WRITING SAMPLE:

CHAPTER 1

FOR ONE DOES NOT CREATE A HUMAN SOCIETY ON MOUNDS OF CORPSES – LOUIS LECOIN

INTRODUCTION

According to the Correlates of War data project, 76 wars were initiated

between 1990 and 2007 of which 67 were intrastate, or civil conflicts (Ghosn et al,

2004).1 Since 1935, approximately 25 million people have been killed in civil

conflicts, the majority of which have taken place in developing countries (Farrell

and Schmitt, 2012). This staggering number does not take into account the millions

more whose health has been affected by civil war in a myriad of immediate and

lasting ways. Forced displacement, destruction of integral health services and food

sources, and the breakdown of state functionality can have long-term effects for the

progress of a developing country and all its inhabitants thus extending the

destruction wrought by pervasive and systematic violence far beyond the signing of

peace accords.

1 This research uses the Uppsala Conflict Data Project definition of intrastate conflict: “a conflict between a government and a non-governmental party [within a sovereign territory], with no [direct] interference from other countries” (Uppsala Conflict Data Program “Definitions”, 2014). Note that civil/intrastate war/conflict are used interchangeably throughout this work.

Conflict is motivated by a number of different factors that can be separated

into greed-motivated or criminal wars (wars that are motivated against a

government primarily for financial gain) or grievance-motivated or ethnolinguistic

wars (wars that are motivated by dominance of one ethnic, religious, or linguistic

group over another, usually involving a territorial component) (Ballentine, 2003).2

This research looks at these different war motivations within civil conflicts and their

short- and long-term effects on population health.3

Population health4 in war-torn countries is worse than in similar countries

unaffected by war. Access to basic health services can be interrupted for a multitude

of reasons, leading to a decrease in standards of care and an increase in

communicable and treatable diseases and injuries. The burden of communicable

diseases is highest in low income and politically unstable countries – those most

prone to civil conflict (The World Health Organization, 2005) – and is exacerbated

by conflict. Vaccination rates drop precipitously during times of conflict as a result

of disruption of services (GAVI, 2013), leading to an increase in otherwise

2 Given the interrelationships between war type and conflict motivation that is explained in more detail later in this chapter and in chapter two, the term greed-motivated wars will be used interchangeably with criminalistic or criminally motivated wars throughout this work. Grievance-motivated wars will be used interchangeably with ethnolinguistic wars. 3 Because of the effect of GDP on health and the lack of civil conflict within OECD countries, this research only looks at non-OECD countries in the analysis of health and civil conflict. This is consistent with other works in conflict and world politics (Anderson & Poullier, 1999; Kanavos & Mossialos, 1999; Heshmate, 2001; Collier, 2012). 4 Population health is defined by Kindig and Stoddard (2003) as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group… the field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two.” This relates to the basic health quality and general health level of a population within a country or within a particular group.

preventable deaths in children under the age of five (The World Health

Organization, 2010).

Infrastructure destruction tends to be the main target in civil conflicts and is

used in an effort to undermine state functionality (Collier, 1999). Even when the

intentional targeting of civilians is not evident, widespread infrastructure

destruction has an extensive effect on the ability of a government to provide basic

necessities and services to the population (Collier, 1999; Murdoch and Sandler,

2002, 2004; Hoeffler and Reynal-Querol, 2003; Kang and Meernik, 2005).

The lack of adequate health facilities, supplies, and monitoring can lead to

increases in mortality from injury and disease (Ugalde, 2000; Ghobarah, et. al.,

2003). Forced migration into refugee and internally displaced persons camps also

causes an increase in non-combat mortality. A study done of the Tigrayan refugee

population in East Sudan and Cambodian refugees in Thailand in 1984/1985

showed a non-combat mortality rate of 14 to 24 per 1,000 refugees per month

(Toole, Nieburg and Waldman, 1988). This was far higher than the mortality rate of

civilians outside the refugee camps. The destruction of population health wrought

today can have long-term effects on the growth capabilities of a developing society.

THE CURRENT STATE OF WAR AND HEALTH

Both intra- and interstate wars have decreased since the end of the Cold War,

but intrastate, or civil wars are still prevalent. As shown in Figure 1, the number of

active wars was highest in the early 1990s, directly after the fall of the Soviet Union.

