No global health without peace: from Afghanistan to Ukraine violence casts long shadows in the 21st century

Some of the articles in this issue of Medicine, Conflict & Survival cover conflicts in Libya, the Democratic Republic of Congo, Somalia and Afghanistan, all reminders that - despite the understandable domination of the conflict in Ukraine in the media – longer running armed conflicts and situations of chronic insecurity continue to have terrible and accumulative health consequences for those affected. No doubt there will be articles on Ukraine in the future.

It is perhaps a lazy excuse to say that truth is always the first casualty of war, and it can be expected that those actively involved in conflict will put out their own version of events. However, it does seem that the awfulness of the Ukraine invasion has created completely different narratives put out by ‘independent’ journalists, think tanks and public commentators, and many of these narratives do not concentrate on the urgent need for a rapid and peaceful resolution.

There are so many reasons not to stoke the fires of the Ukraine war. The health consequences of a prolonged conflict are enough but the danger of – a possibly accidental – use of nuclear weapons would multiply those consequences drastically. As the Joint International Health Statement for the 1st Meeting of States Parties of the Treaty on the Prohibition of Nuclear Weapons states: ‘Diplomacy is urgently needed to remove the danger of nuclear escalation in the current crisis, and needs to progress to negotiations among all nuclear-armed states to eliminate their nuclear arsenals under strict verification and timelines’ (IPPNW 2022).

Nutritionally, those countries whose citizens are already at risk face a perfect storm that they have done the least to create. Countries whose citizens have the smallest carbon footprints, and who were treated as last-in-line for vaccines during the COVID-19 pandemic, will be catastrophically affected by the present rise in food prices and food accessibility globally. The 135 million people facing acute food insecurity has risen to 276 million since 2019, and 48.9 million people are facing emergency levels of hunger in May 2022 (WFP 2022). Russia and Ukraine supply 28% of globally traded wheat, 29% of the barley, 15% of the maize and 75% of the sunflower oil (The Economist 2022). If the stocks presently unable to be exported out of their warehouses due to blockades and mined waterways are going to move, it will take talks and collaboration, not more aggression and supply of arms.

If there is anything positive to come out of the Ukraine conflict, it is the welcome that has been extended to Ukrainian refugees. This has, however, also exposed some staggering double standards in the response to those fleeing war and armed conflict. Refugees from elsewhere are dying of exposure in forests (MSF 2022) and drowning in the Mediterranean or the English Channel (Lee and Faulkner 2021). The British Home Secretary claims that many trying to cross the English Channel are ‘economic migrants’ and not fleeing because of conflict (Independent 2022); yet, her own department’s figures show that Afghanis make up the largest national group trying to cross the English Channel – a country devastated by a high-profile conflict (Lee 2022). The welcome given to Ukrainians should set the standard.

Two of the commentaries in this issue reflect the current and anticipated health situation in Afghanistan since the takeover of the government by the Taliban in late 2021. Essar et al’.s Poor healthcare capacity in Afghanistan amidst a surge in COVID-19 cases and a humanitarian crisis and Ahmadi et al’.s Taliban takeover of Afghanistan: what will be its impact on healthcare both make key recommendations and show the absolute necessity of continuing to engage for the health of the Afghan population.

The mental health and psychosocial damage caused by conflict receives considerably more attention than it used to, although the implications of long-term insecurity are less researched. Two commentaries in this issue look at this problem in Libya (Gaffaz et al. Libya: mental health challenges a decade after the Arab spring) and Somalia (Essar et al. Implications of conflict on mental health in Somalia and beyond). These situations of on/off conflict and prolonged insecurity must be particularly challenging for those who live through them and should add to the mountain of evidence that true peace is urgently needed. The particular effects on the mental health of those whose loved ones have simply disappeared – over 48,000 documented across the continent of Africa – is clearly described in Ajagbe et al.’s The disappearance of loved ones and its psychological impacts in Africa: an ignored cankerworm. Described as ‘unconfirmed loss’, uncertainty and guilt are just some of the complex emotions experienced.

Sexual and gender-based violence (SGBV) linked to armed conflict has also received far more attention in the last few decades, and while it is increasingly recognized that this does not only affect women, research into the consequences for men is limited. The article in this issue by Alexandre et al. A man never cries: barriers to holistic care for male survivors of sexual violence in eastern DRC makes an important contribution to the research, developing a conceptual framework that includes seven levels of barriers to care to help address this issue.

This journal has recently published articles on the consequences of the conflict in Colombia and the ongoing peace process (Caicedo and Arriola 2022; Bonilla-Escobar et al. 2021). Tovani-Palone et al.’s commentary Colombia protests amidst the COVID-19 pandemic: implications and recommendations in this issue covers the Colombian governments attempts to respond to the COVID-19 pandemic and subsequent public reaction, and makes recommendations for the way forward.

Positive results from research in Somalia illustrates how solar power in the low resource setting of a general hospital can help save lives: Implementation of solar powered oxygen delivery in a conflict zone: preliminary findings from Somalia on feasibility and usefulness by Hawkes et al. shows the potential for this use of solar power even in an unpredictable conflict situation. Particularly useful in the time of the COVID-19 pandemic, it is also essential in the treatment of many hypoxaemic conditions and post-operatively.

Book reviews cover two key texts on subjects which are central to this journal: attacks on healthcare and nuclear deterrence. A review of Perilous medicine: the struggle to protect healthcare from the violence of war by Leonard Rubenstein – who as Chair of the Safeguarding Health in Conflict Coalition is eminently qualified to write it – recommends it as essential reading for anyone concerned about this subject. John Loretz’s review of Supreme emergency: How Britain lives with the bomb, by Andrew Corbett, expresses some real concerns about this book and unpicks in detail the author’s justification of nuclear deterrence: reading for anyone needing to argue against ongoing attempts to justify the ownership of nuclear weapons.

Thank you to all the authors who have contributed to this issue and to our readers for their support.

Disclosure statement

No potential conflict of interest was reported by the author(s).