Andrew Testa / Panos Pictures
Part IV examines the impact of armed conflict on society. Battle-death
counts are the commonly used indicators of the severity of conflicts.
But while important, they measure only a small part of the real human
cost of war.
Counting the Indirect
Costs of War
P A R T I V
H U M A N S E C U R I T Y R E P O R T 2 0 0 5
124
Counting the Indirect
Costs of War
Introduction
Beyond battle-deaths
127
Counting the costs of political violence is no simple task. The numbers of armed conflicts, battle-
deaths, and deaths from politicides and genocides are critically important measures, but relying
on them alone risks trivialising and distorting the true impact of war on societies.
Measuring the hidden costs of armed conflict
129
Most attempts to measure war-related ‘excess’ deaths from disease and malnutrition rely on in-
dividual epidemiological surveys in war zones. A radical new approach pioneered by researchers
at Yale University uses World Health Organization data to estimate the long-term and indirect
effects of wars.
HIV/AIDS and conflict
135
Claims that war accelerates the spread of HIV/AIDS and that high levels of AIDS increase the
risk of conflict have become increasingly common. But closer examination reveals a more com-
plex picture. Some of sub-Saharan Africa’s most peaceful countries have the highest rates of HIV
infection in the world, while infection rates in some wartorn countries are very low.
P A R T I V
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125
Introduction
The death toll from combat is an important, but
incomplete, measure of the true costs of armed
conflict. Warfare destroys infrastuctures, disrupts
trade, causes capital flight and triggers economic
crises. War-related diseases kill and disable far
more people than bombs and bullets.
Battle-death numbers, as noted previously, are an in-
adequate measure of the total costs of war. In most wars far
more people die from war-related disease and malnutrition
than from combat.
Some idea of just how great the difference between to-
tal war deaths and battle-deaths can be is found in a recent
study by Bethany Lacina and Nils Petter Gleditsch, which
is briefly reviewed in the first section of Part IV.
The authors compare estimates of ‘total war deaths’ in
nine major sub-Saharan African wars with their own count
of battle-deaths in the same wars. The total war death es-
timates were drawn from a diverse variety of sources. They
include battle-deaths, but also the far greater number of
‘indirect’ or ‘excess’ deaths from war-exacerbated disease
and malnutrition.
Case study evidence suggests that the key determi-
nants of excess deaths are the intensity and scope of po-
litical violence, the numbers of people displaced and the
level of development—particularly with respect to health
services. Poor countries, where most wars take place, are
the worst affected.
Three ways of estimating the wider costs of war are
examined in the sections that follow. First is a broad mea-
sure of the ‘societal impact of war’ developed by Monty G.
Marshall. This measure uses a 10-interval scale to rank the
severity of the societal impact of warfare in each country
experiencing armed conflict. The societal impact trend
data—like the armed conflict data—show a dramatic drop
following the end of the Cold War.
A second approach uses epidemiological surveys
to determine numbers of direct and indirect deaths
in war-affected countries.
The International Rescue
Committee carried out a series of epidemiological sur-
veys in the Democratic Republic of the Congo (DRC)
between 1999 and 2002. The surveys estimated that
some 3.3 million people died as a consequence of the
civil war.
A third approach to estimating war-related indirect
death rates has been pioneered by Yale University’s Bruce
Russett and colleagues. The Yale team used two datasets.
The first was of battle-deaths in some 51 civil wars that
took place between 1991 and 1997. The second was the
Leo Erken / Panos Pictures
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126
World Health O rganization’s 1999 dataset on mortality
and disability rates from various causes—from disease to
traffic accidents.
Controlling for other social and economic influences,
the team sought to determine the association between the
direct civil war fatalities from 1991 to 1997 and the death
and disability rates reported by WHO in 1999.
The measure of the indirect impact of war wasn’t
simply the number of deaths, but rather the number
of healthy years of life lost as a consequence of death,
disease or other harmful conditions that develop as a
consequence of war.
Using WHO data for 1999, the researchers found
that for each civil war battle-death between 1991 and
1997 there were almost four additional years of healthy
life lost in 1999.
As indicated in the earlier discussion of WHO’s
‘direct’ war death data, there are many uncer tainties
associated with the organisation’s mortality data. The
measurement process is, in Professor Russett’s words,
an exercise ‘subject to considerable approximation and
speculation’.
