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The Disease of War

Surviving the intentional disruption of public health

The New Physician December 2007
In October 1993, Melchior Ndadaye, president of Burundi, was killed during an attempted military coup. Politicians stirred tribal divides in the small Central African nation for their own ends, and Hutu and Tutsi populations began a clash that would last a decade and cost 200,000 lives in Burundi alone.


The fighting stayed just beyond the edge of the world’s perspective, apparently lacking the journalistic impact of the genocide in neighboring Rwanda, which had itself been sparked by Burundi’s civil war. But the killings in Burundi were happening, just more measured. Slower. A village razed here, a school destroyed weeks later, children still inside.


The next year, Deogratias Niyizonkiza escaped the country and the fighting at the age of 23, though he didn’t escape the violence: Contacting family members in Burundi was difficult at best, and impossible for a time.


The conflict did not fully subside until 2005. Now, the factions exhausted, peace has settled in, as have the health consequences of a decade of tribal war, indistinguishably meshed with the difficulties faced by an already resource-poor nation.


Setting medical school aside after two years of class in the United States, Niyizonkiza has chosen to tackle the reminders of war by forming a clinic in rural Burundi, working with U.S. colleagues and Burundian community members.


Niyizonkiza’s clinic, Village Health Works, formally opens this month. The president of Burundi will attend the ceremony. Already, the project has had fruits: Former enemies worked side by side to build the physical facility.


Conflict exacerbates the health challenges of already stressed regions, and the web of interested parties can become complex. When treating peoples marred by war or even their own governments, today’s international aid organizations and their physicians have to do much more than address the immediate trauma and lasting disease. To be counted as successful, these agents must leave a network of effective local providers in their wake, just as war and poverty may have swept them up.


“The system was there, mostly, during the conflict,” Niyizonkiza says of Burundian hospitals and health care. “But now we have more people who are so dirt poor because of the conflict…. They lost their land; they lost everything.”


The effects of war on public health vary by the nature of the conflict and the international response, or lack thereof. But poverty, hunger and disease are the obvious commonalities—all combined with fear.


“A conflict can be either 24 hours, or four days or a week, but the repercussions last,” says Dr. Jill John-Kall, who has worked in multiple conflict areas in Africa. “Even if the conflict is over, people are still deadly scared to go back [home].”


When John-Kall went to India to attend medical school, the sight of abject poverty shocked her. After residency, she decided to practice where her skills would be most tangible. In June 2004, she left on her first mission, with Médicins Sans Frontières, to Uganda. Afterward, joining the International Medical Corps (IMC), John-Kall worked in southern Sudan, Chad and Sudan’s Darfur region. The latter mission was supposed to last six months, but it became 18.


“If you are living in a rural village, you don’t usually have adequate health care to begin with,” she says. “On top of that, whatever you do have might be destroyed, or the regular people who could offer health care have now run away or been killed.”


Or perhaps lured away by other regional efforts. “Nowadays, most of the physicians that were in Burundi are working in Rwanda because Rwanda is getting so much help from the international community,” Niyizonkiza says. “But in Burundi, nothing.”


Though the response to conflict often involves a similar network of
aid organizations as natural disaster response, war can tear down even the most meager of infrastructure and order. After the 2006 earthquake in Pakistan, the Pakistani army helped organize and assist the responding NGOs and multilateral agencies.


In a civil war scenario, however, those groups may find military forces pitted against their efforts. In any circumstance, the citizenship of those affected bears heavily on their outcomes.


Internally displaced persons (IDPs) have lost their homes but stayed within their home country’s borders, while refugees have crossed national lines into an often-reluctant host country.


The host country usually wants as little to do as possible with the refugees. They are sequestered in camps away from cities, lest they settle permanently, even though many conflicted regions have national borders arbitrary at best, and the populations may share common language, culture and even ancestry.


John-Kall found working in Chad with refugees displaced from neighboring Sudan easier than working with the internally displaced Sudanese. Because the Chadian government steered clear of responsibility, aid workers and NGOs were able to operate with great autonomy.


At the same time, the care received by refugees—or those internally displaced—can cause significant resentment among the local population, as John-Kall saw in Chad. “The refugees were getting all kinds of services, where the actual Chadian population had almost nothing,” she says. “We tackled that through mobile clinics, which are definitely in and of themselves a temporary measure. They are not sustainable, but at least it decreased the tensions.”


By August of this year, the U.N.’s Office for the Coordination of Humanitarian Affairs (OCHA)—an important player in conflict and disaster relief efforts—tallied 2.2 million IDPs in the Darfur region. On the whole, Sudan has the highest number of IDPs in the world, thanks to multiple vicious conflicts in its borders. As recently as September, aerial bombardment, attacks by militia and fighting between government and opposition groups continued to drive Sudanese from their homes. The U.N. has reported the deaths of five aid workers in Darfur during 2007 alone, the wounding of several others and the carjacking of dozens of official vehicles.


Conflict isn’t always outright war between two factions, leaving an opening for aid groups to set up their system. Sometimes the conflict comes in the form of massive governmental oppression.


The Burmese government has been trying to overtake land held by an ethnic minority population along its eastern border for 30 years. Just across the line, in Thailand, the usual soup of intergovernmental agencies tend to camps for refugees. But people still within Burma’s borders have to rely on help from their own ranks. The Planet Care/Global Health Access Program (GHAP), organized by U.S. physicians in the 1990s, trains Burmese medics in Thailand. Those medics return to their villages to provide care, while GHAP lends them technical support and helps supply them. Most of their medics are trained at the Mae Tao Clinic, where they spend a six-month to two-year internship.


