During war, the news media often focus on civilian injuries and deaths due to explosive weapons. But the indirect health impacts of war among civilians occur more frequently—often out of sight and out of mind. OUPblog - Academic insights for the ...
During war, the news media often focus on civilian injuries and deaths due to explosive weapons. But the indirect health impacts of war among civilians occur more frequently—often out of sight and out of mind.
These indirect impacts include communicable diseases, malnutrition, exacerbations of chronic noncommunicable diseases, maternal and infant disorders, and mental health problems. They are caused primarily by forced displacement of populations and by damage to civilian infrastructure, including farms and food supply systems, water treatment plants, healthcare and public health facilities, and networks for electric power, communication, and transportation.
Increasingly, damage to civilian infrastructure is caused by targeted attacks—as a strategy of war, resulting in reduced access to food, safe drinking water, healthcare, and shelter. When water treatment plants and supply lines are damaged during war, people often have no choice but to drink water from sources that may be contaminated with microorganisms or toxic substances. Healthcare facilities have been increasingly targeted during war; for example, during the first 18 months of the war in Ukraine, there were 1,014 attacks on healthcare facilities, which injured and killed many patients and healthcare workers, and caused much damage, which reduced access to healthcare for many people.
Globally, there are now more than 108 million people who have been displaced from their homes, many as a result of war. Most of these displaced people have been internally displaced within their own countries, often facing greater health and security risks than refugees, who have fled to other countries. And during war, many more people live in continual fear that they may be forcibly displaced.
Major categories of communicable diseases during war include diarrheal diseases and respiratory disorders. These diarrheal diseases result mainly from decreased access to safe drinking water and reduced levels of sanitation and hygiene, leading to increased fecal-oral transmission of bacterial and viral agents. Among respiratory disorders, measles is of great concern because it is highly contagious and associated with high mortality rates among unimmunized children. Another major concern is tuberculosis, which can spread easily among war-affected populations and is difficult to treat without continuity of care. Crowding in bomb shelters, refugee camps, and other locations during war facilitates the spread of both diarrheal diseases and respiratory disorders. Disruption of public health services leads to reduced access to immunizations and reduced resources to investigate and control outbreaks of communicable disease. During war, bacterial resistance to antibiotics increases because people have decreased access to antibiotics and therefore take inappropriate antibiotics or shortened courses of treatment.
Malnutrition often increases during war, thereby increasing the risks of acquiring and dying from many communicable diseases. Infants and children are at greatest risk of becoming malnourished and suffering from its adverse health consequences. Micronutrient deficiencies during pregnancy can lead to birth defects. And severe malnutrition during war can increase the risk of hypertension, coronary artery disease, and diabetes in later life.
During war, exacerbations of preexisting cases of noncommunicable disease increase, mainly because of reduced access to medical care and medications for treating common chronic diseases. For example, a survey by the World Health Organization in Ukraine in 2022 found that about half of the respondents experienced reduced access to medical care and almost one-fourth could not acquire necessary medications that they needed. Without these medications, people with hypertension were at increased risk of myocardial infarction and stroke, people with asthma were at increased risk of life-threatening attacks, people with diabetes were at increased risk of serious complications, and people with epilepsy were at increased risk of seizures.
War exerts adverse effects on reproductive health. Access to prenatal care, postpartum and neonatal care, and reproductive health services are frequently decreased. As a result, complications of pregnancy, including maternal deaths, occur more frequently and there are increased rates of infant deaths and of infants being born prematurely or with low birthweight.
Mental and behavioral disorders occur more frequently during war, including posttraumatic stress disorder (PTSD), depression and anxiety, alcoholism and drug abuse, and suicide. There are many contributing factors to increasing the risk of these disorders, including physical and sexual trauma, witnessing of atrocities, forced displacement, family separation, deaths of loved ones, loss of employment and education, and uncertainty about the future.
