Civil wars in the modern era are associated with generating significant flows of refugees and internally displaced persons. Since the mid 1980s, the turbulent Western Upper Nile region of the Sudan has seen the emergence of epidemic visceral leishmaniasis, and massive mortality of the local population. Seaman et al. note that the epidemic began in 1983, when the civil war between the Nilotic peoples of the South and the Arab-African populations of the North began again in earnest, as a result of the introduction of the parasite through troop vectors from its regions of endemicity. This low-intensity but protracted civil war has resulted in complete disruption of the health-care infrastructure in the area, in increased malnutrition, and in huge population movements of both combatants and civilians. According to Seaman, "movement to escape the fighting and to search for food . . . has probably increased the rate of transmission and facilitated the spread of the epidemic within [the western upper Nile region] and beyond. Agriculture and cattle rearing have been disrupted by the war, resulting in more persistent malnutrition which has probably contributed to a higher conversion rate to clinical disease . . . and hence to high mortality."92 Moreover, the hostilities have disrupted both coherent epidemiological surveillance of the epidemic and the provision of treatment to the infected, as expatriate medical staff are often evacuated because of the fighting.93 As a result, this conflict-induced epidemic has resulted in catastrophic mortality throughout the region: "Between 38 percent and 58 percent of the population reportedly died, and up to 70 percent in the most affected areas. . . . 80,000-136,000 people who might otherwise have been expected to live, have died since 1984."94
Rey et al. note that refugees returning to Kosovo after the conflict with the Serbs in 1998 generated an epidemic of hepatitis (HAV and HEV, specifically) in that region.95 The displacement of populations as a result of civil war has also been associated with recent outbreaks of epidemic typhus in sub-Saharan Africa. According to the epidemiologists J. Ndi-hokubwayo and D. Raoult, Burundi's lengthy civil war of 1993-2006 forced a significant proportion of the population to "live in the cold, promiscuity, and malnutrition of makeshift refugee camps." They conclude that "political unrest as well as numerous civil wars are now epi-demiological factors favor[ing] outbreaks of epidemic typhus at any time."96 Toole and Waldman concur, noting that war generates conditions of stress, malnourishment, lack of sanitary facilities, and lack of access to public health provision that contribute directly to the spread of communicable diseases within densely populated refugee camps.97 Ghobarah concurs:
Prolonged and bloody civil wars are likely to displace large populations, either internally or as refugees. Epidemic diseases—tuberculosis, measles, pneumonia, cholera, typhoid, paratyphoid, and dysentery—are likely to emerge from crowding, bad water, and poor sanitation in camps, while malnutrition and stress compromise people's immune systems. [Furthermore] the camps become vectors for transmitting disease to other regions. Prevention and treatment programs already weakened by the destruction of health-care infrastructure during civil wars become overwhelmed as new strains of infectious disease bloom. For example, efforts to eradicate Guinea worm, river blindness, and polio—successful in most countries—have been severely disrupted in states experiencing the most severe civil wars.98
Smallman-Raynor and Cliff conclude that civil war can affect the spread of epidemic disease through various mechanisms of diffusion: ". . . the population movements engendered by the Cuban Insurrection (1895-98) and the Philippine-American War (1899-1902) were found to be associated with a strengthening of the geographical corridors of epidemic transmission that would ordinarily be witnessed in peace-time."99 Przeworski et al. argue that political disruption generates persistent and negative effects on economic growth rates in affected polities.100 Thus, the economic shortfall induced by political instability typically results in a reduction of government revenues available for expenditure on public goods such as health care, clean water, and sanitation, which in turn greatly facilitates the proliferation of pathogens in a society. The pernicious effects of war on capital (both fiscal and human), particularly as they affect the provision of public health, are very much in need of further empirical investigation.
War may be seen as malign not only in and of itself but also in its role as the progenitor and disseminator of disease. Consequently, war should be understood as amplifying disease through its contribution to contagion as a function of emergent properties. Thus, even regional wars may generate the circumstances for pathogenic emergence (and further evolution) that contribute to the spread of global public bads in the form of pandemic diseases. "If we fail to recognize the evolutionary changes in pathogen virulence that our activities may inadvertently cause," Ewald warns, "then we will pay the price in sickness and death not just until our activities change the environment back to a state that favors the benign forms, but rather until the evolutionary change toward benign-ness is completed."101 Collectively, such preliminary evidence reinforces the hypothesis that war and disease may operate synergistically as symbiotic externalities wherein the former extensively reinforces the latter, with this malign nexus operating at domestic, regional, and global levels.
In summation, the following factors, generated or exacerbated by conflict, contribute directly to the emergence and/or proliferation of pathogens:
• increased population density (combatants and civilian)
• famine-induced malnourishment, compromising immunity
• conflict-related mobility or vectors (troops and refugees)
• lack of hygienic conditions (water, etc.)
• destruction of health infrastructure
• lack of access to health services
• impediments to treatment
• poverty (induced or exacerbated)
• inhibition of effective public health surveillance
• sexual coercion and commercial sex
• physical and psychological stress, compromising host immunity.
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