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



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.
Journal of Public Health Policy (2023) 44:196–210
International humanitarian law violations innorthern
Uganda: victims’ health, policy, andprogramming
AnastasiaMarshak3 · TeddyAtim1,2· DyanMazurana1
Accepted: 23 March 2023 / Published online: 20 April 2023
© The Author(s) 2023
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
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.
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
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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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 [69]. 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 [1013], with less attention to the physical consequences
and impacts on livelihoods [1417]. 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 [1820].
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, 2527].
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:…
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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A.Marshak et al.
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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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
Access’ for serious
Availability Travel time
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:
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-
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.
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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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.
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.
Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of
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A.Marshak et al.
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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Full-text available
Background The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data. Methods We estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting. Findings Globally, for females, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias in both 1990 and 2017. For males, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and tuberculosis including latent tuberculosis infection in both 1990 and 2017. In terms of YLDs, low back pain, headache disorders, and dietary iron deficiency were the leading Level 3 causes of YLD counts in 1990, whereas low back pain, headache disorders, and depressive disorders were the leading causes in 2017 for both sexes combined. All-cause age-standardised YLD rates decreased by 3·9% (95% uncertainty interval [UI] 3·1–4·6) from 1990 to 2017; however, the all-age YLD rate increased by 7·2% (6·0–8·4) while the total sum of global YLDs increased from 562 million (421–723) to 853 million (642–1100). The increases for males and females were similar, with increases in all-age YLD rates of 7·9% (6·6–9·2) for males and 6·5% (5·4–7·7) for females. We found significant differences between males and females in terms of age-standardised prevalence estimates for multiple causes. The causes with the greatest relative differences between sexes in 2017 included substance use disorders (3018 cases [95% UI 2782–3252] per 100 000 in males vs s1400 [1279–1524] per 100 000 in females), transport injuries (3322 [3082–3583] vs 2336 [2154–2535]), and self-harm and interpersonal violence (3265 [2943–3630] vs 5643 [5057–6302]). Interpretation Global all-cause age-standardised YLD rates have improved only slightly over a period spanning nearly three decades. However, the magnitude of the non-fatal disease burden has expanded globally, with increasing numbers of people who have a wide spectrum of conditions. A subset of conditions has remained globally pervasive since 1990, whereas other conditions have displayed more dynamic trends, with different ages, sexes, and geographies across the globe experiencing varying burdens and trends of health loss. This study emphasises how global improvements in premature mortality for select conditions have led to older populations with complex and potentially expensive diseases, yet also highlights global achievements in certain domains of disease and injury.
Full-text available
Following the ICC intervention in 2005, northern Uganda has been at the heart of international justice debates. The emergent controversy, however, missed crucial aspects of Acholi realities: that the primary moral imperative in the wake of wrongdoing was not punishment but, instead, the restoration of social harmony. Drawing upon abundant fieldwork and in-depth interviews with almost 200 women, Holly Porter examines issues surrounding wrongdoing and justice, and sexual violence and rape, among the Acholi people in northern Uganda. This intricate exploration offers evidence of a more complicated and nuanced explanation of rape and its aftermath, suggesting a re-imagining of the meanings of post-atrocity justice, whilst acknowledging the role of sex, power and politics in all sexual experiences between coercion and consent. With its wide investigation of social life in northern Uganda, this provocative study offers vital analysis for those interested in sexual and gender violence, post-conflict reconstruction and human rights.
Technical Report
Full-text available
Public-goods provision, equitable growth and rights-based development are at their most challenging in places affected by fragility, conflict and violence – which is why donors and agencies maintain a particular focus on such areas. However, while it is essential that such investments are based on solid evidence, understanding of how post-conflict recovery and state-building processes happen is limited. The Secure Livelihoods Research Consortium (SLRC) works to address this lack of evidence. As a key component of its work, SLRC has established longitudinal panels with individuals as the unit of analysis in five countries: Democratic Republic of Congo (DRC), Nepal, Pakistan, Sri Lanka and Uganda. This report summarises the main findings from both waves of the survey, which collected data on people’s livelihoods; their access to or experience with basic services, and their relationship with governance processes and practices.
Full-text available
Armed conflict potentially poses serious challenges to access and quality of maternal and reproductive health (MRH) services, resulting in increased maternal morbidity and mortality. The effects of armed conflict may vary from one setting to another, including the mechanisms/channels through which the conflict may lead to poor access to and quality of health services. This study aims to explore the effects of armed conflict on MRH in Burundi and Northern Uganda. This is a descriptive qualitative study that used in-depth interviews (IDIs) and focus group discussions (FGDs) with women, health providers and staff of NGOs for data collection. Issues discussed include the effects of armed conflict on access and quality of MRH services and outcomes, and the mechanisms through which armed conflict leads to poor access and quality of MRH services. A total of 63 IDIs and 8 FGDs were conducted involving 115 participants. The main themes that emerged from the study were: armed conflict as a cause of limited access to and poor quality of MRH services; armed conflict as a cause of poor MRH outcomes; and armed conflict as a route to improved access to health care. The main mechanisms through which the conflict led to poor access and quality of MRH services varied across the sites: attacks on health facilities and looting of medical supplies in both sites; targeted killing of health personnel and favouritism in the provision of healthcare in Burundi; and abduction of health providers in Northern Uganda. The perceived effects of the conflict on MRH outcomes included: increased maternal and newborn morbidity and mortality; high prevalence of HIV/AIDS and SGBV; increased levels of prostitution, teenage pregnancy and clandestine abortion; and high fertility levels. Relocation to government recognised IDP camps was perceived to improve access to health services. The effects of armed conflict on MRH services and outcomes are substantial. The mechanisms through which armed conflict leads to poor access and quality of MRH services vary from one setting to another. All these issues need to be considered in the design and implementation of interventions to improve MRH in these settings.
