Perspective Chapter: Armed Conflict and Its Impact on Human Migration – The Healthcare Perspective

Abstract

Armed conflict can result in loss of human life, displace people, and violate human rights. While human migration often results from various causes like the search for food and shelter, armed conflicts also cause migration. Most armed conflicts stem from bad governance and religious radicalism. With bad governance, revendication from the marginalised often results in severe opposite repression from the state instead of dialogue. Migration from armed conflict imposes a disproportionate distribution of the population with the displaced lodged in camps thanks to some United Nations (UN) agencies like the High Commissioner for Refugees (UNHCR), the World Food Program (WFP), the UN Population Fund (UNFPA), and the United Nation Children’s Emergency Fund (UNICEF), in the areas of food provision, shelter, and medical care to the displaced and affected populations. Refugee camps can become an epicentre for diseases outbreaks like Tuberculosis, childhood diarrhoea, cholera, and HIV. Health workers are caught in the web, being attacked by armed groups, taking care of the wounded, while caring for themselves as well. It is important to address the major causes of armed conflict if we truly want to attain Universal Health Coverage, maintain a peaceful world, and achieve the Sustainable Development Goals by 2030.

1. Introduction

Armed conflicts have become preponderant in the world today. Almost every continent of the world has an epicentre of armed conflicts. Over 110 armed conflicts exist in the world over, with some having lasted as much as 50 years [1]. While some continents may have multicentric armed conflict zones, others have just occasional clashes that may occur sporadically between groups of varying opinion and ethnicity. Some of the armed conflict areas around the world include, but are not limited to Ukraine, Iran, Yemen, Ethiopia, Democratic Republic of Congo (DRC), The Sahel Region (Islamic Insurgencies), Haiti, Pakistan, and a probable armed conflict in Taiwan if care is not taken [2]. North Africa and the Middle East appear to be the most affected of all the world continents, while Australia appears to be the most peaceful. Figure 1 below illustrates the conflict hotspots on the globe.

Figure 1.

Armed Conflict Hotspots, 2021. Source; SIPRI Year Book 2022.

From Figure 1, we observe a preponderance of armed conflicts in Northern Africa, the Middle East, South-East Asia, and the Northern part of South America. Of note is especially conflicts that claim more than 10,000 lives in conflict-related deaths. The question remains: why is there such a rapid proliferation of armed conflicts in these areas? This is probably attributable to the persistent susceptibility to armed conflicts in these areas due to governance failures in most Arab countries, the still unfolding consequences of the 2003 US-led Iraq invasion, and the complex relations and rivalries among regional powers [3].

The real impact of armed conflicts on each continent is diverse and depends on a couple of factors. One of the latest conflicts, which is affecting almost the entire globe is the Russo-Ukrainian war, whose impact on each region varies. The impact of this war on the African continent is derailing its slow recovery from the COVID-19, bringing diverse effects on the economy [4]. Armed conflicts in Africa have moved from focusing on the autonomy of the states (pre-independence) to that of the struggle to control political power post-independence [5], thus practically stagnating, and in some cases, pushing the economy to like 10 to 15 years pre-conflict.

In Asia, especially Southeast Asia, and Europe, the Russo-Ukrainian war threatens the balance of power and peace in the European Union (EU), thus endangering the peace in Europe that has reigned post World War II [6], with resultant rises in prices in the global south, and destabilising their economic and fiscal conditions. Most countries are struggling to meet their energy requirements. Ghimire, underscores the prediction from the world bank that 60% of the poorest countries were already in debt distress or at high risk because of the global pandemic, and the Russo-Ukrainian war has compounded the distress due their dependence on 3F imports (Food, Fuel and Fertilisers). Therefore, armed conflicts have a detrimental effect on the economic and social wellbeing of people [7], indicating that the economy proves to be a more decisive factor than others in predicting the incidence and demonstrating the aftermath of armed conflicts.

2. Definition of terms

2.1 Armed conflicts

Armed conflicts are defined as political conflicts where the use of armed force by two parties of which at least one is the Government of a State results in at least 25 battle-related deaths [8]. A ‘major armed conflict’ is a contested incompatibility concerning government and/or territory over which the use of armed forces between the military forces of two parties of which at least one is the government of a state results in at least 1000 deaths in the course of the conflict in a single calendar year [9].

Two categories of armed conflict are identified: international armed conflicts (IAC) occurring between two or more States; and non-international armed conflicts (NIAC) which occur between State and non-governmental armed groups, or only between armed groups [8].

Summarily, according to the International Committee of the Red Cross [10] the following must apply for a situation to be considered and “armed conflict” under humanitarian low:

1. The armed groups have a level of organisation that enables them to carry out military operations (i.e., conduct hostilities).

2. Those groups have the capacity to maintain protracted operations.

3. The armed clashes are of a military nature.

4. The armed clashes are between the government’s armed forces and organised armed groups, or between organised armed groups.

5. The armed clashes occur within the territory of a State.

The above definition does not take into consideration armed conflicts that arise between ethnic groups within a country, though the causes may be similar to those of armed conflicts as defined above. Besides, the death tool used above to define armed conflicts ignores deaths less than 25. To determine the exact death toll during conflict is rendered complex by the fact that a qualified medical practitioner seldom certifies death [11]. One limitation, however, to the above definition, is that the actual conflict-related death toll could be much more different, especially in areas where the nature of the conflict makes it difficult to determine such figures, like burial in mass graves. No matter the number of deaths registered, every human life is valuable, and must be protected. Any conflict that results in death violates the fundamental human right to life [12] and by extension, deprives the affected from food, education, work, health, and liberty.

2.2 Refugees

Refugees are people who have fled war, violence, conflict, or persecution, and have crossed international boundaries to find safety in another country [13]. Internally Displaced Persons (IDPs), on the other hand refers to people who have been forced to flee their home or places of habitual residence, as a result of, or in order to avoid the effects of armed conflicts, situations of generalised violence, violations of human rights, or natural home-made disasters, and who have not crossed an internationally recognised border [14].