1
In the final section we examine the much-discussed
relationship between security and HIV/AIDS, which
Professor Russett’s research found headed the list of dis-
eases that are exacerbated by war.
The growing literature that deals with the AIDS-war
nexus makes two important claims. First, that war is a
major driver of HIV infections, and second, that the AIDS
pandemic increases the risk of armed conflict by reducing
state capacity.
However, the relationship is more complex than
much of the literature suggests and challenges some of
the assumptions of the new conventional wisdom on the
AIDS-war nexus. Some long-duration wars are associated
with very low levels of HIV infection, while some countries
where HIV/AIDS is most prevalent are among the least
prone to civil war.
Although the Human Security Report 2005 offers one
of the most comprehensive surveys of global political
violence ever published, we are unable to do more than
speculate about the true human costs of warfare. We know
that indirect deaths in most wars greatly outnumber bat-
tle-deaths, but that is all.
Because the indirect human costs of war remain
largely hidden and are under-researched and too of-
ten ignored, they will be a central theme of the Human
Security Report 2006.
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Beyond battle-deaths
Comparisons of battle-deaths and total war
death tolls reveal that the latter often exceed
the former by a huge margin. To determine the
societal impact of armed conflict we need to look
at a range of indicators.
Thus far this report has analysed battle-deaths—a rel-
atively simple and straightforward measure. But as Figure
4.1 indicates, battle-deaths represent only a small fraction
of the total number of people who die as a consequence
of war.
Figure 4.1 presents some findings of a study by Bethany
Lacina and Nils Petter Gleditsch, who compare battle-
death totals with estimates of total war deaths in nine
major conflicts in sub-Saharan Africa since the end of
World War II.
2
The differences are sometimes huge—in
Ethiopia, the extreme case, the number of battle-deaths
was less than 2% of the total war death toll.
The ‘total war death’ figures include both battle-
deaths and ‘indirect’ or ‘excess’ deaths. These figures
come from a variety of sources —scholars, NGOs and
journalists. Few can be considered reliable. They should
be viewed as speculative ‘guesstimates’ rather than accu-
rate measures. However, there is no doubt that far more
people die from the indirect effects of political violence
than are killed in battle.
The societal impact of war
Recognising the limitations of death tolls as indicators of the
total cost of warfare, Monty G. Marshall of the University
of Maryland developed a more inclusive yardstick. His ‘so-
cietal impact of war’ measure embraces not just war deaths
but population dislocations, damage to ‘societal networks’,
environmental and infrastructure damage, resource diver-
sion and ‘diminished quality of life’.
The ‘societal impact of war’ measure
embraces not just war deaths but
population dislocations and damage
to ‘societal networks’ as well.
Examining 291 cases of armed conflict from 1946 to
2004, the Maryland researchers scored each country in
conflict on a scale of 1 to 10, with 1 indicating very low war
costs, and 10 indicating total destruction.
The difference between each level on the scale is the
same; two Level 4 conflicts, for example, will have the same
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societal impact as one Level 8 conflict or four Level 2 con-
flicts.
3
Because the difference between each consecutive
level of conflict is assumed to have equal weight, it is pos-
sible to sum the impact-of-war scores for all countries to
arrive at the annual global totals shown in Figure 4.2.
The trend data in Figure 4.2 reveal that since the end
of the Cold War the societal costs of armed conflict have
declined more rapidly than the number of armed conflicts,
or battle-deaths per conflict.
This has important and encouraging implications for
post-conflict recovery. All things being equal, the lower the
societal costs of warfare, the greater the prospects for swift
and successful recovery once a conflict ends.
Warfare Totals (Societal + All Interstate)
Societal Warfare (intrastate)
All Interstate Wars (inc. colonial wars)
Interstate Warfare
0
50
100
150
200
Source: Peace and Conflict 2005
5
The global trend in the cost of conflict follows a
similar pattern to the conflict numbers: several
decades of increase then a sharp decline.
Figure 4.2 The falling cost of armed conflict
Figure 4.1 Battle-deaths versus total war deaths in selected sub-Saharan African conflicts
Country
Years
Estimates of total
war deaths
Battle-deaths
\
Battle-deaths as
a percentage of
total war deaths
Sudan (Anya Nya
rebellion)
1963–73
250,000–750,000
20,000
3–8%
Nigeria (Biafra
rebellion)
1967–70
500,000–2 million
75,000
4–15%
Angola
1975–2002
1.5 million
160,475
11%
Ethiopia (not inc.