Violations of human rights and international humanitarian law occur frequently during war. In addition to those already mentioned, these violations include gender-based violence, summary executions, kidnapping, denial of humanitarian aid, and use of indiscriminate weapons, such as antipersonnel landmines.
The possible use of nuclear weapons represents a profound threat whenever nuclear powers are engaged in war, partly because these weapons could be launched by accident or because of misinterpretation or miscommunication. Even a small nuclear war could cause huge numbers of deaths and severe injuries and could lower temperatures globally, leading to widespread famine.
Environmental damage during war can result from chemical contamination of air, water, and soil; presence of landmines and unexploded ordnance; release of ionizing radiation from nuclear power plants or conventional weapons containing radioactive materials (“dirty bombs”); destruction of the built environment; and damage to animal habitats and ecosystems. In addition, war and the preparation for war consume large amounts of fossil fuels, which generate greenhouse gases, which, in turn, cause global warming.
Protection of civilians and civilian infrastructure during war and improved humanitarian assistance can reduce the indirect health impacts of war. But the only way to eliminate these impacts is to eliminate war. The risk of war can be reduced by resolving disputes before they turn violent; by reducing the root causes of war, such as socioeconomic inequities, militarism, ethnic and religious hatred, poor governance, and environmental stress; and by strengthening the infrastructure for peace. Peace can be achieved and sustained by rehabilitating nations and reintegrating people after war has ended, strengthening civil society, promoting the rule of law, ensuring citizen participation, and holding aggressors accountable.
Barry S. Levy is the author of From Horror to Hope: Recognizing and Preventing the Health Impacts of War (Oxford University Press, 2022). He is an Adjunct Professor of Public Health at Tufts University School of Medicine and a past president of the American Public Health Association.
Ethnicity and ethnic identity have been recently brought to the fore in the Western world. One important reason is that immigration and globalization have resulted in a variety of clashes among different groups in very different contexts. However, there is another reason: DNA ancestry testing. Margo Georgiadis, president & chief executive officer of the major company in the field, Ancestry.com, has estimated that in early 2020, 30 million people had taken a DNA test, of which over 16 million was with her company. These companies tell you that by simply spitting into a tube or swabbing the inside of your cheek, you can find out a lot about your origins and your ancestors through DNA. Indeed, the way these tests are sometimes marketed may make people think that ethnicity is something “written” in their DNA. In many cases, people have to deal with surprising revelations that make them reconsider their ethnic identity, and in some cases reveal that the person whom they called father is their biological one.
Identity matters a lot to people, because it affects both how we perceive ourselves and how we are perceived by others. There are two big issues with how people tend to think about ethnic identity. On the one hand, it is assumed that people of the same ethnicity are a lot more similar than they actually are. On the other hand, it is assumed that people of different ethnicities are much more different from one another than they actually are. Therefore, once considered as members of particular ethnic groups, each person is no longer considered as an individual, but as a representative of particular ethnic types. This has an important consequence: people are not considered on the basis of what they really are, but rather on the basis of what they are expected to be given the ethnic group to which they belong. And this is where false stereotypes can easily prevail. Here DNA ancestry companies enter the scene by arguing that their tests can indicate to which ethnic group one belongs. Thus, these tests privilege notions of ethnicity based on genetics, contributing to the myth of genetic ethnicities.
Research in psychology has supported the conclusion that people believe that they have internal, immutable essences that influence who they are. This kind of thinking is called psychological essentialism; when genes, and DNA more general, are considered as being these internal and immutable essences, the view is described as genetic essentialism. This is an intuitive view that makes people find natural that they belong in one or another group, as well as that these groups are internally homogeneous and entirely discrete from one another. Therefore, if people intuitively tend to think of ethnic groups in genetic essentialist terms, it might seem natural to them that there exist discrete ethnic groups that are both genetically homogeneous and genetically distinct from one another.
