The dirty war index: a public health and human rights tool for examining and monitoring armed conflict outcomes

Medición de indicadores de salud mental de población en contexto de conflicto armado en Colombia: revisión de alcance

El conflicto armado ha marcado las diferentes dimensiones de vida de la población colombiana por lo que ha sido objeto de diversos estudios, generando la necesidad de evaluar el abordaje e instrumentos utilizados para medir indicadores de salud mental de población en contexto de conflicto armado. Esta investigación pretende analizar artículos científicos que aborden dichos indicadores y que utilicen instrumentos psicométricos para tal fin. Se realizó una revisión de alcance siguiendo la metodología PRISMA y utilizando el software CADIMA. La búsqueda bibliográfica se hizo en las bases de datos Web of Science, Scielo y Scopus, usando términos claves en inglés y español. Se analizaron 21 artículos en los que se identifica el uso de 53 instrumentos, siendo los más aplicados el AUDIT y la CIDI-CAPI. La mayoría de los artículos reportaron afectaciones relacionadas con estrés postraumático, ansiedad, depresión y consumo de sustancias. Se encontraron pocos estudios de validación o construcción de instrumentos. Es necesario fortalecer el trabajo en el desarrollo y validación de pruebas para evaluar indicadores de salud mental en poblaciones víctimas del conflicto armado colombiano, con las que se posibilite una mejor valoración de las afectaciones.

Armed conflict and public health: into the 21st century

BACKGROUND

Many people worldwide are affected by conflict, and countries affected are less likely to meet the UN Sustainable Development Goals. This review outlines the effects of conflict on health and focuses on areas requiring more attention.

METHODS

We completed a search of the literature using Medline, Embase and Global Health.

RESULTS

Health effects of conflict include trauma; mental health; non-communicable diseases (NCDs); child health; sexual, reproductive and maternal health; and infectious diseases. Conflict damages health directly through fighting, and indirectly through wider socioeconomic effects. Health outcomes are influenced by pre-existing population health and demographics, and access to appropriate healthcare. Vulnerable populations (the elderly, children, neonates and women) are especially at risk.

CONCLUSION

Several areas pose key challenges including: tactics of war as a public health problem; a lack of focus on neonatal care and NCDs; the long-term consequences of conflict across a life-course and into future generations; and the need to focus on wellbeing beyond standard health parameters. Clear decisions about prioritisation need to be made. The effects on civilians must be documented and recorded. Further research is required to understand chronic health needs and effects on future generations, to support fair and equitable resource prioritisation to best meet the needs of conflict-affected populations.

Patterns of civilian and child deaths due to war-related violence in Syria: a comparative analysis from the Violation Documentation Center dataset, 2011-16

BACKGROUND

Since March, 2011, the Syrian civil war has lowered life expectancy by as much as 20 years. We describe demographic, spatial, and temporal patterns of direct deaths of civilians and opposition combatants from conflict-related violence in 6 years of war.

METHODS

We analysed conflict-related violent deaths with complete information on date, place, and cause of death and demographic group occurring from March 18, 2011, to Dec 31, 2016, recorded by the Violation Documentation Center (VDC). We included civilian and combatant deaths in all Syrian governorates, excluding government-controlled areas. We did not include detainees and missing persons, nor deaths from siege conditions or insufficient medical care. We categorised deaths based on VDC weapon type. We used χ² testing to compare deaths from different weapons in civilian men, women, boys, and girls and adult and child combatants. We analysed deaths by governorate and over time.