In 2011, the Uppsala Conflict Data Program recognized twenty-seven active

intrastate wars with over 25 annual war-related casualties per year (UCDP, 2013).

This was an increase from twenty-two in 2010. Though many of these conflicts are

considered to be “low intensity wars” (over 25 but fewer than 1,000 war-related

casualties per annum), the lack of settled peace agreements could interrupt the

normal functioning of the state.

Figure 1: Global Trends in Armed Conflicts 1946-2011 [intrastate wars are titled ‘societal warfare’ in this graph] (Center for Systemic Peace, 2013)

Figure 2 illustrates the interrelationship between gross domestic product

(GDP), state fragility,5 and the likelihood of conflict. The majority of these conflicts

took place in Africa and Asia, with a smaller proportion in the Middle East. Most of

5 The OECD defines a fragile state as “a state with weak capacity to carry out the basic state functions of governing a population and its territory and that lacks the ability or political will to develop mutually constructive and reinforcing relations with society.” (Organization for Economic Cooperation and Development “Conflict and Fragility”, 2014)

these countries are considered to be “developing”6 (The International Statistical

Institute, 2013).

Figure 2: The State Fragility Index (Center for Systemic Peace, 2011)

The health prospects within low income, fragile countries also vary

significantly from their higher income and more stable counterparts. Figure 3

displays the environmental burden of disease as calculated by the World Health

Organization in 2005. Communicable disease burden is still highest in the

developing world, particularly Africa. Vaccination rates for preventable diseases

vary from region to region, and may be greatly affected by disruption of services,

which are ubiquitous during conflict (GAVI, 2013). According to The World Health

Organization, between 2000 and 2010 58% of deaths in children under the age of

five were caused by infectious diseases such as pneumonia, diarrheal disease, and

6 Developing countries are defined as countries with a GNI of US$ 11,905 and less in 2010. (World Bank “How we Classify Countries”, 2014)

malaria (figure 4). War also affects the other common causes of child and infant

death such as pre-term birth complications and injuries (The World Health

Organization “Causes of Death Among Children Aged Under Five Years”, 2010).

Figure 3: Environmental burden of disease throughout the world (The World Health Organization “Environmental Burden of Disease Globally”, 2005)

Figure 4: Causes of mortality among children aged under five years (The World Health Organization “Causes of child mortality for the year 2010”, 2010)

Why is improved and stable population health so integral in post-conflict

developing countries? The economic effects of war influence current and future

growth, which can translate directly into a lack of resources for basic human

necessities, like health care supplies and workforce (Hoeffler and Reynal-Querol,

2003; Iqbal, 2006). This can have a direct effect on the future development of a

society. Research on the relationship between health and economic growth show

that healthy populations are more productive, and improvements in the adult

survival rate within developing countries lead to improved GDP growth rates and

higher rates of usable human capital7 (Spurr, 1983; Feachem, 1992; Strauss and

Thomas, 1998; Bhargava, 2001). Scholars working from the Solow growth model of

human capital (1956) found that the effects of health on growth are most

pronounced in developing societies (Knowles and Owen, 1995, 1997; Rivera and

Currais, 1999). These effects also seem to be cyclical – as development and GDP

improve, general population health tends to improve as well (Preston, 1976).

The inverse in these findings reveal that worse population health leads to

lower productivity and stunted GDP growth (Feachem, 1992). A 1996 study by

Murray and Lopez found that 0.6 disability adjusted life years8 (DALYs) per capita

7 Human capital is defined as “a measure of the economic value of an employee's skill set. This measure builds on the basic production input of labor measure where all labor is thought to be equal. The concept of human capital recognizes that not all labor is equal and that the quality of employees can be improved by investing in them. The education, experience and abilities of an employee have an economic value for employers and for the economy as a whole” (Investopedia “Human Capital”, 2014). 8 According to the World Health Organization, a DALY “can be thought of as one lost year of "healthy" life. The sum of these DALYs across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability” (World Health Organization “Metrics: Disability Adjusted Life Years, 2014).

were lost due to premature mortality and years lived with disability in sub-Saharan

Africa (Murray and Lopez, 1995).9 These years lost in the “working age” population

can add up to a loss in economic and societal productivity. The infrastructure

destruction that is inherent to war can exacerbate the already tenuous balance of

population health and economic growth within a developing country.