Ethnic groups are real, but are socially and culturally constructed. More often than not, these groups have not had continuity across time historically, linguistically, culturally, and of course biologically. However, people intuitively tend to essentialize these groups, and DNA often serves as the placeholders for this. Population genetics provides an objective means for distinguishing among human groups; however, even though there are many different ways to do this, people (and researchers themselves) often tend to privilege those groupings that align with previously perceived, extant categories, such as continental and racial groupings. People living in the same continent are indeed more likely to have recent common ancestors among themselves than with people living in other continents. But what really exists at the genetic level are gradients of genetic variation, not distinct groupings. Human genetic variation is continuous and the genetic differences among people are overall very minor. For this reason, ethnic groups, nations, or races are not biological entities.
As a result, any ethnically, nationally, or racially distinctive genetic markers exist only in a probabilistic sense, and what ancestry tests provide are just probabilistic estimations of similarities between the test-takers and particular reference populations, consisting of people living today. But being related genetically to people living today somewhere does not necessarily mean that their ancestors came from that place. Furthermore, as more people take such tests, these reference groups change and as a result the ethnicity estimates for the same person can change across time. DNA provides partial information about our ancestors, which is the outcome of a process of interpretation. Therefore, DNA cannot reveal our true ethnic identity and the genetic ethnicities to which test-takers are assigned are imagined. However, this does not devalue these tests as their results can indeed provide some valuable insights and information to people who may not know much about their ancestors. Indeed, the tests are very good for finding close relatives, and this is perhaps why the industry should be rebranded to DNA family testing.
The quality improvement in healthcare movement has been around for the past 25 years with variable degrees of success. The focus on quality and safety commenced with the publication of a few seminal reports: Crossing the Quality Chasm and To Err is Human in the USA, and Organisation with a Memory in the United Kingdom. In 2018, just prior to the pandemic, two international reports, Crossing the Global Quality Chasm, a follow up of the initial report, and the Lancet Commission reported on the quality and safety of healthcare world-wide. These reports demonstrated that in lower middle income countries there was a challenge to improve safety and quality in the context of delivering universal health coverage. The quality of healthcare in upper income countries has improved but is variable. In 2021, the World Health Organisation published the Global Action Plan for Patient Safety, starting the decade with a focus on patient safety. All the reports documented the need to improve quality and safety of patient care. The COVID pandemic added to this imperative, and added new dimensions, such as the wellbeing of all.
“An ongoing challenge has been spreading successful improvement outcomes at scale.”
Academics often focus on writing such reports, which are called for by policy makers who use them to develop strategic plans for action. The NHS and other health systems are littered with strategies that come and go with each leadership change. Strategies result in setting standards with a system of inspection and regulation. The reports and standards should be an impetus to change, but they are far removed from the realities of working on the frontline of healthcare. Standards and strategies to implement change do not necessarily improve the quality of care. The real question is how do we get smart people, i.e. doctors and nurses and other health professionals, to deliver safe, high quality care all of the time. An ongoing challenge has been spreading successful improvement outcomes at scale. Partly, this is due to a lack of sound implementation processes; partly, due to a lack of data on what works; and finally to a simplistic view that what is successful in one context can be applied elsewhere.
Healthcare policy planners have stated they want to have safe and person-centred healthcare services that are efficient and effective. The desired outcomes have not been widely achieved for several reasons including:
the theories and methods are not understood or accepted by clinicians,
and there are competing demands and resultant time constraints.
The lack of uptake within the medical profession, and to a lesser degree by nursing and other healthcare workers, has been a specific challenge. This may be the result of jargon, the variable evidence base, and their lack of knowledge of the new sciences of improvement and implementation. The study of improvement theory and method is not an integral part of the medical curricula. We train healthcare workers to have excellence in subject matter knowledge but do not provide them with the education to apply that knowledge equally. If one adds the complexity of professionalism it is difficult to decrease the widespread variation that exists in the delivery of healthcare.