Full-text available
In June, 2011 at the United Nations (UN) in New York City, the World Health Organization (WHO) and the World Bank launched the first World Report on Disability. This short overview of the Report provides information about its purpose, development and content, intended audiences, and outcomes. Special attention is directed to the sections of the Report which address telerehabilitation and information and communication technology.
This article explores the prevalence of disabilities resulting from war crimes committed by parties to the conflict between the Government of Uganda and the Lord’s Resistance Army. We compare these individuals and their households with persons in the same geographic area in households with no disabled members. We focus our comparison on livelihoods, education, health care access, food insecurity and wealth, and frame our discussion within the political economy of northern Uganda and its marginalisation vis-à-vis the rest of Uganda. We also examine Uganda’s promising legal framework of rights for persons with disabilities and the realities of their ongoing challenges.
This survey-based study gathered information on health professionals’ attitudes and behaviors regarding victims of sexual assault, focusing on the applicability and utility of best practices put forth by the World Health Organization and the United Nations. This cross-sectional study involved a self-administered, 84-question survey to health care professionals affiliated with Mulago National Referral and Kayunga Hospitals in Uganda. The survey included demographic questions as well as questions about participants’ attitudes toward sexual violence and the role of HPs in addressing sexual violence. The remainder of the survey transformed two sets of international guidelines into a series of statements with which participants could agree or disagree using a Likert-type scale. In total, 75 partially or fully completed surveys were collected, 45 from Mulago, and 30 from Kayunga. A minority of participants indicated that the guidelines were unrealistic (4.1%) or culturally inappropriate (14.1%). Most HPs agreed (91.8%) with the key components of recommended care. However, many respondents highlighted the need for additional training (68%). Nearly half of participants were uncertain or disagreed that there was a clear protocol for care of survivors of sexual violence (48%). Targets for improvement identified by participants included enhanced support of staff, access to resources, and relationships with community partners. Ugandan HPs have been receptive to the World Health Organization and United Nations guidelines. The majority of participants felt that the guidelines were realistic and culturally appropriate. Furthermore, many of these guidelines have been implemented. However, additional steps identified by Ugandan health workers could be undertaken to further improve the care received by survivors of sexual violence.
STUDY OBJECTIVE To test the validity of proxy measures of household wealth and income that can be readily implemented in health surveys in rural Africa. DESIGN Data are drawn from four different integrated household surveys. The assumptions underlying the choice of wealth proxy are described, and correlations with the true value are assessed in two different settings. The expenditure proxy is developed and then tested for replicability in two independent datasets representing the same population. SETTING Rural areas of Mali, Malawi, and Côte d'Ivoire (two national surveys). PARTICIPANTS Random sample of rural households in each setting (n=275, 707, 910, and 856, respectively). MAIN RESULTS In both Mali and Malawi, the wealth proxy correlated highly (r⩾0.74) with the more complex monetary value method. For rural areas of Côte d'Ivoire, it was possible to generate a list of just 10 expenditure items, the values of which when summed correlated highly with expenditures on all items combined (r=0.74, development dataset,r=0.72, validation dataset). Total household expenditure is an accepted alternative to household income in developing country settings. CONCLUSIONS It is feasible to approximate both household wealth and expenditures in rural African settings without dramatically lengthening questionnaires that have a primary focus on health outcomes.
This study aimed to refine a dimensional scale for measuring psychosocial adjustment in African youth using item response theory (IRT). A 60-item scale derived from qualitative data was administered to 667 war-affected adolescents (55% female). Exploratory factor analysis (EFA) determined the dimensionality of items based on goodness-of-fit indices. Items with loadings less than 0.4 were dropped. Confirmatory factor analysis (CFA) was used to confirm the scale's dimensionality found under the EFA. Item discrimination and difficulty were estimated using a graded response model for each subscale using weighted least squares means and variances. Predictive validity was examined through correlations between IRT scores (θ) for each subscale and ratings of functional impairment. All models were assessed using goodness-of-fit and comparative fit indices. Fisher's Information curves examined item precision at different underlying ranges of each trait. Original scale items were optimized and reconfigured into an empirically-robust 41-item scale, the African Youth Psychosocial Assessment (AYPA). Refined subscales assess internalizing and externalizing problems, prosocial attitudes/behaviors and somatic complaints without medical cause. The AYPA is a refined dimensional assessment of emotional and behavioral problems in African youth with good psychometric properties. Validation studies in other cultures are recommended. Copyright © 2014 John Wiley & Sons, Ltd.
In times of war, women are likely to experience, in addition to the "normal" violence of peacetime, random cruelties perpetrated by the enemy against all members of the community. During research conducted with Palestinian refugees and Shi'i Muslims in Lebanon, women described various forms of violence and, in this article, I examine violence suffered by women in the context of conflict from three perspectives: victimization, trauma, and resistance. I argue that traumatic events have the effect of obliterating identity, but they can also strengthen the resolve to resist.