Eritrean insurgency)
1976–91
1–2 million
16,000
<2%
Mozambique
1976–92
500,000–1 million
145,400
15–29%
Somalia
1981–96
250,000–350,000
(to mid-1990s)
66,750
19–27%
Sudan
1983–2002
2 million
55,000
3%
Liberia
1989–96
150,000–200,000
23,500
12–16%
Democratic Republic
of the Congo
1998–2001
2.5 million
145,000
6%
The indirect impact of war in sub-Saharan Africa is revealed by the comparison of battle-deaths with
estimates of war deaths from all causes—primarily disease and malnutrition.
Source: Lacina and Gleditsch, 2004
4
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Measuring the hidden costs of
armed conflict
The greatest human costs of war are the ‘indi-
rect’ deaths caused by disease and the lack of
access to food, clean water and health care ser-
vices. A recent study uses WHO mortality and
morbidity data to estimate the impact of war
on population health.
According to a recent study of battle-deaths around
the world, some 134,000 people died as a direct and im-
mediate consequence of armed conflicts in 1999.
6
These
casualties are only the tip of the iceberg. Long after the
shooting stops, wars continue to kill people indirectly.
Wars destroy property, disrupt economic activity, divert
resources from health care and raise crime rates after the
fighting has ended. Crowded into camps, susceptible refu-
gees fall ill from infectious diseases and contribute to the
further spread of these diseases.
Because many of these indirect effects may take
years to manifest and are difficult to distinguish from the
effects of diseases and conditions not attributable to war,
they are often ignored in favour of immediate body counts.
But disregarding indirect mortality and morbidity gross-
ly underestimates both the human costs of war and the
level of expenditure and effort needed to mitigate post-
conflict suffering.
By using WHO data it is possible to estimate the long-
term and indirect effects of wars, while holding constant
other influences known to affect health outcomes. These
include per capita income and health spending, type of po-
litical system, inequality of income distribution, urbanisa-
tion and women’s education.
In a recent study, Hazem Ghobarah, Paul Huth and
Bruce Russett considered 1999 data from selected formerly
wartorn countries and their neighbours. They concluded
that nearly twice as many years of healthy life were lost
to indirectly caused death and disability as were lost from
direct combat.
7
Why does the misery last so long.
Wars increase exposure to conditions that, in turn, increase
the risk of disease, injury and death. Prolonged and bloody
civil wars usually displace large populations—either inter-
nally or across borders.
The Rwandan civil war, for example, generated 1.4
million internally displaced persons and sent some 1.5 mil-
lion refugees fleeing into neighbouring Zaire (now known
as the Democratic Republic of the Congo), Tanzania
and Burundi.
Eric Miller / Panos Pictures
H U M A N S E C U R I T Y R E P O R T 2 0 0 5
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Unable or unwilling to return home, refugees often
stay in crowded makeshift camps for years. Bad food, con-
taminated water, poor sanitation and inadequate shelter
can combine to transform camps into vectors for infec-
tious disease—measles, respiratory disease and acute di-
arrhoea—while malnutrition and stress compromise peo-
ple’s immune systems. Diseases rampant in refugee camps
easily spread to wider populations. Mortality rates among
newly arrived refugees from countries ravaged by civil wars
can be 5 to 12 times higher than normal.
8
Prevention and treatment programs, already weak-
ened by the wartime destruction of health care infrastruc-
ture, simply cannot cope with new threats posed by mass
population displacements. In Africa, efforts to eradicate
Guinea worm, river blindness and polio, successful in most
countries, have been severely disrupted in states experi-
encing intense civil wars. Both soldiers and refugees are
implicated in the spread of HIV/AIDS in Africa.
As well, murders, suicides and even accidental deaths
often rise in the aftermath of civil war.
9
The widespread
availability of small arms in most post-conflict situations
makes violence difficult to control.
Civil wars typically have a severe short-term (approxi-
mately five-year) negative impact on economic growth fol-
lowing the end of hostilities.
10
Poor economic performance
reduces tax revenues needed to finance public health care,
while lower incomes mean people are less able to access
the private health care sector. Civil wars also deplete the
human and fixed capital of the health care system. Heavy
fighting often destroys clinics, hospitals and laboratories,
as well as water treatment and electrical systems.