It is known that war leads to poor health, and poor health leads to stunted

growth within a society. What is unclear is if and how dissimilar types of wars affect

health differently. Because of the ever-present threat of intrastate conflict, we

should explore whether diverse war motivations lead to poor health in both the

present and the future of a country. If war type does have a differing effect on

population health, we should attempt to discern why those variations are present.

This understanding may help policymakers approach post-conflict reconstruction

and rehabilitation in a targeted manner, focusing on the specific reconstruction

needs within a particular country. This in turn should allow more meaningful and

comprehensive structural changes post-conflict, leaving to improvements in the

health sector and beyond.

THEORY

There are a number of qualitative and quantitative studies demonstrating

that the presence of war has adverse effects on population health. Destruction of

9 An update to this work was published in 2013. Though the authors found that the percentage of burden of disease had shifted, communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden in sub-Saharan Africa (Murray et. al., 2013).

infrastructure, loss of funding for healthcare, disruption of food supply, and

heightened susceptibility to infectious diseases are common during war, regardless

of the motivations behind the conflict (Ugalde et al., 2000; Ghobarah, et. al., 2003;

Levy and Sidel, 2008). The quantitative analyses in chapter three support and

reinforce this relationship. What is not clear is how different types of war may affect

health.

There are no standard theories with which to approach the problem of war

type and the effects on health, but using theories of conflict and health from multiple

academic fields, I have synthesized a theory to approach the effect of war type on

population health in the short- and long-term:

(1) Wars in general are detrimental to population health in the short-term,

regardless of the type.

(2) Criminally motivated conflicts, typified by government incompatibility10,

may have a different effect on particular areas that affect health than

ethnolinguistic conflicts (such as the stealing of supplies versus

infrastructure targeting, respectively), but in the short-term, all conflict will

affect population health equally.

(3) While all conflicts will have immediate ill effects on population health,

ethnolinguistic conflicts with a territorial component will have more long-

term effects, due to conflict length, historical disparities, the nature of

segregation, and purposeful and endemic access denial for marginalized

groups before, during, and after conflict.

10 UCDP defines “government incompatibility” as an “incompatibility concerning type of political system, the replacement of the central government or the change of its composition or policies” (Uppsala Conflict Data Program “Definitions”, 2014).

To explain this synthesized theory, we first consider the political, economic,

and territorial aspects of war motivation by exploring the greed/grievance conflict

literature along with the literature that considers ethnic and territorial conflict

components. Subsequently, we will combine the above theories with theories of

health and human rights to create an integrated theory explaining the effects of war

type on population health.

First, we examine the greed vs. grievance theory of civil conflict. Greed- or

criminally-motivated conflicts are usually carried out by a small group of rebels or

bandits that use government incompatibility11 as a cover story for their criminal

motivations (Alesina and Perotti, 1996; Konrad and Skaperdas, 1998; Grossman,

1999; Duffield, 2000; Keen, 2000). In these cases, rebels are willing to use

destructive force if they will receive some immediate payoff (Collier and Hoeffler,

2002; Mkandawire, 2002).

In terms of the effects on health, these types of wars produce immediate

health issues, rather than long-term ones. Attacking healthcare facilities, workers,

and supplies is exogenous to the motivations for the conflict. These attacks are only

done for the immediate payoff in terms of resale value of supplies or medications,

for the purpose of using the goods for their own benefit, or in direct retaliation

towards particular individuals, rather than as a way of affecting an entire segment of

the population (Grossman, 1999; Collier and Hoeffler, 2002). Fighters on both sides

may attack healthcare access as a way of hindering the other’s capabilities in the

11 Government incompatibility refers to the dissatisfaction with the rebel group over the type of government, the particular leaders, or standard policies or laws enforced by the government (Uppsala Conflict Data Program “Definitions”, 2014).

present, but not to cause lasting destruction for society at large or despair for a

particular ethnic or religious group.

These attacks produce detrimental outcomes in the short-term, but do not

tend to have systemic, long-term effects.12 The eleven-year civil war in Sierra Leone

saw many atrocities on the part of both rebels and government forces directly

related the quest for control over the lucrative diamond mines within the country.

During the fighting, hospitals, aid facilities and humanitarian workers were attacked

for their stores of, or access to drugs and medical supplies (Smillie et. al., 2000;

Klare, 2001). Since the conclusion of the conflict in 2002, the country has seen the

“second fastest improvements in the world on the UN Human Development Index”

(Africa Governance Initiative “Sierra Leone”, 2014). The criminally motivated

conflict of the 1990s did little to stem growth after the conclusion of the war.

