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Women, children, and adolescents living in humanitarian and conflict contexts must not be forgotten

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By Jennifer Requejo, Pauline Irungu, Jonathan D. Klein, Sophie Arseneault, and the PMNCH Accountability Working Group

This year’s Lives in the Balance Summit on 19 May 2022 on delivering for women and children in humanitarian and conflict settings is highly attuned to current events. The Summit is happening as we enter the third year of the COVID-19 pandemic, which has resulted in profound disruptions to health care systems, social and educational services, and economies around the world. The pandemic’s long-term toll on the health of women, children, and adolescents remains unknown. It will likely vary across and within countries, exacerbating persistent inequalities in access to essential services, life opportunities, and health and development trajectories, leaving the most vulnerable women and children further behind.

At the same time, the year preceding the Summit has been punctuated by record-breaking high temperatures and weather-related catastrophes linked to climate change. Those natural disasters along with the Ukraine crisis have driven sharp increases in food insecurity and the displacement of millions of families. Rising political and economic instability in many countries also present an acute threat to women’s, children’s, and adolescents’ health and well-being that will top the Lives in the Balance Summit agenda.

These three existential threats to health and well-being – climate change, conflict, and the COVID-19 pandemic – are deeply intertwined. Events related to climate change, for example, can result in greater political instability as populations clamour for increasingly scarce resources such as safe or reliable water or are forced to leave their homes. A warming planet will also potentially expand the geographic reach of existing scourges like malaria and create conditions conducive to the emergence of new pathogens with pandemic potential. The COVID-19 pandemic has shown how disease outbreaks can further destabilize already weak governance structures and health care infrastructures in many low- and middle-income countries as well as erode trust in government and medical institutions in high-income ones when communication from political leaders is inconsistent.

Evidence on conflict shows staggering negative impacts on women’s, children’s, and adolescents’ lives. Half of the 54 countries that are off track for achieving Sustainable Development Goal (SDG) target 3.2.1 on child mortality – under-5 mortality at least as low as 25 per 1,000 live births by 2030 – are considered fragile or conflict-affected (1), as are about 39 per cent of countries for meeting SDG target 3.2.2 on reducing neonatal mortality to at least as low as 12 per 1,000 live births (1). It is telling and discouraging that the five countries with the highest maternal mortality (Afghanistan, Central African Republic, Chad, Somalia, and South Sudan) are all experiencing or recovering from conflict (2).

Similarly, a recent analysis found that women of reproductive age living near high-intensity conflicts experience three times higher mortality than women living in peaceful contexts (3). Women, children, and adolescents are often unable to access essential health care during conflict situations because health care facilities are frequently destroyed; health care workers have fled or otherwise stopped working due to fear, non-payment of salaries, or lack of other kinds of necessary support; and health care and aid workers are often accidental or intended victims of attacks by conflict participants (4).

Those already-vulnerable women, children, and adolescents are also at higher risk of gender-based violence, human trafficking and other forms of exploitation than their peers residing in stable settings (5). The toxic stress of living in a conflict zone also can persist long after the conflict subsides, rendering those who have experienced conflict vulnerable to poor mental and physical health, long-term detrimental developmental consequences, and negative intergenerational effects (6, 7, 8).

The Ukraine situation has rightly captured the world’s attention and the barrage of media coverage has vividly portrayed the horrific effects of the conflict on Ukrainian citizens. Yet, many other countries (e.g., Ethiopia, Afghanistan, and Yemen among others) are in the throes of long-standing or recent armed conflicts and civil strife, and the plight of women, children, and adolescents living in them should not be overlooked as much of the world focuses on Ukraine.

Potential solutions through partnerships

Many of the solutions to sustaining and building resilient health care systems in conflict settings are also relevant to addressing disruptions caused by disease outbreaks, natural disasters, and climate change. Together, the global community can make a difference and each stakeholder has an important role to play – including those highlighted below – in ensuring women, children, and adolescents in fragile and conflict-affected settings receive the care they need and are not forgotten.

