There’s a bit of controversy surrounding “The Human Security Report,” (HSR) published a couple of weeks ago by Andrew Mack and colleagues at Simon Fraser University. It suggests that improvements in public health over the last few decades have continued to lower mortality rates in many African nations, even during times of war. Looking at Figure 2.1, it just seems counter-intuitive that Under-5 mortality would not increase in more countries during periods of conflict.

Epidemiologist Les Roberts (Columbia Univ.) argues forcefully that the report is not very good scholarship (to put it kindly). In his words, “this report draws unjustified conclusions and will leave the world more ignorant and misguided for its release.” Ouch. Roberts makes a strong case to back up his statement, including points like this:

1. A major problem seems to be that Mack et al. have chosen a definition of war that could skew the findings by including very low-intensity conflicts with just 25 killings per year. Roberts argues that “If war was instead defined as occurring in a population where 0.1% was violently killed in a year, I strongly suspect almost all of the HSR conclusions would reverse.”
2. The wars included in the analysis appear to be cherry picked. For example, if Mack argues that mortality continues to decline during war because the nature of war has changed, then Roberts asks (rightfully) why Iraq and Afghanistan were excluded from the analysis. Or, what is the logic in “treating a minor conflict in Senegal with equal weight as the war in Angola”?
3. Roberts also states that “The HSR claims war does not stop the usual mortality decline seen in most poor nations, but then does not study or report on those people affected at the times of war.  The report looks at entire nations where you admit a tiny fraction of people are affected for a tiny fraction of the study period and draw conclusions with data so crude and general as to be meaningless.”

Maybe Mack et al. bring some good news to the table, which is that most wars have been sufficiently limited in scope in recent decades (compared to WWII) to not be able to outweigh the progress made in public health, such as through improved vaccination campaigns and humanitarian intervention. On the other hand, as Roberts pointed out, maybe we shouldn’t be calling those low-intensity conflicts ‘wars’ in the first place. The HSR perhaps also shows the limitations of using national data. Those persons living in severely affected areas of a country (like eastern DRC) surely don’t care that national mortality rates have declined from the 1970s. So much research shows that health deteriorates for war-affected segments of the population ( injury, nutrition, childhood growth, psychological trauma, infection, etc.) that it just seems misguided to highlight, as the HSR does, that: “nationwide death rates actually fall during the course of most of today’s armed conflicts.”

To be fair, the HSR authors stated that “we stress that we do not for a moment dispute the overwhelming evidence that conflict-exacerbated disease and hunger leads to sharply increased death tolls in war zones and among conflict-displaced populations” (p. 18). A huge problem, however, is that we live in a soundbyte society, and the headline in this case (basically, ‘wars are getting better’) could lead at least some people to think that the effects of war are largely behind us. We KNOW that war is an indisputable public health problem. Any deviation from that message just muddies the waters.