Yesterday, Guinea-Bissau buried its former President, Joao Bernardo Vieira. Mr. Vieira was assassinated a week ago by army soldiers, likely in reprisal for the murder of the nation’s top military leader only hours before. The double killings have increased fears that the small African nation will fall back into internal strife, even civil war. What would be the health consequences of a new civil war? The answer lies in history.
Reader Stephen Murphy has completed extensive research on the country and recently sent me a copy of his unpublished 2007 paper on the health effects of Guinea-Bissau’s 1998-1999 civil war. He has graciously given War & Health permission to publish the paper. Enjoy!
Public Health Consequences and Responses in Civil War: Lessons from Epidemiology Research in Guinea-Bissau
Stephen J. Murphy
December 19, 2007
smurphy99 (the “at” symbol) gmail.com
By examining how civil wars affect civilian populations in a manner that goes beyond merely calculating numbers of violent deaths and displaced people, humanitarian aid practitioners can discern practical lessons for mitigating the health impacts of complex emergencies. Studies produced by the Bandim Health Project during the 1998-1999 civil war in Guinea-Bissau provide a unique opportunity to develop a more nuanced understanding of the consequences of war on the health of a population in a least developed country (LDC).
The Bandim Health Project (BHP), an epidemiological research institute, has conducted demographic surveillance since 1978 in four neighborhoods that include over 15% of the population of the capital of Guinea-Bissau. The BHP’s studies related to its own humanitarian interventions and those of other actors during the civil war provide insights that could inform future efforts to reduce disease and mortality in complex emergencies. In this analysis of the BHP war studies, I will examine the diseases and risk factors that contributed to high mortality rates during the war and propose recommendations from the research that could be applied to humanitarian practice in similar contexts.
Guinea-Bissau is an ethnically diverse nation of 1.5 million people located between Senegal and Guinea. The citizens of Guinea-Bissau have struggled with chronic poverty and poor health since the country won independence from Portugal in 1974. Most people in rural areas grow rice for consumption and cashews as a cash crop, while many citizens in Bissau, the capital of approximately 350,000 people, work as traders in the informal sector. Guinea-Bissau consistently ranks near the bottom of the UN Human Development Index, and the country’s citizens have a life expectancy of only 46 years. More than a third of the children under five suffer from malnutrition, which also significantly contributes to the high infant mortality rate of 130 per 1,000 live births. In some rural areas, only a third of the population has access to health services, and in the capital, the hospitals and clinics are severely overburdened. Malaria is the most severe cause of illness and death among children under five, and significant segments of the population also suffer from TB and HIV/AIDS.
Weak governance institutions and corruption have undermined development in Guinea-Bissau throughout the post-colonial era and fostered the political instability that led to the 1998-1999 civil war. The World Bank summarizes the general causes of the war as “failed governance, breakdown of rule of law, and limited accountability and transparency of public sector management.” The immediate cause of the unrest, which lasted from June 1998 to May 1999, was President “Nino” Viera’s sacking of the leader of the military, Ansoumané Mané, after accusing him of selling arms to the Casamance rebels in Senegal. Mané then led the army in revolt against President Viera, who received immediate military support from Senegal and Guinea. During the course of the war, two-thirds of the military and the majority of the population backed Mané. With widespread support, Mané and his troops drove Viera into exile and the Senegalese and Guinean troops out of Guinea-Bissau.
In his analysis of rural civil society in Guinea-Bissau, the anthropologist Joshua Forrest argues that the predominantly rural communities of Guinea-Bissau have effectively resisted the control of the central government during both Portuguese rule and after independence. Forrest characterizes the 1998-1999 war not as a civil conflict between ethnic or geographic factions in a divided nation, but as a national struggle by the military and the population against an ineffective and corrupt government. He claims that Mané’s successful revolt resulted in “another victory for rural civil society,” but considering the loss of life and increased mortality due to disease, the outcome was a pyrrhic victory at best for the people of Guinea-Bissau. During the course of the year-long war, health facilities, schools, and businesses were destroyed, between 2,000 and 6,000 people were killed, and approximately 350,000 citizens, mostly residents of Bissau, became internally displaced persons (IDPs). Since most of the fighting took place in the capital, IDPs moved in with family, friends, and even strangers in surrounding areas; however, they did not congregate in IDP camps. Many residents returned to Bissau after the heavy fighting of the first few months of the war and then fled again for shorter periods of time during increases in violence.
