International humanitarian law violations in northern Uganda: victims' health, policy, and programming implications

Abstract

Experience of serious violations of International Humanitarian Law (IHL) results in complex physical disability and psychosocial trauma amplifying poverty and multi-generational trauma and impeding long-term recovery. We use data from a representative sample of victims in the case Prosecutor V. Dominic Ongwen brought before the International Criminal Court. Thirteen years after the 2004 massacre, the victims were significantly worse off than the general war-affected population that did not experience serious violations of IHL. The differences in health and wellbeing persisted for individuals and their households, including children born after the massacre. The victims have significantly lower availability of appropriate health services and medications, including significantly greater distance to travel to these services. These findings call attention to the needs of people having experienced IHL violations, for provision of physical and emotional trauma care to allow for recovery, and better understanding of the short- and long-term impacts of IHL violations.

Full text

Vol:.(1234567890)
Journal of Public Health Policy (2023) 44:196–210
https://doi.org/10.1057/s41271-023-00407-8
ORIGINAL ARTICLE
International humanitarian law violations innorthern
Uganda: victims’ health, policy, andprogramming
implications
AnastasiaMarshak3 · TeddyAtim1,2· DyanMazurana1
Accepted: 23 March 2023 / Published online: 20 April 2023
© The Author(s) 2023
Abstract
Experience of serious violations of International Humanitarian Law (IHL) results
in complex physical disability and psychosocial trauma amplifying poverty and
multi-generational trauma and impeding long-term recovery. We use data from a
representative sample of victims in the case Prosecutor V. Dominic Ongwen brought
before the International Criminal Court. Thirteen years after the 2004 massacre, the
victims were significantly worse off than the general war-affected population that
did not experience serious violations of IHL. The differences in health and wellbe-
ing persisted for individuals and their households, including children born after the
massacre. The victims have significantly lower availability of appropriate health ser-
vices and medications, including significantly greater distance to travel to these ser-
vices. These findings call attention to the needs of people having experienced IHL
violations, for provision of physical and emotional trauma care to allow for recovery,
and better understanding of the short- and long-term impacts of IHL violations.
Keywords Serious violations of International Humanitarian Law· Uganda· Health
access· Health policy· International Criminal Court
Key messages
• Conflict has long lasting and profound impacts. Thirteen years aftera massacre,
individuals and members of their households who survived experienced far more
physical disability, direct negative effects on their livelihoods, reduced financial
* Anastasia Marshak
anastasia.marshak@tufts.edu
1 Feinstein International Center, Tufts University, Boston, MA, USA
2 York University, Toronto, ON, Canada
3 Feinstein International Center, Tufts University, 75 Kneeland St, 8th Floor, Boston, MA, USA
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International humanitarian law violations innorthern Uganda:…
resources, and increased food insecurity–compared to the general war affected
population that did not experience a human rights violation.
• The effect of surviving a massacre has a multi-generational association with
worse outcomes. Children not yet alive during the massacre but born into victim
households have lower school enrollment and attendance rates than their peers.
• Despite experiencing extremely high levels of disability and poor psychoso-
cial wellbeing, the victim population lacks appropriate physical and emotional
trauma care and therapeutic treatment, inhibiting recovery and leading to multi-
generational differences from the general population.
• Better recognition of human rights violations and the impact of the experience
on wellbeing can improve provision of appropriate health services, therapeutic
treatment, and trauma care.
Introduction
Humanitarian crises—an event or a series of events that are threatening in terms of
health, safety or well-being of a community or large groups of people—are often
caused by complex and protracted conflicts, meaning conflicts that endure over sev-
eral years. Conflicts, as opposed to other humanitarian crises, drive 80% of the cost
of all material and logistic assistance needed during and after a humanitarian crisis
[1]. Current examples include the Ukraine, Democratic Republic of Congo, Afghan-
istan, Yemen, Sudan, South Sudan, Syria, and Somalia. Conflicts contribute to the
global prevalence of people living with disability [2] and psychosocial trauma.
