WAR: THE IMPACT ON HEALTH AND WELL-BEING

Michael Lyons of Veterans For Peace UK writes here on war and its impact on health and well-being, with a particular focus on children.

Introduction

The impact of war and conflict on a population’s health is not measurable in mortality figures alone.  There can be long lasting repercussions for those who survive theatres of war, be they civilian, military, aid worker or journalist.  This may be felt by the individual who has lost one or more people close to them; or by an entire region, either from side effects of biological warfare or damage to health related infrastructure.

In this essay I will focus predominantly on the impact to the civilian populations in areas where fighting took place.  This allows us to examine how long term and intergenerational the repercussions of war and conflict can be.  With that in mind, I shall pay particular attention to the health and wellbeing of children who either grew up during a war, or in its aftermath.  This is due to their complete lack of agency in any decision making surrounding the onset of war.  In spite of this, they often suffer the most.

I will use the example of Operation Ranch Hand in Vietnam to show the impact of chemical warfare on a civilian population.  The use of Agent Orange has been linked to many health defects and due to the volume used and stored in the country, it entered the food cycle through soil and sediment affecting future generations(Schecter et al. 1995; Nham Tuyet & Johansson 2001; Dwernychuk et al. 2002; Schecter et al. 2001; Dwyer & Flesch-Janys 2014). Following on from that, Hiroshima gives us an insight into the long term effects of nuclear war, primarily in terms of physical health but also psychological well-being.  The current Syrian crisis better illustrates the disastrous effects war and conflict can have on a person’s psychological well-being.  Indeed, a new term, human devastation syndrome, has been coined to describe the level of post-traumatic stress disorder experienced by children (Ahmed et al. 2018; Davis 2017).  These are all examples of direct effects to individuals and groups from war and conflict.  I will also use the Gulf war of 1990-1991 and the recent bombing of an NGO hospital in Northern Afghanistan to examine how destruction to infrastructure causes indirect impacts to people’s health through increase in water-borne diseases and an inability to access basic healthcare services.

Vietnam

America entered the Vietnam War in 1965 and continued to deploy troops until their withdrawal in 1973.  During that time their main opposition was the Viet Cong.  Due to the Viet Cong being outnumbered and outgunned, they used their knowledge of the local terrain, predominantly jungle, to wage guerrilla warfare against the US forces.  In an effort to prevent this, American forces used a pesticide known as Agent Orange to defoliate jungle areas, thus preventing the Viet Cong from concealing themselves in the jungle (Schecter et al. 1995; Nham Tuyet & Johansson 2001; Uzych 1991; Yi et al. 2014; Dwernychuk et al. 2002; Dwyer & Flesch-Janys 2014).  Agent Orange contained 2,3,7,8-TCDD which is the most toxic dioxin congener  (Dwyer & Flesch-Janys 2014).  As part of Operation Ranch Hand fixed wing aircraft, helicopters and soldiers sprayed over 12 million gallons of Agent Orange covering, what is thought to be, 10% of South Vietnam (Schecter et al. 1995).

Many of the studies on the long term effects of Agent Orange have been carried out on US servicemen who served in the conflict.  Resulting data shows increased susceptibility to various cancers, dermatological conditions and stomach ulcers (Schecter et al. 1995; Dwernychuk et al. 2002; Dwyer & Flesch-Janys 2014).  In women it has been shown to cause congenital birth defects, miscarriages and other health problems in children (Nham Tuyet & Johansson 2001). American soldiers would usually spend 1 year at a time in Vietnam, ate US military rations and typically wore military boots and fatigues.  The Vietnamese civilians on the other hand would live in mainly rural areas, where they worked in the fields, often barefoot or in open-toed sandals and would eat food from contaminated crops and drink water from contaminated sources.

Studies conducted on Vietnamese civilians and local areas after the war have found elevated levels of TCDD (Schecter et al. 1995; Nham Tuyet & Johansson 2001; Dwernychuk et al. 2002; Schecter et al. 2001).  One study which took place 10-15 years after the end of Operation Ranch Hand found almost 6 times as much TCDD in the blood, on average, of those living in sprayed areas compared to those in non-sprayed areas(Schecter et al. 1995).  They also found over 20 times as much TCDD in the adipose tissue of those in sprayed areas.  In 1973, three years after spraying was said to have stopped, significantly elevated levels of TCDD were found in the milk of nursing mothers (Schecter et al. 1995).

