Conflict and Health began in 2007 with an aim to provide a forum to document public
health responses during and after conflict across the world. The journal has published
over 120 articles that span the range of public health domains including, but not
limited to, infectious disease control, reproductive health and sexual and gender-based
violence, mental health, health system reconstruction, and ethics in emergencies.
The growth of Conflict and Health has taken place during a time of increasing focus
on evidence-based approaches to reducing mortality and morbidity in humanitarian emergencies,
and the increasing prominence of open-access peer-reviewed literature [1-3].
In a world that remains affected by armed conflict, the aim of the journal remains
more relevant than ever. In 2014, conflict is ongoing in countries and regions as
dispte as Central African Republic, Syria, South Sudan, Iraq, Myanmar, and the Sahel
Region and Northern Nigeria. There is increasing awareness, action and data behind
the idea that internally displaced people, refugees and increasingly, residents of
countries, are affected by conflict [4].
Syria in particular provides a clear example of the all-encompassing nature of conflict
on national health and the effects on regional development. Three years into the war,
the scale of the humanitarian emergency in Syria and its neighbors is unprecedented.
Most Syrians are at-risk, with an unknown current number of conflict-affected residents
(nearly 12 million in 2012), 6.5 million internally displaced persons (IDPs) and nearly
three million refugees spread over Egypt, Iraq, Jordan, Lebanon and Turkey in 2013
(and four million refugees projected by the end of 2014) [5,6]. The crisis has reversed
Syria’s two decades of progress. In 2007, the proportion of the population living
in extreme poverty was 0.3%. By 2012–2013, it is 7.2%, back to 1997 levels [7]. By
mid 2013, the 70,000 documented deaths constituted a 50% increase in crude deaths
during the pre-war period [8]. Almost two thirds of public hospitals are damaged or
have no capacity. Measles vaccination coverage among one year olds dropped from 81%
nationally in 2007 to 61% nationally in 2012 [9]. Similarly, oral polio vaccination
coverage (OPV 3) among children under five dropped from 91% in 2010 to 68% in 2012,
resulting in a poliomyelitis outbreak that emerged in Deir Ez Zur province in eastern
Syria and Aleppo and spread to Iraq [10]. Nearly three million children have been
vaccinated during a logistically challenging six rounds of massive vaccination from
December 2013 to April 2014 [11]. Conversely, hypertension, diabetes and mental health
issues make up the burden of disease and issues such as adherence to medications and
continuum of care are essential. Cancer and kidney failure needing renal dialysis
are also serious and expensive illnesses that have become prominent. Syrian refugees
have fled to urban areas in Iraq, Lebanon, Turkey, Egypt and Jordan presenting multiple
new challenges that the humanitarian field is not well-accustomed to sufficiently
addressing, including urban refugees and the control of noncommunicable diseases.
Syria reflects the emerging challenges to humanitarian assistance. In the last two
decades, the numbers of IDPs living within national borders continues to increase
as compared to a fairly stable global number of refugees until the recent Syrian crisis
[12,13]. In addition, conflicts have increased in middle-income countries in the Balkans,
the Caucasus, and the Middle East, who have older populations compared to low-income
counties and suffer proportionally more from diabetes, hypertension and other noncommunicable
diseases, as opposed to the malnutrition and epidemic infectious diseases experienced
in high-density camps in resource poor settings. Writing in The Lancet, Spiegel and
others [3] highlighted key challenges and opportunities to address health in current
conflict settings including: (1) rolling out health services via mass campaigns of
new and underused interventions for maternal and neonatal health, airborne diseases
and neglected tropical diseases to populations normally considered inaccessible; (2)
systematically addressing chronic diseases including HIV/AIDS, tuberculosis, diabetes
and cardiovascular disease; (3) planning and improving health services for conflict-affected
populations in urban areas within existing health systems such as IDP populations
in Nairobi, Cairo and Peshawar; and (4) improving and validating surveillance and
monitoring of health status and population estimation of displaced people.
