In areas of conflict and war, epidemiologic studies must incorporate indicators that measure indirect deaths, rather than looking solely at deaths from combat, argued Frederick Burkle, a senior lecturer at the Harvard Humanitarian Initiative and senior scholar at The Johns Hopkins University. Drawing on his medical experience in combat zones in Asia, the Middle East, Africa, and Eastern Europe—particularly Vietnam and Iraq—Burkle discussed the ways in which the health community can better work with political and military actors to implement effective health programs and accurate monitoring mechanisms in fragile environments. The meeting, which took place on January 10, 2007, was the sixth in the Environmental Change and Security Program's Health, Population, and Fragility series.

Traditionally, international interventions in complex emergencies—politically motivated disasters with high levels of violence and civilian deaths—have focused on limiting the number of military and civilian lives claimed on the battlefield. The human toll, then, is calculated based on lives lost in direct conflict, and does not include deaths due to loss of public health services and infrastructure. As intrastate conflict has increased, argued Burkle, so has the need to develop a new method of calculating loss that includes indirect deaths or excess mortality—deaths that would not have occurred without the conflict or breakdown of social and health services, mass displacement of populations, and the destroyed livelihoods of those affected by violence. Burkle warned that until the international community recognizes the magnitude of indirect deaths incurred during complex emergencies, the human cost of war will remain unknown: "Except for very few countries…the humanitarian community has absolutely no idea of the worldwide impact of indirect deaths."

Linking Indirect Deaths and Health

According to Burkle, the erosion of public health infrastructure and health-service delivery are primary causes of indirect deaths during conflict. A recent assessment of the estimated 2.5 million casualities in the Democratic Republic of the Congo's civil war revealed that 90 percent of those deaths were preventable, resulting from ailments such as diarrhea, malnutrition, and malaria. Lives are often claimed during complex emergencies, he argued, because civilians are often unable to receive treatment for diseases once conflict erupts: "[A]s political violence increases…the window of opportunity to seek care narrows." Intrastate violence can also contribute to the number of deaths caused by malnutrition, particularly among the elderly; rape and war-related trauma, which can trigger or instigate mental illness; as well as the rapid spread of infectious disease. Poverty, inequality, and cultural incompatibilities are also contributing factors to indirect deaths, said Burkle, but he admitted that the precise impact of these factors are "difficult, if not impossible," to measure.

Little is known about the long-term effects of political violence on individuals and communities. But we do know that post-conflict settings are often plagued by a substantial decrease in health care, raising the risk of infectious disease. In Iraq, for example, an outbreak of cholera was reported for the first time in two decades as a result of the country's decimated public health infrastructure following the first Gulf War in 1990-91. And since the start of the recent Iraq conflict in 2003, the country's health infrastructure has been significantly impaired, and is to blame for an outbreak of typhoid fever; 6,000 cases of the disease were reported within the first six months of 2004 alone.

Studies conducted in Afghanistan and Croatia indicate that suicide, depression, alcohol, and drug use increase in postwar environments, particularly among demobilized soldiers and adolescent sons of dead soldiers. Finally, women and children are the most common long-term victims of civil war or conflict, a fact highlighted by increases in gender-based violence and lower school enrollment rates for girls. Burkle maintained that postwar public health effects of civil conflict must be researched in greater detail: "[We know that] increases in casualties far exceed the immediate losses from the civil war."

Lessons Learned

The number of lives claimed both during and after conflict as a result of destroyed or failing public health systems prompted Burkle to conclude that measures to protect civilians require new protocols and approaches. He stressed that because humanitarian work has become politicized and militarized, protecting public heath must be viewed as a strategic security issue requiring close collaboration with humanitarian and military personnel. In Iraq, where he served as the first director of the Ministry of Health under the Coalition Provisional Authority, the absence of a comprehensive strategy to rebuild the country's public health system after the war was partly to blame for an increase in Iraqi deaths from non-violent causes between 2005 and 2006.

But any attempt to redefine public health as a security issue must be coupled with efforts to develop a more comprehensive account of the human cost of modern-day war and conflict. Burkle urged the creation of better defined and universally accepted outcome indicators that would help the humanitarian community monitor the efficiency of national health systems. Some indicators are already available: for example, rates of dengue fever—which often emerges where trash collection is inadequate—can indicate poor governance and urban decay.

Despite the pressing need to develop an approach to provide sustained public health services in conflict zones, the international community is far from realizing this goal, warned Burkle: "We really do not know how to recover or protect urban public health." Unless measures are taken to develop ways to include indirect deaths, calculating the human cost of war will remain an inexact process of estimation by political scientists and military analysts. The lives lost, he said, will "remain unseen, uncounted, and unnoticed."

Drafted by Ken Crist.