Mortality rates among newly arrived
refugees from countries ravaged by
civil wars can be 5 to 12 times higher
than normal.
Even when funds are available, rebuilding health in-
frastructure takes a long time. Severe civil wars may also
induce the flight of highly trained medical professionals,
who may not return or be replaced until long after the
war ends. Authorities are faced with many daunting chal-
lenges, including:
Rebuilding infrastructure and repairing the environ-
ment.
Reforming and rebuilding army and police forces, judi-
cial systems and administrative capacity.
Responding to continuing military and security threats.
(Security threats may derive from domestic insurgent
groups or from a powerful military force built up by a
neighbouring state to fight its own civil war.)
11
To meet these post-war demands, decision-makers
must choose between competing priorities—with health
care only one among many.
Measuring indirect health effects
WHO considers overall health achievement in any coun-
try by using the Health-Adjusted Life Expectancy index,
which measures an individual’s normal healthy life expec-
tancy at birth. From this figure, WHO subtracts the number
of years of healthy life an individual in a particular country
loses through death, or through living with a major dis-
ability caused by either disease or injury.
This measure of lost years of healthy and productive
life varies greatly by region and income level. In rich coun-
tries, most disabilities are associated with chronic condi-
tions of old age—and, at that point, relatively short life
expectancies.
By contrast, in poor tropical countries, infant mortality
is much higher and more health problems arise from the
burden of infectious diseases such as malaria and schis-
tosomiasis. These costs are most often borne by children
and young adults who may live a long time, but do so with
seriously impaired health and quality of life.
Another useful indicator employed by WHO is the
Disability-Adjusted Life Year or DALY, which measures
the number of potentially healthy years of life lost to death
and disability by gender and by age group. DALYs are also
broken down according to 23 major disease categories and
H U M A N S E C U R I T Y R E P O R T 2 0 0 5
131
conditions.
12
A statistical model can then identify the ‘nor-
mal’ levels of death and disability from each disease in each
country. This provides a baseline for measuring the ‘excess’
deaths and cases of disability caused by war, that is, those
that would not have occurred had there been no war.
Thus, the WHO data can be used to determine wheth-
er war increases the burden of disease after the fighting has
stopped. The data can also show how disease and other
conditions arising from war affect a population differently
according to age and gender.
Using the DALY measure
The following analysis focuses on civil wars. Not only are
these conflicts 20 times more common than interstate
wars, they are often far more deadly
13
in both their direct
and indirect effects.
Following customary practice among conflict research-
ers, civil wars are defined here as armed conflicts challeng-
ing the sovereignty of an internationally recognised state,
occurring within that state’s boundary, and resulting in
1000 or more fatalities in at least one year.
The analysis covers civil wars during the years from
1991 to 1997 and uses immediate battle-related deaths as
its key indicator of the intensity of the conflict in question.
14
(There are no reliable data on injuries for all countries.) To
determine the intensity of civil war, war deaths per 100
people are measured in the country in question. For the
51 countries that experienced civil war during the period,
mortality rates ranged from 0.001 to 9.420.
For most infectious diseases the time
lag is usually short (less than five
years), while the effects of damage
to the health care system typically
last five to ten years.
To determine the indirect effect of civil wars, war deaths
between 1991 and 1997 are examined against DALY rates
for 1999. It is assumed that the effects are not instanta-
neous, and the time lag used here is an approximation.
For most infectious diseases—the principal cause of
indirect civil war deaths—the time lag is usually short (less
than five years), while the effects of damage to infrastruc-
ture and the health care system typically last five to ten
years. The delay preceding clinical manifestation of HIV/
AIDS and many cancers can be even longer. In war zones
in the developing world, borders are frequently porous and
fighters can cross at will into neighbouring countries, often
Figure 4.3 The long-term impacts of civil wars by disease/condition
Disease/condition
Gender and age group affected
HIV/AIDS
Both genders about equal, and all age groups; greatest impact on children 0–4 years
and men and women 15–59 years
Malaria
Both genders and all age groups; greatest impact on children 0–4 years
Tuberculosis, respiratory
and other infections
Both genders, all age groups, but children 0–4 years particularly affected
Transportation accidents
Both genders, 15–59 years
Homicide
Girls, women and older boys and young men
Cervical cancer,
maternal conditions
Older girls and women
Source: Bruce Russett, 2004
The indirect impacts of wars vary according to the age and gender of citizens.