Conflicts can also lead to experiences of serious violations under International
Humanitarian Law (IHL) (also known as war crimes). IHL is a set of rules which
seek to limit the effects of armed conflict, specifically protecting persons who are
not or are no longer participating in the hostilities and restricts the means and meth-
ods of warfare. Serious violations of IHL can take place in international or non-
international armed conflicts. Violations of IHL are considered serious if they
endanger protected persons (such as civilians) or objects (such as infrastructure) or
breach important values. Specific war crimes or serious violations of IHL include
murder, attempted murder, torture, enslavement, outrages upon personal dignity, pil-
laging, destruction of property and persecution, forced marriage, rape, sexual slav-
ery, enslavement, forced pregnancy, and conscripting children under the age of 15
[3].
Having experienced serios violations of IHL inhibits long term recovery. The
most frequently quoted figure, although not updated since 2004, is that 15% of the
world population experiences a disability [4]. More recent evidence points to an
increase in that proportion, driven by an aging population, climate disasters, and
conflict [2]. A 2018 Needs Assessment from Syria following the war shows that
99% of all individuals above 59years of age had a disability, as did almost one-
fifth of all children under the age of 18 [5]. To improve policy and programming
in conflict affected contexts, we need to better understand the impact of serious
violations of IHL and resulting experience of physical and mental disability and
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198
A.Marshak et al.
overall wellbeingand to investigate whether appropriate health services are avail-
able to contribute to recovery and prevent multi-generational trauma.
Research on the impact of war violence on civilian populations has focused
primarily on mortality, malnutrition, and infectious disease and shows worse out-
comes for war-affected populations [6–9]. A body of literature is growing on the
role of specific forms of serious violations of IHL on mental health outcomes for
victims and survivors [10–13], with less attention to the physical consequences
and impacts on livelihoods [14–17]. Studies found that victims of violations or
abuses, who vary by sex and age, often have diminished mental and physical
health and quality of life, reduced economic and educational opportunities, and
experience stigma by their families or communities. Some studies also found that
female victims, in particular, may have experienced increased domestic and sex-
ual violence post conflict [18–20].
There is less focus in the literature on the availability and use of appropri-
ate health care for victims of war violence. Most research focuses on combat-
ants showing that in low resource countries, there is poor availability of thera-
peutic health care [18, 21, 22]. Even in high resource countries like the United
States, veterans from wars in Iraq and Afghanistan seeking health care are so
abundant that they have overwhelmed the Veterans Health System with their seri-
ous health care needs, resulting in inadequate overall care [23, 24]. Most health-
focused studies on war violence against civilians focus on framing, diagnosing,
and describing the mental and psychosocial health of their study populations [10,
12, 25–27].
To improve our understanding of the association of serious violations of IHL with
outcomes of well-being, we draw on a novel set of data originally collected by the
authors as part the case Prosecutor V. Dominic Ongwen in conflict-affected Uganda
brought before the International Criminal Court (ICC). The ICC investigates and,
where warranted, tries individuals charged with serious violations of IHL. The ICC
is governed by an international treaty called the Rome Statute, which establishes the
ICC as a permanent institution that has the power to exercise its jurisdiction over
persons for the most serious crimes of international concern. It serves as a comple-
mentary institution to national criminal jurisdictions. The ICC put Dominic Ongwen
on trial in 2015 for a series of war crimes committed in northern Uganda (see Sup-
plementary TableS1).
This study documents the physical, material, and psychosocial harm suffered by
the victims of Ongwen in massacres committed in three Internally Displaced Camps
(IDP), assesses the immediate and repercussive effects on the victims and their
households and recommends appropriate responses. We use a unique approach to
assess or hypothesize “impact” by comparing data directly from the victims to the
general war affected population in the Lango and Acholi sub-region that did not suf-
fer a serious violation of IHL. The use of data from a research study, as opposed to
individual witness testimonials, in an international criminal proceeding is novel and
offers insights into the long-term (13years after the event) harms of serious viola-
tions of IHL. In the supplementary material, we provide a timeline of events relevant
for the massacres in the three IDP camps northern Uganda in 2004 and the method-
ology used for the data collection and analysis.
