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More children die from the indirect impact of armed conflict in Africa than those killed in the crossfire and on the battlefields, according to a new study by Stanford researchers. 

The study is the first comprehensive analysis of the large and lingering effects of armed conflicts — civil wars, rebellions and interstate conflicts — on the health of noncombatants.

The numbers are sobering: 3.1 to 3.5 million infants born within 30 miles of armed conflict died from indirect consequences of battle zones between 1995 and 2005. That number jumps to 5 million deaths of children under 5 in those same conflict zones.

“The indirect effects on children are so much greater than the direct deaths from conflict,” said Stanford Health Policy's Eran Bendavid, senior author of the study published today in The Lancet.

The authors also found evidence of increased mortality risk from armed conflict as far as 60 miles away and for eight years after conflicts. Being born in the same year as a nearby armed conflict is riskiest for young infants, the authors found, with the lingering effects raising the risk of death for infants by over 30 percent.

On the entire continent, the authors wrote, the number of infant deaths related to conflict from 1995 to 2015 were more than three times the number of direct deaths from armed conflict. Further, they demonstrated a strong and stable increase of 7.7 percent in the risk of dying before age 1 among babies born within 30 miles of an armed conflict.

The authors recognize it is not surprising that African children are vulnerable to nearby armed conflict. But they show that this burden is substantially higher than previously indicated. 

“We wanted to understands the effects of war and conflict, and discovered that this was surprisingly poorly understood,” said Bendavid, an associate professor of medicine at Stanford Medicine.  “The most authoritative source, the Global Burden of Disease, only counts the direct deaths from conflict, and those estimates suggest that conflicts are a minuscule cause of death.”

Paul Wise, a professor of pediatrics at Stanford Medicine and a senior fellow at the Freeman Spogli Institute for International Studies, has long argued that lack of health care, vaccines, food, water and shelter kills more civilians than combatants from bombs and bullets. 

This study has now put data behind the theory when it comes to children.

“We hope to redefine what conflict means for civilian populations by showing how enduring and how far-reaching the destructive effects of conflict have on child health,” said Bendavid, an infectious disease physician whose co-authors include Marshall Burke, PhD, an assistant professor of earth systems science and fellow at the Center on Food Security and the Environment.

“Lack of access to key health services or to adequate nutrition are the standard explanations for stubbornly high infant mortality rates in parts of Africa,” said Burke. “But our data suggest that conflict can itself be a key driver of these outcomes, affecting health services and nutritional outcomes hundreds of kilometers away and for nearly a decade after the conflict event”. 

The results suggest efforts to reduce conflict could lead to large health benefits for children.

The Data

The authors matched data on 15,441 armed-conflict events with data on 1.99 million births and subsequent child survival across 35 African countries. Their primary conflict data came from the Uppsala Conflict Data Program Georeferenced Events Dataset, which includes detailed information about the time, location, type and intensity of conflict events from 1946 to 2016. 

The researchers also used all available data from the Demographic and Health Surveys conducted in 35 African countries from 1995 to 2015 as the primary data sources on child mortality in their analysis.

The data, they said, shows that the indirect toll of armed conflict among children is three-to-five times greater than the estimated number of direct casualties in conflict. The indirect toll is likely even higher when considering the effects on women and other vulnerable populations.

Zachary Wagner, a health economist at RAND Corporation and first author of the study, said he knows few are surprised that conflict is bad for child health.

“However, this work shows that the relationship between conflict and child mortality is stronger than previously thought and children in conflict zones remain at risk for many years after the conflict ends.” 

He notes that nearly 7 percent of child deaths in Africa are related to conflict and reiterated the grim fact that child deaths greatly outnumber direct combatant deaths.

“We hope our findings lead to enhanced efforts to reach children in conflict zones with humanitarian interventions,” Wagner said. “But we need more research that studies the reasons for why children in conflict zones have worse outcomes in order to effectively intervene.” 

Another author, Sam Heft-Neal, PhD, is a research fellow at the Center for Food Security and the Environment and in the Department of Earth Systems Science. He, Burke and Bendavid have been working together to identify the impacts of extreme climate events on infant mortality in Africa.