H U M A N S E C U R I T Y R E P O R T 2 0 0 5
132
spreading disease and causing disruption, death and inju-
ry. But the most significant health impact on border states
comes from the floods of refugees seeking cross-border
sanctuary from the fighting at home.
The effect of a civil war in a neighbouring country can
be measured by the rate of immediate war deaths in that
neighbouring country, adjusted for a measure of the bor-
der’s permeability—the more porous the border, the easier
it is for refugees to cross it.
15
If more than one contigu-
ous state experiences civil war, their measures are added
accordingly. The maximum value is for Zaire (now known
as the Democratic Republic of the Congo), which borders
seven countries that experienced civil war in this period
and was affected by major wars in four of these countries—
Rwanda, Angola, Sudan and Burundi.
These effects were identified by statistical (multiple
regression) analysis of data from 165 countries during the
late 1990s. The analysis holds constant the effects of sev-
eral influences known to affect a country’s average level
of overall health. These include public and private sector
health spending, educational levels (especially of women),
rapid urbanisation and inequality of income. The last re-
duces average health levels by devoting more resources to
a minority of wealthy households and substantially less to
the poor majority.
By controlling for these social and economic in.u-
ences, we can then ask what the additional effect of direct
and immediate civil war fatalities in previous years is, and
how these diminish healthy life expectancy below what
would be expected in the absence of a war. The reduction
in healthy life expectancy comes from diseases or condi-
tions that develop—or increase—as a consequence of
the war.
The multiple and long-lasting impacts of war
Inadequate health spending and lack of female education
lead to a statistically significant loss of healthy years of life
in countries that aren’t at war, while rapid urbanisation and
income inequality significantly increase that loss. When
data analysts control for the impact of these influences, we
see that civil wars result in additional loss. Countries ex-
periencing civil war earlier in the 1990s subsequently suf-
fered a significantly increased loss of healthy life in every
age and gender category—amounting to almost 3.9 years
of healthy life lost to death and disability for every direct
and immediate civil war death.
Between 1991 and 1997 direct and immediate war
deaths totalled approximately 3.1 million. This suggests
that 12 million years of healthy life were lost indirectly from
those previous wars in 1999 alone. In many age groups the
impact was higher for females than for males. For some
countries and some population subsets, the consequences
were much worse. In the extreme case of Rwanda, where
there were 9.4 civil war/genocide deaths per 100 people—
most of them in 1994—subsequent losses amounted to 63
DALYs per 100 boys younger than five.
The implications become clearer in the impact of
wars on the incidence of specific diseases and conditions
( Figure 4.3).
The most significant health impact
on border states comes from refu-
gees seeking cross-border sanctuary
from the fighting at home.
Topping the list of diseases magnified by war is HIV/
AIDS, hitting both genders hard in all age groups. The
most devastating losses are concentrated in economical-
ly productive age groups (especially men aged 15 to 44,
where the loss rate is more than two DALYs per 100 males)
and on very young children (more than one DALY per 100
children). And this is the impact of just one disease out
of many—the misery deepens with the accumulated losses
wrought by other diseases and by an increase in injuries.
The next most damaging disease is malaria, which
also affects all age and gender groups. Controlling for
other factors, however, the greatest impact from malaria
is reserved for the very young (1.75 years of healthy life
lost per 100 boys younger than five). Three other major
disease groups showing sig nificant increases in the wake
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of civil wars are tuberculosis, acute respiratory infections
and diarrhoeal infections—again, for both genders and
most ages.
But infectious diseases are not the only killers. Included
among the 23 categories of disease and other health-
threatening conditions are ‘transportation accidents’, ‘other
unintentional injuries’, ‘homicides’ and ‘suicides’. Among
young and middle-aged adults, a higher rate of transporta-
tion accidents may in part reflect the deterioration of roads
and vehicles but is also consistent with greater stress and
the breakdown of law and order. A more obvious indica-
tor of breakdown in the social order is the increase in ho-
micides—the victims being primarily women and younger
men. Increases in other unintentional injuries within the
same groups may also derive from stress and include un-
reported suicides.
Reports of elevated cervical cancer rates may seem
sur prising, g iven that cervical cancer usually develops
too slowly to be seen in the fairly short time lag used in
this analysis, but there are two possible connections to
civil wars. First, the finding is consistent with the ex-
pectation of a breakdown in social norms—in this case,
norms against forced sexual relations. Second, infection
with some strains of the human papilloma virus (HPV )
plays an important role in the development of cervical
cancer,
16
and civil wars increase the incidence of many
infectious diseases. In addition, in traditional societies,
other sexually transmitted diseases may be recorded as
cervical cancer.
