Public Health and Armed Conflict: Immunization in Times of Systemic Disruptions

"In order to design effective immunization and other public health campaigns in areas plagued by armed conflict, one needs a more nuanced understanding of how violence impacts children's immunization rates."

Armed conflicts and other emergencies have for a long time been a concern for human development and public health, particularly in sub-Saharan Africa (SSA). Vaccination programmes can be highly politicised and subjected to major security constraints in war zones, reducing their effectiveness. This article studies how armed conflict impacts immunisation rates among children, using health data for 15 conflict-affected countries in SSA, including multiple Demographic and Health Survey rounds for most. It also offers policy implications for the design of postwar immunisation strategies.

The article reviews existing evidence on ways in which armed conflict may impact both the supply and demand sides of vaccination. Supply-side factors include declining public expenditures on health, increased logistical challenges, direct targeting of health infrastructure and personnel by the warring parties, and displacement of populations to areas with weak health infrastructure. With regard to demand, armed conflict may create a general lack of public trust in the public health system, affecting international and/or governmental organisations that run vaccination programmes. A particular challenge is vaccination refusal based on religious and/or cultural issues that may become more salient during conflict.

Thus, careful planning and policy design specific to conflict environments is needed in the face of deep mistrust. The polio eradication campaign in the Democratic Republic of the Congo in 1997 is a successful case in point in this regard. The United States Agency for International Development (USAID) managed to use back-door channels to develop relationships with rebel leaders and persuaded them that vaccination would be welcomed by parents, carried no costs, and was supported by the international health community. Vaccination campaigns may be successful when they are supported by the warring parties. Prior to the Central Intelligence Agency (CIA) plot against Osama bin Laden, the International Committee of the Red Cross had convinced the Taliban spiritual leader, Mullah Omar, to sign a letter ensuring polio vaccination staff safe passage through Taliban-controlled areas.

The research exploits the fact that age-appropriate vaccinations should take place in the child's first year of life and compares children aged one to five with varying degrees of (local) conflict exposure in their first year of life within the same countries and communities. It differentiates between the effects of local- and country-level exposure to conflict on childhood immunisation rates. The main outcome variable is a child's complete immunisation rate, while the main independent variable is conflict intensity, measured as the number of conflict-related events and the number of battle-related deaths (scaled by 100) that occurred in the first 12 months of a child's life within a 25-kilometre radius of the child's current residence. The analysis controls for key household characteristics that affect demand for immunisation, such as mother's education, age, fertility variables, and household wealth.

The regression results suggest that conflict exposure does not have a significant impact on the child immunisation rate generally. However, once the conflict event count metric is replaced with conflict intensity, measured as the number of deaths, there is a small but statistically significant impact of conflict intensity on the child vaccination rate. Further, when the researchers differentiate between exposure to "minor" and "major" conflict intensity, they find that children exposed to the minor (major) conflict have significantly higher (lower) completed vaccination rates. They infer that, at low levels of conflict intensity, government and international organisations may increase health supply in the affected areas. At high levels of conflict intensity, reduced access to affected areas for national and international health providers may instead cause severe disruptions to the health systems. Furthermore, during times of extended, high-intensity civil war, funding for health care may be shifted away to finance the war economy.

Overall, the results suggest that exposure to a major conflict decreases a child's chances of completing the full World Health Organization (WHO)-recommended vaccine schedule, and this effect is driven by the national channel, while minor conflict may have a positive impact on immunisation, possibly driven by an increase in aid. Literature cited here indicates that some of the key success factors in immunisation programmes during conflict include: an exclusive focus on the immunisation of children; neutrality; transparency about the aim of the campaigns; inclusion of diverse political groups in facilitating campaigns; a concentrated effort in time to take advantage of temporary ceasefires; and the undercommunication of any political or strategic goals beyond disease prevention.

As nonmigrant children's immunisation is less impacted by conflict, the researchers recommend increased attention to how vaccines are being made available to migrant populations, who may fall through the cracks and have lower access to services. In particular, addressing the particularities of health services provision in various camp settings is key to understanding how to improve immunisation of children in displaced households.