Another study carried out in 1999 in Bien Hoa, an area close to an air base that flew spraying missions where an Agent Orange spill had occurred 30 years prior, also found elevated levels of TCDD (Schecter et al. 2001).  Blood samples were taken and compared to people in Hanoi, where no Agent Orange had been used.  They found 135 times more TCDD, on average, in the people of Bien Hoa (Schecter et al. 2001).  This included people who had moved to the area after the war, due to TCDD entering the food chain via the soil and sediment.  The transfer from sediment to food chain was explored and determined in another study conducted around the same time in the Aluoi Valley in Central Vietnam (Dwernychuk et al. 2002).  They found a direct chain of Agent Orange entering the soil and sediment, transferred to flora and fauna and being significantly raised in the blood and milk of humans (Dwernychuk et al. 2002).

This shows that even decades after the initial use of hazardous chemical agents, people living in the area are exposed to these agents through food and pass this on to infants through breastfeeding (Schecter et al. 1995; Nham Tuyet & Johansson 2001; Dwernychuk et al. 2002; Schecter et al. 2001; Dwyer & Flesch-Janys 2014).  Exposure to TCDD leaves the civilian populations in affected areas susceptible to higher risks of cancers, birth defects and other child health problems.

Hiroshima

Related to the long-lasting effects of hazardous chemical agents are the long-term effects of ionising radiation on a population as a result of a nuclear attack.  On 6^th August 1945 America dropped Little Boy, a 15 kiloton atom bomb, on Hiroshima. An estimated 100,000 people, the majority of which were civilians, were killed in the initial blast and firestorms (Zinn 2005; Lifton n.d.; Okubo 2012; Douple et al. 2011; Rizzo 1986). Another 70,000 were injured.  Over the next 6 months many more people died painful deaths due to acute radiation sickness.  Symptoms include nausea, vomiting, hair loss, headaches and haemorrhaging from various mucous membranes and organ systems (Okubo 2012).

If a lethal dose of radiation has not been absorbed, ionising radiation can still affect the immune system through its impact on T lymphocytes.  It has been shown to reduce the amount of CD4 helper T cells and naïve CD4 and CD8 T cells (Douple et al. 2011; Akiyama 1995; Kusunoki & Hayashi 2008).  This not only increases the susceptibility of people to infections from any burns or trauma felt from the blast, or encountered in the aftermath; but also the severity of the infection. This effect is compounded by three other factors. The psychological effect of surviving such an attack, the horrors witnessed in its immediate aftermath and the destruction of healthcare related infrastructure.  Not only hospitals and medical supplies, but infrastructure related to sanitation, water and food.

After rebuilding health related infrastructure, long term health problems persisted for survivors of Hiroshima.  The life span study (LSS) started in 1958 sampled survivors who were heavily exposed, within 2500 m of the initial blast; less exposed, 10,000 m from the blast and non-exposed (Okubo 2012; Douple et al. 2011).  The non-exposed group had moved to either Hiroshima or Nagasaki within 5 years of the explosion.  It has shown exposure to ionising radiation resulting from a nuclear bomb increases the risk of cancer particularly oesophageal, breast, lung and colon.  The risk of other medical conditions also rises in relation to radiation dose received such as respiratory disease, stroke and heart disease.  Microencephaly has also been documented amongst children exposed to radiation in utero.

Many of the people of Hiroshima and Nagasaki who survived the initial attack would feel the biomedical effects late into their lives.  There was also the psychological aspect of witnessing such destruction and devastation.  Not many studies were carried out on the subject in the aftermath.  Indeed in the following 10-20 years only a handful of psychological studies looked at the victims of the attack.  Robert J. Lifton, an American psychologist at the University of Hiroshima, conducted a 6 month study in 1962 and found there to be an overwhelming shift from a ‘normal existence to an overwhelming encounter with death. (Lifton 1968; Zwigenberg 2017; Rizzo 1986)’ He details shock, mindless behaviour and ‘psychic numbing.’  This was followed by instances of survivor guilt escalating sometimes exhibited as anger and paranoia.  This would cause some people to refuse help due to a lack of trust for anyone or anything (Lifton 1968; Zwigenberg 2017; Rizzo 1986).

The impacts of nuclear attacks, which are a very real possibility in modern day wars and conflicts, can devastate and annihilate civilian population both immediately and for decades afterwards.  This can occur in a physical sense and a psychological one.

