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Indirect effects on health
A wide variety of indirect effects on health arise from the disruptive social changes accompanying collective violence. Collective violence typically creates population displacement and a substantial degradation of social infrastructure such as health care systems and food production and distribution networks. Not infrequently, life sustaining infrastructure of civilian populations is specifically targeted in conflicts through acts such as execution of health care workers, and destruction of food and water distribution complexes. Research in these settings has shown a significant reduction in indicators such as vaccination status which accompany collective violence.
While it is difficult to estimate the burden of health effects that are attributable to these changes with precision, available evidence suggests they are substantial. Crude mortality rates in displaced populations fleeing collective violence have been reported at 5 to 12 times above baseline rates, and were substantially higher among those fleeing the Rwandan genocide who arrived in Goma. The primary causes of death in these circumstances are communicable diseases and malnutrition, and the incidence of AIDS in Africa is thought to have increased considerably as a direct result of civil wars. Over and above morbidity and mortality related to communicable disease and malnutrition a broad range of other health outcomes have been documented in populations exposed to collective violence, including sequelae in the domains of psychosocial, disability and reproductive health.
Due to the nature of collective violence, it seems reasonable to expect that these indirect health effects would not be limited to the time period during which violence is occurring. A recent statistical assessment using cross sectional data indicates that the total disability adjusted life years lost in 1999 due to the indirect effects of collective violence occurring between 1991 and 1997 was about the same as the number lost through direct effects of collective violence in 1999.
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