“In an active conflict, where international institutions can’t reach you because you are in a conflict zone…, health care is best provided by people from that region,” says Emily Whichard, who has worked with GHAP for two and a half years. “That kind of organizing around health care is really important [to rebuilding] community during crisis-ridden times.”


The conflict in Burma, Whichard says, is characterized more by human rights violations and limitations on movement than by perpetual active combat. This doesn’t lessen its immediate impact, however. The Burmese military still makes use of landmines. When the roving military depletes local food stores—a common practice—villagers are forced to seek sustenance outside the confines of their town. And that’s where the mines are.


Burma illustrates another difficulty in the politics of conflict: health information. Studies from data gathered by medics working in Burma show infant and maternal mortality rates in Eastern Burma comparable to the highest rates in the world. “Those numbers differ significantly from the published data from the Burmese government, obviously, because they are certainly not collecting data in the areas [in which] they are fighting,” Whichard says. “That’s a huge component of conflict and health: the kind of health information you are able to glean and how you can plan appropriately.”


Even without deliberate interference, reliable numbers amid the disruption of war can be a tremendous blind spot. “Even today, no one really knows what the rate of HIV is in Burundi,” Niyizonkiza says. The World Health Organization (WHO) and the government have some figures to hand out. “These numbers have been around since the mid-’80s.” Village Health Works will conduct an independent survey of health needs in their region of Burundi as part of their initial effort.


Even in areas where war has ceased, there are needs that some would consider a luxury to those in such extreme circumstances, like mental health services, which has added utility in the healing of ephemeral wounds.


“There are so many parents who lost their children or lost everything, and they feel that they…are no longer useful,” Niyizonkiza says. “And they take their life, and that is the end of it. And this is a country that has not a single psychiatrist…. It’s really frightening. People are so desensitized.”


THE WEB OF CONFLICT RELIEF


Though conflict compounds health problems, dramatic coverage can bring world attention and, hopefully, aid and assistance.


By October, U.S. government funding alone in Sudan totaled $687 million for the 2007 fiscal year. Roughly half of that money was provided to groups working in Darfur, and $90 million to those working in neighboring Chad.


Most U.S. spending is distributed by offices under USAID, like the Office
for Foreign Disaster Assistance (OFDA). The State Department also chips in, as relief in conflict areas also serves diplomatic and political purposes.


On the ground, coordination between aid groups and funding bodies
is often provided by OCHA. Each
“sector” of the effort, like sanitation, medical care or food provenance, is led by groups recognized for their expertise in that area. The WHO, for instance, often coordinates health care while the World Food Programme might lead feeding efforts.


OCHA brings these leading groups together at sector-level meetings for a look at the bigger picture. Down the line, the sector-leaders direct NGOs and the actual workers on the ground, providing a level of interconnection among groups that might otherwise be thought of as competitors.


The groups can coordinate the movement of workers and supplies around the region, or respond to changes in migration, health or safety.


Funders set the tone for how the NGOs respond to crises. By placing requirements on their grant applicants, they can influence the methods and efficiency of the NGOs on the ground. OFDA, for example, has a set of best practices they require grant recipients to use. One of those best practices, and current buzzwords, is capacity building.


HEALING THE SYSTEM


Training Burmese medics to treat malaria, tuberculosis and landmine injuries, GHAP focuses exclusively on capacity building: It provides no direct care, instead establishing a base of knowledge and experience in the local community to sustain it once international aid has subsided.


IMC, which operates in dozens of countries, uses a two-pronged approach: emergency response plus capacity building. “Eventually, when we leave, we want to hand over these programs to the national staff, so these programs are sustainable,” John-Kall says.


“Even if they burn down your clinic, nobody can take away the knowledge that you’ve imparted to another human being,” she says. “So all you have to do is rebuild that [physical] clinic, and all of the players are still in place to run that program.”


What constitutes capacity building depends on what the country’s baseline needs are. “In Chad, we were basically looking at more clinical teaching because that’s what they needed,” John-Kall explains, “whereas in Darfur, they had the clinical basics because their programs were so much bigger.”


Many of the “national” staff used in Darfur had been recruited from Khartoum, which had a medical education infrastructure. In that setting, national staff members were sent for more sophisticated training. One member went to Nairobi to learn about a malaria program while another headed for Bangladesh to learn about controlling cholera.


After her year and a half in Darfur, John-Kall took a break this past fall, pursuing a master’s in tropical medicine and international health in London. “It does change you. It changes your view on what you can do, what you can’t do,” she says. “It is frustrating…and you pay a very emotional price, even though you don’t really know it.”


GHAP’s Whichard is now a first-year at the University of California, San Francisco, School of Medicine, but she plans on working with trainees on
the Thailand-Burma border next summer.


Although the extent of disease and the toll of Burundi’s war is not yet known, Niyizonkiza is notably positive in discussing the trajectory of the beleaguered country. The people’s exhaustion with fighting gives him hope that the conflict is really over.


“They’ve learned a lesson the hard way,” he says. “They just need help to rebuild their own lives, and say, ‘never again.’”
Pete Thomson is editor of The New Physician.