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International humanitarian law violations innorthern Uganda:…
Results
IHL violations
As a result of the LRA attacks against the three IDP camps in 2004, the 396 liv-
ing victims experienced an average of 6.9 serious violations of IHL. The experience
of IHL indicates that serious violations clustered during the attacks, with half of
the victim population (VP) experiencing 6 or more serious violations. Critical for
understanding the association of IHL violations with well-being is understanding
the collective experience of all members of the household. Ninety-one percent of
victims came from a household where a household member, other than the respond-
ent, experienced a serious violation of IHL. On average, each of the VP households
experienced 22 serious violations. We present a qualitative narrative of the house-
hold level impact described by the VP below (Table1).
Psychosocial wellbeing
Using the AYPA tool, we observed significant differences between men and women,
with women doing worse when it comes to depression, anxiety, and somatic com-
plaints without medical causes. More so, experience of multiple IHL violations had
a compounding effect for women (p < 0.01), with each additional violation increas-
ing the AYPA by 1 point (out of 96), compared to 0.33 points for men (p = 0.09).
Of all the IHL violations, the experience of losing a child or having one’s child
injured had the greatest contribution to the AYPA (p < 0.05), together contr ibuting
to 22 percent of the mean score. The association between psychosocial trauma and
loss, but particularly the loss of a child comes out clearly in the testimonials (#2
in Table1). Although we cannot compare the overall AYPA score between the VP
and the general population (GP), given that each IHL violation is associated with an
increase in the AYPA, we can hypothesize that the VP would have a higher AYPA
score, indicating overall worse psychosocial wellbeing.
Health services availability
Two-thirds of the VP reported having a disability compared to 16% of the GP (Table2).
A VP has on average 2 disabled individuals in the household with 70% of household
members classified as dependents, compared to 47% in the GP. Disability can have long
lasting effects on livelihood opportunities and income for both the affected individuals
and their caretakers (#3 in Table1).
Given the high level of physical harm experienced by the VP population with
respect to the GP, we look at ‘access’ to health services for routine and serious
health problems. ‘Access’ encompasses availability of appropriate treatment, cost
of treatment, and distance needed to travel for treatment all in one question. Com-
pared to the GP, it takes VP households significantly longer (in minutes) to reach
a health clinic, VP were significantly less likely to say they can ‘access’ a health
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Table 1 Direct quotations from victim population
Citation # Quote References
1 On the day of the attack at Abok, I had just returned back from hospital because of an earlier LRA attack that had
left me wounded. My brother and I had gone to the village [from the camp in Abok] to dig and that is when we
were attacked by the rebels. My brother was killed while I was hacked on the head with a machete. On the day of
the attack at Odek, my wife and children were set ablaze in the hut, but they managed to escape away. The rebels
also looted all our property while destroying some of the things they could not take with them
Male interviewee from Abok
2 Due to the war, our life and the entire community has been destroyed so much. Trauma is still there to date in the
families who were affected. Like for us, we lost about 40 people from our close family during the attack. They
were all were related to us—from the same lineage. So, life is not the same. There is high level of alcoholism in
the community to as a way to help people forget what happened to them. But due to the high level of alcoholism,
people are unable to work or function normally. They are not well enough to produce enough and provide for
their families, thus poverty is on the increase in most households
For me, I had a lot of dreams. I would dream of my sister’s son who I played with together, but he was killed in the
attack. Sometimes I would see him in my dream with a panga [machete] coming to kill me so I could go where
he is. This is because after his death, I thought about him so much because I felt so lonely and this caused me
those dreams
Male interviewee from Lukodi
3 During the time my sister was with the rebels (was abducted the day of the attack and spent seven years in rebel
captivity returning with a child), she was wounded on her leg and also had a bullet lodged in her chest. That bul-
let was removed when she returned home
Once the pain starts, she is unable to do even basic things such as farm the land or cook. Because of my sister’s
injury and mental condition (spirit attacks), I have to provide for all her needs. That is why we live close to each
other so I can support her and her child
Female interviewee from Odek
4 She has to see a doctor all the time but we can’t afford the costs. We also have to check or have her brain examined
to ascertain the extent of the damage on her head, but we have not yet done it. We don’t know how…we can’t
afford it
We have to buy her medication each time she complains of headache, which she has constantly especially when
she is exposed in the heat for a long time. If she has taken a long time in the sunshine, that causes her nose to
bleed all the more. So, she can’t be exposed in sunshine for long because it will cause her headache and bleeding
from her nose. We can’t afford to take her to hospital that can provide her good help
Female interviewee from Abok
5 Because there was no men to help us [after the murder of my father in the Odek attack], we couldn’t produce
enough food for the family. We always had food shortages at home. My mother alone couldn’t produce enough
on her own to feed the entire family. There was nothing extra to sell to send us to school
Female interviewee from Odek
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International humanitarian law violations innorthern Uganda:…
Table 1 (continued)
Citation # Quote References
6 We are unable to continue with school because getting money has become a lot harder today because our main
source of livelihoods was lost [in the Lukodi attack]. If my elder brother was here [he was abducted during the
attack and never returned], possibly he would be supporting our parents to raise income to send the younger ones
to school, as is expected of any elder brother
Male interviewee from Lukodi
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202
A.Marshak et al.
