By Jasper Kan
It was not until Florence Nightingale’s work did the world attribute the lack of healthcare as a major cause of casualties at war. Exposed wounds serve as an optimal breeding ground of pathogens, while healthcare personnel treating them were sabotaged. Also, the impact of direct injuries were dwarfed by its indirect acceleration of epidemic transmission. Nowadays, with the rise of new threats to public health, they prove to be uncontrollable with the onset of military conflicts.
Even before modern epidemical diseases (like SARS-CoV 1/2, MERS and Ebola) emerged; healthcare in war zones is already limited in quantity and quality. There have been several reasons that may increase mortality of patients, such as the skyrocketing patient-to-doctor ratio. With doctors either retreating to safer places or prevented from helping due to clashes, those who stay were forced to discharge less critical patients prematurely after treatments. For critical patients, proper treatment was also hindered due to a lack of medicine and disinfectant supply. Apparently, this can result in injured people in a war zone never exiting the hospital alive.
Yet, military statistics prove the opposite. With only 1850s medical technology, ~85% of injured combatants during the Crimean War and American Civil War left healthcare units alive. With the advent of medical technology, survival rates increased as expected to >95% in wars during the 1990s. From a 1994 estimate, 60-65% of casualties would still survive without treatment for seven days.1 This shows that proper post-injury treatment is not as important as people think when it comes to saving lives. In fact, survival rates plummet at the first few hours after injury before gradually levelling off. They show that most deaths were instantaneous and mostly due to the severity of the wound rather than postponed treatments. If a patient’s condition is too critical, even timely urgent surgeries will be ineffective to save them. In fact, the survival rate corresponding to the point of levelling off did not increase significantly even with surgical intervention, proving that the seriousness of the injury affects survival the most.
This shows that while military conflicts may increase the number of injuries, mortality rates remain low as we underestimate the human body’s endurance to survive. For those enduring milder injuries to their vital organs, modern prevalence of non-invasive first aid techniques, like resuscitations, can be easily taught to many and could also help even more patients get past the critical few hours alive, and further lower the death toll.1
Beyond direct injuries from bullets and explosives, military conflicts indirectly accelerate transmission of epidemics. For example, during the ongoing Russian invasion of Ukraine, given the urgency of Ukrainian refugees to flee for safety and its military to act, anti-COVID measures like social distancing, mask wearing, and vaccinating are put aside. Alas this entails increasing risk of COVID transmission. Moreover, hospitalisation efforts diminished dramatically due to Russian attacks, resulting in a shortage of medicine, oxygen and even a segregated COVID-only zone in hospitals2. COVID patients thus have their recovery delayed while exposing themselves to non-COVID patients, the latter possibly with weakened immune systems and are prone to infection. At times of war, most medical resources were focused on national defence. For example, in order to fuel the war effort, treatment of injured military personnel which increase survival rates from ~60% to >95% is prioritised.1 Although recovered soldiers could continue fighting, this meant fewer resources were devoted to tracking and treating COVID, facilitating its transmission.
Another prominent example would be the 2018-19 Ebola outbreak amid insurgencies in eastern Democratic Republic of the Congo (DRC). Unlike Ukraine, much of the DRC had a relatively underdeveloped public health system and many had misconceptions regarding Ebola.3 Track-and-tracing was ineffective, as 61% of the confirmed cases in a 30-day period had no known links.4 This increased the incidence of Ebola transmission, while preventing appropriate treatment and prevention measures timely.
More importantly, the DRC is far from a united country. Instead, multiple factions fight each other. There were twenty highly active insurgencies and eighty others according to reports, and armed peacekeepers accompanied international delegates to protect their lives.5 However, I believe this could be counterproductive as locals could easily equate the convoy to enforcers of unwanted treatment, so that potential Ebola carriers would fight or flee them, eventually making the epidemic harder to control. Moreover, due to deep-rooted mistrust between insurgents and the internationally recognised government, conflict prone areas in the DRC tend to decline government and international aid while the former’s sympathisers may be reluctant to be treated. This is hypothesised to adversely affect measures to control Ebola.
Findings indicate a weak but significant association between conflict numbers (per 10000) and Ebola incidence (per 10000) in general.6 Also, there were reports of obstructed tracing, case isolation and vaccination, and deliberate attacks on Ebola treatment centres at times of conflict escalation. Preventable delays in tracing and isolation (delayed by 1.91 days) lower the effectiveness to trace transmission chains and increases proportion of Ebola patients with no known links. Vaccination effectiveness would even decrease by 36% even when delayed for one week. In addition, while the RE value (number of new infections caused by an Ebola patient) with vaccine interventions maintained at 0.7-0.8 people when conflicts stopped, it rose to 1.9 during their onset. This erases the prevention effect of Ebola vaccines, since the RE value was only 1.66 before vaccinations started7 and matches the hypothesis. This shows the unwanted power of armed conflict to hinder Ebola control.
All in all, while distressing bloodshed in military conflicts is crucial to treat, more should be focused on treating increased transmission of contagious epidemics caused by a lack of prevention measures at war. After all, unlike wounds that limit their effect to the injured person, the hidden presence of infected patients poses a bigger threat of disease transmission to other able-bodied people.
- Coupland R M. Epidemiological approach to surgical management of the casualties of war BMJ 1994; 308 :1693 doi:10.1136/bmj.308.6945.1693
- Chumachenko, D. Chumachenko, T. Impact of war on the dynamics of COVID-19 in Ukraine. 2022. doi.10.1136/bmjgh-2022-009173. BMJ Global Health. e009173. https://gh.bmj.com/content/bmjgh/7/4/e009173.full.pdf
- Claude K.M., Underschultz J., Hawkes M.T., Ebola virus epidemic in war-torn eastern DR Congo. 2018. https://doi.org/10.1016/S0140-6736(18)32419-X. Elsevier Ltd
- Gostin, Lawrence O. Kavanagh, Matthew M. Cameron, Elizabeth. Ebola and War in the Democratic Republic of Congo Avoiding Failure and Thinking Ahead. 2019. DOI: 10.1001/jama.2018.19743
- Jon Cohen (Science Insider). Out of the frying pan, into the fire with a new Ebola outbreak in Congo. doi: 10.1126/science.aav0226 [Accessed in 16 May 2022]
- Kraemer, M.U.G., Pigott, D.M., Hill, S.C. et al. Dynamics of conflict during the Ebola outbreak in the Democratic Republic of the Congo 2018–2019. BMC Med 18, 113 (2020). https://doi.org/10.1186/s12916-020-01574-1
- Wells, Chad R et al. “The exacerbation of Ebola outbreaks by conflict in the Democratic Republic of the Congo.” Proceedings of the National Academy of Sciences of the United States of America vol. 116,48 (2019): 24366-24372. doi:10.1073/pnas.1913980116
Article written in June, 2022