Elsevier

The Lancet

Volume 392, Issue 10150, 8–14 September 2018, Pages 857-865
The Lancet

Articles
Armed conflict and child mortality in Africa: a geospatial analysis

https://doi.org/10.1016/S0140-6736(18)31437-5Get rights and content

Summary

Background

A substantial portion of child deaths in Africa take place in countries with recent history of armed conflict and political instability. However, the extent to which armed conflict is an important cause of child mortality, especially in Africa, remains unknown.

Methods

We matched child survival with proximity to armed conflict using information in the Uppsala Conflict Data Program Georeferenced Events Dataset on the location and intensity of armed conflict from 1995 to 2015 together with the location, timing, and survival of infants younger than 1 year (primary outcome) in 35 African countries. We measured the increase in mortality risk for infants exposed to armed conflicts within 50 km in the year of birth and, to study conflicts' extended health risks, up to 250 km away and 10 years before birth. We also examined the effects of conflicts of varying intensity and chronicity (conflicts lasting several years), and effect heterogeneity by residence and sex of the child. We then estimated the number and portion of deaths of infants younger than 1 year related to conflict.

Findings

We identified 15 441 armed conflict events that led to 968 444 combat-related deaths and matched these data with 1·99 million births and 133 361 infant deaths (infant mortality of 67 deaths per 1000 births) between 1995 and 2015. A child born within 50 km of an armed conflict had a risk of dying before reaching age 1 year of 5·2 per 1000 births higher than being born in the same region during periods without conflict (95% CI 3·7–6·7; a 7·7% increase above baseline). This increased risk of dying ranged from a 3·0% increase for armed conflicts with one to four deaths to a 26·7% increase for armed conflicts with more than 1000 deaths. We find evidence of increased mortality risk from an armed conflict up to 100 km away, and for 8 years after conflicts, with cumulative increase in infant mortality two to four times higher than the contemporaneous increase. In the entire continent, the number of infant deaths related to conflict from 1995 to 2015 was between 3·2 and 3·6 times the number of direct deaths from armed conflicts.

Interpretation

Armed conflict substantially and persistently increases infant mortality in Africa, with effect sizes on a scale with malnutrition and several times greater than existing estimates of the mortality burden of conflict. The toll of conflict on children, who are presumably not combatants, underscores the indirect toll of conflict on civilian populations, and the importance of developing interventions to address child health in areas of conflict.

Funding

The Doris Duke Charitable Foundation, and the Centre for Global Child Health at the Hospital for Sick Children.

Introduction

The extent to which armed conflicts—events such as civil wars, rebellions, and interstate conflicts—are an important driver of child mortality is unclear. While young children are rarely direct combatants in armed conflict, the violent and destructive nature of such events might harm vulnerable populations residing in conflict-affected areas.1, 2 A 2017 review3 estimated that deaths of individuals not involved in combat outnumber deaths of those directly involved in the conflict, often more than five to one. At the same time, national child mortality continues to decline, even in highly conflict-prone countries such as Angola or the Democratic Republic of the Congo.4 With few notable exceptions, such as the Rwandan genocide or the ongoing Syrian Civil War, conflicts have not had clear reflections in national child mortality trends.5, 6, 7 The Global Burden of Disease study8 estimated that, since 1994, conflicts caused less than 0·4% of deaths of children younger than 5 years in Africa, raising questions about the role of conflict in the global epidemiology of child mortality.

The extent to which conflict matters to child mortality therefore remains largely unmeasured beyond specific conflicts.9, 10, 11 In Africa, conflict-prone countries also have some of the highest child mortality, but this might be a reflection of generalised underdevelopment resulting in proneness to conflict as well as high child mortality, rather than a direct relationship.12 In this analysis we aimed to shed new light on the effects of armed conflict on child mortality in Africa. We established the effects on child mortality of armed conflict in whom conflict-related deaths are not the result of active involvement in conflict, but of other consequences of conflict. We examined the duration of lingering conflict effects, and the geographical breadth of the observed effects, using geospatially explicit information on conflict location and number of conflict-related casualties. We then used our findings to estimate the burden of armed conflict on children younger than 5 years in Africa.