Grievance motivated wars, on the other hand, are concerned with long-term

capabilities and the effect of attacks on the capabilities of the other side. Grievance

motivated wars tend to be of an ethnic, linguistic, or religious nature, and may have

a territorial component, where rebels are fighting for access to or secession of their

traditional homeland (Reynal-Querol, 2002). Scholars have found that in cases of

long-term discrimination, ethnolinguistic minorities will reach a level of suffering in

which they choose to fight back against the government (Ngaruko and Nkurunziza,

2005). These types of wars tend to have deep-seated, historic connotation in which

the “reasons” for war are passed down through generations, and the “enemy” is

12 The author wants to insure the reader that she is aware that even in criminally motivated wars where ethnic or religious hatred or oppression is not the overall motivating factor, the effects of war can be widespread and horrifying, regardless of their long-term effects.

anyone with a connection to that group, whether they participate in the war or not

(Stavenhagen, 1996).

In these types of wars healthcare services, providers, and supplies are not

only seen as an immediate resource for rebels, but also as a way to weaken

opponents and those who support them. Limiting basic health services can be used

as a strategy to weaken the enemy and force supporters to withdraw their support

for fear of losing access to care. This was the case in the former Yugoslavia where

hospitals known for serving enemy combatants were targeted by government

forces, and non-Serbian minorities were allowed only second-rate or no healthcare

due only to their ethnic affiliation. The support for rebel fighters lost strength as

civilians began to suffer due to widespread restrictions (Buwa and Vuori, 2006).

Population health effects will be prolonged in cases of ethnolinguistic grievance

conflicts because both enemy combatants and entire segments of the civilian

population are denied access to acceptable healthcare.

Territorial conflicts tend to be ethnolinguistic or grievance motivated, and

can aggravate the discriminatory aspects of such conflicts (Yiftachel, 1996, 2006;

Diehl, 1999; Newman, 2006). According to Kubo (2011), territorial secession

conflicts and ethnic grievance go hand-in-hand so frequently that they have become

synonymous (see also Denny and Walter, 2014). These cases have a stronger long-

term effect on health because an entire group considered to be the enemy and they

tend to be isolated and segregated within a distinct area. Poor health infrastructure

and limited access for these groups and areas are likely entrenched in the structures

of society (Cederman and Girardin, 2007; Weidmann, 2009; Wimmer, Cederman

and Min, 2009).

Healthcare services and resources in secessionist or segregated areas may be

inferior or they may be cut off altogether producing poor health outcomes that

continue long after the bullets stop flying (Ghobarah et. al., 2004). This was the case

in Sri Lanka where healthcare quality in the northern Tamil areas was significantly

worse, even during times of peace, and health resources and non-profit healthcare

organizations were prohibited from entering the area during times of heightened

conflict. Though population health and access have improved in the north since the

cessation of violence, they are still behind their southern and western Sinhalese

neighbors after years of restricted access (Reilley et. al., 2002; Nagai, et. al., 2007).

Territorially motivated ethnic conflicts also tend to last longer, with a mean

of approximately 14-years versus eight for criminal, non-secession conflicts (Denny

and Walter, 2014). This is the result of bargaining and settlement problems inherent

in ethnic and territorial conflicts (Hassner, 2003; Goddard, 2006; Toft, 2006). Ethnic

groups may have historical or cultural ties to a region that they are unwilling to part

with regardless of the rising costs. Even if a mutually agreeable settlement can be

reached, the group may remain isolated having to rebuild health infrastructure from

the ground up, without the support system provided by an established government.

As shown above, theories of war and health from various fields can be

combined to support the research question explored in this work: how does war type

effect population health? This question is examined and broken into corresponding

hypotheses below, and investigated with quantitative and qualitative techniques in

the remaining chapters.

