More children die from the indirect impact of armed conflict in Africa than those killed in the crossfire and on the battlefields, according to a new study by Stanford researchers. 

The study is the first comprehensive analysis of the large and lingering effects of armed conflicts — civil wars, rebellions and interstate conflicts — on the health of noncombatants.

The numbers are sobering: 3.1 to 3.5 million infants born within 30 miles of armed conflict died from indirect consequences of battle zones between 1995 and 2005. That number jumps to 5 million deaths of children under 5 in those same conflict zones.

“The indirect effects on children are so much greater than the direct deaths from conflict,” said Stanford Health Policy's Eran Bendavid, senior author of the study published today in The Lancet.

The authors also found evidence of increased mortality risk from armed conflict as far as 60 miles away and for eight years after conflicts. Being born in the same year as a nearby armed conflict is riskiest for young infants, the authors found, with the lingering effects raising the risk of death for infants by over 30 percent.

On the entire continent, the authors wrote, the number of infant deaths related to conflict from 1995 to 2015 were more than three times the number of direct deaths from armed conflict. Further, they demonstrated a strong and stable increase of 7.7 percent in the risk of dying before age 1 among babies born within 30 miles of an armed conflict.

The authors recognize it is not surprising that African children are vulnerable to nearby armed conflict. But they show that this burden is substantially higher than previously indicated. 

“We wanted to understands the effects of war and conflict, and discovered that this was surprisingly poorly understood,” said Bendavid, an associate professor of medicine at Stanford Medicine.  “The most authoritative source, the Global Burden of Disease, only counts the direct deaths from conflict, and those estimates suggest that conflicts are a minuscule cause of death.”

Paul Wise, a professor of pediatrics at Stanford Medicine and a senior fellow at the Freeman Spogli Institute for International Studies, has long argued that lack of health care, vaccines, food, water and shelter kills more civilians than combatants from bombs and bullets. 

This study has now put data behind the theory when it comes to children.

“We hope to redefine what conflict means for civilian populations by showing how enduring and how far-reaching the destructive effects of conflict have on child health,” said Bendavid, an infectious disease physician whose co-authors include Marshall Burke, PhD, an assistant professor of earth systems science and fellow at the Center on Food Security and the Environment.

“Lack of access to key health services or to adequate nutrition are the standard explanations for stubbornly high infant mortality rates in parts of Africa,” said Burke. “But our data suggest that conflict can itself be a key driver of these outcomes, affecting health services and nutritional outcomes hundreds of kilometers away and for nearly a decade after the conflict event”. 

The results suggest efforts to reduce conflict could lead to large health benefits for children.

The Data

The authors matched data on 15,441 armed-conflict events with data on 1.99 million births and subsequent child survival across 35 African countries. Their primary conflict data came from the Uppsala Conflict Data Program Georeferenced Events Dataset, which includes detailed information about the time, location, type and intensity of conflict events from 1946 to 2016. 

The researchers also used all available data from the Demographic and Health Surveys conducted in 35 African countries from 1995 to 2015 as the primary data sources on child mortality in their analysis.

The data, they said, shows that the indirect toll of armed conflict among children is three-to-five times greater than the estimated number of direct casualties in conflict. The indirect toll is likely even higher when considering the effects on women and other vulnerable populations.

Zachary Wagner, a health economist at RAND Corporation and first author of the study, said he knows few are surprised that conflict is bad for child health.

“However, this work shows that the relationship between conflict and child mortality is stronger than previously thought and children in conflict zones remain at risk for many years after the conflict ends.” 

He notes that nearly 7 percent of child deaths in Africa are related to conflict and reiterated the grim fact that child deaths greatly outnumber direct combatant deaths.

“We hope our findings lead to enhanced efforts to reach children in conflict zones with humanitarian interventions,” Wagner said. “But we need more research that studies the reasons for why children in conflict zones have worse outcomes in order to effectively intervene.” 

Another author, Sam Heft-Neal, PhD, is a research fellow at the Center for Food Security and the Environment and in the Department of Earth Systems Science. He, Burke and Bendavid have been working together to identify the impacts of extreme climate events on infant mortality in Africa.

The Freeman Spogli Institute for International Studies (FSI) at Stanford University is pleased to announce that former U.S. Ambassador and World Food Programme (WFP) Executive Director Ertharin Cousin will return for a second year at Stanford. Cousin will serve as the Frank E. and Arthur W. Payne Distinguished Lecturer at FSI and Distinguished Fellow at the Center on Food Security and the Environment and the Center on Democracy, Development and the Rule of Law.

Cousin brings over 30 years of experience addressing hunger and food security strategies on both a national and international scale. As U.S. Ambassador to the United Nations Agencies for Food and Agriculture, she focused on advocating for longer-term solutions to food insecurity and hunger, and at WFP she addressed the challenges of food insecurity in conflict situations.

We caught up with Cousin to ask about her plans for this upcoming school year.

If you had to pick out one thing that most concerns you in the realm of food security, what would it be?

Water access, particularly in terms of smallholder farmer centered irrigation and water management. The development community spent much of the past 10 years working to improve farmers’ access to the right seeds and tools – recognizing the need to increase the quality and quantity of their yields. A significant amount of work has also been performed related to improving private sector investment and to the development of markets including access for smallholder farmers.

