JRSM >
Volume 100, Number 12 >
Pp. 564-570
1 Consultant paediatrician, Department of Paediatrics, University Hospital of
Wales, Cardiff, Heath Park, Cardiff CF14 4XN Email:
bernadetteohare{at}doctors.org.uk
2 Consultant paediatrician, University Hospital of North Staffordshire,
Stoke-on-Trent and Honorary Medical Director, Childhealth Advocacy
International, 17A London Road,
http://www.caiuk.org/
Email:
davids{at}doctors.org.uk
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Design We compared the under-5 mortality rate in 2004 and the adjusted maternal mortality ratio in SSA which have and have not experienced recent armed conflict (post-1990). We also compared the percentage of children who are underweight in both sets of countries, and expenditure on defence, health and education.
Setting Demographic data and central government expenditure details (1994-2004) were taken from UNICEF's The State of the World's Children 2006 report.
Main outcome measures Under-5 mortality, adjusted maternal mortality, and government expenditure.
Results 21 countries have and 21 countries have not experienced recent conflict in this dataset of 42 countries in SSA. Median under-5 mortality in countries with recent conflict is 197/1000 live births, versus 137/1000 live births in countries without recent conflict. In countries which have experienced recent conflict, a median of 27% of under-5s were moderately underweight, versus 22% in countries without recent conflict. The median adjusted maternal mortality in countries with recent conflict was 1000/100,000 births versus 690/100,000 births in countries without recent conflict. Median reported maternal mortality ratio is also significantly higher in countries with recent conflict. Expenditure on health and education is significantly lower and expenditure on defence significantly higher if there has been recent conflict.
Conclusions There appears to be an association between recent conflict and higher rates of under-5 mortality, malnutrition and maternal mortality. Governments spend more on defence and less on health and education if there has been a recent conflict. SALW are the main weapon used and France and the UK appear to be the two main suppliers of SALW to SSA.
| INTRODUCTION |
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The impact of conflicts on maternal and child health in SSA is difficult to ascertain, as reliable data is not available in politically unstable regions. During conflict, data becomes even sparser and is of doubtful quality.3 We compared the under-5 mortality rate in 2004 and the adjusted maternal mortality ratio in countries in SSA which have and have not experienced recent armed conflict (‘recent’ being defined as since 1990). Given that more than half of the deaths in the under-5 age group are associated with malnutrition,4 we compared the percentage of children who are underweight in both sets of countries. We also compared expenditure on defence, health and education in SSA countries with and without recent conflict.
Since 1990, in 94% of conflicts, Small Arms and Light Weapons (SALW) were the only weapons used.5 In modern conflicts, most deaths are from preventable illness and malnutrition: over 80% of all deaths are civilian deaths,6 and 90% of direct deaths are caused by small arms.7 We have reviewed the supply of SALW to SSA.
| METHODS |
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Demographic data
Demographic data and central government expenditure on health, education
and defence (1994-2004) were taken from UNICEF's The State of the World's
Children for
2006.9 There are 42
countries in this dataset, which includes all countries on the main continent
of Africa other than those above the Sahara in North Africa—namely
Morocco, Western Sahara, Algeria, Tunisia, Libya and Egypt—as well as
South Africa. Madagascar is included although it is not on the main continent
as its demographics are very similar to the other countries on the continent;
the islands of Mauritius and Cape Verde are not included. South Africa is not
included as it is generally not regarded as a developing country.
For all summaries and calculations, the Statistical Package for Social Sciences (SPSS) was used.
Conflict data
Data on conflict for these 42 countries have been taken from work by the
Institute of Development
Studies.2 We have
defined recent conflict as a country experiencing conflict, beginning or
ongoing between 1990 and the present day. During this time period there have
been 21 countries which experienced conflict. A conflict is arbitrarily but
conventionally defined as such when there are at least 1000 conflict-related
deaths per
annum.10
Small arms data
Defence expenditure includes the funding of personnel, major conventional
weapons and SALW. Given that SALW were the only weapon used in 94% of
conflicts, the supply of these to SSA was reviewed. The Norwegian Institute on
Small Arms Transfers (NISAT), collects information on transfers of SALW from
1962 to the present
day11 from all
available data sources. Because not all countries disclose their arms imports
and exports, it is not a complete record. The database produces two types of
dataset; base and mirror. For a given country, there will be reported exports
(base) as well as reported imports from recipient countries (mirror). Using an
agglomerated data tool, NISAT reduces the likelihood of double-counting by
matching base and mirror data and deleting the least reliable transfer records
(by calculating the reliability of each transfer record). We looked at the
SALW transfers to the 42 SSA countries.
