War & Health

The 20/20 Health Systems Project just launched with a new web-accessible database of health systems statistics:

The Health Systems Database draws data from publicly available and internationally comparable databases. Sources are publications from the World Health Organization (WHO), the World Bank, and the United Nations Children’s Fund (UNICEF). More recent data may be available from other sources including in-country sources. The user contribution section of this tool is designed to capture and share such information.

Hat tip to the Global Health Policy blog.

Full list of variables in the datasets after the break.

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HIV rates in Uganda’s Karamoja region are rising fast. Non-governmental organizations (NGOs) are well placed to tackle the problem through medical and public health services. Many of these organizations have been dealing with HIV for decades. They have the resources and experience to make a great, positive difference. However, in the case of Karamoja there is not much anyone can do.

Karamoja is the Afghanistan of Africa: tribal, pastoral, violent, and without infrastructure. Government control, let alone health services, in the region is minimal. In this environment NGOs have been largely forced out by instability.

Most aid organisations function with only essential personnel on the ground, if at all, because of the region’s insecurity - cattle raids on neighbouring communities are common, and increasingly fatal with the introduction of modern arms - while the difficulty of travelling between districts forces non-governmental organisations (NGOs) either to manage their programmes in Karamoja remotely or give the region a wide berth.

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“We can’t invest more money because of the limited capacity for absorption; loads of money can go into Karamoja, but if no infrastructure or conducive policy environment is built, then the possibilities are limited,” said Savio Carvalho, Oxfam’s country programme manager. “There needs to be a framework.”

Carvalho is talking about system disruption. The roads, energy, social services , security, political control, and social network of a region are all part of its ’system’. Conflicts disrupt these systems. The role of IGOs/NGOs is to repair or strengthen areas of systems through various methods. These include building new infrastructures (wells, clinics, schools) and providing health services. The problem in Karamoja is that the region’s system is below the threshold necessary for NGOs to operate. NGOs are designed to build upon existing systems, not create them from scratch. Carvalho refers to the existing system as the needed “framework”.

HIV health services are particularly vulnerable to system disruption. Antiretrovirals (ARVs), which make HIV a chronic (opposed to fatal) disease, must be taken regularly for the entire lifespan of the patient. When the system is disrupted (through road blocks, population movements, looting, etc…) and access to ARVs is interrupted, there is the very real risk the virus will become resistant to the treatment. Thus, ARVs are highly dependent on a stable system enabling the medical/logistical operation required to deliver and distribute the drugs throughout the region.

The takeaway point: The provision of health services requires a certain level of ’system’ in place. When conflict is the primary disruptor of a region’s system, the ability to provide long term security (either from national or international sources) is a prerequisite to successful health interventions.

A few weeks ago, I had the pleasure of attending a talk given by Colonel Peter Mansoor. Col. Mansoor is a member of Petreus’ inner circle and has been influential in the development of the US Army’s counterinsurgency doctrine. Mansoor is also an architect of the surge strategy in Iraq and recently published Baghdad at Sunrise: A Brigade Commander’s War in Iraq, an analysis of counterinsurgency in Iraq from a mid-level officer.

During the questions and answer section I asked the Colonel what was the role of providing health and social services in modern counterinsurgency doctrine. He took the (very reasonable) position that the primary concern of civilian populations is security. That is, without security, nothing else matters. However, once a certain level of security has been established, the population looks for the provision of services (including health services). In this ’second stage’, of counterinsurgency the provision of health services plays a major role in winning hearts and minds. Mansoor’s position is that Iraq was just barely in this second stage.

I agree with Mansoor, but believe the effect is more nuanced. The two stages (security and services) are not firmly separated. Rather, as the population gradually feels less security needs, people begin to look for the provision of services.

Benini, Aldo A, and Lawrence H Moulton. 2004. “Civilian Victims in an Asymmetrical Conflict: Operation Enduring Freedom, Afghanistan.” Journal of Peace Research 41(4):403-422. [Download Data Here]

This dataset on Afghan towns and villages exposed to hostilities after 11 September 2001 is the by-product of a landmine and UXO contamination assessment. The assessment, with a view to creating an inventory of freshly contaminated sites for rapid clearance purposes, was done by the Afghan NGO Mine Clearance Planning Agency (MCPA) with the help of the Vietnam Veterans of America Foundation (VVAF), an advocacy and victim assistance organization in humanitarian mine action (Benini & Donahue, 2003).