2.3 Human migration

The Encyclopaedia Britannica defines Human Migration as the permanent change of residence by an individual or group; it excludes such movements as nomadism, migrant labour, commuting, and tourism, all of which are transitory in nature [15]. According to National Geographic, on the other hand, Migration is defined as “movement from one country, place, or locality to another [16], not necessarily on a permanent basis. We shall adopt this second definition for the purpose of this work.

2.4 Some hotspots of armed conflicts

We will now highlight some armed conflict areas in the world. The ones elaborated below are not exhaustive of all armed conflict spots but intends to establish the effects that armed conflicts have on human migration especially from the healthcare perspective.

2.5 The crisis in Central African Republic (CAR)

Since the CAR gained independence in 1960, decades of violence and instability have characterised this country [17]. The debut of the current armed conflicts dates as far back as 2013 when the Séléka Rebel coalition seized power from the then president Bozizé. In response, self-defence groups emerged with the prominent one being the Anti-Balaka group. From then till date, different armed groups and warlords now control different communities in the republic. The conflicts have been demarcated along religious lines, since the coalition of armed Muslim groups had Christians as their major target, an act which equally led to the coalition of Christian fighters to repress the advances of the Séléka coalition.

Though the conflict degenerated, religious leaders, who have strong ties to Central Africans throughout the republic can influence their faithful and mediate for peace, though the extent of their influence can fluctuate significantly [18]. Local religious leaders are on the frontlines in a different way, they live among CAR’s armed groups. Collins further argues that from this position they play a careful, often overlooked, but ongoing role in managing CAR’s increasingly local patchwork of conflicts, as main mediators and parties to local peace and stabilisation processes. However, the religious leaders are being accused by the government of collaborating with the armed groups in their mediation process.

The Central African Republic conflict has permeated every facet of society leading to Schools closure. Central Africans have been forced to flee their homes. A shortage of skilled health workers and medical supplies mean the health care system in Central African Republic is barely functioning. Besides, attacks against medical facilities, attacks on patients and ambulances threaten what little health care is available [19]. The humanitarian consequences of this armed conflict are lawlessness has become the order of the day throughout the country, while the population has flown to other countries as refugees in Cameroon, Sudan, DRC, Tchad, Congo, and South Sudan [20].

2.6 Crises in The Cameroon

Cameroon is plagued within the last 10 years with multicentric (tripartite) crises: the Boko Haram insurgencies in Northern Cameroon since 2014, especially around the Lake Tchad Basin [21], the Anglophone Crisis since 2016, and pressure in the eastern region in relation to the displacement and vulnerability of refugees from the Central African Republic (CAR) [22].

2.6.1 Refugee crisis in the East Region of Cameroon

The war in CAR activated an influx of refugees fleeing to zones of perceived safety. These refugees are civilians fleeing violence and abuses from the fighting men. The surge in refugee influx happened in 2014 following escalation of the violence in CAR [22]. The result was a triggering of a humanitarian crisis in the East regions of Cameroon which houses about 270,000 refugees as of 2020, a figure that rose to almost 500,000 by November 2022 [23].

With this growing refugee population, hunger continues to be a problem as more and more people are uprooted in CAR to relocate neighbouring countries, thus competing for the meagre economic resources in these countries. More than one in three refugee children under the age of 5 suffers chronic malnutrition. Meanwhile, funding to support humanitarian activities has declined significantly. In 2019, the world food program (WFP) was forced to cut its cash assistance by half. By November they had stopped altogether [24].

2.6.2 The Boko Haram Insurgency in Northern Cameroon

The Islamic sect Boko Haram, which began its remote operations in North-eastern Nigeria as far back as 2002 manifested more brutal activities by 2009 following the extrajudicial killing of its founding leader Mohamed Yusuf. Its operations became more pronounced and widespread in 2014 under the leadership of Abubakar Shekau, and spread over to Cameroon, Tchad, and Niger [25]. The group is suspected of having possible links with Al-Qaeda. As of 2015, Boko Haram’s activities became more concentrated around the Lake Tchad basin. As a result, the Multinational Joint Task Force (MNJTF), that has been dormant for some time was reactivated in this same year to contain the activities of this sect [25]. Violence, abduction, and child suicide have been their major modus operandi, with significant violations of human rights. All their success is thanks to them being able to smuggle weapons and supplies across the borders, as well as recruitment of child soldiers.

The Boko Haram crisis’ impact on Cameroon is compounded by Intercommunal clashes that erupted in Cameroon’s Far North region in December 2021, leaving over 50 dead and driving at least 100,000 people from their homes, although the actual numbers may be much higher [26]. It is possible that people who fled the intercommunal violence fell into the dragnets of the dangerous sect. This crisis has disrupted almost every facet of the society, with healthcare facilities suffering at sometimes as the target of their attacks. Consequently, some health workers have fled the area [27], and any attempt to move health commodities to this area has been frustrated by their attacks.

2.6.3 The crisis in the North-West and South-West Regions of Cameroon

The anglophone regions of Cameroon – the North-West and South-West Regions – make up approximately 20% of the population of Cameron, but just about 9.2% of its surface area, yet these two regions play a pivotal role in Cameroon’s Economy especially in agriculture and Oil industries [28].

In October 2016, teachers trade union and lawyers mobilised in a peaceful protest and presented a couple of grievances against the government. These grievances can be summarised as bad governance and marginalisation of the English-speaking Cameroonians, especially within the legal and educational systems. The challenges included, inter alia, the mandatory use of the French language in schools and law courts in the English-speaking regions [29], and the gradual depletion of the Anglo-Saxon culture. Failure by the Government to address the concerns attracted political activists. The activists attempted to address the concern of bad governance and the continual marginalisation of the English-Speaking population of Cameroon from the time Cameroon gained independence in January 1960. Contrary to normal expectation, the government responded harshly: the executive arm of the government resorted to issuing decrees banning even peaceful protest, and a resultant crackdown on the peaceful, armless protesters by the security forces [29] that resulted in the imprisonment of the protest leaders. This wrongful response from the government gave rise, in 2018, to armed secessionists demanding the independence of the English-Speaking Cameroons to a sovereign state.