FINDINGS

The VDC recorded 143 630 conflict-related violent deaths with complete information between March 18, 2011, and Dec 31, 2016. Syrian civilians constituted 101 453 (70·6%) of the deaths compared with 42 177 (29·4%) opposition combatants. Direct deaths were caused by wide-area weapons of shelling and air bombardments in 58 099 (57·3%) civilians, including 8285 (74·6%) civilian women and 13 810 (79·4%) civilian children, and in 4058 (9·6%) opposition combatants. Proportions of children among civilian deaths increased from 8·9% (388 of 4254 civilian deaths) in 2011 to 19·0% (4927 of 25 972) in 2013 and to 23·3% (2662 of 11 444) in 2016. Of 7566 deaths from barrel bombs, 7351 (97·2%) were civilians, of whom 2007 (27·3%) were children. Of 20 281 deaths by execution, 18 747 (92·4%) were civilians and 1534 (7·6%) were opposition combatants. Compared with opposition child soldiers who were male (n=333), deaths of civilian male children (n=11 730) were caused more often by air bombardments (39·2% vs 5·4%, p<0·0001) and shelling (37·3% vs 13·2%, p<0·0001) and less often by shooting (12·5% vs 76·0%, p<0·0001).

INTERPRETATION

Aerial bombing and shelling rapidly became primary causes of direct deaths of women and children and had disproportionate lethal effects on civilians, calling into question the use of wide-area explosive weapons in urban areas. Increased reliance on aerial bombing by the Syrian Government and international partners is likely to have contributed to findings that children were killed in increasing proportions over time, ultimately comprising a quarter of civilian deaths in 2016. The inordinate proportion of civilians among the executed is consistent with deliberate tactics to terrorise civilians. Deaths from barrel bombs were overwhelmingly civilian rather than opposition combatants, suggesting indiscriminate or targeted warfare contrary to international humanitarian law and possibly constituting a war crime.

FUNDING

None.

Variation of gunshot injury patterns in mortality associated with human rights abuses and armed conflict: an exploratory study

The analysis of the distribution of gunshot injuries in a sample of 777 sets of human remains of proven human rights abuse from Somaliland, the Balkans and Peru is compared to frequencies of injuries sustained by combatants in contemporary conflicts reported in the literature. Principal Component Analysis (PCA) reduced the data to three components accounting for 82.94% of the variance. The first component with 38.31% of variance shows segments Arms and thorax/abdomen to be positively correlated (0.887 and 0.662, respectively); the segment head/neck is strongly correlated (0.951) to the second component while the segment thorax/abdomen shows a low, negative correlation (-0.388). Finally in the third component only the legs are strongly correlated (0.991). Data was further subjected to a K-means cluster analysis to determine the likely groupings combining the four types of injuries. Each of the three clusters reproduced similar patterns observed in the PCA: Cluster 1 shows the prevalence of injuries to the thorax/abdomen and extremities in addition to injuries to the head/neck; Cluster 2 shows injuries to the head/neck and Cluster 3 injuries to the thorax/abdomen and a lower representation of the arms and legs. Most of the cases (70.5%), irrespective of geography and type of site (attack or detention), were grouped into Cluster 2. Such comparison shows that in human rights abuse, irrespective of their geography, gunshot injuries tend to follow a pattern favouring the head/neck and thorax/abdomen areas over the extremities, the reverse pattern observed in contemporary combat operations. In those settings gunshot wound trauma is the second cause of mortality/morbidity (after fragmenting ammunition) and its distribution concentrates on the extremities, thorax/abdomen and head; following the pattern of protective armour when it is used. Considering that human rights abuses are often presented as encounters between two armed groups in the context of counter-insurgency operations, a careful analysis of gunshot injury patterns could serve as an indicator that in fact murder, rather than combat, took place and the intention was to kill rather than to maim or render people unfit for battle.

OBJECTIVE

To compare the variation of gunshot injury patterns between mortality associated with human rights abuses and armed conflict in selected samples from different countries.

DESIGN

Literature review and case analysis.

SETTINGS

Original statistical analysis of gunshot injuries on human remains (n=777) recovered from mass or clandestine graves associated with human rights abuses in countries in Somaliland, the Balkans and Peru (1983-1995) and literature review of mortality caused by armed conflicts.

MAIN OUTCOME MEASURE

Mechanism of gunshot injury and wound distribution pattern in geographically diverse samples of human rights abuse.

