The human consequences of war

Addressing the physical and mental health effects of conflict.

War has long been a tragic constant of human history. The past is a record of much progress, but it is also, in large part, a litany of violent struggles waged throughout the centuries. In the present moment, conflicts around the world rightly command our attention. With all wars, there are a range of complexities—historical, political, strategic—that inform the emergence of conflicts. It is important to resist easy narratives and the tendency to dehumanize that is so much a part of war and always has been. It is easy, when we speak of war in the language of strategy and geopolitics, to lose sight of what war actually is: the shattering of individual lives. Behind every statistic is a person—a parent searching for a child, a doctor working without supplies, a family fleeing with nothing but what they can carry. War is not an abstraction. It is real people, real bodies, real grief, and the pain does not confine itself to the boundaries we draw on maps or the timelines we impose on conflicts. It is in times of war, then, that it is more necessary than ever to engage with nuance, to seek the facts, to read and think widely about the forces shaping the global ruptures that lead to conflict.

It is also essential, when conflicts emerge, for us to talk about them, to not look away, because there are members of all communities, including our own, who are affected by them. So, while we have a responsibility to the world to address conflicts when they happen—like the wars in Ukraine and Gaza and the conflict in and around Iran—we also have a responsibility to our own communities to engage with what we are seeing, with the shock and uncertainty of the moment.

This means, centrally, thinking about war’s consequences for health. War is uncertain and can mean many things. Victory for some, loss for others. The redrawing of maps. The leaving in its wake a world more stable or more unsettled. We cannot know how conflicts will unfold, what their near- or long-term implications will be. What we can know for certain is that they will have consequences for health. It does not matter where the conflict occurs, the “precision” of the weapons used, the justice or injustice of the cause at issue. It is in the nature of war to undermine health, to bring suffering and death to many. Every war produces its own particular suffering—the injuries that reshape a life in an instant, the grief that settles into a community and does not leave, the quiet desperation of those who survive but find the world they knew has been erased. Understanding this, bearing witness to it, has always seemed to me our central responsibility in times of war, even as we act on this understanding to support health during conflicts and their aftermath. In the interest of bearing witness, then, some observations about the health consequences of conflict.

In the near-term, war threatens the physical and mental health of populations. Military action results in the death of soldiers, yes, but also of civilians, whether by accident, so-called “collateral damage,” or by design. The deliberate targeting of civilians by Hamas, for example, catalyzed Israel’s response in Gaza, which led to over 70,000 deaths, many of them civilians. War also often involves the destruction of vital infrastructure, which can include water and sanitation systems, communications networks, and transportation systems, any one of which is necessary for sustaining quality of life and health. The disruption of key services—from education, to food production, to healthcare—contributes to this context of poor health. When disease emerges in such contexts, the conditions of war make it harder to prevent and treat, allowing infections to take, and keep, hold. This was the case, for example, in World War I, when the 1918 flu pandemic posed a threat as deadly as any enemy. War also devastates economies, undermining further the material conditions necessary for health, and creating ripple effects which can affect cost-of-living throughout the world. The war in Ukraine, for example, significantly increased European energy prices, as Russia’s actions, and the retaliatory sanctions they provoked, roiled global energy markets.

A particularly insidious feature of war’s near-term effects is its intersection with what we might call “progress.” It is during war that new technologies are often applied to the purposes of death, or new advances are discovered and perfected in pursuit of battlefield success. In this sense, the more advanced we are as a species, the more devastating our wars, combining as they do the fruits of human reason with the persistent backwardness of elements of human nature. The American Civil War, for example, saw the rise of many new technologies, such as the Gattling Gun and ironclad ships. World Wars I and II were key in the development of air travel, as armies explored the uses of aerial bombing. Perhaps the most devastating, and consequential, intersection of war and technological progress came during World War II, which saw the development and use of the atomic bomb, a breakthrough which continues to threaten every life on earth. The conflict in Ukraine has seen leaps in the use of AI and drone technology, which will also likely characterize ongoing military actions in the Middle East. All of these advances reflect war’s ability to refine the capacity of human beings to harm each other in new, more devastating ways, posing threats to the health of populations and the sustainability of life on earth.