Consequently, countless, violent armed confrontations have been recorded between the Cameroon security forces and the secessionist groups [30]. The different secessionist groups are dispersed throughout the anglophone regions, controlling different parts of the region. However, their activities are not coordinated locally, apart from the attempted coordination from the diaspora, which again brings different groups at loggerheads. The exigencies of one group are the direct opposite of the other. It therefore becomes difficult, at moment, to know who to dialogue with (even if the government was to consider this option), considering the major leaders of the movement were thrown into gaol and have, since then been held incommunicado. Worse still, most of the gaoled individuals were tried before military courts — in violation of international human rights law — and sentenced under the country’s repressive 2014 anti-terror law [31].

The promise of a special status to the English-Speaking part of Cameroon in the “pseudo” national dialogue held in 2019 seem to have only fuelled the conflict [30]. With the persistence of the conflict, over 6000 people have been killed (though this figure could be grossly underestimated because the regions are largely inaccessible for accurate data collection [32]), while 86,000 (men, women, and children) currently live in south-eastern Nigeria [33] as refugees, being supported by the government together with the UN Refugee Agency. Others have fled to the French-Speaking region as IDPs.

The consequences of the above crises are devastating. People die at home because it is impossible to take them to any nearby health facility as roads are blocked with very heavy logs of wood; healthcare workers are caught in the web between treating wounded military (and receiving torture from separatist fighters who accuse them of collaborating with the military) and treating wounded separatist fighters (and receiving torture from the military and accusations for collaborating with the armed group). Both sides have committed regular humanitarian violations [34] during security operations. These range from rape, torture, and killings of both the young and the old not directly involved in the conflict.

Children have been deprived of the right to education for over 7 years, teachers have gone jobless for years and have had to resort to other means to earn a living, businesses have closed down, while others that attempt to continue to thrive are faced with two major challenges: exceedingly low returns, and increased expenditure due to the exigencies from the armed groups to get their services financed by the population. Transportation has quadrupled in almost all areas of the Northwest and Southwest regions, and movement is subject to multiple controls both from the Government forces and the separatist fighters.

2.7 The conflict in Somalia

Somalis are a unique community in Africa. Different from the reality in most countries, the Somalians are nearly a homogenous ethnicity [35]. The Somali people have suffered oppression and violence for prolonged periods. Interestingly and paradoxically, the violence has been from fellow Somalis, who are almost of same ethnicity. The suffering dates to the democratic, post-independence era until the military regime in 1969. According to the World Bank report, clannism and clan cleavages are a source of conflict [36]. This led to the division of Somalis, and as a result fuelled endemic clashes over resources and power, as well as mobilising militia, thus rendering broad-based reconciliation very difficult to achieve. Elmi & Barise establish that the war has multiple and complex causes that span through the political, economic, cultural, and psychological landscapes. Again, bad governance appears to play a pivotal role both in the debut and continuity of the war in Somalia, plunging the country into a very complicated situation.

Somalia, after over 2 decades of internal conflicts started re-emerging as of 2013 slowly but steadily [37]. The conflict caused over a million Somalis to migrate and became refugees in neighbouring countries with another one million internally displaced [38]. This migration did not just commence because of the war, but the aftermath of the war drastically changed the level and extent of migration in this country. The minority groups, which were initially isolated and immobile became exposed to significant levels of discrimination and marginalisation from the majority groups ethnicities; this resulted in impunity and significant suppression of these minority groups ethnicities, with the result being that the minority groups were almost completely expelled from the country.

Years of conflict, natural disasters, famine, and insecurity, all have contributed to very low scores for most humanitarian indicators. Despite high mortality caused by civil war and famine, Somalia’s population is growing rapidly due to a high fertility rate [39]. This rapid population growth puts a strain on the country’s poor health care and social services. About 60% of Somalia’s population is younger than 25 years. These were born during the civil war, and periods of conflict have almost become a norm to them. These adverse childhood experience bring about a high prevalence of long-term health effects in adulthood. In all, Somalia’s health system has been weakened by decades of conflict and recurring natural disasters, with no comprehensive Health Information Management System (HIMS) capable of electronically collecting and sharing information from community to national level [40].

2.8 The Russo-Ukrainian conflict

The Russo-Ukrainian conflict is a culmination of a tug-of-war between two camps in Europe, and deterioration of bilateral relations between Russia and Ukraine since 2014 [41]. Cheng underscores the fact that Ukraine’s membership to the North Atlantic Treaty Organisation (NATO), the territorial status of Crimea and the independence of Eastern Ukraine, and security interests in Russia are the three forces that contributed to and fuel the continuity of the current war with Ukraine as the Epicentre.

After the collapse of the Soviet Union, post-Soviet states have achieved “quasi” independence, that caused them to be closely associated with Russia. This has been the case because Russia used comprehensive sanctions against the newly independent states which relied on Russia to export their products or import energy and other inputs [42] Thus, a Russian federation with resultant re-emergence of the Soviet Union was judged highly plausible. The United States and NATO engaged in forging closer ties with post-Soviet states to limit Russia’s influence and control over these states [41]. These closer ties have evidently excluded Russia. NATO’s expansion Eastwards formed a semi-circle with Russia at the centre, thus increasing NATO’s membership from 16 to 30 states. Ukraine sought membership to NATO in 2014, in the wake of the Crimea rises, a request that was formalised in 2020. This Eastwards expansion of NATO has exerted military, political, economic, and cultural pressure on Russia [41].

Russia is one of the world’s leading self-sufficient countries in natural resources, natural gas, crude oil, iron, apatite, gold, wheat, and a couple of others. Therefore, all the economic sanctions imposed on Russia could not bring Russia to its knees [41]. There is significant energy dependence on Russia by the EU [43], any sanctions imposed on Russia almost always result in a direct negative impact of the EU member states, with the International Monetary Fund believing Russia’s economy could even grow by 0.7% in 2023.

The Russo-Ukraine war began on February 24, 2022, when the Russian President Vladimir Putin announced a ‘special’ military operation, claiming to protect people (the autonomous republic or Crimea) who have been subject to genocide for 8 years [44]. He attempted to take over the Ukrainian capital city of Kyiv [45], an attack that was countered by the Ukrainian forces. The fighting has continued till date with heavy losses in human life, reducing many key cities to ruins, and redressing the economic situation of Ukraine a couple of years back. A report from Office of the United Nations High Commissioner for Refugees, published by Statista, states that the estimated number of civilian casualties as of May 2023 is about 8900, a figure that could likely be less than the reality, with over 15,100 injured [46].