In spring and early summer 2002, MCPA interviewer teams visited all communities suspected to have been subject to airstrikes or ground operations during Operation Enduring Freedom. These communities - villages or urban neighborhoods - had been nominated by provincial administrations and by neighboring communities; moreover, MCPA had access to coalition airstrike imprints. The teams visited 747 suspect communities, among which exactly 600 were determined to have had at least one airstrike or ground operation. These affected communities were scattered in 102 districts in 25 of the 32 provinces.

In each community confirmed exposed to post-9/11 hostilities, a team would conduct an interview, using a modular questionnaire, with a small group of local key informants. These groups, variable in size and composition, would share information on dates and types of hostilities, prewar and current population, old and new contaminated areas and broad types of munitions, types and numbers of property damaged or destroyed, and finally, victims. Victim numbers were elicited, broken down in several dimensions - by age and sex, cause (direct violence vs. landmine and unexploded ordnance strikes), outcome (deaths and injuries) - as well as two periods of time. Counts were requested of all who had come to harm between 11 September 2001 and the date of survey - a 9-month period on average. Retrospective counts were requested for the period of 12 months prior to 9/11. No attempt was made to attribute the violence that caused these victims to any specific parties to the conflict. Before leaving the community, teams took GPS (Global Positioning System) measurements of the coordinates of a central location such as its mosque.

A colleague of mine stumbled upon a fascinating book by Stephan Stedman and Fred Tanner on (and titled) Refugee Manipulation. The book explores the manipulation of the international refugee regime (i.e. UNHCR, NGOs, States hosting refugees, etc…) by warring parties. That is, the strategic creation and/or use of refugee camps in armed conflict:

Hence some refugee camps become a breeding ground for refugee warriors: disaffected individuals, who-with the assistance of overseas diasporas, host governments, and interested states–equip themselves for battle to retrieve an idealized, mythical lost community. Facing military defeat at home, the warring party uses the suffering of refugees for its own political purpose: to siphon off aid, establish the international legitimacy of their cause, and, by manipulating access to them, ensure that they will not repatriate. As long as armies control refugee populations, they can demand a seat in negotiations.

As the authors point out, the answer to refugee manipulation is in changing the incentives. That is, incentivizing and empowering 1) states hosting refugee camps to maintain control and security, 2) refugee leaders to reject armed groups militarizing camps, and 3) NGOs to prevent the maldistribution of their aid.

Source:

Stedman, Stephen John, and Fred Tanner. 2003. Refugee manipulation: war, politics, and the abuse of human suffering. Brookings Institution Press.

Iraqi forces swept unopposed into Baghdad’s Sadr City today after a compromise with firebrand cleric Moktada al-Sadr. Most commentary focused on the impressive showing of the Iraqi Army, which conducted the operation largely independently. However, I (and also Dr. iRack from Abu Muqawama) noticed something else:

By late Tuesday, Iraqi troops had pushed deep into the district and set up positions around hospitals and police stations, which the Iraqi government was seeking to bring under its control.

A primary target for Iraqi forces seems to have been the facilities providing health services in the area. In the recent weeks Al-Sadr’s militia has tried to use ownership of these services to gain support amongst the population. Now with Iraqi forces firmly in control of Sadr City’s hospitals, it is a race against time to expand and improve available health services to win the support and loyalty of local residents.

Dr. Irack put it well: “[counterinsurgency] is a contest to influence and control the population”. The provision of health services is a low cost, yet powerful, approach to winning that contest. Those providing health services have a significant advantage in winning hearts, minds, and legitimacy in the population. By providing services, the government is aligning itself with the population’s interest. From then on, insurgent attacks are not simply a strike by one side against another, but an attack  against the providers of the population’s health. In turn, the population is more willing to cooperate with local security forces in routing out insurgents and sympathizers. If in counterinsurgency populations are the battlefields, then hospitals are part of the commanding heights.

This morning I attended a blogger’s roundtable with US Air Force Captain Trevor Hall. Capt. Hall was the pilot-in-command for the first US military humanitarian flight into Burma since the disaster. His C-130 transport aircraft carried food, water, and medical supplies into Rangoon International Airport. Since then, a number of further US Air Force and Marine flights have taken place.

Capt. Hall described the Burmese military personnel offloading the plane as “ecstatic” for US help, some even wanting to have their pictures taken with the crew and aircraft. Hearing this, I was reminded of Operation Little Vittles, when US pilots participating in the Berlin Airlift dropped candy from their aircraft while flying over the city. The actions of the pilots won the hearts and minds of a generation of Berliners, who dubbed the aircraft “Rosinenbombers” (Candy Bombers), and still remember the act today.