“One must add ideas of implementation science and make quality relevant to the workforce […]”
The understanding of what is required to improve healthcare and to be safe and person centred is now well understood. However, implementing what we know works is not easy. Setting standards is essential and can be regarded as Quality 1.0. Unfortunately, many see this as the solution when in fact it is only the start of the quality journey. Learning technical skills using the theories and methods of improvement can be termed Quality 2.0. This is where the focus has been for the past 25 years. Most interventions to improve quality of care have focussed on teaching healthcare workers patient safety or quality improvement methodology. This is essential but will not achieve quality care at scale. One must add ideas of implementation science and make quality relevant to the workforce in an age of pressing issues—such as climate change and the delivery of equitable care. This leads to a different approach to achieving quality.
“Every healthcare worker requires the power, agency, and/or courage to improve care, supported by knowledge and expertise.”
The future of quality in healthcare is the coproduction of solutions and interventions, Quality 3.0. This process may use standards and improvement as well as safety theories and methods, but will be owned by the patients as well as doctors, nurses, or other healthcare workers. The transfer of power is challenging and complex. Yet if not adopted, it will be difficult to achieve high quality care at scale. Every healthcare worker requires the power, agency, and/or courage to improve care, supported by knowledge and expertise. Only then can there be a difference for the people receiving care.
Many older adults struggle with isolation and loneliness. Could cats be the solution? At the same time, many humane societies have more cats to rehome than they can manage. Could lonely older adults be the solution?
Researchers at the University of Georgia and Brenau University developed a novel program where older adults were paired with a foster cat coming from a local humane society, with the opportunity to adopt. A Human-Animal Bond Research Institute (HABRI)-funded feasibility study explored the impact of this program on the older adult participants and the cats. Researchers explored how fostering a shelter cat could impact loneliness and well-being in older adults living alone. They also wanted to learn if these older adults would be more likely to adopt their foster cat after common barriers, such as pet deposit fees, were paid by the study. Could it really be a win-win situation?
The study enrolled adults aged 60 and older living alone and without any pets. Participants completed health surveys before placement with cats and completed follow-up surveys at 1-month and 4-months post-placement. Participants could choose to adopt their foster cat any time between 1- and 4-months post-placement. If participants chose to adopt their foster cat, the study paid the adoption fee, and a 12-month post-placement survey was completed.
Findings from the study revealed that loneliness scores significantly decreased at the 4-month mark after the cat fostering began. A similar 4-month improvement that approached statistical significance was observed for mental health. However, at the 12-month follow-up, loneliness scores were no longer statistically significant. The researchers suggest that these one-year reports were impacted by the COVID-19 pandemic, which resulted in a substantial proportion of older adults experiencing elevated levels of loneliness.
Alexis Winger and Ambi
Alexis states that before she got Ambi, “I lived alone, and the loneliness was becoming oppressive. Ambi has brought an end to oppressive loneliness. There are still times when I am away from people too long, when I have no one to talk to and lonelines settles in, but then Ambi settles into my lap or just runs through the room, and I am not alone. Ambi has brought me smiles, laughter, responsibility and love.”
The day that Alexis picked out Ambi at the Athens Area Humane Society to foster. Alexis states “I didn’t expect to find a cat for me at the first visit, but as I walked in, my eyes connected with hers in the end cage. The minute she was in my arms, she was mine.”
This is a picture and text message that Alexis sent to Sherry Sanderson, one of the researchers in the study, during the Pandemic.
Photo Credit: Alexis Winger
Alexis still gets lonely occasionally, but it is not the oppressive loneliness she felt before she got Ambi. Alexis says “Ambi has brought me an end to oppressive loneliness.”
Photo credit: Photo and text message Alexis Winger sent to Sherry Sanderson.
What about the cats? Almost all (95.7%) of study participants decided to adopt their foster cat at the completion of the study. Dr. Sherry Sanderson, the team lead and Associate Professor at the University of Georgia’s College of Veterinary Medicine, noted: “Our results show that by removing some perceived barriers to pet ownership, including pet deposit fees, pet adoption fees, pet care supplies and veterinary support, we can not only help older adults live healthier, happier lives but we can also encourage the fostering and adoption of shelter cats into loving homes”.