Table 2 Self-reported outcomes by study group and gender of participant (%/mean with confidence interval in brackets)
***Significant at p value < 0.001, **significant at p value < 0.01, *significant at p value < 0.05
Male Female Total
Victim population General population Victim population General population Victim population General population
Have a disability (%) 64.5** 16.6 69.3** 23.6 67.0** 21.1
[57.7–71.2] [12.3–20.8] [62.8–75.9] [20.0–27.3] [62.3–71.7] [18.3–23.9]
Number of people w/disabilities in
thehousehold (mean)
2.07** 0.47 2.15** 0.53 2.11** 0.51
[1.85–2.30] [0.38–0.56] [1.92–2.38] [0.46–0.60] [1.95–2.27] [0.46–0.56]
Dependency ratioa0.67** 0.45 0.72** 0.48 0.70** 0.47
[0.64–0.70] [0.42–0.48] [0.69–0.75] [0.46–0.50] [0.67–0.72] [0.45–0.49]
Travel time (minutes) 143** 93 143** 100 143** 98
[124–163] [83–102] [126–161] [92–109] [130–156] [91–104]
‘Access’ for routine healthproblems
(%)
4.6* 9.8 5.5* 11.8 5.0** 11.1
[1.6–7.5] [6.4–13.2] [2.3–8.6] [9.1–14.6] [2.9–7.2] [9.0–13.3]
‘Access’ for serious healthproblems
(%)
3.6 8.3 4.1* 9.2 3.9** 8.6
[1.0–6.2] [4.5–12.1] [1.3–7.0] [6.7–11.7] [1.9–5.8] [6.7–10.5]
Availability (%) 7.4** 19.4 10.9** 20.6 9.7** 20.2
[4.4–10.4] [14.9–23.9] [6.6–15.3] [17.2–24.1] [6.7–12.6] [17.4–22.9]
Financial capacity 4.95** 5.37 4.48* 4.76 4.70** 4.98
[4.78–5.12] [5.22–5.52] [4.31–4.66] [4.64–4.88] [4.58–4.83] [4.88–5.08]
Food insecurity 21.7** 14.0 20.5** 15.4 21.1** 14.9
[19.8–23.7] [12.7–15.4] [18.7–22.4] [14.4–16.4] [19.8–22.4] [14.1–15.7]
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International humanitarian law violations innorthern Uganda:…
clinic that has the services they need for routine and serious health problems, and
the VP were significantly less likely to report that the clinic had the necessary
services and medication available (Table2). These differences remain when con-
trolling for other individual and household level characteristics (Table3).
Using the MSI as indication for the financial capacity to pay for services,
we found that the VP population has significantly less assets and hence finan-
cial capacity than the GP (Table2). The more IHL violations experienced by an
individual or in a household, the lower their financial resources (p = 0.02 and
p < 0.01, respectively). A mother explains the relationship between IHL viola-
tions and financial resourceswhen speaking about her daughter who as a child
was severely burned by the LRA during the attack (see #4 in Table1).