2.8.1 Conflict-related deaths in Ukraine from 2014 to 2021, the link with Crimea

The real figure of conflict-related deaths dates to 2014 when Russia annexed Crimea, and this sparked military conflicts between the Ukraine Government and Separatist fighters supported by the Government of Russia in Donetsk and Luhansk. Therefore, OHCHR estimates that between 14,200 and 14,400 people were killed from April 2014 to December 2021. This figure includes civilians and military personnel [46].

2.8.2 Migration in relation to the Russo-Ukrainian Conflict

From February 2022 till May 2023 the Organisation for Economic Cooperation and Development (OECD)reports that over 5.3 million Ukrainian refugees are spread over neighbouring European countries, majority of whom are housed by Poland [47]. From a population of over 43 million inhabitants as of 2021 [48], this figure reveals that close to 12% of the country’s population has fled to neighbouring countries as refugees, with obvious economic impact on the countries harbouring the refugees, especially Poland.

The effect on the health system is devastating. Russia has bombed civilian residences and infrastructure such as power plants. It is not clear if health infrastructure has been targeted, but Lancet magazine claims it is becoming increasingly clear, a key characteristic of Russia’s strategy has been attempts to destroy the health system, seriously undermining the Ukrainian people’s right to health [49].

2.9 Armed conflict in Afghanistan

Afghanistan has been a conflict zone since 2001 when the United States and allied forces invaded the country, quickly ousting the Taliban regime. This was following their refusal to hand over terrorist leader Osama Bin Laden after the 09/11 attack on the world trade centre [50]. The conflict, which has been largely between the Government forces and Taliban forces continued till 2014 when the US-led coalition formally ended its combat mission in 2014 [51]. Then, the Afghan National Defence and Security forces (ANDSF) have been in charge of Afghan’s Security.

However, the Taliban continue to perpetrate attacks on civilian populations with suicide attacks in major cities, and attacks carried out on rural districts. With these continuous attacks on the civilian populations, the United Nations Assistance Mission in Afghanistan (UNAMA) documented almost 11,000 civilian casualties in 2018 [52]. These continuous attacks resulted in complete takeover of the country in August 2021 by the Taliban. With total takeover of the country by Taliban, and their close ties with al-Qaeda, Afghanistan has literally been transformed into a terrorist haven [53]. Figure 2 is another illustration of the conflict hotspots, indicating their concentration around North Africa and the Middle East where Afghanistan is located.

Figure 2.

Conflict spots in the world. Source: Global Conflict Tracker (https://www.cfr.org/global-conflict-tracker).

2.9.1 Afghanistan Refugee crisis

According to the UNHCR [33], an estimated 24 million Afghans are in need of humanitarian assistance. Over 6 million were forcibly displaced from their homes by the end of 2021, with 2.7 million hosted as refugees, accounting for the highest protracted refugee situation in the world. Most Afghan refugees fled to neighbouring Iran and Pakistan 80% of whom are women and children.

The effect of the Afghan war on healthcare are devastating. The war-torn South Asian country faces an additional issue of funding as it struggles to build its healthcare system. In this effort to rebuild the health system, there is continual spending on war. This is why, in a recent address to Afghanistan’s healthcare providers, Chief Executive Abdullah Abdullah said, “With what we spend on a single day of war, we could build a state-of-the-art hospital [54].” Thus, while spending on war, Afghanistan is in need of funding for its healthcare system. To make matters worse, Health facilities in Afghanistan have come under attack from armed groups [54]. According to the World Health Organisation, there were 34 reported attacks on healthcare facilities in the first quarter of 2019, killing at least nine workers and patients and causing the closure of at least 87 medical facilities. These attacks have been recurrent over the years [55] and on civilians hors de combat.

2.10 Crises in Venezuela

Venezuela is a petrostate [51], with the largest oil reserves in the world [56]. After the death of Hugo Chavez in 2013, Maduro, the Vice President took over interim position as president, and was subsequently elected to office. Because the country was in a state of economic crisis (from corruption in the reign of his predecessor), all his attempts to reverse the situation were futile, resulting in a full-blown crisis in 2015. Though not being an armed conflict per se, according to the definition mentioned earlier, the International Organisation for Migration (IOM) estimates that these crises have generated an estimated 6.1 million Venezuelans fleeing the country to neighbouring Latin America the Caribbean and Columbia [57]. The number of refugees and asylum seekers outnumber the absorption capacity of these neighbouring countries.

Though already out of the headlines, the health effect of the political and economic crisis is devastating. Available evidence shows a health system near collapse and the reversal of several decades of health gains [58]. Food and medication shortages, and the spread of infectious diseases plunged the country’s health system to a chaos.

2.11 Non-international armed conflict in Yemen

The conflict in Yemen is in multiple fronts. First, there has been a longstanding conflict between the Houthis and government forces to the extent that in 2015, the Houthis took control of Yemen’s capital. This forced the President Abdrabbuh Mansour Hadi to flee from the country but invited an international coalition led by Saudi Arabia, which successfully forced the Houthis out of the capital city. Since then, waves of violence have rocked the country leading to significant human losses and some cities reduced to ruins [59].

The Government is faced with yet another adversary, al-Qaeda in the Arabian Peninsula. The al-Qaeda and Houthis formed a coalition, which did not last too long due to conflicts of interest, that resulted in them fighting each other.

Besides, the Southern Transitional Council (STC) is calling for separation between the North and South of Yemen, a call which plunged the country again deeper in the already existent armed conflict [60].

About 14% of the population has been forced to flee their homes because of the crises, 75% of whom are women and children. The internally displaced live in dangerous locations characterised by food insecurity and lack of basic services, including healthcare services. According to UN Office for the Coordination of Humanitarian Affairs (OCHA), a devastated health system, disruption of water and sanitation networks, and massive numbers of displaced people have fuelled the rapid spread of diseases including cholera, diphtheria, measles, polio, and dengue [61].

