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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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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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Marshall Burke
Marshall Burke
Solomon Hsiang
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Adam Gorlick
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Philanthropist and software giant Bill Gates spoke to a Stanford audience last week about the importance of foreign aid and product innovation in the fight against chronic hunger, poverty and disease in the developing world.

His message goes hand-in-hand with the ongoing work of researchers at Stanford’s Freeman Spogli Institute for International Studies. Much of that work is supported by FSI’s Global Underdevelopment Action Fund, which provides seed grants to help faculty members design research experiments and conduct fieldwork in some of the world’s poorest places.

Four FSI senior fellows – Larry Diamond, Jeremy Weinstein, Paul Wise and Walter Falcon – respond to some of the points made by Gates and share insight into their own research and ideas about how to advance and secure the most fragile nations.

Without first improving people’s health, Gates says it’s harder to build good governance and reliable infrastructure in a developing country. Is that the best way to prioritize when thinking about foreign aid?

Larry Diamond: I have immense admiration for what Bill Gates is doing to reduce childhood and maternal fatality and improve the quality of life in poor countries.  He is literally saving millions of lives.  But in two respects (at least), it's misguided to think that public health should come "before" improvements in governance.  

First, there is no reason why we need to choose, or why the two types of interventions should be in conflict.  People need vaccines against endemic and preventable diseases – and they need institutional reforms to strengthen societal resistance to corruption, a sociopolitical disease that drains society of the energy and resources to fight poverty, ignorance, and disease.  

Second, good governance is a vital facilitator of improved public health.  When corruption is controlled, public resources are used efficiently and justly to build modern sanitation and transportation systems, and to train and operate modern health care systems.  With good, accountable governance, public health and life expectancy improve much more dramatically.  When corruption is endemic, life-saving vaccines, drugs, and treatments too often fall beyond the reach of poor people who cannot make under-the-table payments. 

Foreign aid has come under criticism for not being effective, and most countries have very small foreign aid budgets. How do you make the case that foreign aid is a worthy investment?

Jeremy M. Weinstein: While foreign aid may be a small part of most countries’ national budgets, global development assistance has increased markedly in the past 50 years. Between 2000 and 2010, global aid increased from $78 billion to nearly $130 billion – and the U.S. continues to be the world’s leading donor.

The challenge in the next decade will be to sustain high aid volumes given the economic challenges that now confront developed countries. I am confident that we can and will sustain these volumes for three reasons.

First, a strong core of leading voices in both parties recognizes that promoting development serves our national interest. In this interconnected world, our security and prosperity depend in important ways on the security and prosperity of those who live beyond our borders.

Second, providing assistance is a reflection of our values – it is these humanitarian motives that drove the unprecedented U.S. commitment to fighting HIV/AIDS during the Bush Administration.

Perhaps most importantly, especially in tight budget times, development agencies are learning a great deal about what works in foreign assistance, and are putting taxpayers’ dollars to better use to reduce poverty, fight disease, increase productivity, and strengthen governance – with increasing evidence to show for it.

Some of the most dire situations in the developing world are found in conflict zones. How can philanthropists and nongovernmental organizations best work in places with unstable governments and public health crises? Is there a role for larger groups like the Gates Foundation to play in war-torn areas?

Paul H. Wise: As a pediatrician, the central challenge is this: The majority of preventable child deaths in Sub-Saharan Africa and in much of the world occur in areas of political instability and poor governance. 

This means that if we are to make real progress in improving child health we must be able to enhance the provision of critical, highly efficacious health interventions in areas that are characterized by complex political environments – often where corruption, civil conflict, and poor public management are the rule. 

Currently, most of the major global health funders tend to avoid working in such areas, as they would rather invest their efforts and resources in supportive, well-functioning locations.  This is understandable. However, given where the preventable deaths are occurring, it is not acceptable. 

Our efforts are directed at creating new strategies capable of bringing essential services to unstable regions of the world.  This will require new collaborations between health professionals, global security experts, political scientists, and management specialists in order to craft integrated child health strategies that respect both the technical requirements of critical health services and the political and management innovations that will ensure that these life-saving interventions reach all children in need.

Gates says innovation is essential to improving agricultural production for small farmers in the poorest places. What is the most-needed invention or idea that needs to be put into place to fight global hunger?

Walter P. Falcon: No single innovation will end hunger, but widespread use of cell phone technology could help.

Most poor agricultural communities receive few benefits from agricultural extension services, many of which were decimated during earlier periods of structural reform. But small farmers often have cell phones or live in villages where phones are present.

My priority innovation is for a  $10 smart phone, to be complemented with a series of very specific applications designed for transferring knowledge about new agricultural technologies to particular regions.  Using the wiki-like potential of these applications, it would also be possible for farmers from different villages to teach each other, share critical local knowledge, and also interact with crop and livestock specialists.

Language and visual qualities of the applications would be key, and literacy problems would be constraining.  But the potential payoff seems enormous.

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Climate change will lead to massive conflicts, according to claims of such prominent sources as Sir Nicholas Stern and the US National Security Agency - claims repeated by the media. Efforts to tease a specific climate change signal from historical records of civil conflict have proved inconclusive, however: they postulate that farmers will become fighters when resources become critically scarce; but they have been unable to illuminate what specific mechanisms may be involved. Yet the potential for climate change to cause significant civil conflict seems intuitively obvious, and the need for better understanding remains urgent. My research focuses on sub-Saharan Africa, the most conflict-prone region in the world; and it asks what factors make some countries erupt in civil conflict, while others do not. I find that drops in agricultural exports diminish government capacity as tax revenues shrink, leading to an increase in the risk of civil conflict. Thus, government capacity to provide security and services is likely to become weak just at the time when climate change is increasing the need for both. How governments respond will determine the risk of civil conflict, but this research shows that their capacity to respond will, in fact, also be affected. The implications of these conclusions apply beyond sub-Saharan Africa, and begin to move the debate from questions around if climate change will cause conflict to more productive discussions of how climate change may affect conflict risk.

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Kaitlin Shilling
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The hardest evidence for a link so far comes from a team led by Marshall Burke of the University of California and FSE Research Associate, and co-authored with FSE Fellow David Lobell. They studied African wars from 1980 to 2002 and found that rising temperatures are indeed associated with crop failure, economic decline and a sharp rise in the likelihood of war. It predicted a “50% increase” in the chance of civil war in Africa by 2030.

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In a recent paper, we documented strong historical linkages between temperature and civil conflict in Africa (1). Sutton et al. (2) raise two concerns with our findings: that the relationship between temperature and war is based on common trends and is therefore spurious, and that our model appears overly sensitive to small specification changes. Both concerns reflect a basic misunderstanding of the analysis.

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Marshall Burke
Marshall Burke
Edward Miguel
Shanker Satyanath
John A. Dykema
David Lobell
David Lobell
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