The people of Guinea-Bissau received little external aid during the crisis. This was partially due to the country’s lack of geo-political significance to donors, the fact that there were few external refugees, and that IDP camps were not necessary. During the war, the Ministry of Health headed a national committee to coordinate the work of humanitarian aid partners, which included the BHP, ICRC, WFP, local NGOs, and Catholic missionaries. Little research has been published on the humanitarian response to the war in Guinea-Bissau; however, the BHP’s epidemiology studies present significant information regarding the toll on public health and the effectiveness of interventions in reducing illness, malnutrition, and mortality. In addition to conducting its regular health surveillance research during the war, the BHP distributed food and medicine to IDPs and the families that hosted them near Bissau. As IDPs returned to Bissau, the BHP also provided them with other forms of aid, including supplementary feeding for malnourished children, vitamin A supplementation, and treated bednets for pregnant mothers.
Based on their epidemiological surveillance data, the BHP conducted studies on a variety of diseases and interventions during the war, and its research examining mortality rates, breastfeeding, IDP and host family nutrition, and TB treatment reveal critical findings about factors that influence the spread of disease and the effectiveness of relief efforts during wartime. In their study of mortality patterns, Nielsen et al compared mortality rates in BHP’s surveillance zone during the war with those of the previous three years to estimate the excess mortality due to war. To account for the indirect health consequences of war, the researchers separated deaths related to direct acts of war. Unlike most mortality studies of war-related emergencies that focus on refugees or IDPs isolated in camps far from the frontlines, the authors studied a population while it was displaced near the central conflict zone. Nielsen at al found that the overall crude mortality rate (CMR) rose 78% for the first six months of the war (June-November 1998) when IDPs fled the capital to surrounding areas, but the CMR dropped to a normal level during the final six months of the war when most IDPs had returned to their homes. The crude mortality rate for children under five (CMRU5) increased about 100% over the normal expected rate during the first six months of the war. From December 1998 to November 1999, CMRU5 showed a 40% increase above normal, and during the final three months of the conflict, the researchers measured a 20% increase in child mortality. Nielsen and his colleagues attribute the less severe excess mortality in the second half of the war to “reduced crowding and improved hygiene when people returned to their normal homes.” Therefore, humanitarian actors may decrease the spread of disease and associated mortality by facilitating the return of IDPs to their homes as soon as possible during a complex emergency. However, the BHP study also notes that the goal of quick re-settlement must be balanced with the security situation in the home communities. Interestingly, a related BHP study found that child mortality in the pediatric hospital in Bissau actually decreased dramatically due to a number of factors associated with the war and humanitarian response. Sodemann et al principally attribute the drop in mortality among hospitalized children to the increase in aid that the hospital received during the war from BHP and other actors. Aid agencies distributed essential drugs (which were normally not available) free of charge and ensured that the blood bank functioned properly. They also reduced incentives for the staff to charge for care by providing the health care workers with food each day.
The BHP study on breastfeeding during the civil war in Guinea-Bissau reveals how a commonly recommended practice can have profound affects on protecting the health of infants in a complex humanitarian emergency (CHE). Focusing on the first three months of the year-long war, Jakobsen et al compared mortality rates of breastfed children between the ages of 9 to 20 months with weaned children of the same age. The researchers determined that the mortality rate for the weaned children was six times that of the breastfed children; however, prior to the war, their was little difference in mortality levels among breastfed and weaned children. The increase in mortality for weaned children is “most likely because of higher infection pressure during the war when people lived in overcrowded houses in the rural area with less access to care.” According to Jakobsen at al, diarrhea, lower respiratory infections, and malnutrition frequently cause death in CHEs and breastfeeding is believed to help prevent or mitigate the severity of each of these conditions. The BHP study concludes that “in emergency situations with increased risk of infections, maintaining breastfeeding is even more critical than under normal conditions.” Moreover, the researchers identify weaned children under 21 months as a particular risk group that humanitarian actors should focus on during relief efforts.
