Llately I have been thinking about the underreported or overlooked health consequences of war. The effects too complicated or dull to deserve a TED Talk or a spot on the evening news. One area that keeps coming up in my mind is the budgetary trade-off between security and health care provision.
Faced with an armed threat to their sovereignty or the survival of their regime, governments often prioritize defense spending over social service spending. Governments always face dueling pressures for allotting spending between “guns vs. butter”. However, during civil wars spending priorities often swing heavily in favor of the military. Military spending has been found to rise from (on average) 2.8 percent of GDP during peacetime to five percent during civil war. This has direct, negative impacts on health system budgets. During the Spanish civil war, the republican government created a Ministry of Health and Social Care to provide health services to citizens and prevent wartime epidemics, however “the military campaign drained public funds and the financial resources of the Ministry were tiny” (Baron and Perdiguero-Gil 2008, 108). A similar focus on the military has been documented in Mozambique, where government spending on health decreased from 10.7% to 4.6% during a five period in the war. Peroff and Podolak-Warren (1979) conducted a time-series analysis of appropriation requests by the US government between 1929 and 1979. They found some evidence of a trade-off in public expenditures relating to conflict, with Vietnam War producing the greatest effect during the study period. Apostolakis (1992) later conducted a more thorough analysis, using time-series data from nineteen Latin American countries between 1953 and 1987. The analysis found strong evidence of a trade-off between military spending and health. For example, every dollar increase in Argentinian military expenditures decreased health spending by 31 cents. Recently there has been renewed interesting in this trade-off. In an analysis of government spending during both intrastate and interstate wars, Iqbal (2010) found that states often favor defense spending over health care spending and that the effect is influenced by the severity of the conflict. Governments involved in minor conflicts increase the percentage of total government expenditures used for military spending by six percent, while they decrease the percentage for health spending by two percent. This represents a 25 percent decrease in health care expenditures. During major conflict the change was only more pronounced, with military and health expenditures as a percentage of total government expenditures increasing 12 percent and decreasing four percent, respectively — representing a 50 percent decrease in health expenditures.
I‘ve talked before about rape as a weapon in war, particularly with regards to the Democratic Republic Of Congo. Usually discussions of sexual violence center around women and children as the victims. Now, a new study by Mervy Christian of Johns Hopkins School of nursing says that sexual violence against man by armed combatants is a growing problem. The study uses focus groups and interviews of male rape survivors in South Kivu. Christian found that the perpetrators of the sexual assaults were armed combatants.
The question that keeping coming to my mind is this: what were the motivations behind DRC’s sexual violence. One explanation often presented is that rapes in the DRC are conducted to force populations to flee areas. This is possible, but unsubstantiated through any academic research I have been able to find. Another motivation, described in Lisa Jackson’s remarkable documentary is that raping someone is a key component of the “magic potions” used by some armed groups:
Congo Soldier: “The magic potion worked in such a way that you’ve got to rape women in order to overcome the enemies who’ve invaded our country, the Congo.”
This superstition not just held by a few soldiers, the documentary goes on to describe how soldiers were sometimes ordered to rape. Since this belief is widely held, then sexual violence could be a strategy in two ways. First, whatever the reality, the soldiers believe they are acting strategically: raping improves combat effectiveness. That might be irrational, but it is no means irrelevant to believers. Second, political leaders could be promoting the “magic potion” superstition to motivate their fighters to conduct sexual violence which furthers the political and military goals. That is, these leaders could be strategically attacking populations by tricking their fighters into committing sexual crimes they might not otherwise do. Simply put, rape could be a weapon and the rapists do not even know it.
CCTV has a new video from Sirte’s main hospital just after it was taken by NTC forces:
Two things to take from this video. First, most of the senior medical staff had fled, leaving nurses and medical students. Why? I can’t be sure, but it is likely that many of the senior staff had some connections to the Gaddafi regime (often the case in one-party autocracies) and feared reprisal. This flight has left the hospital lacking in a number of major specialties. Second, NTC fighters had and continue to violate medical neutrality by entering hospital grounds to detain patients suspected of being Gaddafi loyalist. This is not the first time I have heard these accusations. This is utterly unacceptable. More needs to be done to force the NTC to stop such practices amongst it’s fighters.
In a new paper in the Journal of Forensic Sciences, Debra Komar of Liverpool John Moores University and Sarah Lathrop of the University of New Mexico have published [gated] a new survey of the pattern of injuries suffered by residents of Timor Leste during the 1999 violence. During the civil conflict, Indonesian-financed armed groups perpetrated widespread violence around the small island nation, killing a reported 1000-2000. In their paper, the researchers looked at 105 autopsy and anthropology reports during that time period. Here are their results:
No trauma was found in 25% of the sample, while a further 5% had only minor, nonlethal wounds.
Where trauma was evident, sharp force injuries were most common (35%), followed by gunshot (20%) and blunt force (13.33%). (Abstract)
The pattern of wounds found in the Timor Leste sample suggest many of the wounds were caused by improvised blades and farming equipment, a fact that “strongly suggests that the perpetrators were drawn from the local citizenry, rather than representing an adequately equipped military force”. The authors also note that this distribution of wounds looks more similar to Rwanda than it does from similar studies of mass violence in Cambodia, Bosnia, Croatia, and Afghanistan.