Syria

In terms of psychological effects on health and wellbeing in relation to war and conflict, I will shift focus to the on-going crisis in Syria.  Some medical professionals have coined the term ‘Human Devastation Syndrome (Ahmed et al. 2018; Davis 2017)’ to describe the effects of the war on the children of Syria.  The current conflict is very complex with a web of actors involved (Carpenter 2013).  Droughts between 2007 and 2010 caused internal migrations from rural areas to cities exacerbating poverty and unrest.  Then in 2011, during the Arab Spring uprisings across various countries in North Africa and the Middle East, peaceful protestors in Syria were met with violent responses by Assad’s forces.  This caused many from within the army to defect and create the Free Syrian Army starting the most recent civil war.  A sectarian dimension has been added to the situation as well as the interference of many other countries both local to the area, Iran, Iraq, Israel, Saudi Arabia and Turkey; and further afield, America, Russia and the UK.  The British contribution has been predominantly airstrikes, despite the passionate opposition from various politicians across the political spectrum and large scale protests.

Currently 400,000 people have been killed and 12,000,000 (over half the pre-conflict population) have been displaced either internally or externally (Ahmed et al. 2018; Acarturk et al. 2017; Kazour et al. 2017; Can 2017).  Half of those affected are children.  Refugees are at a higher risk of psychiatric morbidity, particularly post-traumatic stress disorder (PTSD) (Chung et al. 2018; Kazour et al. 2017; Thabet et al. 2004; Ahmed et al. 2018).  This is due to a compound effect of the initial traumatic experiences that caused their particular exodus and the experience of resettlement in a new setting under difficult socioeconomic situations.  One study of 9-15 year old Syrian refugees in Turkey found over 50% of the 218 participants had lost someone important to them and 70% had witnessed fire-fights.  In terms of torture, 42.5% had witnessed such acts, while 25.6% had personally experienced some form of It (Gormez et al. 2018).  This along with other studies confirmed a positive correlation between horrors witnessed, and/or experienced, during war and the onset of PTSD and other anxiety related conditions (Chung et al. 2018; Kazour et al. 2017; Thabet et al. 2004).

The compounded experiences of many Syrian children caught up in the violence has given rise to a new condition called Human Devastation Syndrome (Ahmed et al. 2018; Davis 2017).  The term is credited to Dr. M. K. Hamza, a neuropsychologist with the Syrian American Medical Society, and describes the level of PTSD severity suffered by the children of Syria.  He stated:

“these children of war have experienced more trauma — physical and emotional — than the medical professionals who care for them have ever seen: the shredded remains of their mom or dad, blown apart by a regime barrel bomb, a Russian cruise missile, or, increasingly, U.S. airstrikes”(Davis 2017)

The effects on a person’s wellbeing, both physically and psychologically, in relation to first-hand experience of war and conflict can be devastating and felt for the remainder their life.  It is important in this respect to have access to healthcare infrastructure such as hospitals, clinics, clean water supplies and nutritional access.

Gulf War Iraq 1990 – 1991

So far we have looked at instances where people are affected directly, through exposure to hazardous materials or as witness to the horrors of war.  Using the modern day gulf wars we will now explore the effect damage to healthcare infrastructure has on people’s health and wellbeing.  Prior to the 1990-1991 Gulf war, Iraq had seen extraordinary development.  Between 1985 and 1987, all of the large urban populations had access to potable water, 93% of the population could access free primary healthcare and infant mortality was at 42/1000 (Armijo-Hussein et al. 1991; Choonara 2013; Goldson 1996).

By the end of the bombing campaign only 2 out of the original 20 power plants remained operational.  Power output dropped to less than 4% of its pre-war capability.  By early May in 1991 this had risen to less than a quarter of pre-war output.  This had huge effects on water purification, water distribution and sewage treatment.  Many hospitals and clinics did not have access to safe running water vital for basic sanitary requirements such as flushing toilets, bathing patients or general cleaning.  Both of Baghdad’s sewage treatment plants went offline in the first days of the war due to lack of power. One plant was destroyed by bombs and leaked sewage into the Tigris River for at least 4 months.  When the surviving plant was back online it was only able to treat 50% of Baghdad’s sewage due to lack of power.  This resulted in contaminated drinking water.  Elsewhere sewage leaked into drainage ditches and pooled near residential areas (Armijo-Hussein et al. 1991; Lee & Haines 1991; Hooglund 1991; Goldson 1996).

These issues saw an increase in water-borne diseases such as typhoid, cholera and severe gastroenteritis.  In Irbil paediatric hospital, 63 out 65 patients on the infectious diseases ward and 10% of the general ward were being treated for typhoid.  The senior paediatric resident in Baghdad’s Al Qadisia Hospital reported 10 to 15 times as many cases of cholera per week in April of 1991 compared with April of 1990. Similarly Kirkuk Paediatric hospital saw a tenfold rise in patients presenting with gastroenteritis per day in April of 1991 compared with April of 1990(Armijo-Hussein et al. 1991).