The role of public health in the prevention of war: rationale and competencies

In 2009 the American Public Health Association approved the policy statement, "The Role of Public Health Practitioners, Academics, and Advocates in Relation to Armed Conflict and War." Despite the known health effects of war, the development of competencies to prevent war has received little attention. Public health's ethical principles of practice prioritize addressing the fundamental causes of disease and adverse health outcomes. A working group grew out of the American Public Health Association's Peace Caucus to build upon the 2009 policy by proposing competencies to understand and prevent the political, economic, social, and cultural determinants of war, particularly militarism. The working group recommends that schools of public health and public health organizations incorporate these competencies into professional preparation programs, research, and advocacy.

Armed conflict, homonegativity and forced internal displacement: implications for HIV among Colombian gay, bisexual and transgender individuals

Colombia has endured six decades of civil unrest, population displacement and violence. We examined the relationships between contextual conditions, displacement and HIV among gay, bisexual and transgender individuals in Bogotá, Colombia. A total of 19 key informants provided information about internal displacement of sexual minorities. Life-history interviews were conducted with 42 participants aged 18 to 48 years and included questions about displacement experiences, sexual behaviour, life prior to displacement and participants' economic and social situation in Bogotá. The interplay of a variety of factors - including internal conflict and violence, homonegativity and 'social cleansing', gender and sexual identity and poverty - strongly shaped the varied experiences of displacement. Migration, sexual violence, exchange sex and low rates of HIV testing were risk factors that increased vulnerability for HIV in this displaced sample. Although displacement and HIV in Colombia are major problems, both are understudied.

How to stir up trouble…while riding a rollercoaster

PLOS Medicine's Chief Editor looks back at some highlights in the way the journal has sought to constructively disrupt medical publishing over its history. Please see later in the article for the Editors' Summary

Global comparison of warring groups in 2002-2007: fatalities from targeting civilians vs. fighting battles

Background

Warring groups that compete to dominate a civilian population confront contending behavioral options: target civilians or battle the enemy. We aimed to describe degrees to which combatant groups concentrated lethal behavior into intentionally targeting civilians as opposed to engaging in battle with opponents in contemporary armed conflict.

Methodology/Principal Findings

We identified all 226 formally organized state and non-state groups (i.e. actors) that engaged in lethal armed conflict during 2002–2007: 43 state and 183 non-state. We summed civilians killed by an actor's intentional targeting with civilians and combatants killed in battles in which the actor was involved for total fatalities associated with each actor, indicating overall scale of armed conflict. We used a Civilian Targeting Index (CTI), defined as the proportion of total fatalities caused by intentional targeting of civilians, to measure the concentration of lethal behavior into civilian targeting. We report actor-specific findings and four significant trends: 1.) 61% of all 226 actors (95% CI 55% to 67%) refrained from targeting civilians. 2.) Logistic regression showed actors were more likely to have targeted civilians if conflict duration was three or more years rather than one year. 3.) In the 88 actors that targeted civilians, multiple regressions showed an inverse correlation between CTI values and the total number of fatalities. Conflict duration of three or more years was associated with lower CTI values than conflict duration of one year. 4.) When conflict scale and duration were accounted for, state and non-state actors did not differ. We describe civilian targeting by actors in prolonged conflict. We discuss comparable patterns found in nature and interdisciplinary research.

Conclusions/Significance

Most warring groups in 2002–2007 did not target civilians. Warring groups that targeted civilians in small-scale, brief conflict concentrated more lethal behavior into targeting civilians, and less into battles, than groups in larger-scale, longer conflict.

''What are you?'' A recurring question in a cross-cultural psychiatrist's life and career

This article contributes to the Transcultural Psychiatry special issue of autobiographical articles on: ''The Personal and the Professional: Lives and Careers of Cultural Psychiatrists.'' The author describes influences and themes in her professional development as a cross-cultural psychiatrist and academic. Growing up as a part-Chinese, part-white child in rural Midwestern America resulted in frequently being asked: ''What are you?'' This abrupt, bald, but essential question eventually became a useful tool in the productive, repeated re-working of identity, values, and goals throughout her personal and professional life. Experiences of being an outsider, family histories, and early observations of racism are linked to later interests in cross-cultural psychiatry, ethics, and the protection of vulnerable populations. She describes her research on cross-cultural measurement, depression, suicidality, domestic violence and violence in war. Issues of career advancement and internal conflict are described for women academics who occupy three simultaneous, primary roles: academic, doctor and mother. The theme of ''crossing,'' as in ''cross-cultural,'' indicates the effort and intention required to move between races, cultures, classes, intellectual disciplines, personal and professional identities, clinical and academic roles, and social roles allocated to men and women.

