Historically, infectious disease have killed more soldiers in war zones than the conflict itself. Whilst this statistic is changing, infectious disease remains the cause of themajority of civilian deaths in modern day war. Prolonged conflict results in damaged infrastructure, unsafe travel routes, closure of medical facilities, and immuno-compromised civilians. These factors result in the consumption of virus and bacterial matter, which if left untreated lead to morbidity and even death. Civilians are often unwilling participants in conflict, and more must be done to uphold humanitarian conventions and protect people from the indirect detriments of war activity.

In August 2018, The Lancet published a report which indicated that more than 5 million African children had died as a result of preventable diseases in the last 2 decades. Many of these deaths were due to infectious diseases spread through war damaged infrastructure (i.e. destroyed water bores and sanitation routes), poor vaccination rates, and the lack of accessibility to medical facilities in general. Civilians in war torn countries, especially living in rural areas, are also often difficult to reach for humanitarian aid organisations. Just weeks before the publishing of the aforementioned report by The Lancet, the Democratic Republic of Congo saw its 10^th outbreak of Ebola since 1976. Although, an Ebola vaccine is available, as of 2016, patients that are living in a ‘red zone’ makes them inaccessible for humanitarian aid. The area of concern, North Kivu, has been involved in the Kivu Conflict since 2004. This prolonged period of fighting has devastated the infrastructure, economy, and medical resources in the region.

Poverty also plays a vital role in the perpetuation of infectious disease in war zones. Dr. Joxel Garcia, the deputy director of the Pan American Health Organization, states that health systems often fail in poverty-stricken areas due to a lack of resources “if you don’t have primary care, if you don’t have nurses in public health, if you don’t have doctors, if you don’t have the infrastructure to create systems related to health, then you cannot sustain the approach.” Without essential material commodities health services cannot be provided. Research also suggests that people living in poverty often suffer with more than one disease which makes treatment more complex. Health care systems, mostly provided through aid organisations, may be unable to treat comorbidities due to the lack of resources available in conflict areas.

Infectious diseases are also spread, exacerbated, and perpetuated by displaced persons who are forced out of their home due to conflict. The United Nations Refugee Agency estimated that by the end of 2017 68.5 million people were displaced as a result of war, and/or persecution or other violent circumstances. This large, mobile population has the potential to transmit diseases across borders as they often bring with them plant matter, livestock, and companion animals, that may contain existing infections. Dr. Garcia recounts the impact of migration on disease prevalence “they’re moving from one town to another, or one country to another (and) they may bring with them some prevalence of disease that may not be a disease that is present in that other country.” The reverse of this situation is also apparent. New migrants, especially those victim to war atrocities, are susceptible (as a result of poor vaccination, immune compromise etc.) to common diseases in their new location.

Currently, vaccination programs are being rolled out in areas like Kivu, Democratic Republic of Congo to stop the spread of disease. Whilst it’s difficult to reach these areas, the Ministry of Health in the DRG work with local nurses to monitor the situation. Local solutions are often the most effective as they operate at a functional level. The Minister for Health Oly Ilunga Kalenga spoke to media during a visit to the region about further methods to battle disease outbreak. He stated that security was of utmost priority and that “health personnel and materials are accompanied by an escort when travelling.” By ensuring the safety of health services in these regions more patients can be treated and the spread of infectious diseases halted. However, local agencies cannot fully eradicate disease as they often lack vital resources with facilities compromised by violence.

The World Health Organisation is also working with Governments and aid organisations to ensure the proper treatment of the sick. This program includes a provision of isolation facilities, funding of medical personnel, and temporary infrastructure to reduce the transmission of disease. Aid provided in refugee camps is also beneficial in preventing incidences of new diseases within countries. Living conditions in these camps are often conducive to the spread of disease: over-crowding, poor sanitation, lack of clean water, human-animal cohabitation etc. By creating more sustainable refugee settlements, with some provision of basic resources, large populations of displaced persons can be prevented from transmitting disease. There is evidence to suggest that progress is being made towards the reduction of infectious disease in conflict areas. However, UNICEF reported that much of the world is not meeting ideal targets in the reduction of transmission and more must be done to stop millions more dying from preventable infectious diseases.

Stewart Parkinson, from Population Services International, says that the lack of acknowledgement of disease impact is perpetuating the problem “if you don’t acknowledge it, you don’t tackle it. If you don’t tackle it, it spreads.” Political impacts in some countries are hindering progress towards disease prevention. The most prominent example of this is the concealment of AIDS statistics in an effort to mitigate negative perceptions. Mr. Parkinson continues “Many countries suffering from AIDS, for instance, don’t want to publicize that there is a prevalence of HIV because they are afraid it will affect tourism, and therefore affect national revenue. So there are all kinds of considerations that mitigate against good public health and these are driven by political considerations and not health considerations.” It is essential that countries acknowledge the prevalence of disease and actively create solutions.

The case of Ebola in the Democratic Republic of Congo represents the need for preventative strategies. The Ebola vaccination is readily available and proper distribution can assist in stopping transmission of disease, especially in ‘red zone’ areas, by reducing the number of carriers. Prevention may also include assisting the construction of and or repair of damaged sanitation and clean water systems to reduce the contact with bacteria. Governments should further invest in prevention strategies to reduce the, resource and financial, burden of providing medical treatment in areas with active conflict. By improving the living conditions of residents in these areas, mortality rates of civilians will significantly decline.

Although prevention is beneficial, the root cause of millions of preventable deaths in war-torn countries is conflict itself. If conflict were to cease infrastructure could be re-established, medical services could operate safely, and the economy could be stabilised. It is not enough to create temporary solutions based on aid provisions. The only way to ensure the health and well being of residents is to agree to ceasefire arrangements and negotiate peace treaties. Until these resolutions can be complete the onus falls up those in power, namely government bodies, to prioritise health care above military gain. Without adequate health care and protection from preventable diseases human suffering will continue to rise. As more people require curative treatment, the burden upon the already struggling health care systems also climbs. However, by supporting civilian health care and ending conflict governments not only gain loyal supporters but also an active workforce to regenerate the economy of the country. After all, if you don’t have your health – you don’t have anything.