The brutal war in Ukraine is now over a year old. While estimates of the numbers of civilians killed and injured vary, the Office of the High Commissioner for Human Rights has estimated that 8,317 civilians have been killed and a further 13,892 injured from the beginning of the war on February 24 2022 to March 20 2023, the most recent date for which figures are available. On March 16 2023, the World Health Organization (WHO) announced it had recorded 859 attacks on healthcare facilities in Ukraine.
Russian attacks on civilians and the most vulnerable targets, including maternity hospitals, have been a feature of the conflict from its beginning. On March 9 2022, the now-infamous Russian missile attack destroyed Maternity Hospital No.3 in the besieged city of Mariupol. Ukrainian president Volodymyr Zelensky said the attack constituted a war crime, adding:
"What kind of a country is this, the Russian Federation, that it is afraid of hospitals and maternity wards and destroys them?"
In a statement to the UN security council, the WHO’s director-general Dr Tedros Adhanom Ghebreyesus said the immediate effects of the "widespread destruction of infrastructure, including health facilities" would lead to a "severe disruption to health services and access to basic commodities". He also pointed to the longer-term consequences of the conflict:
"The war in Ukraine is having devastating consequences for the health of Ukraine’s people; consequences that will reverberate for years or decades to come."
My research involves investigating whether different types of conflict - major inter-state and civil wars - have similar or different consequences on arguably the most vulnerable populations: infants (children up to one year of age). In research published in The Journal of Human Rights, I presented evidence that tends to corroborate Tedros’s statement.
As well as deaths due to the actual fighting, there are many other causes of death during a war. These include increased exposure to disease, food shortages, and civilians’ lack of access to medicines and medical care. Attacks on healthcare facilities and infrastructure place greater demands on governments that are having to switch funding from healthcare provision to defence.
I found that civil wars are associated with an average increase in the infant mortality rate of 5.2% the following year. To illustrate this, when civil war erupted in Tajikistan in 1992, the infant mortality rate (IMR) jumped from 81.8 to 88.4 per 1,000 the following year - an 8.1% increase.
Wars between countries increase IMRs by a greater extent - about 10.5%, on average. In some instances, there can be a sizeable jump: Iraq’s IMR, for example, rose from 67.4 in 1990 to 99.7 with the start of the first Gulf War in 1991 - a 47.9% increase.
The situation gets worse, predictably, the longer a conflict lasts and the more bitter and destructive the fighting.
The cumulative effect of the wholesale destruction of healthcare institutions and support systems, as well as access to clean water and sanitation and food and vaccines, means public health outcomes continue to worsen long after the fighting stops.
Controlling for other predictors of IMRs to isolate the effects of war, when I compared countries not involved in major interstate wars with those that had spent almost their entire time as independent states involved in such conflicts, I found a massive increase in IMRs for the latter - up 100.7% (from 61 to 122.4 per 1,000).
Azerbaijan is a particularly good example of this. The country gained independence from the Soviet Union in 1991, and was almost immediately embroiled in the Nagorno-Karabakh conflict against Armenia, which lasted until 1994. In 1991, Azerbaijan had an IMR of 62.6. By May 1994, when the signing of the Bishkek Protocol brought a (temporary) end to hostilities, the IMR had increased to 75.3 per 1,000. But the negative effects of the conflict on Azerbaijan continued: by 1997, its IMR had reached 80.8 per 1,000 - an overall increase of 29.1%.
I made the same comparison involving countries that had spent their whole time as independent states involved in civil war. These war-torn societies, on average, experienced an 11.5% increase in their IMRs (from 62.5 to 69.7).
One example is the Angolan civil war, from 1975 to 1994. When it began, Angola already had a high IMR of 163.4 deaths per 1,000 live births. By the last year of the major civil war in 1994, the rate had jumped to 200.3 deaths per 1,000 live births, a 22.6% increase.
Some important issues emerge from this research. First, while we might expect the Geneva Conventions to prevent governments involved in international conflict from targeting civilians, the evidence from wars between separate countries suggests the opposite - these conflicts are much more deadly for infants compared with civil wars.
Civil wars, while disastrous for the communities they devastate, may not involve the same intensity of fighting or scale of destruction by bombing and heavy artillery.
But the terrible consequences of all war for people - not least, the infants that have been the subject of my research - should remind all those involved in conflict that they must adhere to the Geneva Conventions, or face the consequences of committing war crimes.
It’s hard to imagine war crimes more heinous than those committed against infant children who have not yet reached their first birthday.
This article first appeared in The Conversation on 13 April 2023.
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