The hidden toll of war

During war, the news media often focus on civilian injuries and deaths due to explosive weapons. But the indirect health impacts of war among civilians occur more frequently—often out of sight and out of mind.

These indirect impacts include communicable diseases, malnutrition, exacerbations of chronic noncommunicable diseases, maternal and infant disorders, and mental health problems. They are caused primarily by forced displacement of populations and by damage to civilian infrastructure, including farms and food supply systems, water treatment plants, healthcare and public health facilities, and networks for electric power, communication, and transportation.

Increasingly, damage to civilian infrastructure is caused by targeted attacks—as a strategy of war, resulting in reduced access to food, safe drinking water, healthcare, and shelter. When water treatment plants and supply lines are damaged during war, people often have no choice but to drink water from sources that may be contaminated with microorganisms or toxic substances. Healthcare facilities have been increasingly targeted during war; for example, during the first 18 months of the war in Ukraine, there were 1,014 attacks on healthcare facilities, which injured and killed many patients and healthcare workers, and caused much damage, which reduced access to healthcare for many people.

Globally, there are now more than 108 million people who have been displaced from their homes, many as a result of war. Most of these displaced people have been internally displaced within their own countries, often facing greater health and security risks than refugees, who have fled to other countries. And during war, many more people live in continual fear that they may be forcibly displaced.

Major categories of communicable diseases during war include diarrheal diseases and respiratory disorders. These diarrheal diseases result mainly from decreased access to safe drinking water and reduced levels of sanitation and hygiene, leading to increased fecal-oral transmission of bacterial and viral agents. Among respiratory disorders, measles is of great concern because it is highly contagious and associated with high mortality rates among unimmunized children. Another major concern is tuberculosis, which can spread easily among war-affected populations and is difficult to treat without continuity of care. Crowding in bomb shelters, refugee camps, and other locations during war facilitates the spread of both diarrheal diseases and respiratory disorders. Disruption of public health services leads to reduced access to immunizations and reduced resources to investigate and control outbreaks of communicable disease. During war, bacterial resistance to antibiotics increases because people have decreased access to antibiotics and therefore take inappropriate antibiotics or shortened courses of treatment.

Malnutrition often increases during war, thereby increasing the risks of acquiring and dying from many communicable diseases. Infants and children are at greatest risk of becoming malnourished and suffering from its adverse health consequences. Micronutrient deficiencies during pregnancy can lead to birth defects. And severe malnutrition during war can increase the risk of hypertension, coronary artery disease, and diabetes in later life.

During war, exacerbations of preexisting cases of noncommunicable disease increase, mainly because of reduced access to medical care and medications for treating common chronic diseases. For example, a survey by the World Health Organization in Ukraine in 2022 found that about half of the respondents experienced reduced access to medical care and almost one-fourth could not acquire necessary medications that they needed. Without these medications, people with hypertension were at increased risk of myocardial infarction and stroke, people with asthma were at increased risk of life-threatening attacks, people with diabetes were at increased risk of serious complications, and people with epilepsy were at increased risk of seizures.

War exerts adverse effects on reproductive health. Access to prenatal care, postpartum and neonatal care, and reproductive health services are frequently decreased. As a result, complications of pregnancy, including maternal deaths, occur more frequently and there are increased rates of infant deaths and of infants being born prematurely or with low birthweight.

Mental and behavioral disorders occur more frequently during war, including posttraumatic stress disorder (PTSD), depression and anxiety, alcoholism and drug abuse, and suicide. There are many contributing factors to increasing the risk of these disorders, including physical and sexual trauma, witnessing of atrocities, forced displacement, family separation, deaths of loved ones, loss of employment and education, and uncertainty about the future.

Violations of human rights and international humanitarian law occur frequently during war. In addition to those already mentioned, these violations include gender-based violence, summary executions, kidnapping, denial of humanitarian aid, and use of indiscriminate weapons, such as antipersonnel landmines.

The possible use of nuclear weapons represents a profound threat whenever nuclear powers are engaged in war, partly because these weapons could be launched by accident or because of misinterpretation or miscommunication. Even a small nuclear war could cause huge numbers of deaths and severe injuries and could lower temperatures globally, leading to widespread famine.

Environmental damage during war can result from chemical contamination of air, water, and soil; presence of landmines and unexploded ordnance; release of ionizing radiation from nuclear power plants or conventional weapons containing radioactive materials (“dirty bombs”); destruction of the built environment; and damage to animal habitats and ecosystems. In addition, war and the preparation for war consume large amounts of fossil fuels, which generate greenhouse gases, which, in turn, cause global warming.

Protection of civilians and civilian infrastructure during war and improved humanitarian assistance can reduce the indirect health impacts of war. But the only way to eliminate these impacts is to eliminate war. The risk of war can be reduced by resolving disputes before they turn violent; by reducing the root causes of war, such as socioeconomic inequities, militarism, ethnic and religious hatred, poor governance, and environmental stress; and by strengthening the infrastructure for peace. Peace can be achieved and sustained by rehabilitating nations and reintegrating people after war has ended, strengthening civil society, promoting the rule of law, ensuring citizen participation, and holding aggressors accountable.

Barry S. Levy is the author of From Horror to Hope: Recognizing and Preventing the Health Impacts of War (Oxford University Press, 2022). He is an Adjunct Professor of Public Health at Tufts University School of Medicine and a past president of the American Public Health Association.

_{Featured image: Markus Spiske via Unsplash, public domain.}