2.12 The war in South Sudan

South Sudan voted to secede from Sudan in January 2011 and became a sovereign state on July 09th of the same year [62]. However, just above 2 years after its independence, a civil war emanated and frustrated most of the plans of this new and hopefully emerging country [62]. Government forces of President Salva Kir faced sudden opposition from Sudan People’s Liberation Army in Opposition (SPLA-IO). This resulted in 2020 to the formation of the Revitalised Transition Government of National Unity (RTGoNU) [63]. With members of the warring parties in the new government, fighting has reduced significantly, but has not come to a halt because the peace deal and the government of national unity seemed to address symptoms, and not the root cause of the conflict [62]. As the country enters the extended 24 months of the Transitional Period, the spirit of forgiveness among the leadership of the RTGoNU is required [63].

According to Amnesty International, via its regional director for east and southern Africa [64], the cause and continuity of the armed conflict is due to ethno-political wrangling and competition among the elites over access to power and financial resources, with the mentality behind the fight that “the winner takes it all”. However, in 2022, the latest cycle of violent confrontations arose, driven mainly by ferocity of national political competition, abetted by impunity from past human rights violations [65].

The USA UNHCR announced that more than 4.3 million people are in need of humanitarian assistance from South Sudan, including refugees, IDPs and asylum seekers [66]. South Sudan records the highest refugee crisis in Africa, with over 63% being under 18 most of whom are travelling alone. The women who are fleeing are survivors of violent attack and sexual assault.

The health effects of the conflict are devastating. Many weapon-wounded patients are received in the hospitals, having been air-lifted from the conflict zones that were rather hard-to-reach [67]. Sexual and gender-based violence (SGBV) has been used as a weapon of conflict, with systematic ethnically and politically motivated attacks [68]. Across the country, people have been subject to destruction, displacement, disease, and death. Violence disrupts access to healthcare, including routine vaccination, while increasing the risk of disease transmission and food insecurity, reports OCHA Services.

2.13 Overall

In all, armed conflicts have claimed millions of lives with the highest death toll recorded in armed conflict between states, followed by armed conflicts with foreign state intervention. Though the death toll from armed conflicts diminishes over the years post World War II, the figures are not negligible [69]. Quoting from Uppsala Conflict Database Program / Peace Research Institute Oslo, Roser presents the millions of lives lost so far. This is illustrated in Figure 3 below in the average number of deaths per conflict since 1946, by type.

Figure 3.

Average deaths by conflict since 1946. Source: Uppsala Conflict Database Program/Peace Research Institute Oslo.

Contrary to the diminishing number of deaths from armed conflicts post World War II, state-based conflicts have increased drastically, claiming more lives as illustrated in Figure 4.

Figure 4.

Deaths in state-based conflicts by regions. Source: Uppsala Conflict Database Program/Peace Research Institute Oslo.

2.14 The effect of armed conflicts on human migration

Traditionally, man is a migratory being. Man moves from place to place ever since the prehistoric era in search of food and shelter. In an otherwise calm environment, the major reasons for human migration tend to shift significantly to favour the search for better jobs, better education, better standards of living and even better health. This is usually the reason for rural-urban migration from the countryside to the cities. Rural exodus contributed to the rise in European Economies [70].

Irrespective of the cause, armed conflicts result in the vulnerable people seeking refuge in neighbouring localities or countries. Armed conflicts lead to forced migration [71]. Once migration is forced, its purpose is never just the search for food and shelter, but a place to escape being terminated. When refuge is sought within the country, the displaced are referred to as internally displaced people (IDPs). Whenever the migrating population cross national boundaries to another state, we refer to them as refugees.

Some of the reasons for forced human migration (both during war and peace) include the following:

• The search for food: Before globalisation reached its peak, most people depended solely on foodstuff obtained from within their countries but with globalisation, there is some level of liberalisation of cross border trade. This permits countries deficient of some food stuff to import from neighbouring countries. Conflict situations come to challenge cross border trade, internal agricultural efforts, and exposes people to adverse health and hygienic conditions. With all of these arising as a result of the armed conflicts, movement is thus significantly restricted. Food scarcity becomes acute due to increased demand and the inability of the farmers to continue with their farming activities. It thus becomes imperative for some UN agencies like the UNHCR, UNFPA, UNICEF and others to step in to assist in food provision to people displaced to neighbouring countries.

• The search for shelter: Armed conflicts come to destabilise whole communities and at times whole regions of a country. Mass destruction of property is not uncommon, including destruction of habitats and reducing whole localities to ruins. Those deprived of their shelter in the comfort of their homes are left with just two alternatives, either to stay in the conflict area and be exposed to death or move to a new location where there is perceived security. This has been the case with many Central African Republic citizens who fled the war to seek refuge in neighbouring Cameroon, DR Congo, and Tchad [72].

• Agro pastoralism: This is one of the commonest forms of migration in the arid and semi-arid regions especially of Africa North of the Sahara. In Somalia, for instance, migration becomes cyclical, deliberate, strategic, and anticipatory determined by the region’s erratic rainfall patterns [38]. This causes the nomadic population to congregate in areas of permanent wells or other reliable sources of water to have access to pasture for their livestock, a pattern that reverses during the wet season.

• Seeking medical care: Armed conflicts can have devastating consequences on a community. Health facilities may well be functional in conflict areas within a country, but the highest challenge is to get health commodities through the last mile to the point of use. Logisticians, personnel who attempt to get health commodities through this last mile, expose themselves to stray bullets, torture, and kidnapping [73] with the resultant demand for a ransom by the warring factions in some cases. Left with these vulnerabilities, the health care system may deteriorate drastically to a level that the available institutions will not be able to meet the needs of the population. Thus, displacement to a calm area with good health care facilities assures the health of the displaced.

2.15 The notion of refugees

Refugees are people who have fled war, violence, conflict, or persecution, and have crossed international boundaries to find safety in another country. Refugees often flee with little or nothing, apart from a few clothes on the back [74]. Thus, they leave behind homes, possession, jobs and loved ones. Movement to another country imposes challenges to the refugees as well as to the host country’s economy. The limited resources have automatically to be shared to harbour refugees and stop other humanitarian crises from surfacing. Therefore, armed conflicts almost always generates either refugees or IDPs.