In what can only be described as a direct attack on the medical community, Bahrain’s civilian-military “security court” just sentenced 13 doctors and nurses to 15 years in jail for treating anti-government protestors during demonstrations earlier this year. Al Jazeera has the details:
Evading the terror in the hospital corridors, a group of doctors affiliated with the hospital were said to have set up a network of secret field clinics throughout Tripoli, away from the eyes of security forces.
Private homes, schools and other buildings were converted into makeshift operating theatres, supplied with medical equipment that the doctors smuggled out of the hospital’s storage rooms.
It was, according to the doctors, a dangerous undertaking, as stealing equipment from the hospital was sanctioned by severe punishment if discovered.
“We were undercover doctors,” Noureddine Hassan Aribi, a vascular surgeon who was recently appointed as the hospital’s director, recalls when asked about the days when it all started.
“It was a nightmare. There were horrible injuries. My colleagues and I treated many people in houses in the neighbourhood of this hospital. If the wounds were too complicated, we’d take them to a private clinic. We removed bullets and stabilised fractures, using primitive tools such a planks of wood and pieces of metal.
“We created 24 secret field hospitals all over Tripoli. Some of the doctors were caught by Gaddafi’s forces and were taken to prison. At least one of them was killed and another one is still missing,” doctor Aribi told Al Jazeera.
This is not the first time clandestine clinics have been established during civil conflicts. In the 1990s, Slobodan Milošević revoked the autonomy of Kosovo and expanded the power of the Serbian government over Kosovo’s institutions, including the police, courts, educational institutions, and health system.
The change devastated Kosovo’s health system. Almost two thousand ethnic Albanian health workers were dismissed including 263 doctors and 140 professors of medicine. Many others quit after threats and intimidation. By 1991, while ethnic Albanians made up 82% of Kosovo’s population, they made up less than five percent of Kosovo’s public health workforce. The remaining ethnic Albanian health workers were relegated to non-management positions. New rules set down by the Belgrade demanded that Serbian be the official language used in Kosovo hospitals — a language unfamiliar to many ethnic Albanian health workers and patients. Within a few years sixty-four percent of ethnic Albanian health workers had voluntarily or involuntarily left their jobs. The Milošević government filled the vacancies with health workers brought in from other regions of Yugoslavia and from outside the country, many lacking the appropriate expertise. The political interference in the health system undermined patient confidence. After the dismissal of over forty ethnic Albanian doctors, one obstetrics and gynecology department dropped from thirty deliveries per days to fewer than two because Albanian patients did not trust the Serbian health workers.
In response ethnic Albanians organized a “parallel” health care system including private practices in their houses and a network of clinics called the Mother Theresa Society. The Mother Theresa Society ran 96 clinics around Kosovo and was supported by volunteers and a parallel tax system. The ethnic Albanian medical professors and staff fired from University of Pristina even founded a parallel medical school. Instruction was conducted in Albanian and provided students with strong medical knowledge but, due to their lack of access to health facilities, weak clinical skills. During the 1990s this underground medical school graduated 600 doctors and 1,200 nurses. However, the clinic was not safe from violence: during the Kosovo War 90% of Mother Theresa clinics were looted or destroyed.
Continuing our impromptuexploration of ambulance-based health workers in warzones, here is a video made by the ICRC, shot by André Liohn, about the challenges and threats faced by health workers on Libya’s front lines:
This week the International Committee of the Red Cross (ICRC) took a big step into the blogosphere with the launch of Intercross. The new blog is written and curated by Simon Schorno, ICRC’s spokesman in DC:
Intercross is about the plight of children, women and men affected by armed conflict and armed violence. Intercross is about humanitarian action. It is about the work the ICRC and international humanitarian law and the rich history of the institution I am proud to be part of. And it is about interacting with you, our readers, and building a place for news and commentary on armed conflict that is credible and, hopefully, relevant.
The initial set of posts on the blog are great, some new articles and some old op-eds. The ICRC has long had a presence on the internet, but from the looks of it Intercross is their first true blog: personal, informal, and at least somewhat opinionated (which is rather rare for the ICRC). I look forward to see how their blog develops and wish them luck!
Over the weekend, the Wall Street Journal reported on revelations of gross negligence and criminal mistreatment of patients at Dawood National Military Hospital, the Afghan military’s main hospital. American military officers serving as mentors in the hospital discovered last year that patients in the hospital, where the salaries are subsidized by the US, were being forced to pay bribes to receive food and even basic care:
A beefed-up group of at least two dozen U.S. military mentors had arrived at the hospital in August 2010 as part of the “surge” of American forces in Afghanistan. They began to deploy throughout the wards, replacing an earlier group that had less direct contact with patients.
By the following month, the new mentors began to document what they describe as horrific conditions. Maggots fed off patients’ open wounds. Nurses and doctors refused to help amputees to the bathroom, and they soiled their beds for days.
Several patients died of simple infections because their bandages would go unchanged for weeks, while at least four died of complications related to malnourishment, according to mentors and internal documents.
The US military is reportedly now conducting a full-court push to improve conditions in the hospital.
While clinicians might get the bad press, blame for the tragedy at Dawood National Military Hospital must also be directed at the hospital’s administrators. Time and again I find that the success of post-conflict health reconstruction is determined not by the number of beds in a country, but the presence of strong and responsible health administrators willing and able to manage and enforce the requisite standards of care. Although not as sexy as training health practitioners, the education and training of health administrators is often more important.
Christopher R. Albon Political science Ph.D. specializing in armed conflict, public health, human security, and health diplomacy. Homepage, Contact, Twitter.