Other threats to women’s health in post-conflict situ-
ations include increased maternal mortality and morbid-
ity—although some data may merely reflect the misreport-
ing of sexually transmitted diseases.
Countries bordering on those that have been afflicted
by civil war also experience rises in disease rates and other
war-related health problems caused by military, refugee
and other human traffic across borders during wartime.
Once again, it is HIV/AIDS that exerts the greatest impact,
with those most susceptible being young and middle-aged
adults. Very young children make up the other major cat-
egory of HIV/AIDS victims.
Civil wars, in one’s own country or
a neighbouring country, produce
damage to health and health care
systems that extends well beyond
the period of active warfare.
Malaria, tuberculosis, and respiratory or other infec-
tions are responsible for the other big post-war jumps in
disease. Homicides of girls and younger women also in-
crease sharply. Liver cancer increases in many age and
gender groups, which probably represents the results of
infectious hepatitis.
In sum, civil wars, in either one’s own country or
a neighbouring country, produce long-term damage
to health and to health care systems that extends well be-
yond the period of active warfare. Women and children
are most affected by these delayed war-induced neg ative
health impacts.
Recall that some 12 million DALYs were lost in 1999 as
a consequence of the delayed effects of the civil wars that
took place between 1991 and 1997. If another 25% is added
to take into account the estimated impact of these wars
on neighbouring countries, the total number of DALYs
lost becomes 15 million. These losses include only those
incurred during a single year of a post-war process that
lasts many years.
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The shocking death toll in the Democratic Republic of
the Congo made headlines only because researchers from
the International Rescue Committee (IRC) had carried out
a series of health surveys in the DRC during the war—and
made major efforts to communicate their findings through
the media. The 23 epidemiological surveys recorded crude
mortality rates in rural areas of the DRC, and the causes of
death.
1 7
Over the three years in which the surveys were car-
ried out (1999–2002), the average crude mortality rate was
2.5 to 3.7 times the estimated pre-war rate of 1.5 deaths per
1000 per month. Knowing these ratios enabled the IRC re-
searchers to estimate the total number of conflict-induced
‘excess’ deaths—that is, those that exceed the normal peace-
time death rate. Of the 2223 civilian deaths reported from the
surveys, only 8% resulted from violence. Infectious diseases
caused most of the fatalities, with anemia and malnutrition
being the most common other causes.
The surveys also revealed that the areas with the great-
est rates of violence tended to experience the highest num-
bers of deaths from non-violent causes. This correlation is
highlighted in the death rate in Kalonge, an administra-
tive area within Sud-Kivu province. In November 1999,
Rwandan government troops and their allies, the Congolese
Rally for Democracy, withdrew from Kalonge, which led to
an immediate takeover by rebels, including both Congolese
Mayi-Mayi insurgents and former Rwandan soldiers who
had fled to the DRC following the 1994 genocide. Killings
of civilians were widespread and interviewees reported that
virtually the entire population of 62,000 fled the area over a
two-month period. The survey data showed that the rebel
takeover was associated with a sixfold increase in the murder
rate and a fourfold increase in the death rate from malaria
and other febrile diseases. Lacking shelter, adequate cloth-
ing and access to health services, those w ho fled were highly
susceptible to infectious diseases.
Two of the regions surveyed in 2001
1 8
were surveyed
again in 2002
1 9
after a ceasefi re agreement that sharply re-
duced the violence. Similar questions were asked in both
surveys. In both districts violence-specific and crude mor-
tality rates were initially exceptionally high, but following
the troop withdrawals in 2002 the rate of violent death de-
creased by 96%, while the rate of excess deaths from other
causes decreased by only 67%.
20
The IRC conducted a repeat survey in the fall of 2004,
21
two years after the ceasefi re and withdrawal of foreign
troops, and found that the crude mortality rate was 2.3 per
1000 per month in the war-torn eastern provinces. This
translates to approximately 31,000 deaths per month above
the baseline rate that existed prior to the Rwandan and
Ugandan invasion.