The operations in Iraq and Afghanistan have proven the power in winning a population’s hearts and minds. Modern humanitarian airlifts represent not only a chance to fulfill our responsibility to humanity, but also to create an entire generation with fond memories of American aircraft dropping American aid. In the long term, the resulting support might pay back hundreds of times over.

Update: Blackfive has a recording of the entire interview.

Academic (and blogger) Chris Blattman just published a new report on young women in one of Africa’s longest conflicts, between the Joseph Kony’s Lord’s Resistance Army and the Ugandan government. The LRA is the definition of brutality: routinely targeting civilians, attacking aid convoys, practicing mutilations, and abducting adults and children to swell their ranks.

Chris’ report contains many insights and is a fascinating read, but one particular point stands out: the role of abducted women in the LRA. Male abductees are primarily used as expendable troops and it has typically been assumed captive women are used as sexual slaves and forced wives for LRA officers. However, the report finds the vast majority of female LRA abductees are used in combat support roles with almost two thirds of women employed as porters or cooks. Only 7.5% of returned abductees reported being “wives” of LRA members and 7.4% used primarily for childcare.

The statistics offer a rare glimpse of the LRA as a rational, functioning organization requiring significant human resources to perform essential combat support duties rather than their more common, but simplistic portrayal as madmen.

Photo Credit: 1) DoD, 2) SWAY

At approximately 10:00am on May 3rd, the United States fired three precision-guided weapons at a small building next to Sadr General Hospital in the Sadr City slum of Baghdad. The building is alleged by coalition forces to be a “criminal element command and control center“. The first munition struck the small building, the second struck the hospital’s ambulance parking lot and broke the hospital’s water line, and the third hit a generator used by the neighborhood but not the hospital.

McClatchy’s Leila Fadel and Shashank Bengali described the damage:

Sadr Hospital, one of two main hospitals serving the massive Shiite Muslim slum, is operating on a backup water supply that wasn’t expected to last longer than 48 hours. On Sunday afternoon, a main street outside the hospital was flooded as workmen tried to repair a series of underground pipes that ruptured when the missiles targeted what U.S. military officials described as a militia outpost a few yards from the hospital.

“If there are no more attacks, we might be able to fix it. We don’t know,” said a hospital security official who gave his name as Abu Sajjad. “Otherwise, in two days we will run out of water and the hospital can’t go on.”

The official said that the U.S. strike also damaged 15 ambulances and forced many hospital staff to flee. Not everyone returned to work Sunday, leaving a Spartan emergency ward nearly empty of doctors.

The airstrike betrays an understandable ignorance in coalition forces towards the nature of health care delivery. While coalition forces avoid targeting hospitals directly, this does not protect the ability of the hospital to function. The rational for not striking hospitals is to keep them operating and providing health to the local population. However, any hospital’s functions are reliant on a large network of facilities and services. This network includes ambulance facilities and water lines. Most of these network nodes exist outside the hospital’s physical perimeter and whose presence is not calculated into airstrike planning. If policy makers truly want to maintain access to healthcare during armed conflict they must consider not only the hospital’s physical facilities but also key nodes in the area’s health care network, regardless of whether or not they fly the red cross.

Last month, American and Iraqi forces launched a major push into the Sadr City section of Baghdad. The operations led to intense fighting and crippled Sadr City’s already flimsy infrastructure. As a result, large swaths of Sadr City are currently without trash collection, sewer systems, electricity, food, and access to health services.

The situation in Sadr city represents not only a humanitarian disaster, but also a direct threat to winning hearts and minds. Michael Gordon, in his New York Times article, points out the problem:

On Saturday, three Sadr City residents gingerly approached an American Army position to deliver a warning: Unless the Iraqi government or its American partner did something to restore essential services and remove the piles of garbage, the militias would gain more support.

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“Through a ‘Hezbollah-like’ scheme, the Shiite Sadrist movement has established itself as the main service provider in the country,” notes a recent report by Refugees International, an advocacy group. “As a result of the importance of nonstate actors in the delivery of assistance and security, civilians are joining militias.”

The lack of infrastructure, sanitation, and health services offer opportunities for militias to move quickly, winning hearts and minds by merely providing token services to residents. While the Iraqi government can provide greater levels of support, militias can provide support right now. For example, the Iraqi government is promising $150 million to bolster Sadr City’s infrastructure, however, it will not do so until the security situation improves. The speed of the Sadrists allows them to compete against the Iraqi government for public support at a fraction of the cost. That is, in the battle for hearts and minds, $100 today is worth more than a $10,000 a year from now.