Research in context

Evidence before this study

The burden of armed conflict on child mortality is unclear. On one hand, the vulnerability of young children and the destructiveness and intensity of armed conflict suggest that conflict exacts a high toll on children. On the other hand, child mortality continues to fall even in countries heavily affected by conflict, and the Global Burden of Disease study 2015 estimates that conflict accounts for less than 0·4% of child deaths in Africa. Empirical studies of the effects of armed conflict on the civilian population show effects on educational attainment, personal economic outcomes, and national economic growth. Studies from specific conflicts also show effects on stunting of growth in children and maternal health care. However, the continent-wide effect of armed conflict on mortality remains unknown. We searched Google Scholar using the terms “child mortality, Africa, and [conflict or war].” We then read all relevant studies published since 1995.

Added value of this study

To our knowledge, our study is the first comprehensive analysis of the large and lingering effects of armed conflict events on the health of non-combatant populations. We provide unique insights along several important dimensions into the study of armed conflict in Africa, between 1995 and 2015. First, our analysis encompasses the entire African continent. Second, we quantify the increase in the risk of dying before reaching age 1 year among infants born within 50 km of armed conflict, and show that this risk is related to the number of deaths in nearby armed conflicts, and to the duration of the conflict. Third, we identify the boundaries in space (up to 100 km) and time (up to 8 years after conflict) of increased risk of infant mortality. Finally, we estimate that the number of infant deaths related to conflict is several times greater than the number of direct deaths in armed conflicts.

Implications of all the available evidence

The burden of conflict on infant and child mortality is substantial and higher than available estimates. The available evidence suggests that conflict increases child mortality risk through effects on maternal health, infectious disease risk, and malnutrition. These findings have implications for the targeting of interventions for promoting child health during and after armed conflicts. Future analyses should identify effects in other conflict-prone regions. This work should prompt re-examination of armed conflict as a cause of, or risk factor for, child mortality.

We used a dataset of geospatially explicit information on armed conflict in Africa, including location, timing, and number of armed conflict deaths. These data have been used primarily in political science to study features of armed conflict, such as why armed conflicts erupt or end and the role of state and non-state participants in conflict.13, 14 The availability of data on location and timing of conflicts, however, enables identification of the relationship with location and timing of child births and deaths. We use this identification throughout this analysis. Recognising the extent to which armed conflicts spill over to jeopardise the lives of young children would help prioritise approaches to deliver crucial services and other protective measures to populations living in unstable areas.

Section snippets

Overview

This analysis proceeds in several stages. We first estimated the relationship between armed conflict and child mortality. We examined the mortality response of infants (children younger than 1 year) to the intensity and duration of nearby armed conflicts. We then presented a series of extended analyses on the long-term destructive effects of conflict, on the spatial limits of conflict's effects, on possible mechanisms leading from conflict to child mortality, and on the mortality implications

Results

Our data consisted of 1·99 million births, 133 361 deaths of infants younger than 1 year, and 204 101 deaths of children younger than 5 years in 35 countries between 1995 and 2015. These data were linked to 15 441 armed conflict events with 968 444 conflict-related deaths. Aggregate data on the study sample, including information on the number of births, child deaths, and conflicts available for analysis are given in Table 1, Table 2. Country-level data are given in the appendix. The

Discussion

More frequent and more intense armed conflicts have taken place in Africa over the past 30 years than in any other continent.34, 35 This analysis shows that the effects of armed conflict extend beyond the deaths of combatants and physical devastation: armed conflict substantially increases the risk of death of young children, for a long period of time. It might not be surprising that young children are vulnerable to nearby armed conflicts, but we show that this burden is substantially higher

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