These surveys demonstrate how prolonged conflict
can make a population extremely susceptible to death from
diseases endemic in the population before the violence
began. The link betw een violent death and death from in-
fectious disease was strong, whether comparing the same
populations at different times or different populations at the
same time.
The interplay between violence and infectious diseas-
es is complex and differs from year to year and country to
country. But the evidence clearly suggests that the greater
the wartime violence and the poorer and more vulnerable
a country, the greater the number of excess deaths due to
non-violent causes. The IRC’s analysis of the first 11 studies
undertaken when the fighting was at its peak between 1999
and 2001 found that for every violent civilian death there
were six excess non-violent civilian deaths.
The IRC’s surveys also clearly demonstrate that attempt-
ing to assess the impact of war by counting only those who
die as a direct result of violence grossly underestimates the
real human costs of conflict—particularly in poor countries.
WAR
AND
DISEASE
IN
THE
DEMOCRATIC
REPUBLIC
OF
THE
CONGO
Between August 1998 and November 2002, an estimated 3.3 million people died in the Democratic
Republic of the Congo (DRC) as a consequence of civil war. The overwhelming majority of deaths did
not result from violence, but from malnutrition and diseases associated with the war.
H U M A N S E C U R I T Y R E P O R T 2 0 0 5
135
HIV/AIDS and conflict
In both times of conflict and times of peace,
the spread of HIV/AIDS depends on a complex
range of factors. In some cases war contributes
to the spread of the disease, in others it is as-
sociated with very low levels of infection. Claims
that high rates of HIV/AIDS increase the risk of
state failure appear to have little evidence to
support them.
War and disease have been partners throughout
history. The disruption of social structures, the mass
movement of armies and refugees, and restricted ac-
cess to food and clean water have always created cond-
itions in which diseases flourish, often causing great-
er casualties than military action. In ancient Greece,
Athens was ravaged by plague during its con flict with
Sparta. In the 16th century Americas, severe outbreaks
of smallpox, measles and typhus among Aboriginal
peoples helped Europeans in their violent colonisation
of the New World. In 1994 cholera and dysentery took
the lives of almost 50,000 refugees in the first month
after they fled from the Rwandan genocide.
22
Between
1998 and 2004, 3.8 million people are estimated to have
died as the result of conflict in the Democratic Republic
of the Congo; the vast majority were killed by disease,
not violence.
23
Rates of sexually transmitted infections (STIs) also
rise in wartime. Men and women become more sexu-
ally active as uncertainty over the future reduces inhi-
bitions among soldiers
24
and civilians; more people are
encouraged by pover ty or opportunism to sell sex; the
incidence of rape often rises. Syphilis was first identified
in the wake of the French invasion of Italy in 1494. In
the 1960s, STI rates among US soldiers in Vietnam were
nine times higher than among soldiers in the United
States.
25
Conflict can also lead to increased HIV infection. The
virus probably first affected humans in central Africa in
the 1930s in communities where patterns of sexual activ-
ity did not allow it to spread widely; in the late 1970s the
many rapes committed during the Ugandan civil war and
its spillover into Tanzania may have trig gered the HIV
epidemic in that part of the world.
26
HIV incidence in ru-
ral Rwanda, where approximately 95% of the population
live, was considerably higher following the 1994 geno-
cide—11% in 1997 compared to 1% prewar.
27
And reports
from Sudan in 2004 showed HIV incidence rising to 21%
in the conflict-ridden south, compared with 2.6% in the
general adult population.
28
Pep Bonet / Panos Pictures
H U M A N S E C U R I T Y R E P O R T 2 0 0 5
136
In both conflict and peacetime the extent to which HIV
spreads depends on a combination of factors, including
the following :
Initial infection rates.
Patterns of sexual behaviour (what percentage of the
population changes partners and how of ten).
The frequency of rape.
Infectivity (individuals are more likely to pass the
virus to others when they themselves have been re-
cently infected).
The presence or absence of other sexually transmitted
infections which facilitate the transmission of HIV.
The age of female partners (women under 25 are more
vulnerable).
The presence or absence of economic or social pres-
sure on women to be sexually active, usually without
the right to ensure condom use.
The extent to which condoms are available, affordable
and socio-culturally acceptable.
Whether the male partner is circumcised (male cir-
cumcision reduces vulnerability) and whether, how
often and with whom condoms are used.
