As Russian troops cross into Ukraine, we need to remind ourselves of the impact of war on healthBMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o499 (Published 25 February 2022) Cite this as: BMJ 2022;376:o499
The effects of war on health are both intimate and general. Health impacts are immediate—people are wounded and killed—and then the impacts ripple outwards, in space and time. The repercussions echo through individual lives and, all too often, down the generations. In the first minutes, hours, and days of a hot war, physical trauma is primary: individual human bodies are mutilated by the ferocity of modern munitions. Lives end or are changed forever. For all the talk of “smart” weapons, and targeted attacks, the first onslaughts are seldom restricted to combatants. Recent conflicts, such those in the greater Middle East, have sucked huge numbers of citizens into the maelstrom, with devastating effect. Conflicts in Rwanda and Kosovo in the 1990s saw as much as 90 per cent of fatalities among civilians. It is difficult to comprehend the scale of slaughter unleashed by industrial and technological war: the 20th century saw an estimated 191 million conflict related deaths—approaching half the current population of Europe.1
The health impacts of war do not stop with trauma from the fighting. Crude estimates suggest that for each person killed directly by war, nine will be killed indirectly—although much will depend upon the nature of the conflict and the underlying conditions for health in the countries in which it is fought.2 War degrades environments. Recent conflicts in Syria and Yemen have seen the deliberate targeting of both built environments and the health services integral to them. Even if the Ukraine is spared direct targeting of its health facilities, the impact on health services and public health will likely be shattering, particularly if conflict spreads into urban areas. Civilian infrastructure is exquisitely vulnerable to modern conflict. With transport impeded, the flow of essential health goods interrupted, and health staff and patients unable to move, health outcomes, particularly and initially among pregnant women and young children, will rapidly deteriorate—we know that child and birth-related mortality are hit hard by armed conflict.3
Without a rapid halt to hostilities, a cascade of longer term health problems will be released. Where civilian infrastructure, including access to fresh water, sanitation, and a stable food supply are disrupted, infectious diseases re-emerge. Unsurprisingly, human behaviour changes during conflict and non-communicable diseases linked to riskier behaviour increase. The mental health impacts of the conflict are likely to be extreme. The Ukrainian people have been living with anxiety about the intentions of its powerful neighbour for many years. They watched Russia annex the Crimea, and wage proxy wars in the Donetsk and Luhansk oblasts in Eastern Ukraine. They know they are without direct western protection. And now, as a war of invasion gets under way, the mental health effects will be serious and enduring. Those directly caught up in the conflict will be at immediate risk of post traumatic stress disorder, but depression, anxiety, and other stress-related conditions, including alcohol and drug misuse will also increase, and once again these may have life long and even inter-generational impacts.
As we know from recent conflicts, the health effects of war can be displaced far beyond the borders of the countries involved. Among the most significant global issues in health and human rights arises from the health needs of millions of people displaced by modern conflict. People leaving war zones take their trauma with them. They suffer appallingly on the migrant routes into the more stable parts of the world. They are prey to a range of infectious diseases, they struggle to find nutritious food and housing that can support health.
The people of the Ukraine have been victims of successive brutal regimes. In the Holodomor, or great famine of 1932-33, three and a half million Ukrainians were killed by Stalin’s deliberate policy of starvation. Hitler invaded the Ukraine in June 1941—three and a half million Ukrainian citizens were killed during the years of German occupation. Millions more Ukrainians died as soldiers in the Red Army. Once again Russia seeks to incorporate it, whatever the cost in human suffering. No surprise that historian Timothy Snyder called his book on the Ukraine and its surrounding territories Bloodlands.
War destroys more than bodies and minds. It tears up the roots of human wellbeing, rips the fabric of human community, severs bonds between people and the places they inhabit. And it leaves an enduring legacy. War contaminates places of human habitation physically and psychologically. Traumatic memory can make the search for peace impossible. And without peace there can be no real hope of human health or flourishing. This invasion is not just a tragedy for today’s Ukrainians. It will also lie heavily on the wellbeing of future generations.
Competing interests: none declared
Provenance and peer review: commissioned, not peer reviewed