Health services may provide the foundation for democracy in some post-conflict countries, argued Ross Anthony of the RAND Corporation, at the third meeting in the Environmental Change and Security Program's Health, Population, and Fragility series. Anthony and his colleague Seth Jones discussed their new edited volume, Securing Health: Lessons From Nation-Building Missions, which reviews past efforts to establish health services in countries recovering from conflict. The book's contributors examine how post-conflict instability affects health programming, as well as how such programming forms an essential component of nation building.

Health as an Outreach Effort

According to Anthony, the world has become increasingly alienated from, and hostile to, the United States. Furthermore, even traditionally staunch allies have been reevaluating their relationships with the United States. Health programming can, he argued, provide a reasonable and effective means to counter such negative images. Providing humanitarian health assistance to less fortunate countries is a good way to build goodwill and cooperation, which can then be parlayed into more significant ties. Health programming can also be an effective international relations tool, because it can change not only how people think about the United States but also how they think about themselves and their place in the world. Offering marginalized people some of the concrete benefits of globalization could help them integrate into the new economic world.

The Theoretical Framework of Post-Conflict Health

"We wanted to look at…seven distinct efforts after U.S. nation-building operations, and look specifically at the health care system…the effects of the nation building, and health effects on that process," said Anthony. The authors studied nation building in Germany, Japan, Iraq, Afghanistan, Haiti, Kosovo, and Somalia. Determining the extent of improvements in post-conflict countries can be extremely difficult. Commonly used indicators (e.g., life expectancy, infant mortality, birth/death rates, etc.) provide the best means of measuring overall levels of health and healthcare, according to the authors, but in many cases data are either nonexistent or of questionable reliability. However, some members of the audience questioned whether these problems were as widespread as claimed.

Gathering new survey data in post-conflict countries can also be problematic due to low levels of security. The authors gathered as much data as possible to chart trends (pre-conflict and post-conflict), which were then compared with security indicators—such as the number of violent attacks, amount of civil unrest, and civilian casualties—in an attempt to establish links between security and health.

The Case for Correlation Between Health and Security: The Country Studies

Drawing on some examples of health program reconstruction in post-conflict countries, Seth Jones showed that nation building cannot be successful without at least partial success in building health. Broadly speaking, the countries they studied fell into one of three categories: very successful (Japan and Germany), mixed success (Iraq and Kosovo), and failures (Somalia, Afghanistan, and Haiti). Both Japan and Germany experienced a relatively rapid expansion in the provision of both public health services and commodities, leading to a commensurate increase in all of the health indicators. Both countries' post-conflict security level was very high and extremely stable; for example, not a single American soldier died due to enemy action during the post-WWII occupation of Japan. Both countries were devastated by the war, yet health indicators reached higher levels than before the war relatively quickly. A large part of this recovery must be attributed to the high levels of pre-war healthcare and organization, leading the population to expect the state to provide certain levels of care.

In contrast, in the mixed cases (Kosovo and Iraq) the health indicators may be recovering, but they have not recovered to pre-war levels or been obtained through sustainable local means or management. In Iraq, the war caused a precipitous decline in the level of health indicators across the board, and the situation has not improved much since the end of the conflict. While the causes for this are myriad and complex, the general conclusion is clear: the lack of security has drastically affected the ability of health programmers to conduct interventions on the large scale necessary to effect real change, and the lack of basic health services has negatively affected the coalition's ability to build the trust and confidence necessary to improve security. In Iraq, clinics and health service providers, along with health system infrastructure and the supply chain, have been the victims of violent attacks. In Kosovo, while there has been a marked improvement in many health indicators, the improvements have not been achieved in conjunction with local leadership, and are therefore not sustainable. Some audience members pointed out that the situation in Iraq, like Afghanistan, is still developing, and suggested that it was too soon to assign a definitive category to such countries.

The failures—including Afghanistan, Haiti, and Somalia—share common characteristics. First, the country's infrastructure has been devastated, leaving extremely little basis for rebuilding. Second, the countries lack human capital (e.g., skilled practitioners), and the population does not hold high expectations for service delivery. Finally, and most significantly, NGOs and governmental actors do not coordinate, which leads to duplicate or counterproductive efforts. All of these problems are exacerbated by security issues: it can be difficult to coordinate if convoys cannot get through to service sites, just as it is difficult to maintain human capital when violence is high, as people with marketable skills tend to leave the country.

Lessons Learned

Anthony pointed out that security does not impact the development of health services in only one aspect, but in every single one. As such, health programmers must take the security situation into account when planning, executing, and developing expectations for new programs. Overcoming the challenges of rebuilding health in devastated nations requires planning and coordination, infrastructure and resources (including human resources), and strong leadership. In low security countries, these requirements are much more difficult to meet; it may make more sense to operate on a small scale in these situations while preparing for a larger intervention when conditions improve.

Health aid can clearly provide an independent benefit not only by improving relations between countries, but also by decreasing the economic drain of poor health and lost productivity on rebuilding efforts. Officials focused on ensuring stability and fostering democracy must view rebuilding the health sector in post-conflict countries as a critical ingredient for success, instead of a low-priority luxury item. Jones concluded, "Health in most of these cases can have an important independent effect; in some cases it can have a negative impact on hearts and minds (as in Iraq), in some cases a positive one as we found with Japan. It can also provide the groundwork for democracy in some cases." As such, health programming must be viewed not only as a means to the end of security or economic reconstruction, but as a fully-fledged facet of post-conflict nation building.

Drafted by Matthew Robinson.