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Ending world hunger is a universal goal, yet progress and social awareness of the issue waxes and wanes in the course of broader political and economic developments. The massive famine in China under Chairman Mao’s 1958–62 Great Leap Forward, a succession of severe droughts and associated famines in India in 1965–66, and the political violence that accompanied regime change in Indonesia in 1964–67 left tens of millions of people starving and drew global attention to the threat of food insecurity. What emerged from these events was an international commitment to agricultural technology transfers, water resource development, and foreign assistance – partly in the spirit of humanitarian goodwill and partly in pursuit of long-term geopolitical and economic interests revolving around the Cold War. Whatever the motivation, the outcome over the ensuing decades was more than a doubling of staple cereal yields in Asia, and a steady decline in real (inflation-adjusted) cereal prices.

Despite these gains, a second, quite different, rallying cry for food security resounded in 2007–8 as international grain prices spiked, food riots erupted in numerous cities throughout the developing world, and the global economy headed into a deep recession. Several factors sparked this crisis, but unlike the earlier periods of dire food shortages, the root causes included unwieldy financial markets and escalating demands for food, animal feeds, and fuel (including biofuels) in a globalized economy. This episode prompted new analyses of the connection between global commodity markets and food security, the political-economy foundations of agricultural development, and the differential impacts of food prices on net producers and net consumers. In the five-year period from 2007 to 2012, international cereal prices were highly unstable, varying by as much as 300 percent.

Today, international agricultural markets have settled at relatively low prices, but civil conflicts, extreme climate events, and other natural disasters are blocking the path toward ending hunger. In February 2017, the United Nations declared a famine in South Sudan, as war and economic collapse ravaged the newly independent nation. Although the famine officially ended in mid-2017, food emergencies and severe undernourishment still threaten tens of millions of people in South Sudan, Yemen, Nigeria, Somalia, and Syria, due to a combination of civil conflict, prolonged droughts, and occasional floods. On the surface, it seems incomprehensible that there could be such difficulty in addressing these looming famines at a time when global cereal production and stocks are at historical highs. But the problem is not a matter of food supply; the problem is war.

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Rosamond L. Naylor
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Stanford welcomes Cousin, a global hunger expert, to the Center on Food Security and the Environment.

The Freeman Spogli Institute for International Studies (FSI) at Stanford University is pleased to announce that former U.S. Ambassador and World Food Programme (WFP) Director Ertharin Cousin will serve as this year’s Frank E. and Arthur W. Payne Distinguished Lecturer and Visiting Fellow at the Center on Food Security and the Environment (FSE).  

Cousin brings over 25 years of experience addressing hunger and food security strategies on both a national and international scale. As U.S. Ambassador to the United Nations Agencies for Food and Agriculture, she focused on advocating for longer-term solutions to food insecurity and hunger, and at WFP she addressed the challenges of food insecurity in conflict situations.

“Dr. Cousin’s outstanding leadership at the WFP and extensive experience in public service exemplifies the attributes we seek for Payne Lecturers,” says FSI Director Michael McFaul. The Payne Distinguished Lectureship is awarded to scholars with international reputations as leaders, with an emphasis on visionary thinking, practical problem solving, and the capacity to clearly articulate an important perspective on the global political and social situation. Past Payne Lecturers include Bill Gates, Nobel Laureate Mohamed El Baradei, UNAIDS Executive Director Peter Piot, and novelist Ian McEwan.

As a visiting fellow with FSE, Cousin will be working to further her research focus on global food security and humanitarian efforts. In November 2015, FSE welcomed Cousin as the featured speaker in their Food and Nutrition Symposium series, where she presented her paper “Achieving food security and nutrition for the furthest behind in an era of conflict and climate change.” FSE Director, Roz Naylor, sees Cousin’s appointment as a pivotal opportunity for FSE and FSI to advance a global agenda on food security and human rights. “Ertharin Cousin is one of the most inspirational leaders we could ever hope to attract to Stanford as a year-long visitor,” Naylor says.

“This is a truly humbling, yet exciting prospect,” says Cousin. “This position provides an opportunity for scholarly work and dialogue with distinguished academics across Stanford's schools and policy institutes.  I also look forward to the opportunity to convene thought leaders from a broad variety of backgrounds, who can help us explore some of the intractable issues plaguing humanitarian and development practitioners today.”

Following the completion of her term with the WFP, Cousin accepted an appointment as a Distinguished Fellow with The Chicago Council on Global Affairs, which conducts research on food and agriculture, global cities, economics, energy, immigration, security, public opinion, and water. Cousin hopes her appointments can provide a unique collaborative opportunity to expand her work on food security and nutrition issues.