As of mid-2022, the UNHCR estimated 103 million forcibly displaced people, 53.2 million of whom are internally displaced and 32.5 million are refugees. 4.9 million are asylum seekers, while 5.3 million are other people in need of international protection [75].

Of those displaced, 72% arise just from Syrian Arab Republic, Venezuela, Ukraine, Afghanistan, and South Sudan. 36.5 million are children while 1.5 million are children borne as refugees [76]. Launched in 1950 with an initial budget of USD 300000, the annual budget rose to over USD 1 billion in 1990, and exceeded USD 9.15 billion in 2021 [76] owing to the continuous growing number of refugees and IDPs.

2.16 Armed conflicts and disease dynamics

War and conflicts can generate and exacerbate infectious disease outbreaks over both short and long timeframes [77]. Armed conflicts generate refugees who usually concentrate in camps. Concentration in camps is thanks to the efforts of the UN agencies and local/national governments to assist the displaced who are already vulnerable in a foreign country/region. In the event of any infectious and contagious disease outbreak, it can easily become an epidemic that could evolve to a pandemic if care is not taken. This usually happens when the basic infection prevention processes like handwashing with soap and running water, and drinking of clean water are compromised.

The reality of disease dynamics and the link to armed conflicts is a direct attack on the unfinished journey to the Global Health Security Agenda (GHSA). The Global Health Security Agenda that was launched in 2014 by a group of 29 countries [78], the World Health Organisation (WHO), the Food and Agricultural Organisation (FAO), and the World Organisation for Animal Health seeks to make the world a safe place against infection diseases. With a current membership of over 70, the vision of the GHSA is to have a world safe and secure from global threats posed by infectious diseases [79]. This agenda has three key interventions in the prevention of infectious diseases [80], prevent, detect, and respond to infectious disease threats. This implies:

• Prevent avoidable disease outbreaks.

• Detect threats early enough; and

• Respond rapidly and effectively when outbreaks occur.

In conflict-affected areas, avoidable outbreaks may not easily be prevented. Normally, vaccines, antibiotics, and antiviral drugs can play a critical role in mitigating a pandemic by reducing the infectiousness of symptomatic patients and the susceptibility of uninfected individuals [81]. In an already fragile and fragmented supply chain for health commodities, (the reality in most armed-conflict zones around the world), it is almost impossible to respond to prevent vaccine-preventable infectious diseases and to treat the inflected to limit the spread of the infectious disease. Taking commodities to the population along the last mile may encounter numerous obstacles, and the much-needed cold chain that must be maintained with vaccines becomes difficult. The effort to provide healthcare during armed conflicts usually arises from the international community health actors stepping in to fill the gap because the state most often is unable or unwilling to provide adequate health services to the population [82].

During armed conflict, there is breakdown of the health system infrastructure, shortage of medicines and medical supplies, shortage of health workers, insufficient financial resources, as well as gaps in health data arising from the breakdown of the infrastructure [83]. It thus becomes very difficult to detect threats early enough and to determine the exact needs of the health system, and to respond with a rapid intervention.

Prevention, detection, and rapid response to outbreaks occurs within the framework of pandemic preparedness. According to WHO, pandemic preparedness should be seen as an integral part of preparedness to threats to human health caused by emergency (outbreak of any disease, or the occurrence of natural disasters of chemical incidents) [84]. “Pandemic preparedness is a continuous process of planning, exercising, revising and translating into action national and sub-national pandemic preparedness and response plans” [84]. Any level of pandemic preparedness is always compromised in conflict situation, thus compromising the Global Health Security Agenda to detect, prevent and respond to outbreaks.

In Yemen and Northern Syria, cholera outbreaks have been reported. The brutal war and armed conflicts basically damage the infrastructure of these areas, including healthcare infrastructure, besides diminishing the chances for people ever reaching healthcare and other social services. Thus, access to essential care is compromised, with less than half of the health facilities functional; and as if to worsen an already dreadful situation, the health facilities that remain open are without basic equipment [85]. Without security, adequate healthcare is impossible.

In December 2022, the International Rescue Commission (IRC) announced a 55-fold increase in cholera cases and an outbreak of measles in Kenyan refugee camp [86]. These outbreaks affected refugees largely from Somalia with three dead as of December 2022. Figure 5 illustrates the locations and case prevalence of these cholera outbreaks.

Figure 5.

Map of reporting UNHCR locations and cumulative reported cholera count, 2009–2016. Source: [87].

Overcrowding, scarce clean water, and poor sanitation and hygiene practices, together with pre-existing malnutrition, comorbidities and limited access to medical care all contribute to the morbidity and mortality in the refugee population [87]. Cholera outbreaks in refugee camps was quite preponderant in the 1980s and 1990s, with almost 50% mortality in the absence of proper treatment (as opposed to the expected below 1% in normal systems where water, sanitation, and hygiene (WASH) standards are properly maintained in the health service delivery.

In a recent analysis [88], one hundred and twenty-eight (128) outbreak events involving forcibly displaced were identified over the period 1996–2016, with over 840,000 confirmed or suspected cases of measles, cholera, cutaneous leishmaniasis, dengue, and others were reported in 48 destination countries/territories. Based on the analysis of origin and destination, Desai et al. identified that Kenya experienced the highest number of distinct outbreaks, followed by Uganda, with 25% of cases imported from the location of origin of the migrated population.

Another health challenge faced by displaced people is HIV/AIDS. In emergency situations, HIV is the least concern for rescue workers in the immediate wake of a disaster since more urgent needs present themselves and need to be addressed. In a UNAIDS publication that dates as far back as 1997 [89], it is highlighted that refugees are more vulnerable, especially women and children because of the risk of sexual violence, rape, and trafficking. Besides, lack of safe blood supply (in the event of transfusion), injection drug users, lack of access to condoms and to health care inter alia are the major causes of the high preponderance of HIV/AIDS in displaced populations (either IDPs or refugees).

