Featured Journal Content
Sep 01, 2018 Volume 392 Number 10149 p711-794
Childhood mortality during conflicts in Africa
Emelda A Okiro, Philip Ayieko
Published: August 30, 2018DOI:https://doi.org/10.1016/S0140-6736(18)31373-4
The International humanitarian law differentiates two types of armed conflicts: international (between states) and non-international (domestic). 1 Since 1989, 75% of non-state armed conflicts have been in Africa. 2 Children and women bear most of the burden of these events. Childhood deaths due to conflicts present a real threat to the achievement of the global target of ending preventable deaths of children by 2030. 3 Despite the link between armed conflicts and direct deaths (combat-related) and indirect deaths (excess mortality because of worsening health disparities and disruption of basic health services), most assessments of childhood deaths done to date have not explicitly incorporated the effect of conflicts on child survival. 4 The need to address this gap takes on a greater urgency in the African region, where there has been a flare-up in both intensity and magnitude of armed conflicts. 5,, 6
Armed conflict and child mortality in Africa: a geospatial analysis
Zachary Wagner, Sam Heft-Neal, Zulfiqar A Bhutta, Robert E Black, Marshall Burke, Eran Bendavid
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.
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.
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.
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.
The Doris Duke Charitable Foundation, and the Centre for Global Child Health at the Hospital for Sick Children.