“In my career I have never before been given the opportunity of pursuing intellectual inspiration. Just thinking about the ‘what’s possible’ gives me genuine pleasure,” Cousin said.

About FSE

The Center on Food Security and the Environment (FSE) is a research center at Stanford University, jointly funded by the Freeman Spogli Institute for International Studies and the Stanford Woods Institute for the Environment.

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Abstract: A growing body of empirical evidence indicates that changes in climate are associated with increases in human violence.  I review new and recent evidence on this topic, using data ranging from baseball games in the US to civil war in Africa.  Across disparate settings, warmer-than-average temperatures are shown to cause increases in violence, with effect sizes that are both consistent and large.  Economic theories of conflict appear to explain some of the linkage between climate and conflict, but are not consistent with the data in all settings. Constructive engagement with the political science and security communities will be very helpful in understanding and interpreting these findings.

About the Speaker: Marshall Burke is assistant professor in the Department of Earth System Science, and Center Fellow at the Center on Food Security and the Environment at Stanford University. His research focuses on social and economic impacts of environmental change, and on the economics of rural development in Africa. His work has appeared in both economics and scientific journals, including recent publications in Nature, Science, the Proceedings of the National Academy of Sciences, and the Review of Economics and Statistics. He holds a PhD in Agricultural and Resource Economics from UC Berkeley, and a BA in International Relations from Stanford.

Marshall Burke Assistant Professor, Dept. of Earth System Science Stanford University
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The ongoing decline in under-5 mortality ranks among the most significant public and population health successes of the past 30 years. Deaths of children under the age of 5 years have fallen from nearly 13 million per year in 1990 to less than 6 million per year in 2015, even as the world's under-5 population grew by nearly 100 million children. However, the amount of variability underlying this broad global progress is substantial. On a regional level, east Asia and the Pacific have surpassed the Millennium Development Goal target of a two-thirds reduction in under-5 mortality rate between 1990 and 2015, whereas sub-Saharan Africa has had only a 24% decline over the same period. Large differences in progress are also evident within sub-Saharan Africa, where mortality rates have declined by more than 70% from 1990 to 2015 in some countries and increased in others; in 2015, the mortality rate in some countries was more than three times that in others.

What explains this remarkable variation in progress against under-5 mortality? Answering this question requires understanding of where the main sources of variation in mortality lie. One view that is implicit in the way that mortality rates are tracked and targeted is that national policies and conditions drive first-order changes in under-5 mortality. This country-level focus is justified by research that emphasises the role of institutional factors in explaining variation in mortality—factors such as universal health coverage, women's education, and the effectiveness of national health systems. It is argued that these factors, which vary measurably at the country level, fundamentally shape the ability of individuals and communities to affect more proximate causes of child death such as malaria and diarrhoeal disease.

An alternate view has focused on exploring the importance of subnational variation in the distribution of disease. In the USA, studies on the geographical distribution of health care and mortality have been influential for targeting of resources and policy design. Similar studies in developing regions have shown the substantial variability in the distribution and changes of important health outcomes such HIV, malaria, and schistosomiasis—information that can then be used to improve the targeting of interventions. Nevertheless, the relative contribution of within-country and between-country differences in explaining under-5 mortality remains unknown. Improved understanding of the relative contribution of national and sub-national factors could provide insight into the drivers of mortality levels and declines in mortality, as well as improve the targeting of interventions to the areas where they are most needed.

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The Lancet Global Health
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Marshall Burke
Sam Heft-Neal
Eran Bendavid
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We review the emerging literature on climate and conflict. We consider multiple types of human conflict, including both interpersonal conflict, such as assault and murder, and intergroup conflict, including riots and civil war. We discuss key methodological issues in estimating causal relationships and largely focus on natural experiments that exploit variation in climate over time. Using a hierarchical meta-analysis that allows us to both estimate the mean effect and quantify the degree of variability across 55 studies, we find that deviations from moderate temperatures and precipitation patterns systematically increase conflict risk. Contemporaneous temperature has the largest average impact, with each 1σ increase in temperature increasing interpersonal conflict by 2.4% and intergroup conflict by 11.3%. We conclude by highlighting research priorities, including a better understanding of the mechanisms linking climate to conflict, societies’ ability to adapt to climatic changes, and the likely impacts of future global warming.

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Annual Review of Economics
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Marshall Burke
Marshall Burke
Solomon Hsiang
Edward Miguel
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