Refugees do not necessarily display higher rates of HIV infection than the non-refugee population, but the trying conditions under which they live may increase their susceptibility to other diseases, HIV/AIDS inclusive [76]. Female refugees may indulge themselves in commercial sexual activity to survive, given the sometimes-harsh conditions in the host countries. Refugees usually undergo three phases in the cycle of displacement:

• Emergency Phase: Conflict or persecution causes populations to flee their homes, being thus deprived of vital resources like food, shelter, healthcare, and education.

• Post Emergency Phase: The refugees settle in a foreign country where they receive supplies of the resources that the supplying body feels they need, and which have been lost during the emergency phase.

• The final Phase: Depending on the prevailing circumstances, the refugee will choose to be repatriated to their home country, integrate, and remain in the host country, or seek asylum (resettle) in another country.

We thus see from the above analysis that armed conflicts present themselves as a threat to Global Health Security because of emerging infectious diseases and the eminent challenge to prevent, detect and respond rapidly and effectively to outbreaks. This has been evident with the SARS-CoV-2 (COVID-19) pandemic and other outbreaks in the past like Ebola, H5N1 and H1N1 pandemic. The threat to GHSA caused by armed conflict is compounded by globalisation and free movement across national and regional boarders.

2.17 Armed conflicts on the path of universal health coverage

Universal Health Coverage (UHC) means that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship [90]. To achieve UHC requires people-centred Primary Health Care (PHC) well rooted in the communities they serve. It is but challenging for health systems to thrive well amid conflicts. Armed conflict is a global health challenge having consequences beyond the war-wounded, to affecting the health of the entire community [82]. Dabarre further emphasises that conflict is the ultimate social determinant of health, which causes conflict-affected communities to lag in many things including healthcare. Conflict usually affects all a country’s health system from health-related infrastructure to research, policy and planning, as well as human and financial resources.

Conflict zones frustrate the last mile delivery of health commodities because of the obvious danger this poses on the logistics team. Thus, essential medicines and health technologies, an integral part of the health system cannot reach the population in a conflict zone, leading to avoidable deaths. In many countries, coverage of health services is limited by acute shortages of appropriate health workers, particularly in remote and rural areas [91]. With the few health workers exposed to continuous danger Dabarre underscores the fact that they may flee the conflict zones in search of better jobs in safer environments. It is therefore clear that the 2030 vision of UHC may not be achieved if armed conflict continues to thrive in this universe with almost all continents affected.

Armed conflicts, with the devastating effects on health systems need to be mitigated. There seems to be an established link between armed conflict and natural resources [92]. The analysis advanced by Lujala & Rustad confirm the fact that natural resources play an integral role in sparking and fuelling armed civil conflicts. According to Lujala & Rustad, oil-producing countries are 1.5 to 2 times more likely to experience armed civil conflict than nonproducers, and that when internal conflict occurs in a region that has oil reserves, it lasts twice as long as conflicts that occur in areas without oil reserves, and combatant deaths are twice as high. High-value natural resources increase the risk of conflicts in that access to revenue finances belligerent movements. Equally, grievances are created by unmet expectations or inequalities in the distribution of revenue, jobs, or other benefits. UHC required equitable distribution of wealth. When the wealth-generating resources become a reason for armed conflicts, UHC is compromised.

To mitigate the health effects of armed conflict, the first step is compliance to legislation, like the international humanitarian law (IHW) [93]. According to Lewis, IHL is clear about the protected status of medical facilities, the wounded and sick, and medical transport in armed conflicts. Failure to adhere to this legislation is either deliberate or reckless, and can amount to war crimes, provided the legislation enforces prosecution of perpetrators of such crimes. Tragic attacks have happened in medical facilities in Yemen and US strikes on Médecins Sans Frontières (MSF) facilities in Afghanistan, with evident impunity. Thus, the need to demand accountability and justice to war crimes, crimes against humanity, and violation of other international humanitarian law is warranted.

Secondly, all conflicts can be avoided. Healthcare personnel need to promote concerted global action to stop and prevent wars and promote peaceful solutions to disputes within and among nations [94]. This requires partnership and the engagement of political and economic actors to value human life over all other wants and desires to gain power and control territories, and the contribution healthcare personnel make to the society.

Third, Gebregziabher et al propose advocacy for access to sufficient humanitarian aid to meet population needs in conflict zones to mitigate direct and indirtect harms to heathcare delivery. This starts by recognising that every human life counts, and needs to be protected, and the protection thereof is the responsibility of heathcare personel and the governing bodies that are in place to safeguard the interests of the citizens they govern.

Dialogue seems to be the overall panacea to solve the problem of armed conflicrs and as such mitigate the negative and devastating effects on helathcare. Dialogue address various dimensions of the conflict. This is because sustainable peace depends on engaging with everyone affected by the decisions made by the people at the peace table. This initiative, if led by Global Health Leaders, can immunise groups from violent conflict and its downstream effects through formal and informal educational initiatives. Specifically, this approaches can include tracking early warnings of violence, creating predictive models of its outbreak, and working with local public health and medical experts to mitigate emerging conflict [95].

2.18 Armed conflicts and the sustainable development goals (global goals)

The UN Member states adopted the 17 Sustainable Development Goals (SDGs) in 2015, providing a shared blueprint of peace and prosperity on planet earth, both for now and the future [96]. The 17 SDGs, which have 169 targets, 3818 events, 1344 publications, and 7548 actions, are an urgent call for action by all countries (developed and developing) in global partnership. The 17 goals are presented below:

1. No Poverty (in all its forms everywhere)

2. No Hunger (achieve food security and improved nutrition and promote sustainable agriculture).

3. Good Health and Wellbeing (Ensure healthy lives and promote well-being to all at all ages)

4. Quality Education

5. Gender Equality

6. Clean Water and sanitation

7. Affordable and clean energy

8. Decent work and Economic Growth (promote sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all).

9. Industry, innovation, and infrastructure

10. Reduced inequalities

11. Sustainable cities and communities (Make cities & human settlements inclusive, safe resilient & sustainable).

12. Responsible consumption and production

13. Climate action

14. Life below water

15. Life on land

16. Peace, justice, and strong institutions.

17. Partnership for the goals

Armed conflict led to forceful human migration and challenges almost all the 17 SDGs. Armed conflicts inflict poverty through the destruction of infrastructure, forced displacement of people, loss of jobs and the urgent search for shelter in a foreign land. This could reverse the economic situation of a country more than 10 years in the pre conflict situation. The COVID-19 and the war in Ukraine are a “deadly duo” against the attainment of SDG 1 to end poverty in all its forms. The number of people living in extreme poverty rose from 581 million in the pre-pandemic period to 657–676 million in 2022 [97], attributable to the deadly duo. We therefore see the significant contribution of armed conflicts against the realisation of this SDG.