The nature of a conflict also significantly influences
the likelihood of an epidemic. Short wars that depend on
‘distance’ tactics such as aerial bombardment are less likely
to spread HIV/AIDS than conflicts that lead to long-term
fighting on the ground, to mass movements of soldiers and
civilians, and to opportunities for soldiers and others to
fi nd new sexual partners.
The physical trauma of rape considerably height-
ens the risk of transmitting HIV, to the rapist as well as
to the victim. Rape by individual soldiers acting alone and
as a military tactic has always been a feature of warfare.
The victims are usually women and girls, but rape of men
and boys does occur. Reliable statistics are difficult to ob-
tain, but estimates of mass rape in recent conflicts include
‘thousands’ in Sierra Leone
29
in the 1990s, at least 12,000
in Bosnia in 1992–93
30
and at least 250,000 in Rwanda.
31
Seventy percent of one group of victims in Rwanda later
tested HIV-positive,
32
although it is not known how many
contracted the virus during rape.
HIV infection may also rise in the aftermath of con-
flict. The rise in HIV incidence in Cambodia from 0% in
1990 to 2.6% by 2004 (the highest per capita incidence
Human immunodeficiency virus (HIV) infection
spreads primarily through sexual intercourse. It can also be
transmitted through infected equipment used in recre-
ational drug injection, through transfusion of infected
blood products, through use of contaminated medical and
other skin-piercing instruments ( e.g., tattooing needles)
and from infected mothers to their new born children via
the placenta and breast milk.
Although some soldiers, particularly in insurgent forc-
es, inject drugs, sexual transmission alone is believed to
play a major role in spreading HIV in times of conflict.
Transmission can be prevented through consistent use of
condoms.
Infection with HIV leads to a gradual breakdown of the
immune system. The body becomes vulnerable to ‘opportu-
nistic’ infections that it could normally overcome, such as
pneumonia, fungal infections and long-term diarrhoea.
AIDS (acquired immune deficiency syndrome) is usually
defined as the presence of one or more such infections and
confirmation of HIV infection. Although AIDS is the most
commonly used term, it only refers to the advanced stage of
the disease.
Untreated, AIDS at present is invariably fatal. Antiretro-
viral therapy can keep HIV infection under control, but it is not
widely available or affordable, and cannot cure the disease or
prevent it from being transmitted to other people.
HOW
HIV
SPREADS
HIV can be spread in many ways––from unprotected sex to drug injections. There is no cure for
HIV/AIDS.
H U M A N S E C U R I T Y R E P O R T 2 0 0 5
137
in Asia) has been attributed partly to the presence of
peacekeepers in the early 1990s and partly to the re-
emergence of sex workers after two decades of politi-
cal and social repression. Peacekeepers have significant
physical, moral and economic power, which frequently
enables them to have sex with locals and sex workers,
either consensually, in a short- or long-term relationship
or through some form of coercion. That is not to argue
that peacekeepers ‘introduced’ the virus to Cambodia
or any other country—soldiers from many countries
test HIV-negative before deployment and HIV-positive
on return.
The nature of conflict influences the
likelihood of an epidemic.
A rise in HIV infection is not inevitable in warfare.
Where HIV incidence is minimal at the start of a conflict, as
in several of the countries listed in Figure 4.4, rates do not
rise significantly. Other factors may also reduce spread of
the virus; it is believed that rates remained low during the
Sierra Leone conflict because mass movement, including
cross-border migration, became more difficult and imped-
ed growth of the epidemic.
33
Similar factors may explain
the relatively low rates of infection in Angola after three
decades of war.
34
HIV and the armed forces
Rates of sexually transmitted infection in the armed forces
are usually higher than in the general population. Most
soldiers are young men who spend long periods away from
home and family and who are encouraged by peers, al-
cohol use and other factors to be sexually active. Military
bases attract women who offer sexual services in return for
money, gifts or accommodation, particularly in impover-
ished communities where soldiers have higher than aver-
age incomes. Where relatively few women have many sol-
diers as partners, infection can spread rapidly among both
Figure 4.4 Estimated HIV infection rates in the general population and the armed forces
in sub-Saharan Africa
Country
HIV prevalence in 2001,
15–49 year-olds (%)
HIV prevalence in 1997–2002,
armed forces personnel (%)
Angola
5.5
50 (1999)
Botswana
38.8
33 (1999)
DR Congo
4.8
50 (1999)
Lesotho
31.0
40 (1999)
Malawi
15.0
50 (1999)
Namibia