Statistical analysis
Countries with and without conflict were compared. The median of the two
groups was compared using Mann-Whitney U test for Independent Samples. The
main outcome variables are the under-5 mortality rates, rates of children
being moderately underweight in 2004 and adjusted maternal mortality ratios,
the last review being in 2000. We also looked at the reported maternal
mortality rates for 2004.
| RESULTS |
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Conflict and spending on health and education
Countries vary in the amount of central government expenditure they
allocate to health, education and defence
(Table 2). The median
expenditure on health and education is significantly lower and the median
expenditure on defence significantly higher if there has been recent conflict
(Figure 2).
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Sources of legal trading of SALW to SSA
We have summarized the dataset provided by NISAT for the 13 years 1992-2004
for worldwide reported exports and imports of SALW, in order to look
specifically at imports and the main suppliers of SALW to SSA
(Table 3). The USA is the
leading exporter of small arms to all countries, followed by the UK, Italy,
Germany, France, Russia and Belgium, who together supply 75% of all SALW in
the world.
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Table 4 relates to arms imported only into SSA, and identifies the countries responsible for 90% in value of such total imports. Here, France is the biggest contributor, followed by the UK, then Russia, China and Spain.
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Licensed production in SSA
Licensed production is where a company which holds the patent for a weapon
(licensor), contracts with another company to produce its product (licensee).
The licensor then receives royalties which may include annual fixed payments
or a fixed sum per unit produced. From the viewpoint of arms trading to SSA,
there are two problems with this process. The producing country may have
weaker export controls than the licensor's home country and countries may
continue to produce arms after the licence has
expired.6 Licensed
production is a way to evade export legislation and facilitate export to
prohibited destinations. Legal production of small arms in developing
countries generally means licensed production of foreign
weapons.7 There are
eight countries in SSA, excluding South Africa, which produce arms or
ammunition.11 In
Kenya, for example, one factory has the capacity to produce 20 million rounds
of ammunition per year under license from a Belgian
company.7 Arms
and/or ammunition production is taking place under license in Burkina Faso,
Cameroon, Ethiopia, Kenya, Nigeria, Sudan, Uganda and
Zimbabwe11
(Table 5). Five of these eight
countries have experienced recent conflict.
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| DISCUSSION |
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This is secondary, ecological data and causality cannot be proven. In view of the quality of the data it is not possible to use a multivariate model to clarify whether it is conflict or factors associated with conflict, such as lack of investment in health services and poor governance, which cause an increase in mortality. There are also many confounding factors such as the influence of humanitarian aid.12 Other factors to bear in mind are that conflict may affect a country unevenly but this is countrywide data, nor can this data reflect the differences between urban and rural populations or between different sections of society. It is not possible to say that conflict is causal but this data does support the hypothesis that conflict negatively impacts child and maternal health. This may operate through a large number of pathways including disruption of health services.13
Guha-Sapir confirms children's vulnerability during conflict by looking at 37 different datasets from conflict situations and comparing mortality rates during conflict with pre-conflict rates.12 Our paper compares countrywide data between countries with similar demographics, on the same continent, to see if conflict has an effect at this level.
Bhutta has looked at available health and economic indicators for 60 countries.14 He grouped them into three groups, those representing the highest, intermediate and lowest infant mortality rate, and compared the groups in terms of government spending, population growth and the degree of corruption. Those with the highest infant mortality rate spend more on defence and less on health and are perceived to be more corrupt. Most of the group with the highest infant mortality rate were countries in SSA and they were compared with countries from other parts of the world. Our paper compares countries within SSA, the difference between the two groups being the occurrence of recent conflict.