Long‑term effects
More than a decade after the war, the experience of IHL violations is directly
associated with food insecurity (Table2). Citation 5 (Table1) from a male victim
participant shows the link between the attacks and immediate and prolonged food
insecurity, including how the breakdown of families exacerbates household food
insecurity today.
The association of the serious violations of IHL and worse outcomes is not
limited to the VP but affects all members of the household. Boys and girls in
VP households are significantly less likely to attend school every day (Table4).
The difference remains for children who were between the ages of 5 and 10years
at the time of the survey, and hence were not alive during the massacre in 2004
(p = 0.01) (Citation #6 in Table1).
Table 3 Multivariate logistic and linear regression on health access and quality outcomes (n = 1210)
‘Access’ for routine
healthproblems
‘Access’ for serious
healthproblems
Availability Travel time
(minutes)
Odds ratio p value Odds ratio p value Odds ratio p value Coef p value
GP (reference: VP) 2.20 0.01 1.99 0.04 2.04 0.00 − 43.16 0.00
Female (reference:
male)
1.41 0.16 1.38 0.25 1.16 0.43 − 8.58 0.20
Age 1.00 0.89 1.00 0.86 1.01 0.15 − 0.32 0.10
Educational attain-
ment
1.01 0.68 0.99 0.74 0.99 0.74 − 3.24 0.00
Household size 1.07 0.09 1.06 0.14 0.98 0.49 − 1.92 0.11
Financial capacity 1.08 0.39 1.19 0.10 1.07 0.31 − 4.33 0.08
Food insecurity 0.98 0.08 0.97 0.02 0.99 0.08 0.17 0.49
Constant 0.01 0.00 0.01 0.00 0.04 0.00 252.92 0.00
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A.Marshak et al.
Discussion
The findings from the study and how they were used in the case against Ongwen
illustrate four key things. First, the extent of serious violations of IHL experienced
during the brief massacres in the three IDP camps in 2004 are far greater than what
the average household in war affected Lango and Aholi sub-region experienced
across the entire 20 + years of war. Second, the possible impacts of IHL violations
are compounding and can last for at least a decade after the event, in a multi-gen-
erational manner. Third, despite the association of IHL violations and physical dis-
ability and psychosocial wellbeing, the affected population has less access to the
health services they need, impeding long-term recovery. And fourth, getting data on
the association of serious violations of IHL with key outcomes is not just possible
but absolutely necessary to represent the experiences of the victims and determine
appropriate reparations and national health policy.
Across the 20 + years of war, a representative survey of Acholi and Lango sub-
region (using the same questions as our survey), found that on average, individuals
experienced 0.34 serious violations of IHL, with those who experienced a serious
violation averaging 2.5 violations [20]. In contrast, as a result of the LRA attacks
against the three IDP camps in 2004, victims experienced an average of 6.9 seri-
ous violations of IHL. To put it more starkly, the VP experienced, on average, 20
times more serious violations of IHL compared to the average war affected person
in Acholi and Lango, with children experiencing 14 times more violations than indi-
viduals in the sub-region representative survey. On average, each of the VP house-
holds experienced 22 serious violations, compared to the average household in
Acholi and Lango where members experienced 2.3 violations per household over
the 20years of war [20].