The state of research
Developing more effective and flexible approaches necessitates research done with
rigor. Yet, there are copious reasons for academics to avoid this enterprise altogether.
Research in these settings is logistically difficult and there is limited funding.
It is difficult to position research as a life-saving effort in the short-term. In
the past, research has been cited as distraction to core medical, water and sanitation,
nutrition and protection priorities and at times, research has been conducted in ethically
problematic ways [14].
However, there is a strong need for the development of a basic understanding of the
effectiveness, cost-effectiveness and delivery of interventions. At the broader level
of the health system, how can services, systems and policies perform better and be
more responsive to peoples’ needs? This is underscored by a recent review of health
studies in humanitarian settings [15]. The review found a lack of studies that evaluated
the delivery of interventions, particularly for those topics (i.e., infectious disease
control) where evidence for the effectiveness of an intervention (i.e., the measles
vaccine) exists. Other topics also lacked a body of research on effectiveness of specific
interventions (i.e., gender-based violence and mental and psychosocial health). There
was a lack of research among urban populations and mid to high income settings. Finally,
health assessment methods and cost-effectiveness methods need attention. More positively,
of the 706 studies reviewed, 76% were conducted in the last decade, showing an increased
willingness to conduct research in humanitarian settings.
Conflict and Health provides a forum for demonstrating that rigorous research can
be done in conflict-affected settings by academics and more crucially, local and nongovernmental
organizations. It is clear that a greater commitment to research by academics, NGOs
and governments is needed, but research donors play an important enabling role. Fortunately,
the situation is changing as the recent R2HC programme provides a fund from DfID and
the Wellcome Trust that was created with the explicit aim of building the evidence
base for humanitarian intervention in complex humanitarian emergencies (see, http://www.elrha.org/work/r2hc).
Health scientists from conflict-affected countries, who likely understand the context
and should be contributing to research as disasters happen, should be better placed
to navigate these systems [16,17].
Many field practitioners explicitly aim to fill the gaps that traditional academic
researchers rarely explore, making important contributions to Conflict and Health
and demonstrating innovation. MSF used a series of case studies to examine the successful
provision of antiretroviral treatment (ART) during violent periods in a set of 22
countries where MSF was working [18,19]. An interagency group evaluated family planning
knowledge and behaviors and access to family planning interventions across six conflict-affected
contexts in Africa [20]. Even the most recently published article to date reported
on a rarely explored area: the outcomes of an orthopedic rehabilitation program implemented
after the final siege in Northern Sri Lanka [21].
Conflict and Health has brought particular attention to several under-researched areas
(Table 1). Infectious disease control in emergencies still dominates (26%), which
represents the predominance of the infectious disease burden among affected populations
in Africa and Asia as well as the shift towards including HIV/AIDS programming for
conflict-affected populations [19,22,23]. In addition to the review by MSF listed
above, other practitioners examined the implementation of programs for provision of
ART, adherence to ART and the challenges therein among conflict-affected populations
in Kenya and Republic of Congo [18,24-26]. Mendelsohn and colleagues [24] conducted
a systematic review of 17 studies of adherence to ART that found a range of adherence
from 87 to 99.5%. Bellos and others [25] systematically reviewed the literature to
define the burden of acute respiratory infection in crisis-affected populations, a
first step in defining the evidence base for improved intervention. Of note, while
studies of malaria, pneumonia and diarrheal diseases exist, Human African Trypanosomiasis,
which is characteristic of Sub-Saharan Africa and which persists in conflict settings,
has been the focus on both a review of its prevalence and a debate on its control
[26,27].