Marasmus and kwashiorkor are severe forms of malnutrition most commonly seen in children.  Typically kwashiorkor is a deficiency in protein intake with adequate energy intake, whereas marasmus is an inadequate intake of all forms of energy.  In Kirkuk Hospital 57% of children aged under 5 who were admitted were suffering from a form of severe malnutrition.  A Harvard study attributed this to both the increase in water borne diseases and the shortage of food, particularly infant formula (Armijo-Hussein et al. 1991; Goldson 1996).

Not only were hospitals and health centres struggling to operate effectively due to lack of electricity and clean water, but many of them had been damaged physically in the bombing and fighting (Lee & Haines 1991; Goldson 1996).  One example was the evacuation of Basra Teaching Hospital after bombing left a crater in the hospital garden.  This left the intensive care ward in ruins and three patients dead due to collapsed ceilings and shattered windows.  Also in Basra, 14 of the 19 health centres were closed well after the end of the war.  Staff and resource shortages also became a problem.  Irbil Paediatric Hospital was operating at 33% of the normal roster of doctors and 40-50% of the required nursing staff (Armijo-Hussein et al. 1991; Goldson 1996).  Various medicine shortages included antibiotics, insulin, vaccines, local anaesthetics and IV fluids.  The result of these combined factors led to some estimates of 80-90% of civilian casualties coming after the war (Lee & Haines 1991).

Attacks on hospitals, despite being considered war crimes under the Geneva Convention, continue to be a part of wars and conflicts in the Middle East to this day.  In the early hours of the 3^rd October 2015, a Médecins Sans Frontières (MSF) run hospital in Kunduz, Northern Afghanistan was bombed repeatedly for over an hour.  This occurred in spite of the hospitals GPS location being known by all parties and the hospital informing US and Afghan officials at the time of the attack that they were bombing a hospital. Over 30 people were killed in the attack, both patients and medical personnel, with a further 37 injured.  Due to the damage suffered by the hospital it was unable to continue operations.  It was the only hospital of its kind in North-eastern Afghanistan which provided free trauma care.  The year before the attack it treated 22,000 patients (MSF UK 2016).

Conclusion

The negative acute traumatic impacts of war and conflict on a patient’s health can be devastating and lethal.  Aside from these battle wounds, however, war and conflict can deeply affect a civilian population’s general health and wellbeing for years, decades and even generations.

Deployment of hazardous chemicals, such as the dioxin congener Agent Orange, can cause increased cases of cancers, dermatological conditions, congenital birth defects and miscarriages (Schecter et al. 2001; Schecter et al. 1995; Nham Tuyet & Johansson 2001; Schecter et al. 1995).  The large amount used and stored in the Vietnam during Operation Ranch Hand allowed the hazardous material to enter the food chain through soil and sediment. The effects of which would still be felt over 20 years later with elevated levels of TCDD being detected in nursing mothers breast milk (Schecter et al. 1995; Dwyer & Flesch-Janys 2014).

The atomic bomb dropped on Hiroshima killed 100,000 (Zinn 2005; Douple et al. 2011) and many more within a month from acute radiation sickness (Okubo 2012; Douple et al. 2011).  The radiation dose received by the survivors has been shown to lead to increased chances of various cancers, cataracts, stroke and heart disease (Douple et al. 2011; Okubo 2012; Akiyama 1995; Kusunoki & Hayashi 2008).  In addition the psychological damage of witnessing such an event and experiencing such loss left a lasting mark on a society (Lifton 1968; Zwigenberg 2017).

Psychological damage has also had a profound effect on the children of Syria (Carpenter 2013; Kazour et al. 2017; Chung et al. 2018). Citizens have endured inconceivable levels of violence and displacement during the current civil war that a new term, Human Devastation Syndrome, is now used to describe that trauma (Ahmed et al. 2018; Davis 2017).  This is to articulate the severity of PTSD they have experienced.

Destruction of infrastructure both directly related to healthcare, hospitals and clinics; and indirectly related, electrical power plants and water treatment facilities, also impacts health and wellbeing.  In the aftermath of the Gulf war this worked as a vicious cycle as huge increases in the amount of children being seen with malnutrition, cholera and typhoid were treated in understaffed, ill-equipped healthcare facilities that lacked access to safe water and medication (Armijo-Hussein et al. 1991; Lee & Haines 1991; Goldson 1996).

These examples demonstrate that a particularly saddening aspect of social suffering during war is borne by the least responsible, in terms of actions during and causative decision making. Children, either survivors of war or born in the aftermath, find themselves profoundly and often irreversibly affected.

 

 

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