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Author:
Madeline Roberts, PhD, MSPH
On October 24, the Duke Global Health Institute hosted a seminar
titled “Human Rights, Health and Conflict: Counting Civilian Harm.”
This panel addressed the epidemiology of conflict and war. The stated
aim of the seminar was to cover the challenges of accurately
quantifying these harms from an epidemiological perspective, as well
as how to improve the role of international humanitarian law to
minimize—and hold perpetrators accountable for - the range of harms that
impact civilian life. With the understanding that the cumulative
civilian impact of war extends beyond death tolls, the principal
question the panel sought to answer was: “How do we count the civilian
harms caused by war and conflict?” The panel consisted of Drs. Debarati Guha-Sapir, PhD, and Mara Revkin, JD, PhD, moderated by
Catherine Admay, JD.
In her previous work in
disaster and conflict, Debarati Guha-Sapir has identified holes in
the evidence base for risk mitigation of natural disaster and civil
conflict. These holes originate from the inability to appropriately
quantify loss of human life in crisis settings. Guha-Sapir co-authored
a BMJ article titled “Science
and Politics of Disaster Death Tolls”, which captures both the
role and importance of epidemiology in disaster settings:
“Establishing who died, how, and where—basic epidemiological
questions—also helps direct resources to the most vulnerable
populations, increasing the effectiveness of humanitarian measures.”
On the panel, Guha-Sapir discussed how contention over death tolls
detracts from actual aid and future risk mitigation. She summarized
three main objectives for death tolls:
1.
Accountability
(perhaps most important): international humanitarian law plays a
primary role here, but this is also a moral imperative to honor those
who die, so that their deaths are not in vain.
2.
Advocacy:
get the help to where it’s needed.
3.
Programming:
programming of resources to respond to people’s needs.
Ask the questions, who is dying, where, and why (i.e., are they dying
of disease or violence?)
On the issue of
accountability, Guha-Sapir made the point that death toll estimates
are directly related to the credibility of their source. She discussed
the politics of death tolls: they can be artificially inflated (to
garner international attention and aid) or deflated (which could be
more relevant after natural disasters if a government does not wish to
be implicated for an insufficient response).
Common approaches to death toll estimation include
estimating excess mortality (evaluating death in times of conflict
compared with figures from the same time period in previous years) and
a mortuary and/or death certificate approach. There are limitations to
both and potential biases that must also be considered. For example, a
mortuary approach may be subject to bias in that counting casualties
may occur where combat violence is most intense to the neglect of
other areas.
Dr. Mara Revkin
posited that scholars have been systematically underestimating the
cost of war because they often focus primarily, or exclusively, on
death as the main indicator. More difficult to observe, measure, and
quantify are sexual violence, post-traumatic stress disorder (PTSD),
human rights violations, and impacts on education and child
development. The concept of cumulative harm encompasses not only the
immediate consequences following a strike but also aims to assess the
aftermath that makes it difficult for civilians to recover after war.
Revkin offered an example from her field research in Mosul, when
schools began to resume education after conflict. She observed that
school playgrounds had been converted into informal burial grounds
during the war, with lasting logistical and psychological
ramifications for daily activities once school resumed.
One aspect of cumulative harm is damage to property and
civilian infrastructure, including healthcare infrastructure,
ambulances, and healthcare workers. The National Academies found
more than 4,000 attacks against health care
workers and facilities over between 2016 and
2020. One analytic approach relevant to this issue is the spatial
analysis of healthcare facilities damaged during conflict—counting the
number of healthcare facilities destroyed, their locations, and the
somewhat more subjective question of the extent of damage (i.e.,
broken windows) or destruction (i.e., operating rooms are no longer
functional).
During the Q&A section
of the panel, Dr. Chris Beyrer added to the discussion that the Syrian
conflict is the first where WHO is actively engaged in quantifying and
confirming attacks on healthcare facilities, healthcare providers, and
ambulances. Before this, “there was no formal mechanism to confirm
these kinds of attacks…if you don’t systematically count, you really
can’t say.”
This panel addressed a painful, volatile topic with humility
and professional excellence and highlighted the strength of
interdisciplinary teams such as epidemiology and international
humanitarian law. We came away thinking about how our skills as
epidemiologists can be applied for aid and advocacy even in the most
unthinkable human experiences and the dire need for continuing to
develop rigorous methods to assess the broad set of harms stemming
from conflict. ■ |