RESEARCH QUESTION AND TECHNIQUES

Intrastate conflict is presently more common than inter-state conflict, but

has not been studied to the same extent as conflicts that involve multiple parties,

such as either of the World Wars (Guha-Sapir and Van Panhuis, 2002). This

dissertation combines prior research in the fields of international political economy,

world politics, and global health to explore conflict and post-conflict consequences

of civil war and underlying war motivation on population health while asking the

questions: how does civil war affect population health? Does the “type” of war have

any effect on population health? How long do these effects last? To this end I propose

an analysis of the following intersecting relationships:

Figure 5: Relationship between independent and dependent variables

Figure 5 lays out the variables that are present in all countries at all times

(under economic factors and ‘other factors’) as well as those variables that are

present during times of conflict. These variables weigh on population health to a

varying degree and with varying effect, as explored in chapter three. Using the

framework of variables and relationships laid out above, I will test the following

hypotheses using both quantitative and qualitative research methods:

Hypotheses:

H1a) Civil conflict will have a negative effect on population health (as

measured by infant mortality rate and other population health measures).13

13 In the quantitative analyses presented in chapter three, “short term” or “immediate effects” are shown through quantitative models with no lag or a one-year lag on independent variables (meaning the relationship between the independent variables and dependent variable is either from within the same year, or from one year previous, t-1).

H1b) Civil conflict will have a negative effect on population health in the

long-term.14

H2a) Criminally motivated conflicts typified by government incompatibility

(greed wars) will affect population health differently than ethnolinguistic

conflicts (grievance wars).

H2b) Ethnolinguistic wars with a territorial incompatibility will have a

different effect on population health than ethnolinguistic wars without a

territorial incompatibility.

H2c) The type of war will continue to affect population health differently in

the future.

These hypotheses were explored with a panel data analysis in chapter three,

encompassing a wide number of developing countries over a span of 17 years. The

findings show that the presence of war in general has a severely negative effect on

population health indicators. The effect of war presence stays significant but loses

strength as time passes.

The analyses also show that greed motivated wars tagged have a slightly

worse effect in the present, but the effect dwindles as time passes. Ethnically

motivated wars also have an immediate effect that dwindles. Wars with a territorial

component have an effect on health that grows with time. This corresponds with the

hypotheses, and fits with the theory that the reasons behind attacking healthcare

services and resources have different meanings and goals depending on the “type”

of war. These findings are explored with two case studies in chapter four. With this

14 Long-term effect is shown as through the relationship of the independent variables on the dependent variable either two, three, or five years later in various models.

knowledge we can begin to explore how to best manage post-conflict population

healthcare based on the type of war that was waged.

ORGANIZATION

In the following chapter, I review previous research to shed light on the

effects of conflict on civilian populations using both an international political

economy lens and a public health lens. The relationship between the type of war,

greed versus grievance wars, and the effects of territoriality in war are also

explored. This chapter looks at the differing opinion on the effects of war

motivation, ethnolinguistic versus criminalistic, on the outcomes of civil conflicts,

and the various effects on population health. The chapter then explores the

territorial dimensions of conflict. It also considers the lack of scholarly research into

war motivation and the effects on population health in the short- and long-term.

In chapter three I present empirical analysis of multi-country, multi-year

data to explore the hypotheses stated above. This data is evaluated with quantitative

models using a variety of variables gathered from multiple sources, using the

scholarly research considered in chapter two for assistance and guidance. The

models are presented with no lag and with multiple-year lags on the independent

variables in order to observe the effects of conflict and conflict type on population

health in both the short- and long-term. The models are also presented with a

number of dependent population health proxy-variables in order to better support

the findings.

In chapter four, two case studies, Colombia and Sri Lanka, are presented for

qualitative exploration of the findings from chapter three. The Colombian conflict is

a criminally motivated war of government-incompatibility, while the Sri Lankan

conflict was an ethnically motivated grievance war with a territorial component.

The effects of the type of war on their short and long-term health resources and

general population health match the findings in chapter three, and allow for a more

in-depth look at the effects of war type on population health.

Using the findings from chapter three and four, in chapter five I present the

conclusions to this research as well as recommendations for policy makers to

support improvements in population health both during and after the conclusion of

conflict given the differences in war type and effects, and conclude with the

limitations and further research ideas.

This dissertation attempts to close a gap in the literature by improving on,

combining, and expanding the various disjointed research on health consequences

of war in order to begin on a path towards a coherent theory of population health

after civil conflict. Winston Churchill once said, “healthy citizens are the greatest

asset any country can have.” This dissertation is a first step in understanding how

civil war affects general population health with respect to the motivating factors

behind the conflict, and will be a starting point for better policy making for those

who are most deeply affected after man-made emergency situations, and to allow

for the most positive chances for future development.