  • The United Nations should facilitate a peaceful resolution to any existing conflict and, as necessary, should support the establishment of humanitarian corridors for delivery of assistance and safe extraction of civilians trapped in conflict zones. The international community led by the United Nations should also coordinate delivery of humanitarian aid and ensure that all parties involved in a conflict are abiding by international humanitarian law.
  • Government leaders should take more collective responsibility for moving more rapidly and in a coordinated manner to prevent and mitigate the effects of global health crises throughout the world. Toward that end, there have been multiple calls in response to the COVID-19 pandemic for the establishment of a heads of state-led global health emergency council (9). This year’s World Health Assembly, to be held from 22–28 May, provides a forum for discussions on the governance and operationalization of such a council, which would have relevance for coordinating response efforts to conflicts and for stimulating development of innovative policy and programmatic solutions.
  • International and local non-governmental organizations (NGOs) are essential to address roadblocks to service delivery during conflict situations due to insufficient capacity on the ground. They can work together with regional, national, and local partners to determine what services are most needed and how to deliver them most effectively and efficiently in specific contexts. NGOs have a particularly critical role in elevating the voices of communities, given enhanced power imbalances in humanitarian and conflict settings; NGOs can also work with media partners to raise visibility about the conditions of women, children, and adolescents living in a conflict situation and provide a watchdog function as needed on health and human rights issues (10) (11).
  • Health care professional associations are critical stakeholders in maintaining and rebuilding sustainable health systems in conflict settings and should be included in planning discussions at all levels – global, regional, national, and local.
  • Academic and research institutions can help with generating evidence on the impact of a conflict on women’s, children’s, and adolescents’ lives and on the effectiveness of strategies for delivering health care services in specific humanitarian situations. This evidence should serve as a basis for programmatic and resource allocation decisions well as for documenting human rights violations such as obstruction or denial of access to health care.

The 2022 Lives in the Balance Summit will be held shortly before and as a side event to the World Health Assembly. The Summit is an opportunity for member states to convene and discuss strategies for alleviating the suffering of millions of women, children, and adolescents caught in the crossfire of conflicts and other humanitarian disasters.

We are all accountable for ensuring that women’s, children’s, and adolescents’ voices are heard, that they get the services they need, and that they can survive and thrive. We call on all countries to honour their commitments to the Sustainable Development Goals, including the overarching imperative of preventing harm of all kinds to women, children, and adolescents wherever they live, and to work together to reach our common goals for a peaceful, equitable, and prosperous world.

References

  1. United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), Levels & Trends in Child Mortality: Report 2021, United Nations Children’s Fund, New York, 2021.
  2. United Nations Inter-agency Group for Maternal Mortality Estimation (UN MMEIG), Levels & Trends in Maternal Mortality: 2000-2017, World Health Organization, Geneva, 2019.
  3. Bendavid, Eran, et al., ‘The effects of armed conflict on the health of women and children’, Lancet, 6 February 2021; 397:522-532.
  4. Clark, Helen and Kaljulaid, Kersti, ‘Women, children, and adolescents face extreme vulnerability in conflict – and so do the health workers striving to protect them’, BMJ, 25 April 2022; 377 :o1041.
  5. Clark, Helen, ‘A commitment to support the world’s most vulnerable women, children, and adolescents’, Lancet, vol. 397, 6 February 2021, pp. 50-451.
  6. Abbasi, Kamran, ‘Climate, pandemic, and war: an uncontrolled multicrisis of existential proportions’, BMJ, 17 March 2022; 376:o689.
  7. Bendavid, Eran, et al., ‘The effects of armed conflict on the health of women and children’, Lancet, 6 February 2021; 397:522-532.
  8. Bhutta, Zulfiqar A., Keenan, William J. and Bennett, Susan, ‘Children of war: urgent action is needed to save a generation’, Lancet, 24 September 2016;388(10051):1275-6.
  9. Independent Panel for Pandemic Preparedness and Response, COVID-19: Make it the Last Pandemic, 2021. https://theindependentpanel.org/mainreport/, accessed 10 May 2022.
  10. Schaaf M., et al. (2020). Accountability strategies for sexual and reproductive health and reproductive rights in humanitarian settings: A scoping review. Conflict & Health 14, 18.
  11. https://www.globalhealthvisions.com/docs/in-brief-evidence-on-the-role-of-social-accountability-in-advancing-women-children-and-adolescents-health.

Accountability Working Group members (in alphabetical order): Sana Contractor, Nourhan Darwish, Theresa Diaz, Lucy Fagan, Smita Gaith, Vineeta Gupta, Susannah Hurd, Dan Irvine, Mande Limbu, Jaideep Malhotra, Harriet Nayiga, Oyeyemi Pitan, Petrus Steyn, Miriam Sangiorgio, Goknur Topcu, Jennifer Requejo (co-chair), Pauline Irungu (co-chair), Jonathan D. Klein (vice chair), Sophie Arseneault (vice chair, under 30 years of age), Ilze Kalnina (PMNCH Secretariat). Petra ten Hoop-bender (UNFPA) also contributed to the blog.