Table 1
Publications in Conflict and Health by theme, 2007-2014
Area of focus
Proportion
Infectious diseases and HIV/AIDS
26%
Mental health
20%
Sexual and gender based violence
10%
Mortality
9%
Reproductive health
6%
Health systems
4%
Environmental health
3%
Humanitarian assistance
3%
Substance abuse
3%
Surgery
2%
Editorials
2%
Education
2%
Ethics
2%
Human Rights
2%
Injuries
2%
Noncommunicable disease
2%
Nutrition
2%
Social determinants of health
2%
Child health
1%
The second largest proportion of articles concern mental health (20%) and sexual and
gender based violence (10%). Specifically, surveys of mental health symptoms among
conflict-affected populations have been reported on from a wide variety of settings
including Sub-Saharan Africa, India, Peru, Chechnya and Kosovo [28-32]. In contrast,
nearly half of the sexual and gender based violence studies are from Eastern Democratic
Republic of Congo which is notable, but likely emphasizes that research is not yet
addressing the breadth of the problem across settings [33-37]. One systematic review
looked at the confluence of the two areas by reviewing the effectiveness of mental
health interventions for persons affected by sexual and gender based violence [38].
Mortality is a key indicator of the magnitude of the humanitarian situation and effectiveness
of the humanitarian responses, and nearly 10% of the journal’s output has been reports
of mortality using retrospective surveys, surveillance methods and meta-analyses,
including those from Chad, Democratic Republic of Congo, Haiti, Iraq and Somali refugees
in Kenya [39-46]. Reports on the performance, validity and evaluation of surveillance
systems for mortality and morbidity in emergencies are lacking, although this is routinely
done by humanitarian organizations. Reports on the performance, validity and evaluation
of surveillance systems, survey methods and data collection methods in general in
emergencies are lacking are lacking, and papers published elsewhere have highlighted
the need for further work on these issues [47-50].
Other key areas have attained a niche within the journal. The backbone for ethical
conduct for research in conflict settings was laid out by a team of academics and
field practitioners from Médecins Sans Frontières (MSF) in 2009 [14]. Four observational
studies assessed the associations between exposures to environmental contaminants
resulting from war including mustard gas, uranium and nuclear pathogens in the Middle
East and birth defects and morbidity [51-54]. Some of the rare reports on substance
abuse including tobacco and alcohol among conflict-affected populations in Kenya,
Liberia, Northern Uganda, Iran, Pakistan, and Thailand are found in the journal [55-58].
Similarly, four observational studies of surgery and occupational health following
trauma have set the stage for further investigation of these important topics [21,59-61].
Only two articles were published on NCDs and it is clear that further research is
required on NCDs given their rise globally, with NCD control as a major challenge
in Syria and previous conflicts such as in the Balkans, the Caucasus and Sri Lanka
[62]. The five articles published on health systems reconstruction scratch the surface
of a largely neglected area. In particular, one of the articles takes a comprehensive
view through the use of a case study framework to analyze the impact of the success
of health sector reforms during the health sector reconstruction period in Kosovo
[63]. Comprehensive studies of health sector reform in general are rarely found even
elsewhere, but in general are now needed to document and inform current debates [64-66].
Publication statistics
In 2013, the journal reached 194,000 website hits and more than 10,000 individual
accesses of each of the top 10 accessed articles since the start of the journal. The
full range of countries referred to in the journal represents those affected by conflict
and natural disasters since the 1990s. In particular, five or more articles come from
Democratic Republic of Congo, Uganda, Iraq, Thailand, Kenya and Myanmar. Countries
that are considered forgotten conflicts including Somalia and Central African Republic
also factor into the list. Nonetheless, papers from current and former conflicts in
South America, West Africa and South Asia are largely absent (Figure 1).
Figure 1
Publications by country of study, for countries with greater than one article 2007–2014.
*Countries with less than 1% (or one article) include Armenia, Bangladesh, Bosnia
and Herzegovina, Central African Republic, Chad, Chechnya, Haiti, Indonesia, Iran,
Israel, Israel-Palestine, Liberia, Mozambique, Palestine, Peru, Philippines, Republic
of Congo, Rwanda, Sierra Leone, Sri Lanka, Syria, Tanzania and Timor-Leste. Four articles
from Canada and Sweden were excluded.
