearly 1600 per 100,000 and in Sierra Leone, to 1800 per 100,000 –much
higher than prior to their respective conflicts (Bartlett et al. 2002, 2005,
Government of Sierra Leone 2005). In another study of 21 conflict and 21
non-conflict countries in Sub-Saharan Africa, the authors found that the median
maternal mortality ratio in conflict-countries was 1000 per 100,000 births while
non-conflict countries had a median ratio of 690 per 100,000 (O’Hare and
Southall 2007). Countries outside of Africa also show significant changes in
maternal mortality post-conflict. In Sarajevo and Chiapas (Mexico), maternal
mortality ratios increased significantly from before the conflicts in those
regions (Carballo et al. 1996; Physicians for Human Rights 2006). In addition
to maternal mortality, increased reproductive rate is an indicator of lack of
reproductive health services and has been found to increase after conflicts
where states continue to lack capacity to provide birth control (McGinn 2000,
Debarati and D’Aoust 2010).
Empowering women: sexual and reproductive health infrastructure baselines
and potential improvements
It is clear that conflict is a negative determinant of sexual health (Bornemisza
et al. 2010) but effective interventions are lacking. Some (Steinberg 2005)
reason that creating a unified body that focuses on sexual and women’s
rights and health during the post-conflict period would be effective. Others
argue that creating early frameworks through which women’s rights are docu-
mented and highlighted from the beginning of post-conflict planning would
more effectively protect these populations (Schmeidl and Piza-Lopez 2002,
Chemonics International, 2006). A study of Liberian and Sierra Leonean ref-
ugees in Guinea demonstrated that refugees could, with adequate donor fund-
ing, create, plan and implement effective reproductive health programs for
themselves that would appropriately serve their communities (von Roenne
et al. 2010). Another potential contribution is the creation of a ‘Basic Pack-
age of Health Services’that includes sexual and reproductive health services
for the post-conflict or fragile state. Similar packages have been implemented
in Afghanistan since 2005 and South Sudan since 2006, though they have a
significant neglect of gender-based violence services (Ministry of Public
Health 2005, Ministry of Health, Government of Southern Sudan 2006, Rob-
erts et al. 2008).
306 R.J. Haar and L.S. Rubenstein
Challenges ahead: a research agenda
The complexities of attempting to do research in an ongoing armed conflict are
daunting. Nonetheless, developing informed strategies to protect and promote
health during and after armed conflict should be a global health priority. There
is a great deal of interest in the field in developing more sophisticated and reli-
able means of measuring mortality and morbidity in conflict, and these should
be pursued. Further, questions about the causal relationship among conflict,
fragility and health are gaining attention, along with the potential contributions
of health to state-building. A United States Institute of Peace (USIP) confer-
ence in June 2011 on ‘Health in fragile and post-conflict states’, which was the
inspiration for this paper, underscored the need for both programming to
develop health systems in fragile states and the need for research to understand
the dynamics of health, fragility and conflict (Haar and Rubenstein 2011).
Discussions and talks during the conference served as the basis for a research
agenda summarized here.
One important area of work during conflict is clarifying the extent of and
motivations and incentives behind assaults on healthcare, with the goal of pre-
venting them. Understanding these actions during conflict could help prevent
such attacks in the future. Data on recent brutality against health workers and
patients and assaults on health care facilities –as well as strategies to limit
migration of health workers –must be comprehensively collected and analyzed.
Research on the consequences of armed conflict is still emerging. Potential
contextual factors such as the type of conflict, chronicity, topography, regional
patterns, intensity, pre-conflict state of health services, history and culture may
significantly affect both baseline health and health impacts, and warrant study.
Evidence indicates that health investments can potentially contribute to
state building and, perhaps, to enhanced national and local legitimacy, but the
degree to which they can do so is still not clear. These questions are particu-
larly of interest to donors and governments intent on prioritizing international
stability as a goal of involvement in health systems. Donors also need to
directly confront the choice whether the goal of health investment in fragile
and post-conflict states is for population health or political stabilization. To do
so, they require an informed knowledge base. Given the importance placed by
some donors on building state legitimacy, a robust exploration of how to
structure aid programs in poorly governed states to improve health and health
systems without supporting corrupt or repressive governments deserves atten-
tion. With more focus on the structure of local health systems prior to and
during conflict, it is also important to consider whether decentralization models
are effective to address local grievances or compensate for a weak state.
Another stimulating field of work is how best to empower all stakeholders,
including women in local communities and local health workers and local health
bureaus, to create strong community-based health systems. With the prominence
of community-initiated health programs in recent years, this would be an exciting
Medicine, Conflict and Survival 307
field, particularly in post-conflict and fragile states that have sustained a complete
breakdown of previously hierarchical, top-down infrastructure.
Military assistance is now commonly directed towards advancing disaster
relief, disease surveillance and research and provision of health services in
highly insecure areas. With vast resources, the military is a growing part of the
aid community, but a true understanding of how its actions and its political
stance in different countries could affect civilian health systems –as well as
the tensions between assistance and military objectives –is vital.
Finally, from a broader perspective, it is clear that fragile states need assis-
tance in building effective health systems from the outset. These issues are
beyond the scope of this paper, though we note that there is an emerging body of
writing that brings thoughtful attention to past experiences and lessons drawn
from efforts at post-conflict reconstruction of health systems. Additional work is
needed, including looking at the role of the humanitarian sector and transitioning
from humanitarian to development goals. In particular, attention on how to
restructure humanitarian aid programs with a view towards long-term health sys-
tems development is key to creating rational early-intervention programs with
long-term goals in mind. Humanitarian agencies could begin looking at how their
work influences the stability of national health ministries, especially in high
intensity settings or protracted conflicts. While it is vital to meet short-term health
needs, it is equally important to develop a coherent long-term strategy.
Conclusion
Even allowing for the varying definitions of post-conflict and fragile states,
these states tend to carry a heavier burden of illness and death, especially for
vulnerable populations within them, including women, children and refugees
and displaced persons. Research into conflict and fragility has shown that
health, both generally as well as in realms such as mental health, sexual and
reproductive health and children’s health, is gravely affected by violent politi-
cal circumstances. Further understanding of the health consequences of fragility
and conflict is vital to recovery.
Acknowledgements
We thank Stephen Commins at the International Medical Corps for invaluable
contributions, Margaret Kruk at Columbia University for her advice and mentorship, and
Anjalee Kohli and Suzanne Dyer for their assistance. We also thank the United States
Institute of Peace and all the contributors to their conference on Health in Fragile States in
June 2011, whose dedication and commitment to their work inspired this paper.
Notes on contributors
Rohini J. Haar, MD, is an attending emergency medicine physician at St. Luke’s–
Roosevelt Hospitals at the Columbia University College of Physicians and Surgeons
and a student of public health at the Mailman School of Public Health at Columbia
University. Her most recent work has focused on the impact of humanitarian action on
308 R.J. Haar and L.S. Rubenstein
local healthcare providers and the transition from humanitarian to health systems
models in post-crisis regions.
Leonard Rubenstein, JD, LLM, is Senior Scholar at the Center for Human Rights and
Public Health at the Johns Hopkins Bloomberg School of Public Health. Previously, he
served as Executive Director and then President of Physicians for Human Rights and
chaired the Health and Peace Building Working Group at the United States Institute of
Peace.
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