Dr. Kerstin Emerson, a Gerontologist in the College of Public Health’s Institute of Gerontology, Health Policy & Management at the University of Georgia, and an investigator from the study states, “In May of 2023, the U.S. Surgeon General stated that loneliness and isolation is an epidemic in this country, and their report placed an emphasis on the urgent need for a cure.” Dr. Don Scott, a Geriatrician and Campus Director of Geriatrics and Palliative Care from the Augusta University-University of Georgia Medical Partnership and also a researcher from the study, added, “The ill effects of loneliness and social isolation, particularly for older adults, are well-documented, and more strategies are needed to improve health outcomes for this population.” The investigators from this study plan to do a larger scale study. The hope is when an older adult seeks to prevent or ward off loneliness and isolation, they will collaborate with a support team prepared to explore feline companionship as part of an individualized holistic approach to care, and there will be programs in place and funding available to support this new approach to treating loneliness in older adults.
Judith Atkins and Bashi
Judith is semi-retired from nursing, but she still provides nursing care to some of the residents in the Senior Living Residence that she lives in. When recently asked what Bashi means to her, Judith sent back the following reply:
“He (Bashi) has been a comfort to two of my neighbors. While providing nursing care to a resident who was in hospice care, Bashi stayed with her until she died. I also took him to visit a resident with cancer and breathing problems when I went to visit. I also took Bashi to the nursing home to visit two people I took care of there.”
Judith went on to say, “He still enjoys catching balls and batting them into the hall closet, continues to steal straws from my drinks and claims all boxes. Best of all, he still likes my left shoulder to put his head on to make sure his world is okay. At night at times, I find him asleep on a pillow by my head. His love of people is unlimited, and he will try and go in any apartment with the door open to be loved on by strangers. He escapes into the hall to force me to exercise chasing him, and needless to say he is always the winner.”
Judith was ready to enroll in the study just days before the Pandemic occurred, and the Foster Cat Study was shut down for six months. Once the study resumed, participants were no longer allowed to go to the shelter to pick out their cats to foster. Rather Dr. Sanderson, would go to the shelter and send them pictures and videos of available cats they may be interested in. The picture on the left is from the very first time Judith met Bashi in her apartment. The picture on the right shows that their Human-Animal Bond remains strong. Photo credit: Sherry Sanderson
Judith and Bashi getting ready to make the rounds in the building to visit people. Photo credit: Sherry Sanderson
Judith and Bashi love to hold birthday parties at the Senior Living Residence where they both live. Here are pictures from Bashi’s second birthday party. Photo credit: (L) Sherry Sanderson; (R) Judith Atkins
The October release of Martin Scorsese’s latest film Killers of the Flower Moon has thrust the sordid history of America’s treatment of its indigenous peoples back into the public eye.
On today’s episode of The Oxford Comment, the last for 2023, inspired by the themes in Killers of the Flower Moon, and in celebration of National Native American Heritage Month in the United States, we spotlight two aspects of Native American culture that transcend tribe and nation and have been the recent focus of OUP scholars: language and religious beliefs.
For our first interview, we were joined by Rosemarie Ostler, author of The United States of English: The American Language from Colonial Times to the Twenty-First Century, to speak about the Native American English dialect, how English became more widely spoken amongst Native Americans, and current programs to preserve Native American languages. We then spoke with Gregory Shushan, author of Near-Death Experience in Indigenous Religions about near-death experiences, Native American myths, shamanism, and religious revitalization movements across indigenous cultures in North America.
Check out Episode 89 of The Oxford Comment and subscribe to The Oxford Comment podcast through your favourite podcast app to listen to the latest insights from our expert authors.
Read the chapter exploring near-death experiences (NDEs) in “North America” from Gregory Shushan’s book, Near-Death Experience in Indigenous Religions, which examines the role culture plays in how people experience and interpret NDEs, and reveals how afterlife beliefs often originate in such extraordinary experiences.