Today there are approximately 500 million smallholder farmers in the world. The most vulnerable live and work in places where climate change creates ever more erratic rainy seasons. Particularly, in sub-Saharan Africa where 97 percent of all agriculture remains rain-fed. Too often the short rains don’t come, and the long rains produce insufficient precipitation. Inadequate policy management of diminishing water resources represents a significant problem which we must overcome to make agriculture productive and sustainable for the most vulnerable.

And what work have you been doing to address this issue?

I am working on a number of policy research and development projects. For example, I am co-chairing the Chicago Council on Global Affairs (CCGA) 2019 Global Food Security Symposium’s report exploring the linkages between water management and food security particularly as it relates to nutrition security. The report release will occur March 21, 2019 at the CCGA Food Security Symposium.

Over the past year, you also have been working on a project to encourage the private sector to create sustainable food systems. How is that going?

My work identifying and addressing policy-related challenges impacting private sector partnership and investment in global food system solutions continues. Globally, there is growing recognition that we cannot fix the broken global food system if we do not work to create collaborative efforts between public and private sector, academia, government, non-profits and larger society.

Governments, particularly those in developing countries, often lack both the financial resources and technical capacity required to perform the work and the investment necessary to fix our global food system. Governments and civil society must include private sector as an equal and desired partner. Government policies at the global, state and local level should support and encourage private sector participation.

Using my role here at Stanford as a platform to broker research and information both to private sector as well as to government, has proven quite successful over the past year. In very simple terms, helping global governments understand generating profit does not make the private sector a bad partner.

What successes have you had so far?

I was just in Amsterdam to meet with Royal DSM, a nutrition products manufacturer, with whom I developed a relationship during my tenure at the World Food Programme. In Kigali in Rwanda, DSM and several other partners - including the national government - have developed and are now operating the Africa Improved Foods company, the first European-type baby food manufacturing facility. European-type baby food differs from American products in terms of their lack of sweeteners and conservative use of food preservatives, lack of detectable pesticides (due to farming practices), and their stage-approach: they produce different products for the various stages of baby growth (from birth to 4 years) that cater to the specific nutritional needs of the child. Several farming cooperatives, representing approximately 10,000 Rwandan small farmers, form the sole supply chain for this baby food factory.

WFP serves as a catalyst market for the plant, purchasing the supplemental nutrition product distributed through the region’s targeted nutrition improvement program. The sustainability of the factory is directly related to the partners ability to grow (in addition to WFP) an institutional and a commercial consumer market for this easy-access, nutrient-rich food that is specifically made for children. I am assisting DSM and the government of Rwanda by helping to identify the policy changes required to ensure the sustainability of this public-private partnership. As a proof-of-concept, the success of AIF, will result in new public-private development opportunities. This initiative offers a case study demonstrating how collaboration between the private sector and government actually provides positive benefits for both farmers and nutritious food for consumers.

Why Stanford? How has being here helped your work?

Serving here at Stanford represents my first opportunity to work in academia on a full-time basis. I am a lawyer with over 30 years of experience of working on complicated domestic and global humanitarian and development issues; particularly, hunger related issues. I believe my experience adds value to any academic community. But in many institutions, the value of experience is not readily embraced, particularly because I don't have a PhD and haven’t spent 20 years in a classroom. At Stanford, I discovered collegial faculty, brilliant students and a recognition as well as a respect for my experience-based knowledge. I have received a welcoming response across the campus, collaborating with the law school, colleagues in the medical school, earth system sciences and the business school. The only limit to my participation and partnership with the amazing academic leaders here at Stanford has been time. I am quite looking forward to the opportunities for engagement provided by my additional time on campus.

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The Payne Distinguished Lectureship is awarded to scholars with international reputations as leaders, with an emphasis on visionary thinking, practical problem solving, and the capacity to clearly articulate an important perspective on the global political and social situation. Past Payne Lecturers include Bill Gates, Nobel Laureate Mohamed El Baradei, UNAIDS Executive Director Peter Piot, and novelist Ian McEwan.

The Center on Food Security and the Environment (FSE) addresses critical global issues of hunger, poverty and environmental degradation and is a joint effort of the Freeman Spogli Institute for International Studies and the Stanford Woods Institute for the Environment.

The Center on Democracy, Development and the Rule of Law is an interdisciplinary center for research on development in all of its dimensions:  political, economic, social and legal, and the ways in which these different dimensions interact with one another.

The Trump administration's immigration crackdown may be leading to an unintended consequence: a drop-off in benefits enrollment among legal Hispanic immigrants, according to new research by Stanford Health Policy's Marcella Alsan.

This CBS News story about her work notes that an immigration program called Secure Communities, which was rolled out during the Obama administration, is linked to a lower take-up of benefits such as food stamps and health care enrollment.

In a new paper published by the National Bureau of Economic Research, Alsan and Crystal Yang of Harvard Law School found Hispanic households were particularly hard-hit, even those with legal immigration status.

"We find evidence that our results may be driven by deportation fear rather than lack of benefit information or stigma," the researchers wrote.  "Though not at personal risk of deportation, Hispanic citizens may fear their participation could expose non-citizens in their network to immigration authorities. We find significant declines in SNAP and ACA enrollment, particularly among mixed-citizenship status households and in areas where deportation fear is highest."

Read the CBS News story.