Armed Conflict and climate change, inter alia, are converging to undermine food security worldwide. The advent of conflicts force people to migrate over regional and international boarders, leaving behind everything that has to do with their livelihood. In this new conditioned, yet uncomfortable environment, there is no guarantee for food security. It is only thanks to the effect of the UN agencies like UNHCR and UNICEF that these refugees struggle to adapt themselves to and settle in this new environment.

How can there be good health and well-being in the midst of conflict? Conflict frustrates all efforts of the supply chain to get health commodities through the last mile to troubled spots. Conflict destabilises the work environment such that the medics and paramedical staff cannot function optimally. In fact, Sartorius, quoting from the WHO Constitution of April 07, 1948, Defines health “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [98, 99]. Conflict challenges physical and mental health, as well as social well-being, thus compromising the realisation of this SDG goal 3. If the mental health state of the health professionals is compromised (from trauma imposed by conflict), their capacity to care for the sick and the wounded becomes as well compromised. It therefore becomes unlikely to achieve good health and well-being to all at all ages by 2030.

The first three SDGs are not the only SDGs challenges by armed conflicts and human migration. The attainment of SDG 8 is as well severely compromised by armed conflicts. This SDG aims at promoting sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all. Global economic recovery is hampered, inter alia, by supply chain disruptions which are themselves significantly hampered by armed conflicts, either across international borders or along the last mile. Refugees very rarely have the opportunity to get engaged in the labour force and contribute to economic development, especially in the short run, until they become integrated into their new environment that they can positively contribute to economic development. According to the UN Statistics, there is rebound worker productivity from 1.6% in 2016 to 3.2%, but this is not the case in LMICs where armed conflicts are preponderant.

Armed conflicts challenge any efforts to build sustainable, safe, resilient, and inclusive human settlements -SDG 11. Ninety-nine percent (99%) of the world’s urban population breathe polluted air [26]. The level of pollution increased during armed conflict situations because of significant combustion (burning), at times of whole settlements by warring parties, and decomposition of abandoned human bodies. It is not uncommon to see entire villages set ablaze during armed conflicts, especially when the Government forces perceive such an area as harbouring rebels. This has been observed in the Anglophone regions of Cameroon, in Central African Republic, in South Sudan, in Iraq, as well as other conflict areas around the globe. This renders these settlements unsafe and challenges the attainment of SDG 11. Besides, armed conflicts render the efforts of waste disposal companies impracticable. This is the reason why the UN reports that as of 2022, 55% of municipal solid waste is managed in controlled facilities, leaving 45% to accumulate and make the cities unsafe, and a potential epicentre for some epidemics like Cholera which arises largely because of eating or drinking contaminated food and water respectively. Most dwelling places for refugees could be likened to slums, adding to the over 1 billion slum dwellers.

3. Conclusions and recommendations

Armed conflicts are an evil that threaten man’s existence on earth and gives little protection to man as opposed to some recently enacted laws that apparently project animal rights above human rights. The major cause of armed conflicts is either real or perceived bad governance and the intention to propagate an ideology and make it forcefully accepted by the entire population. Armed conflicts lead to forceful human migration and generates IDPs and refugees, challenging the economy of the host countries. Armed conflicts can paralyse entire Health Systems and send the economy of a country crawling on its knees.

Post conflict, aspects to consider bringing a country, its economy and the healthcare system include inter alia:

• Protecting health workers and health infrastructure to ensure that the entire health system does not collapse as a result of the armed conflict. The health of a people is as good as the healthcare system and the workforce. These two are major building blocks of health system strengthening and must be addressed with the necessary intentionality.

• Access to medicines and health technologies must not be interrupted in conflict situations. If there are no medicines, no health programs can thrive to produce any effects on the population. While the workforce is protected in conflict situations, due consideration must be made to allow delivery of health commodities along the last mile. Either of the warring parties can be beneficiaries of these health commodities, irrespective of the cause of the armed conflict.

• The root cause of the conflicts must be investigated and addressed to ensure lasting peace after the conflict. If the conflict is due to bad governance, as is the case in most situation around the globe, organisation of free, fair, and transparent elections with the mediation of a neutral external body may be the solution to bring about lasting peace.

• During conflict situations, the health infrastructure may be destroyed or the system collapses. When wars end, the affected areas are often left devastated. The large numbers of refugees resulting from conflict, the wounded and trauma victims needs to be rehabilitated. Reconstruction post conflict is necessary but can only succeed if it is initiated by the local population. They should have a significant say in how funding is allocated. However, before any attempt to reconstruct, it must be clear that the conflict has ended, otherwise, the efforts to reconstruct may result in mere wastage of resources which will be destroyed in the not-so-distant future.

• Reconstruction requires huge resources. Compared to the expenditure incurred during the conflict on a single day of war, we could build a state-of-the-art hospital [54]. Therefore, while huge financial resources are required to rebuild the health system infrastructure, this is usually negligible compared to the expenses incurred during the war.

• Ensuring the security of the population is paramount. Post conflict, the population becomes vulnerable, economic instability sets in, and severe poverty establishes itself. Considering that armed is a major social determinant of health, ending the conflict implies reinstating the peace of the population. To reinvigorate the population, food security will be the starting point before other needs are addressed systematically.

• Resettlement of the displaced through peaceful and planned repatriation to their home country will slowly reestablish the economy. This must be done when all the assurance is available that the displaced will return to meet a peaceful environment compared the one at the time of their departure.

If the world dreams to attain the SDGs by 2030 and Universal Health Coverage, armed conflicts must be addressed objectively, while putting aside political ambitions and potential selfish gains that most often come to the negotiation table whenever there is mediation to end an armed conflict. This way, we will align on the path to the Global Health Security Agenda.

Conflict of interest statement

No conflict of interest.