Humanitarian impact
During the 1990s in SSA, 20% of the population were impacted by civil
wars15 and deaths
from violent conflict have killed more people in SSA than in any other
continent in recent
times.16 Conflicts
in Africa have been marked by horrific levels of
brutality,17 and if
the incentive is greed as opposed to grievance, the protagonists may not want
to negotiate a peace
settlement.2
Privatized warfare has an international dimension, including corporate funding
of private armies and warlords accessing global markets to sell commodities
using small arms as currency. Direct conflict deaths are deaths as a result of
injury sustained from guns, bombs and mines. Indirect conflict deaths arise
from illness or starvation that would not have occurred or could have been
readily treated in the absence of conflict. The ratio of direct to indirect
conflict deaths varies, depending on preexisting health care, the aid
available and the duration of the conflict. In SSA, a median of 23% of total
deaths which occur during conflicts are directly due to conflict, with 77% of
deaths due to diseases that should otherwise be easily prevented or
treated.7
There are 13 million internally displaced persons (IDP) and 3.5 million refugees in SSA.16 Most displaced persons are mothers and children and are at a particular risk for violence and sexual abuse.17 The UN High Commissioner for Refugees has noted that ‘armed conflict is now the driving force behind most refugee flows’. In many recent internal conflicts in SSA, combatants deliberately displace local populations to further their pursuit of control over economic resources.18 Maternal mortality in the Democratic Republic of Congo doubled during the recent conflict, when there were hundreds of thousands of displaced people,19 and child mortality rates in displaced populations are 60% higher than baseline rates in the same country.20 In Darfur, where 1.25 million people are displaced at the present time, children die at rates between 1 and 5.9/10,000 per day,21 or between 37 and 215/1000 per year. Similar rates were reported in Angola during the armed conflict there.22 Donated emergency food aid may be diverted from displaced populations to military groups. In parts of SSA only 12% of food aid reached its intended beneficiaries.23 Many refugee camps have become militarized and displaced persons are subjected to armed violence. These camps have also been used to traffic arms.18 The relationship between conflict and the spread of HIV is complex, and influenced by the preexisting prevalence of HIV infection, population movement and health care in camps.24
The opportunity costs of arms spending
It can be difficult to distinguish between cause and effect, but armed
conflict is probably the single most important determinant of poverty in
Africa;25 it has
been estimated that the economic losses due to conflict in Africa amount to
almost $15 billion
annually.14 Whether
or not the country has been able to continue to govern, that is provide public
services, is one of the most important factors that impact on the poor.
Conflict often takes place against a decline in government revenue from taxes,
further compromising services. Foreign loans in foreign currency have to be
repaid and during the years post conflict, an increased proportion of
government expenditure is spent servicing
debts.2 The World
Bank has criticized military spending for having ‘diverted enormous
resources from SSA's development’, and ‘consuming nearly 50 per
cent of government expenditure in countries experiencing the worse
destabilisation’.26
One-fifth of developing world debts are reported to be due to arms
imports.26,27
SALW as the weapons of choice in modern conflicts in SSA
SALW are the only weapon used in the vast majority of modern conflicts. 90%
of the trade in SALW worldwide is legal but more than 50% of the arms in
circulation are illegal. Most illegal arms were initially traded legally but
become illegal by brokered sales, theft and corruption. Ways to evade legal
controls includes producing arms under license in less well regulated
countries. After conflicts, SALW become an accepted part of normal
life,2 and armed
violence remains a problem with mortality rates higher than
baseline.28
The WHO and World Bank estimate that SALW violence contributes 15% of
the burden of disease in developing
countries.15 In the
recent conflict in Rwanda, much of the killing was done with machetes.
However, it was SALW in the hands of the Hutu-dominated government and
militias that tipped the power balance clearly in their
favour.29
Since the cold war the small arms industry has become largely privatized but a license from the producing country's government is required for export. There are 1000 factories in 98 countries, half in Europe and one-third in the USA. While SALW do not cause internal conflict they do multiply the effect, and the impact of development efforts are retarded or reversed by their misuse.15 The importance of not having small arms in a society is witnessed by the crucial role that decommissioning played in the peace process in Northern Ireland. In 2006, at the UN General Assembly, 153 governments supported an Arms Trade Treaty which will prevent arms transfers which fuel conflict, poverty or human rights violations. Only the USA voted against this.30 However, export control in the USA is considered to be one of the world's best18 and it is interesting in our study that despite being the major world producer, the USA is not one of the major exporters to SSA. In 1998 sixteen West African states called for a ban on the import, export and circulation of small arms in their states.
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| Footnotes |
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Contributorship Concept, BOH and DS. Data collection and analysis, BOH. Final draft revisions, DS and BOH.
Acknowledgments We would like to acknowledge Thomas Jackson from The Norwegian Initiative of Small Arms Transfers (http://www.nisat.org/) for supplying the Euro stat agglomerated data and Professor Robert Newcombe, University of Cardiff for help with summarizing this data.
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