At the outbreak of war in June 1998, fighting around the northern perimeter of the city forced many of the residents to flee south to the Prabis peninsula. About 50,000 IDPs moved in with the 7,000 residents that lived in the area. Since the WFP initially evacuated from the Bissau area, the ICRC and BHP distributed the WFP’s stored rice on the peninsula during the first three months of the war before most IDPs returned to their homes in the capital. The ICRC followed the WFP’s regulation of only distributing food to IDPs, but the BHP later started to distribute rice to both IDPs and residents. The BHP studied nutrition and mortality among IDP and resident children between the ages of 9-23 months and discovered that children from both groups had a significantly higher mortality rate during the first three months of the war when the IDPs lived in Prabis. Aaby et al assert that “with the extreme crowding and unhygienic conditions that existed…in Prabis, it is not surprising that mortality was much higher for both residents and refugees.” The researchers found that the effects of crowding and disease were more profound on the health of children than nutrition, and they advocate for health care to be offered alongside food aid in emergencies. Moreover, the study reveals that resident children on the peninsula suffered a mortality rate 4.5% times higher than that of the IDP children. This discovery provides evidence that humanitarian agencies must also consider the needs of households that host IDPs in non-camp emergency settings. In a study of the WFP’s food aid distribution, Hjalte Tin criticizes the WFP for its slow response and inappropriate food aid targeting practices. Supporting Aaby’s conclusions, Tin argues that humanitarian aid agencies should treat families that host IDPs as a “new class of vulnerable persons” in complex emergencies.
Although hospitals in Bissau received essential drugs during the war channeled through the BHP and other aid agencies, the conflict disrupted the supply of TB treatment drugs. The storage facility housing the TB drugs was bombed, and the only TB treatment program was moved to a suburb five kilometers outside of the capital due to fighting. Utilizing the BHP surveillance data of TB patients, Gustafson et al conducted a study of the effects of disrupted treatment by comparing mortality rates of a cohort of patients who received treatment a year before the war (the “peace cohort”) with a cohort of patients whose treatment was interrupted during the war (the “war cohort”). During the first four months of treatment in Guinea-Bissau, TB patients must visit a treatment center on a daily basis to receive directly observed therapy (DOT). During the second four-month phase, patients only take drugs every two weeks. Comparing patients undergoing the initial phase of daily DOT from both cohorts, the BHP study reveals that the mortality rate for those with interrupted treatment was three times higher than for those who received uninterrupted treatment. The researchers did not discern a difference in mortality rates among patients in the second four-month phase of treatment. In their discussion of the increased mortality, Gustafson et al posit that TB patients “may have been particularly vulnerable to stress and infection in the crowded environment” during the war. The researchers also found that HIV-positive TB patients whose treatment was interrupted were eight times more likely to die than HIV-positive patients from the peace cohort. This discovery underscores the vulnerability of those living with HIV/AIDS during CHEs. Based on the BHP study, it is clear that public health officials and humanitarian agencies must develop contingency plans for TB treatment during CHEs, and supplying TB patients, especially those with HIV/AIDS, with drugs should be a priority. Gustafson et al also discuss how the DOT mechanism in Guinea-Bissau does not allow patients to possess more than one dose at a time. Given the potential disruptions to daily treatment, health care providers should have the flexibility to modify DOT regimens during complex emergencies.
The BHP epidemiology studies of the 1998-1999 civil conflict not only examine the health consequences of war beyond casualty figures, but they also highlight new vulnerable groups and recommendations to consider for improving future humanitarian action. The BHP studies provide especially useful evidence regarding the health of both IDPs and resident civilians in non-camp settings. As the BHP analysis of nutrition and mortality in Prabis shows, aid agencies must adapt to the coping mechanisms and cultural patterns of IDPs and local populations when providing aid rather than enforcing bureaucratic regulations that may be counterproductive and result in harm. Throughout the studies, a common theme emerges regarding crowding as a facilitator of disease transmission in emergencies. The BHP provides a sound public health basis for encouraging the re-settlement of concentrated IDPs and refugees as soon as possible. In identifying weaned infants, resident children in non-camp settings, and TB patients in the initial stage of treatment as vulnerable groups, the BHP researchers have also presented information that could potentially improve humanitarian aid in other contexts.