Few studies look at the role and availability of health care for affected popula-
tions. Research among IDPs in Gulu and Amuru districts in northern Uganda
shows that being ill without medical care had the strongest association with post-
traumatic stress disorder and depression, with over half of all respondents having
reported these symptoms; less than one-third being able to get the appropriate care
[28]. Another study in Gulu district identified a lack of services available to vic-
tims of gender-based violence (GBV), specifically limited qualified staff and medi-
cal supplies to detect and manage survivors and services offered without ensuring
Table 4 Attendance at schools
(means with confidence interval
in brackets)
***Significant at p value < 0.001, **significant at p value < 0.01,
*significant at p value < 0.05
Victim population General population
Boys attending
school every day
(%)
48.6** 65.2
[42.9–54.4] [61.0–69.3]
Girls attending
school every day
(%)
46.4** 62.0
[40.6–52.2] [57.8–66.3]
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International humanitarian law violations innorthern Uganda:…
confidential treatment and counseling [29]. A more recent review (2021) found
that almost two-thirds of medical care professionals dealing with GBV in Uganda
needed additional training and nearly half were uncertain or disagreed that there
were clear protocols for care of survivors [30]. A study in three districts in northern
Uganda shows how the conflict itself can directly affect the health services required
by the affected population with direct attacks on health facilities, looting of medi-
cal supplies, and abduction of health providers [31]. While health care access was
poor before the war, the limited evidence to date points to an even further weakened
health care system that is unable to meet the physical and mental health care needs
of the war-affected population. In northern Uganda, Betancourt et al. (2009) and
Porter (2016) investigated how local government health providers dealt with mental
health problems. They have provided important insights into how culture mediates
what constitutes ill-health, its sources and manifestations, and solutions people seek
to restore their health [32, 33].
The reports on serious violations of IHL shows that individuals and their house-
holds affected by a massacre are significantly different from the general war-affected
population, in both their experience of IHL violations [20] and the possible impact
of those violations. The VP are significantly worse off in terms of their psychosocial
and physical well-being; these are directly associated with lower wealth and worse
food insecurity, further exacerbated by less access to and lower rates of utilization
of health services. The complexity of physical and mental health needs of the war-
affected population is rarely addressed and redressed in the northern Uganda context
[34]. The data also show that the association of IHL violations with worse outcomes
is not only for the individual, but also for those in the households where individu-
als live, making recovery even more difficult. When it comes to the VP households,
the association of IHL violations with worse outcomes is apparent in lower rates of
school attendance by children who were not even alive at the time of the attacks. Not
only does the continued association with worse outcomes point to possible multi-
generational impact, but also exacerbates a possible ‘poverty trap’ (the poor cannot
escape their poverty and with lack of resources only get poorer) for affected house-
holds created in part by their lower educational attainment [35]. The experiences of
serious violations of IHL are compounded, with worse outcomes associated with
more IHL violations.
The VP report longer travel time to health facilities, are less likely to have access
(measured as a combination of travel, cost, and availability of services) to the ser-
vices they need for routine or serious health problems and are more likely to report
that the health services and medications that they need were not available. The dif-
ference in ‘access’ to, availability of, and travel time to appropriate health services
between the GP and VP is not likely related to the use of different health centers,
given the geographical proximity, but rather an indication of the significantly greater
needs of the VP population. The IHL violations experienced by the VP populations
is associated with far more complex psychosocial and therapeutic medical needs
than services available at already poor and understaffed health centers. An in-depth
analysis of the war-wounded within the same population in Uganda shows that there
is a lack of the necessary treatments required for their ailments at the health centers,
leading affected individuals to become disillusioned and discouraged from seeking
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206
A.Marshak et al.
the help they need [36]. Previous research in Uganda shows that when health ser-
vices are targeted, they are much more likely to benefit combatants compared to
their non-combatant peers as a result of programming by nongovernmental agencies
focus on youth combatants [18].
The study also indicates that data on the association of IHL violations with key
outcomes can be collected and serve as a new type of evidence to present before
the ICC and to use to improve government policy. Data on the effects of war and
serious violation of IHL are critical to give voice to the affected population in inter-
national cases and to affect national health policy. Witness or expert testimonies in
court cases are traditionally limited to one aspect of the serious violations of IHL
that take place. This study provides holistic evidence about the immediate and long-
term association between the conflict and worse outcomes. The mix of quantita-
tive data and testimonials allows us to demonstrate the effect of the human rights
abuses on the lives of the victims, offer them a means to represent themselves, and
offer the court tangible data for determining reparations. Based on the findings, the
research team was able to give specific recommendations on how to target services
and provide support to the most affected, strengthen psychosocial support and dis-
ability support, provide specialized therapeutic health services, provide education
support, and the need for physical and monetary compensation for destroyed assets
and livelihoods.
