Lack of health care, food and shelter typically kill more civilians than bombs and bullets


children of war
A Syrian boy sits with belongings he collected from the rubble of his house in Aleppo's Al-Arkoub neighbourhood on Dec. 17, 2016, after pro-government forces retook the area from Syrian rebel fighters.
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"Most civilian casualties in war are not the result of direct exposure to bombs and bullets; they are due to the destruction of the essentials of daily living, including food, water, shelter, and health care."


So begins the abstract for an essay in the Winter 2017 edition of Daedalus by Stanford Health Policy’s Paul Wise, the Richard E. Behrman Professor of Child Health and Society and professor of pediatrics at the Stanford School of Medicine.

Wise argues in his essay, “The Epidemiologic Challenge to the Conduct of Just War: Confronting Indirect Civilian Casualties of War," that the death of any child is always a tragedy. But the death of a child from preventable causes is particularly unjust.

“This is, of course, as true in peacetime as it is in war,” he writes. “My argument is that the dramatic growth in our ability to prevent death and disability from the indirect effects of war generates not only humanitarian impulses, but also just war demands for the provision of this capability to populations affected by war.”

The American Academy of Arts & Sciences devoted its Fall 2016 and Winter 2017 issues of its journal, Daedalus, to the theory of Just War. It held its 204th annual meeting at Stanford University in November, with Wise reviewing the main points of his essay. Other speakers included Stanford President Marc Tessier-Lavigne and FSI's Scott Sagan and Joe Felter.

(Videos of all their talks can be found on this page. And you can listen to their conversations in this World Class podcast, "Ethics in War," by the Freeman Spogli Institute for International Studies.)


Just War is a theory dating back to the early Christian theologians, who called on warring parties to justify their use of force and to protect noncombatants and innocent civilians.

The statisticians of war and genocide typically look at the total number of deaths due to combat or murder: 5 to 6 million Jews were exterminated in the Holocaust; the Second Congo War from 1998-2003 is estimated to have claimed more than 3 million civilian lives in direct combat.

More recently, the nonprofit organization, I Am Syria, estimates that 450,000 civilians, 50,000 of whom were children, have been killed in the Syrian civil war that erupted up March 2011. But how many will have died in the eventual aftermath due to lack of medical care, food and shelter?

It is estimated that 2 million Congolese, for example, died from starvation and lack of food and medical care in the years following its civil war.

The numbers that make it to the history books often do not reflect the indirect deaths that come on the sidelines and aftermath of war, particularly among children 5 years old and younger. During the periods of intense conflict in the Democratic Republic of Congo and Darfur, direct trauma-related mortality accounted for less than 20 percent of all excess deaths among children. The leading causes of the excess deaths on top of direct conflict were fever and malaria, measles, diarrhea and acute respiratory infections. In Syria, many of those children who have survived likely will have medical and mental repercussions that will be debilitating or deadly.

Wise notes that a report published by the Geneva Declaration Secretariat suggests that for every violent death resulting from combat and conflict between 2004 and 2007, four more died from war-associated elevations in malnutrition and disease. Global health scholars reported that about one-third of all deaths in Iraq were due to indirect causes.

This is why health-care workers are “the ultimate inheritors of failed social order,” said Wise, who is also a senior fellow at the Freeman Spogli Institute for International Studies. “Sooner or later, a breakdown in the bonds that define collective peace, indeed that ensure social justice, will find tragic expression in the clinic, on the ward, or in the morgue.”

That is the extremely bad news. But there is also some good.

Technological advances to prevent conflict and protect civilians have expanded dramatically, such as social media platforms that allow victims of war to communicate instantly and globally, and the crowdsourcing and early-warning SMS systems that take advantage of the more than 2 billion cellphone users around the world.

The United Nations is looking at GPS tracking systems to protect peacekeeping convoys on search-and-rescue missions, according to another article in the Fall 2016 issue of Daedalus. In another example, the International Bar Association created the eyeWitness to Atrocities app for smartphone cameras designed to record and authenticate atrocities.

All this new technology is allowing for advances in epidemiologic and demographic measurement out in the field, Wise said.

“In the context of just war, technical innovation means more than the creation of more powerful and precise munitions,” Wise writes. “It also means an enhanced capacity to measure and reduce the human impact of war.

“Innovation in these two technical domains — measurement and mitigation — has been sufficient to rethink the application of Just War theory to the indirect effects of war.”

Wise runs the Stanford Children in Crisis Initiative, which seeks to save the lives in children who are suffering from conflict and poor governance. Stanford students and local health-care promoters in rural Guatemala have been working with him for decades to try and end death by malnutrition and other causes among young children there.

The initiative last summer launched an app for tablets, which is making it easier to find malnourished children and decrease the training time for new health promoters. The goal is to eventually distribute the application globally.

The international aid community’s growing ability to measure the indirect impact of war, coupled with the ability to prevent or mitigate the indirect human toll of war, is remarkable, Wise said.

“Advances in epidemiology and the technological means of collecting health data have generated a range of new opportunities to assess the immediate and protracted effects of war,” Wise said. “This field is still young and these new technical strategies are creating an unprecedented capacity to assess the impact of war in even remote communities.”