While the BHP’s research provides ample epidemiological evidence for modifying humanitarian interventions, it does not seem to have had a recorded impact on humanitarian practice. With the exception of Hjalte Tin’s study of WFP food aid policy during the civil war, the available academic literature does not address the application of lessons learned from the crisis in Guinea-Bissau. Student researchers working with the BHP have written theses examining the role of culture and coping mechanisms during the war, bet these remain unpublished. Although the BHP is a research institute generally engaged in epidemiological studies rather than humanitarian interventions, the humanitarian aid community could greatly benefit from a broader dissemination of the BHP’s findings regarding the health consequences and responses from the war period. An opportunity to inform humanitarian practice, particularly in non-camp emergency settings, has not yet been realized. One way to potentially bridge the gap between the BHP’s war research and future practice could be through an effective program evaluation. A thorough evaluation of the relief efforts of the BHP and other aid agencies could provide comprehensive evidence regarding which practices and policies were most effective at reducing disease, malnutrition, and mortality during the civil war. An evaluation could not only present findings to inform relief and development efforts in Guinea-Bissau, but could also produce an easily disseminated publication to be shared widely with the humanitarian aid community to impact policies and practices in other CHEs. The BHP and its donors should actively identity ways of sharing the findings of their wartime epidemiological studies with humanitarian and development practitioners. Moreover, humanitarian donors should prioritize evaluations of the interventions that they fund to facilitate learning that can impact humanitarian practice more broadly.
Aaby, P. et al. “Nutritional status and mortality of refugee and resident children in a non-camp setting during conflict: follow up study in Guinea Bissau.” British Medical Journal. 319: 1-6 electronic publication, 1999.
Barry, Boubacar-Sid et al. “Chapter 2: Conflict Growth, and Poverty in Guinea-Bissau.” Conflict, Livelihoods, and Poverty in Guinea-Bissau. (Washington, DC: The World Bank, 2007).
Forrest, Joshua. Lineages of State Fragility. (Athens, Ohio: Ohio University Press, 2003).
Gacitua-Mario, Estanislao et al. “Chapter 5: Livelihoods in Guinea-Bissau.” Conflict, Livelihoods, and Poverty in Guinea-Bissau. (Washington, DC: The World Bank, 2007).
“Guinea-Bissau Country Profile,” UN Office for the Coordination of Humanitarian Affairs (OCHA), accessed on December 7, 2007: http://www.irinnews.org/country.aspx?CountryCode=GW&RegionCode=WA.
“Guinea-Bissau: Poverty Reduction Strategy Paper (PRSP).” (Washington, DC: International Monetary Fund, 2007). Available at: http://www.imf.org/external/country/GNB/index.htm.
Gustafson, P. et al. “Tuberculosis mortality during a civil war in Guinea-Bissau.” Journal of the American Medical Association. 286:599-603, 2001.
Jakobsen, M. et al. “Breastfeeding status as a predictor of mortality among refugee children in an emergency situation in Guinea-Bissau.” Tropical Medicine and International Health. v. 8 no. 11: 992-996, 2003.
Kovsted, Jens and Finn Tarp. “Guinea-Bissau: War, Reconstruction, and Reform.” UNU World Institute for Development Economics Research (UNU/WIDER) Working Paper No. 168, 1999.
Nielsen, J., et al. “Mortality patterns during a war in Guinea-Bissau 1998-99: changes in risk factors?” International Journal of Epidemiology. 35: 438-446, 2006.
Sodemann, M., et al. “Reduced case fatality among hospitalized children during a war in Guinea-Bissau: a lesson in equity.” Acta Paediatrica. 93: 959-964, 2004.
Tin, Hjalte. “The Benefit of Failure: WFP, Food Aid, and Local Survival in Guinea-Bissau, 1998-99.” Center for Development Research, Copenhagen (June 2001).
Photo Credit: MinesActionCanada.org
Christopher R. Albon is a political science Ph.D. specializing in armed conflict, public health, human security, and health diplomacy.