In the long-term, war can pose challenges for health that echo long after the guns stop firing. I have been engaged, along with colleagues, in the work of understanding and addressing the mental health needs of veterans, who often face physical and mental health challenges such as lost limbs, head trauma, depression, and post-traumatic stress disorder (PTSD), challenges that can be life-changing and lifelong. I have spoken with veterans who describe not just physical wounds but the way war reshapes the architecture of a life—the relationships strained, the sleep that will not come, the ordinary moments that suddenly feel impossible. These are not footnotes in the story of conflict; they are the story. Such challenges are not confined to service members. War also undermines the long-term mental and physical health of populations. This trauma can be multigenerational, shaping health in conflict zones for decades or more. About ten years ago, for example, I was part of a research team which studied PTSD patterns in Nimba County, Liberia. We found, more than twenty years after a civil war there, that PTSD patterns in the region roughly aligned with where the fighting had occurred. War’s long-term effects also include loss of education and opportunity for children as they grow up, a foreclosure of hope for adults and a limiting of possibilities for those who might once have had wider ambitions, which war narrows into the pursuit of basic survival. It is important to remember these long-term effects, particularly when we hear talk of “limited strikes” or the notion that war can be contained by plans and good intentions. War is dynamic, unpredictable. It may end soon, or it may stretch on indefinitely. No matter a conflict’s duration, however, its effects—its physical and mental toll on affected populations—will likely linger, undermining health long into the future.

I raise these consequences, both near- and long-term, as part of the necessary work of bearing witness, of not looking away when conflicts emerge. We also have a responsibility to help, in whatever way we can. This means, most pressingly, doing what we can to help address immediate suffering. Our capacity to do so when a conflict is ongoing is frustratingly limited, but there are many organizations we can turn to who do on the ground work in conflict zones to whom we can lend our support. We should also be mindful that while it can seem like conflicts are happening “over there,” citizens of affected countries are often in our midst, and we should do all we can to support them. In the present conflict, then, we should reach out to our colleagues and friends and to those who hail from neighboring countries currently facing the threat of war.

We can also help by supporting the long-term health of affected populations. We can do so through the work of population health science by generating the data on these populations to shape a clear picture of the mental and physical challenges they face in the wake of war. We also have a responsibility to address the ideological and historical roots of conflict. Wars do not emerge in a vacuum. Their antecedents can reach back decades, even centuries. The current war in Iran, for example, has roots in decades of history, which intersect with a range of ideologically-motivated actions, from US foreign policy intervention to Islamic fundamentalism, to the broader geostrategic maneuverings of great powers. It is on us to learn, to try to understand these factors to the end of contributing to a world that avoids future conflicts. It is particularly worth noting how wars can emerge from injustice that goes long uncorrected—as was the case, for example, with the American Civil War. This urges us to continue our work to build a better world wherever we see it, in the hope that, in doing so, we can deprive future conflicts of the fuel they need in order to rage.

I recognize, in writing this, that all that I have said is, fundamentally, words, and that in times of war, words can seem inadequate. They cannot stop a missile or rebuild a hospital or return a child to their parents. However, words are essential to the work of bearing witness and can help motivate and coordinate action to address conflicts’ effects in the present and future. Words are also core to the evolution of ideas, which are the ground from which much history, including historical conflicts, can spring. Working, then, in the ideas space, we can help to lay the groundwork for a global vision that leaves behind the conflicts of which we have seen too much, to build a future that is radically better, healthier, than our past.

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Also this week

In BMJ Injury Prevention:

Triggering Change: Evaluating the Impact of ATF Actions on Firearm Assault Rates in a Large US City – with Alexandria Byskosh, Annie Buck, Sophia Smith, Crisanto Torres, Tracey Dechert, Noelle Saillant, Joseph Sakran, Mark Seamon, and Dane Scantling

In Health Affairs Scholar:

Progress towards Healthy People 2030 population health goals – with Siddharth Kesiraju, Shriya Garg, Urvish Jain, Aditya Arkalgud, Edward Christopher Dee, and Joseph Kannarkat

Upcoming at WashU School of Public Health:

Join us on March 17 for the inaugural convening of “Better Ways of Knowing,” a multiyear initiative led by the Healthier Futures Lab at WashU School of Public Health, in collaboration with the Alliance for Health Policy and Systems Research. Learn more and register here.

ICYMI, in JAMA Health Forum Conversations, a discussion with Lanhee Chen about market-based solutions to improve US healthcare. Prior thoughts in JAMA Health Forum on a role for market forces in US healthcare.