Health crises in fragile states need urgent attention

While the world remains focused on the COVID-19 pandemic, a pandemic of conflict continues to undermine the health of billions of people around the globe

January 21, 2022 by Paolo Chekhov
People start to rebuild shelters among the burnt-out remains of a part of Cox’s Bazar refugee camp for Rohingya people that was destroyed by fire. Bangladesh, March 2021. Photo: MSF/Pau Miranda

Health crises spiked by conflict continue to rage across the world. OECD’s States of Fragility report defined 57 countries and territories as fragile contexts in its 2020 atlas. The term ‘fragile states’ is used to describe a context of conflict-affected situations: these situations may exist for an indefinite period of time, often lasting for years. For the people living in conflict-ridden areas, this status quo also means struggling with poverty, malnutrition, gender violence, epidemic outbreaks, large-scale displacement, and so on. All these issues have direct and/or indirect bearing on the health of the population.

About 23% (1.8 billion) of the world’s population live in such contexts, which also constitute 76.5% of the world’s population living in extreme poverty. With the advent of COVID-19, life in conflict areas, especially when it comes to matters of health and its wider determinants, such as hunger and gender equality, is getting more and more difficult. Although such determinants are formally recognized as important indicators in the context of global development, for example under the Sustainable Development Goals (SDG) framework, significant action by high-income countries and international organizations is lacking, as illustrated by recent testimonials about widespread hunger in Afghanistan.

Link between conflict and poor health

The political turmoil of fragile states triggering health catastrophes require a much greater degree of attention both in global public discourse and international policy dialogues. The causal chain between poor health, fragility and conflict is well recognized. Approximately 60 per cent of the world’s child and maternal deaths occur in conflict situations.

And while conflict situations will hardly be eradicated while the Global North continues to pursue its own interests at all costs, there have been attempts lately to nudge humanitarian work towards a focus on health outcomes, the strengthening of states, and their right to development. Interventions in health have many positive externalities in the contexts of fragile states: health systems strengthening aids in peace making, state building, and stability enhancement, which inevitably give the state support for creating its social contract.

Recently, international bodies have been devising two-fold strategies to address the crises of fragile states. First, they have come together to craft a coordinated response in tackling health calamities. This attempt is represented by the Partnership Framework for Crisis-Affected Situations, signed between the United Nations (UN) and the World Bank in 2017 to put forth joint operational commitments for enhanced ground-level impact in 50 conflict-affected contexts.

Secondly, multilateral and bilateral partners have been crafting a new form of aid coordination to accommodate humanitarian relief, development programs and peace making in one frame. In this regard, the aid harmonization mechanism called “humanitarian-development-peace nexus,” developed in 2019, is envisaged to address the “vulnerability of people before, during and after crises.” Nonetheless, there is only fragmentary evidence how these experimental mechanisms are addressing the root causes of state fragility and embarking on the path of revival of the state structure.

While programmatically, international institutions are seeing this as an opportune moment to institutionalize the development assistance in health under the framework of the humanitarian-development-peace nexus, the fact remains that the vulnerability factors involved in fragility and conflict situations are not only multidimensional, but also correlated to the overall approach to international development, still dominated by the interests of rich countries.

Intervention in health could, perhaps, be a strategy to address these ever-escalating factors in a more holistic approach in the context of international frameworks. But the financing of health systems in conflict-affected situations needs to go beyond the conventional arrangement of investing in emergency medical aid. International and multilateral efforts should aim primarily at strengthening health systems, and invest strategically in social institutions which can address social determinants of health in a positive way, while preserving the right to self-determination of the local communities.

Different pathways ahead

The Eastern Mediterranean Region of WHO has identified three pathways of social determinants that have wider impact on health in the context of conflict: the violation of human rights in conflict-affected situations, disrespect to the clause of medical neutrality as mentioned in the Geneva Convention under Article 18, and the diseases (including injuries) acquired due to constant exposure to a life-threatening environment. The UN anchored Humanitarian Response Plan, like the one on Afghanistan, has also recognized the multidimensional approach of interventions in the context of conflicts. In this approach, health is seen as a principal clause of engagement to deal with issues like hunger, disability inclusion, gender based violence (GBV), child protection, accountability to affected people (AAP) and protection from sexual exploitation and abuse (PSEA). But advances on this front can hardly be imagined if the standard humanitarian response is not replaced by a different paradigm, which not only covers the crucial service-related gaps but contributes to the strengthening of the state’s structure.

The global health community needs to take a deeper drive to prioritize this global health crisis. The international mobilization behind the pandemic treaty convention indicates the emergence of political interests in patronizing the security paradigm in global health. This might be the right time to reconsider how security is conceptualized in the international community, and what can be done to change this.

In this context, conflicts are first and foremost a political problem, making the response to these situations political as well. Any form of aid is always an external support to meet the gap in service delivery, often short-term. The health of populations can not be reduced to only service delivery. It is intrinsically linked to the well-being of the mental, social, and physical states of the people living in any context. At the time of growing political conflict all over the world, there is a requirement of a new framework that can bring us closer to political solutions to the crisis. Global health could be a catalyst in this case to build social solidarity, bring collective participation, ensure human rights, and meet the health care needs of the people with dignity and respect.

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Paolo Chekhov is a student of global policy and social medicine, a former struggling footballer and current aspiring writer.