Published: 01/29/2021

A new four-paper series in The Lancet exposes the far-reaching effects of modern warfare on women’s and children’s health. Stanford researchers, including Global Health Faculty Fellows Paul Wise and Eran Bendavid, as well as Center for Innovation in Global Health Michele Barry, have joined other academics and health-care experts in calling for an international commitment from humanitarian actors and donors to confront political and security challenges.

By Beth Duff-Brown

Originally published by Stanford Health Policy.

A displaced Syrian woman chats with her son as they sit in front of their tent at a squatter camp on the outskirts of Killi village on Sept. 18, 2019 in Idlib, Syria. Burak Kara/Getty Images

The health of more than 630 million women and children — a staggering 8% of women and girls around the world — is adversely impacted by armed conflict.

In 2017, one in 10 women and almost one in six children worldwide were either forcibly displaced by conflict or living dangerously close to conflict zones. And one third of those affected live in Pakistan, Nigeria, and India.

Yet little political or financial attention is given to these sobering facts when it comes to setting policy and doling out humanitarian aid. Most of the focus is on the conflict, not the health and wellbeing of those affected by the violence.

“This suffering must not continue.” Helen Clark, past head of the U.N. Development Program and now board chair of the Partnership for Maternal, Newborn & Child Health, told a group of global health experts, humanitarians and academics from around the world.

“But to stop it, far greater funding, political commitment and leadership are needed.”

Clark, the former prime minister of New Zealand, was addressing a Jan. 25 online conference to launch The Lancet series of papers tackling the health and humanitarian issues plaguing women and children impacted by armed conflict. The papers explore the changing nature of war and conflict, its short- and long-term health effects on women and children, strategies for identifying best responses, and interventions supported by in-country assessments and studies.

Stanford faculty contributed to the research, including Stanford Health Policy’s Paul Wise and Eran Bendavid, and Stanford Center for Innovation in Global Health’s Michele Barry as well as political science professor Stephen Stedman.

The series papers highlight the failure of the global community to prioritise the health of women and children in areas of conflict. And the authors are calling for an international commitment from humanitarian actors and donors to confront political and security challenges. They are calling for a framework for identifying high-priority interventions to reach the most vulnerable women and children with the best care possible.

Bombs and Bullets

Wise, a professor of pediatrics and senior fellow at the Freeman Spogli Institute for International Studies, is a pediatrician who has devoted much of his life to working with children in conflict.

“Few things test a people’s relationship with its government more than war and disease,” he writes, as lead author of the Lancet paper that looks at the political and security dimensions of the response to violent conflict. “Whenever a society is confronted with a catastrophic threat, technical knowledge becomes inextricably linked to questions of social history, political legitimacy, and societal trust.”

He emphasized during the conference that the impact of violence is not just physical.

“There are the direct effects, the physical and mental trauma due to the direct exposure of bombs and bullets,” Wise said. “Then the indirect effects: mortality due to the destruction of the essentials of life, including shelter, food and water supplies, electric grids, transportation networks and health systems.”

Wise notes the COVID-19 pandemic is also exacerbating conflict and weak governance. The indirect effects are devasting livelihoods and putting additional burdens on traditional humanitarian and health systems.

Women and Children

The number of women and children affected by armed conflict has risen steadily since 2000, as a result of population growth, more conflicts, increasing use of explosive and chemical weapons in urban areas, and growing numbers of refugees and internally displaced people, said Bendavid, an epidemiologist and associate professor of medicine at Stanford Health Policy.

He said the impact of armed conflict on the health and mortality of women and children “far exceeds” the impact of those directly hurt or killed by the violence.

In 2019, there were 54 ongoing armed conflicts in 35 countries, averaging 20 years or more.

“The backdrop for our work is the persistent pattern of armed conflict around the world,” Bendavid told The Lancet conference, adding that the violence today is heavily concentrated in the Middle East, Centra Asia, South Asia and Africa.

He is the lead author on the Lancet paper that looks at the effects of armed conflict on the health of women and children, which finds that more than 10 million deaths in children younger than 5 can be attributed to conflict between 1995 and 2015 globally. And women of reproductive ages living near intense conflict have three times higher mortality than do women in peaceful settings.

“There’s no reason to think that this is going to become a diminishing problem, especially over the last year with all the challenges that have emerged,” Bendavid told the conference. “This is due to a combination of increasing population sizes and the urbanization of many conflicts.”

The Changing Face of War

The authors noted that once mostly confined to warring nations, armed conflict increasingly involves clashes between nations and insurgent groups in control of large geographical areas. It is now characterised by a lack of respect for humanitarian law, the systematic use of explosive and chemical weapons in cities, pervasive sexual violence against women and girls, and hybrid warfare, such as cyberattacks and the manipulation of social media. 

“Given the changing nature of armed conflict, this series underscores the importance of a humanitarian response that includes the empowerment of local communities and leaders as they are best able to deliver life-saving services, services that rely on a community’s capabilities, perceptions, and trust,” said Barry, a co-author of the series, senior associate dean for global health at Stanford Medicine and director of the Center for Innovation in Global Health.

The researchers also assessed the proven health interventions for women and children in 10 conflict-affected countries at different stages of warfare, as well as the geographical, political and economic conditions in Afghanistan, Colombia, Democratic Republic of the Congo, Mali, Nigeria, Pakistan, Somalia, South Sudan and Yemen.

The series co-authors emphasized the need to recognize local agencies, NGOs and academics working in these conflict settings.

“While the needs of conflict-affected communities are great, their voices are also often unheard or overlooked, so it is imperative they have a seat at the table — and that humanitarian actors listen to them — when decisions concerning them are made,” said Neha Singh, co-director of the Health in Humanitarian Crises Centre at The London School of Hygiene & Tropical Medicine.