The findings have direct implications to international and government actors
working in previously conflict affected contexts, not only in Uganda, but across the
multitude of protracted humanitarian contexts driven in part by conflict. Once the
initial conflict subsides, there is a tendency by development partners to treat popula-
tions as `post-conflict’, as though internal differentiation, including varying experi-
ences of serious violations of IHL and related experience of disability and trauma,
is unimportant. The findings from this study support the argument that post conflict
national health actors and development partners cannot safely assume that everyone
is recovering or recovering equally. Instead, these data expose disadvantages pre-
viously unappreciated, including persistent health inequality and multi-generational
trauma to individuals, households, and communities.
Our study confirms that in post-conflict settings, war continues to be associated
with long lasting and profound negative outcomes that need to be directly addressed
in rebuilding war-damaged healthcare systems and treating the war-wounded. More
attention should be given to the psychosocial and physical health needs of civilians
suffering from IHL violations and disability, and the association with their disad-
vantage in receiving therapeutic treatment over time. Knowledge of the prevalence
and negative relationship of war crimes with civilians’ mental and physical health,
disability and access to health should be used to help develop more responsive post
conflict health and psychosocial policies and services.
Study anddata limitations
Because data collection occurred 13 years after the massacres the sample is only
representative of the individuals who survived and did not migrate from the area.
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International humanitarian law violations innorthern Uganda:…
Thus, the sample prevalence of serious violations of IHL is likely biased, either
downward because individuals who were murdered or disappeared are not included
in the sample, or upwards because those who experienced fewer violations might
have been able to migrate since the massacre. Because men were overwhelmingly
more likely to be affected by direct combat, taken as child soldiers, or disappeared
[37], our sample, purposely stratified by sex, is again not representative of the real
sex-based experience of IHL violations. Another limitation is that the data is self-
reported. Although the findings point to a multi-generational association between
IHL violations and worse outcomes, having nutrition and health data collected
from the children under five (using standard anthropometrical methods) would have
been critical to prove this hypothesis. The analysis also operates under the assump-
tion that prior to the attacks the respondents in the VA survey were more likely
to resemble the general population and hence attributes differences in 2018 to the
2004 attack. Without data prior to the attack, we cannot confirm that this is the case;
however, given that the GP sample is representative of the area from which the VA
population was sampled and that the attacks were not targeted based on household
characteristics, we feel confident that we are comparing two populations that more
or less resembled each other prior to the massacre.
Conclusions
The findings from this study were presented by the Legal Representative of the Vic-
tims as testimony during Ongwen’s trial to give voice to the victims and for consid-
eration of reparations. More broadly, these findings illustrate how future studies in
conflict and post-conflict contexts need to prioritize the collection of IHL violation,
disability, and psychosocial trauma data to ensure better programming and policy.
Without appropriate services, disability and psychosocial trauma can have long-term
consequences beyond the affected individual leading to a growing cycle of poverty.
Supplementary Information The online version contains supplementary material available at https:// doi.
org/ 10. 1057/ s41271- 023- 00407-8.
Funding Funding was provided by Office of the Prosecution and Department for International Develop-
ment, UK Governmentand the Leir Foundation.
Declarations
Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of
interest.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as
you give appropriate credit to the original author(s) and the source, provide a link to the Creative Com-
mons licence, and indicate if changes were made. The images or other third party material in this article
are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the
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ses/ by/4. 0/.
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208
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Anastasia Marshak, Ph.D., is a senior researcher at the Feinstein International Center, Tufts University,
Boston, MA, USA, and an Assistant Research Professor at the Friedman School of Nutrition Science and
Policy, Tufts University, Boston, MA, USA.
Teddy Atim, Ph.D.,is a Postdoctoral Fellow at York University, Toronto, Ontario,Canada and continues
to work as a collaborator on research studies in Uganda with the Feinstein International Center as a Visit-
ing Fellow.
Dyan Mazurana, Ph.D.,is a research director at the Feinstein International Center, Tufts University, Bos-
ton, MA, USA, and a Research Professor at the Fletcher School of Diplomacy and the Friedman School
of Nutrition Science and Policy, Tufts University, Boston, MA, USA.
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