Hälsokonsekvenser krig & konflikter Katastrofmedicin 2017 12 19 Anneli Eriksson Centre for Research on Health Care in Disasters Health system and policy Department of Public Health Sciences
1. Krig och konflikter 2. Global utblick 3. Hälsokonsekvenser Allt på Svengelska
Väpnad Konflikt Krig Complex emergency Hälsokonsekvenser
Definition; Väpnad konflikt (state based) An armed conflict is a contested incompatibility which concerns government and/or territory where the use of armed force between two parties, of which at least one is the government of a state, results in at least 25 battlerelated deaths. Uppsala University, Department of Peace and Conflict Research
Mellanstatlig konflikt Conflict, interstate (state-based) A conflict between two or more governments. Uppsala University, Department of Peace and Conflict Research
Non-State conflict The use of armed force between two organised armed groups, neither of which is the government of a state, which results in at least 25 battle-related deaths in a year. Uppsala University, Department of Peace and Conflict Research
Definition: One sided violence The use of armed force by the government of a state or by a formally organised group against civilians which results in at least 25 deaths in a year. à Extrajudicial killings in government facilities are excluded. Uppsala University, Department of Peace and Conflict Research
Definition: krig Ofta anges samma definition som för väpnad konflikt men minst 1 000 stridsrelaterade dödsfall under en ettårsperiod. à T.ex Syrien väpnad konflikt sedan 2011
Aftonbladet: NYHETER Ons 13 jun 2012 Våldsamheterna i Syrien har gått in i en ny fas. Enligt FN råder det ett fullskaligt inbördeskrig i landet.
Complex emergencies Complex emergencies are situations of disrupted livelihoods and threats to life produced by, warfare, civil disturbance and large-scale movements of people à An estimated 300 million people live in countries with complex emergency situations, Leaning J, Guha-Sapir D. 2013
2. Global utblick
UCDP, 2017
UCDP, 2017
3. Hälsokonsekvenser
Mortalitet Direct violence
Mortalitet
Överdödlighet - Excess mortality Easy to explain but difficult to obtain
% indirect deaths as percentage of total excess deaths 100 90 80 70 60 50 40 30 20 10 0 Indirect deaths as percentage of total excess deaths Source: Global Burden of Armed Violence, M. James and A. Potter, Editors. 2008
Darfur
Photo: MSF Kivu 1996
Case GNI:%(PPP) 4%243%dollars%(constant%2005)(source%UNDP) Population%size:% 20>%22%million%people%(varying%in%different%data%bases) Population%>%5: 12% Life%expectancy%at%birth:% 76%years%(source%UNDP) U5%mortality:%% 15,3/%1000%live%birth%(WHO,%2011) Maternal%mortality:% 46%deaths/100,000%live%births%(Unicef) Institutional%deliveries!(%)!80!!(2009) Delivery%with%skilled%birth%attendance:%% 99%/93%!(urban/rural) Wasting:% 11%!(below!52!Z5score) Communicable/Non%communicable%disease% 26%/74%!in!2002!(WHO) Measles!vaccination!coverage!!1!year:! 82%!(unicef)!!over!90%!5!official!national!statistics
Syria: a Low middle income country Case: Syria pre-disaster health situation GNI:%(PPP) 4%243%dollars%(constant%2005)(source%UNDP) Population%size:% 20>%22%million%people%(varying%in%different%data%bases) Population%>%5: 12% Life%expectancy%at%birth:% 76%years%(source%UNDP) U5%mortality:%% 15,3/%1000%live%birth%(WHO,%2011) Maternal%mortality:% 46%deaths/100,000%live%births%(Unicef) Institutional%deliveries!(%)!80!!(2009) Delivery%with%skilled%birth%attendance:%% 99%/93%!(urban/rural) Wasting:% 11%!(below!52!Z5score) Communicable/Non%communicable%disease% 26%/74%!in!2002!(WHO) Measles!vaccination!coverage!!1!year:! 82%!(unicef)!!over!90%!5!official!national!statistics
Syria: context, conflict Uprising started in March 2011 Free Syrian Army versus Government Homs initially main area involved à Involves the whole country today Since July 2012 defined as a civil war (ICRC) Refugees 500 000 + non registered (UNHCR) Internally displaced 1.2 million (UNHCR/UNOCHA) Estimates of casualties uncertain: à Estimated to be < 40 000 by the end of November 2012 (Reuters)
https://vizhub.healthdata.org/gbd-compare/
Access to health care Ø Majority of hospitals and health centers damaged (or destroyed) (WHO March 2012) Ø The conflict itself hinder people from reaching health care Ø Hospitals not safe
Access to health care cont. Access problems reported in relation to: à Conflict areas. à Chronic diseases!! à EPI! à Access to maternal and obstetric care
Health problems Risk factors The conflict Displacement à Camps à Overcrowded villages in border areas Water sources Poverty and food access Traumatic experiences (mental health) Potentially low vaccination coverage in children > 2
Health problems Most common morbidity Upper respiratory tract infections Gastro Enteritis/Diarrhea Skin infections Pneumonia Cardiovascular disease, including hypertension Diabetes According to reports from two clinics (camp and in city)
* No information on population size covered, nor on access War injured Monthly report from one community field hospital Total of 839 cases treated* (950 injuries) <5 years Between 5 and 18 Women Male>18 years Bullet wound Blast injuries Burns Others
Monthly report cont. Type of surgical intervention 800 700 600 500 400 300 200 100 0 Abdominal surgery Orthopedic surgery Chest surgery ICU with or without surgery c-section
Hälsokonsekvenser av Väpnade konflikter och krig Direkt trauma Osäkerhet Displacement à Sårbarhet Förlust av resurser Förslust av social infrastruktur Trångboddhet Brist på mat, rent vatten, sanitet etc. Brolin, K. systematic review not published
Complex emergencies Severe PH consequences mediated by popula:on displacement, food scarcity, collapse of basic health services NCDs in emergencies persons with NCDs more vulnerable, emergencies exacerbate NCDs, mul:faceted impact of NCDs S:ll, most common cause of death in CHEs o@en infec:ous diseases: à Diarrheal diseases à Measles à Acute respiratory infec:ons à Malaria à High prevalence of acute malnutri:on à War- related injuries common in conflict- affected european countries Most deaths in refugee popula:ons are among children under 5 Mental health disorders in complex emergencies neglected and vulnerable group Brolin, K. systematic review not published 37
Gender aspect Armed conflict has also been shown to have a gendered effect on population health, where excess mortality attributed to conflict (both directly and indirectly) is higher among women than men Ghobarah HA, Huth P, Russett, 2004, Plümper T, Neumayer E. 2006, Urdal H, Che C, 2013
Contradictions Use of contraception and institutional deliveries among women in Northern Uganda was significantly lower compared to the rest of the country. However, skilled assistance at birth among women in Northern Uganda was significantly higher. Namasivayam A, et al, 2017