Measuring the true costs of war: consensus and controversy

Robert Muggah discusses the costs of war and a new analysis published in PLoS Medicine by Madelyn Hsiao-Rei Hicks and colleagues that documents the number of Iraqi civilian violent deaths during 2003-2008.

Violent deaths of Iraqi civilians, 2003-2008: analysis by perpetrator, weapon, time, and location

BACKGROUND

Armed violence is a major public health and humanitarian problem in Iraq. In this descriptive statistical analysis we aimed to describe for the first time Iraqi civilian deaths caused by perpetrators of armed violence during the first 5 years of the Iraq war: over time; by weapon used; by region (governorate); and by victim demographics.

METHODS AND FINDINGS

We analyzed the Iraq Body Count database of 92,614 Iraqi civilian direct deaths from armed violence occurring from March 20, 2003 through March 19, 2008, of which Unknown perpetrators caused 74% of deaths (n = 68,396), Coalition forces 12% (n = 11,516), and Anti-Coalition forces 11% (n = 9,954). We analyzed the subset of 60,481 civilian deaths from 14,196 short-duration events of lethal violence to link individual civilian deaths to events involving perpetrators and their methods. One-third of civilian violent death was from extrajudicial executions by Unknown perpetrators; quadratic regression shows these deaths progressively and disproportionately increased as deaths from other forms of violence increased across Iraq's governorates. The highest average number of civilians killed per event in which a civilian died were in Unknown perpetrator suicide bombings targeting civilians (19 per lethal event) and Coalition aerial bombings (17 per lethal event). In temporal analysis, numbers of civilian deaths from Coalition air attacks, and woman and child deaths from Coalition forces, peaked during the invasion. We applied a Woman and Child "Dirty War Index" (DWI), measuring the proportion of women and children among civilian deaths of known demographic status, to the 22,066 civilian victims identified as men, women, or children to indicate relatively indiscriminate perpetrator effects. DWI findings suggest the most indiscriminate effects on women and children were from Unknown perpetrators using mortar fire (DWI  = 79) and nonsuicide vehicle bombs (DWI  = 54) and from Coalition air attacks (DWI  = 69). Coalition forces had higher Woman and Child DWIs than Anti-Coalition forces, with no evidence of decrease over 2003-2008, for all weapons combined and for small arms gunfire, specifically.

CONCLUSIONS

Most Iraqi civilian violent deaths during 2003-2008 of the Iraq war were inflicted by Unknown perpetrators, primarily through extrajudicial executions that disproportionately increased in regions with greater numbers of violent deaths. Unknown perpetrators using suicide bombs, vehicle bombs, and mortars had highly lethal and indiscriminate effects on the Iraqi civilians they targeted. Deaths caused by Coalition forces of Iraqi civilians, women, and children peaked during the invasion period, with relatively indiscriminate effects from aerial weapons. Please see later in the article for the Editors' Summary.

Rape in war is common, devastating, and too often ignored

This month's Editorial discusses the unconscionable use of rape as a weapon of war and calls for more pressure to be put on international authorities to take concerted action and to make protection from sexual violence a central part of peacekeeping efforts.

The dirty war index: statistical issues, feasibility, and interpretation

Nathan Taback discusses statistical limitations of a new tool, the Dirty War Index, which measures rates of particularly undesirable ("dirty") outcomes inflicted on populations during armed conflict.

A new tool for measuring the brutality of war

Egbert Sondorp discusses the public health uses and implications of a new tool, the Dirty War Index, that measures prohibited war outcomes inflicted on populations during conflict.