Analysis of Conflict and Health first authors reveals that research is still largely
led by academics (55%) (Figure 2). However, non-governmental organizations such as
MSF/Epicentre and Healthnet-TPO contribute a fifth of the articles (20%). Local universities
and hospitals such as the Hawler Medical University in Iraq, the Rehabilitation and
Research Centre for Torture Victims of Kosovo and Université de Goma in the DRC, make
up 15% of the articles. McKee, Basu and Stuckler [67] conducted a useful analysis
of the number of health research publications in peer-reviewed journals by national
population size that puts this accomplishment into context. They found that DRC, Myanmar,
Sierra Leone and nearly all of the other countries whose local hospitals and universities
produced first authors for Conflict and Health have 0.13 to 1.5 health research publications
per 100,000 population These are the lowest rates in the world, which McKee hypothesize
is owing to poor research capacity, low political commitment to research and lack
of infrastructure.
Figure 2
Publications by provenance of the first author, 2007–2014.
The way forward
Armed conflict remains a serious threat to health that is currently destroying health
systems and future capacity in places as dispte as Syria, the Central African Republic
and Myanmar. It consistently undermines the Millennium Development Goals, efforts
to implement universal health coverage and the basic human right to health. Seven
years of the journal development has revealed promising opportunities. First, we are
three new Editors-in-Chief and have added a new Editorial Board that explicitly integrates
academics and technical experts from nongovernmental organizations including Epicentre,
ICRC, International Rescue Committee and Médecins Sans Frontières and from affected
countries. Second, though 15% of the articles are already led by authors from conflict-affected
countries, efforts to strengthen the possibilities for authors from affected countries
to contribute to the journal are warranted. At current, publication fees are waived
for authors from low-income and low-middle income countries (see, http://www.biomedcentral.com/authors/oawaiverfund/).
Other strategies may include engaging technical experts from affected countries to
contribute reviews of topics of under-researched areas, and reports on their ongoing
research studies and sponsoring writing workshops to ensure that the publication of
high-quality, sound research is not stymied by a lack of experience in writing journal
papers. Third, there is clear value in ensuring the journal has systems in place to
rapidly evaluate and publish quality research in current crises (e.g. Syria, South
Sudan, Northern Nigeria, Myanmar/Rakhine State) as well as less documented, forgotten
crises (Sri Lanka, Myanmar/Kachin crisis, Columbia, Yemen) to have more immediate
benefits on practice. Fourth, we will address the dearth of evidence for challenging
areas including the delivery methods for health care, epidemiology and control of
noncommunicable diseases, integration of displaced populations into health systems
and monitoring and surveillance of displaced populations and areas that require elucidation
of the evidence base [3,15]. To this end, the journal is collaborating on two special
issues on the global evaluation of the work of the Interagency Working Group on Reproductive
Health in Crises (IWAG), and health systems in fragile and conflict affected states
in partnership with Health Systems Global and the Global Symposium on Health Systems
Research (see, http://blogs.biomedcentral.com/bmcblog/2014/02/18/call-for-papers-filling-the-void-health-systems-in-fragile-and-conflict-affected-states/),
and further special issues are planned. Last, given the increasing volume of publications
and the need to motivate academics to publish with the journal, we intend to apply
for an Impact Factor.
The points of action mentioned above will be crucial to ensure a sustained growth
of the journal, but to ensure that scientific evidence guides public health interventions
in humanitarian settings, we will have to go one step further. In order for Conflict
and Health to contribute to improving the lives of conflict-affected individuals,
we will ensure that findings presented in the journal are easily understood and of
direct relevance to policy-makers, and we will strive for a high uptake of the key
findings published in our articles.
Some practitioners once called the lack of generation of feasible solutions for the
treatment of AIDS among conflict-affected populations a “failure of the imagination”
[68]. Case studies in Conflict and Health and other journals have shown progress in
ART treatment during conflict. Similarly, we hope that the next ten years of Conflict
and Health will encourage public health practitioners and researchers in the North
and South alike to push their creative ideas to develop rigorous research and sound
publications that will fill the void, push the field forward and save and improve
lives.