Ukrainian citizens crossing an improvised path under a destroyed bridge while fleeing Irpin on March 8. More than 4 million Ukrainians have fled the country and 6.5 million are estimated to have been displaced within the country as a result of the war. AP Photo/Felipe Dana

Public Health

School of Public Health Explores the Health Consequences of War

As the war in Ukraine continues, experts from across the globe weigh in on the impact of armed conflict on civilians and healthcare systems

As the war in Ukraine continues to unfold, the world is bearing witness to the terror and trauma being inflicted on the Ukrainian people.  

On March 29, the BU School of Public Health hosted The Health Consequences of War, bringing together experts who have studied other conflicts around the world for a virtual discussion on the long-term effects of war on the health of populations.

“War harms health in a range of ways, in both the near- and long-term,” said Sandro Galea, SPH dean and Robert A. Knox Professor, in his opening remarks. “With the outbreak of war in Ukraine, we have a responsibility in public health to shine a light on these consequences and make the case that a healthier world is one without war.”

The event speakers detailed the consequences of war on civilian health and the destabilizing nature of modern warfare and its attacks on schools, health facilities, and the fabric of day-to-day life.

Theresa Betancourt, Salem Professor in Global Practice at Boston College, began the discussion with an overview of the mental health impacts of armed conflict on children and families, highlighting the trauma’s intergenerational impact. She emphasized that the attacks on places where children learn, grow, and thrive has implications for both their immediate survival and their access to education and other critical life opportunities.

“We were already facing the largest humanitarian crisis since World War II prior to the events in Ukraine,” she said. “Now, estimates from UNICEF show that children living in conflict zones has risen by 74 percent in the last decade. And in Ukraine alone, we have seen 4.3 million children both internally displaced and displaced as refugees.

“This is not a side issue. This is a central public health issue.”

Although children exposed to war suffer from higher rates of traumatic stress reactions, depression, anxiety, and high-risk behaviors, Betancourt emphasized that there is still a lack of research surrounding the impact of war across the life course, as well as around post-conflict protective factors.

“While there are now a growing number of evidence-based mental health interventions for children and families affected by armed conflict, the real challenge going forward is figuring out how we scale up, scale out, and ensure sustainable, high-quality mental health services and systems strengthening for the many in need,” Betancourt said. “We need innovation, and sometimes out of low resources settings comes the most amazing innovation, integrating into employment programs, social protection programs, education programs, and more.”

Abdulkarim Ekzayez, a King’s College London senior research associate and co–principal investigator for the Research for Health System Strengthening in Northern Syria Project, and Larissa Fast, University of Manchester executive director and professor of humanitarian and conflict studies, discussed the health consequences of attacks on the healthcare system.

Ekzayez, formerly a medical doctor in Syria, said that since the start of the Syrian conflict in 2011, there has been severe disruption of health services, leading ultimately to a collapse of the health system in most conflict-affected areas. These attacks on healthcare pose serious threats across the country, cutting off access to care for civilians and forcing healthcare workers to literally work underground to provide care to those who need it.

“Unfortunately, we are seeing a similar pattern of attacks play out in Ukraine,” he said, adding that there is much to be learned from a policy perspective from Syria. “There have been more than 76 attacks reported by the [World Health Organization] since the start of the Russian campaign. We cannot continue to allow this to happen.”

“Far too often, those who perpetrate these relentless attacks go unpunished, and civilians pay the price,” said Fast, noting that according to the WHO, more than 1,000 health facilities in Ukraine are close to the conflict or within areas of changed power and control, which has left many civilians with limited or no access to medicines, facilities, or health professionals, and the treatment of chronic conditions has almost entirely stopped.

Fast also emphasized that while we can think about the impact of war and attacks on health and healthcare in many different ways and at many different levels—for example, the impact of war on the mental health of healthcare workers or that of supply chain disruption on health facilities—there is still work to be done to adequately document and understand the extent of their long-term impact.

Panelist Amir Khorram-Manesh, a University of Gothenburg professor and senior university lecturer, said that since the turn of the century, we have seen a transition from conventional wars that follow international rules and regulations to hybrid wars and terrorism that do not follow traditional rules. Instead, these new conflicts target opponents’ weak points, including their civilian population, and spread misleading information, target social and cultural life, and attack infrastructure, hospitals, and water sources.

The impact of hybrid wars is devastating, Khorram-Manesh said, resulting in disrupted roads, water supply, and food access, the overall loss of public safety, and mass migration, all affecting overwhelmed healthcare systems.

“There is no definitive solution for such issues. The only solution is to stop wars,” he said.

As the event drew to a close, moderator Tiziana Dearing, host of WBUR’s Radio Boston, asked speakers to reflect on current events and their work to determine where we can go from here.

“As someone who has worked in post-conflict Sierra Leone,” Betancourt said, “we cannot continue to wait to think about building back and strengthening systems. As a field, we have let this gap happen, where there is a humanitarian response and then we wait for the development community to pick up the pieces later. We need to stop operating in that manner.”

Watch a recording of the SPH panel session here.