Conflict and health: The health costs of war: can they be measured? Lessons from El Salvador

This is the second of four articles Studies assessing the health impact of armed conflicts have documented the disruption of referrals, immunisation programmes, supplies, and monitoring and surveillance and increased dependence on foreign personnel and funding, 1 2 but measurements have typically focused on deaths, disabilities, infant mortality, and communicable diseases, and occasionally on facilities destroyed.2–4 The case of El Salvador shows that, useful as this quantitative information is, it is insufficient to assess the effects of war on health and to provide guidelines for rehabilitation of health services. Specifically, there are three key areas of underassessment in evaluating the health costs of war: psychosocial behaviours, environmental destruction, and disruption to policy making. #### Summary points Traditional indicators (infant mortality, maternal mortality, malnutrition, rates of communicable diseases) are insufficient to measure the impact of war: selective primary care improves these indicators even when the general health status of the population deteriorates, Policy making is affected during periods of political violence: by conflicting approaches by different agencies, by parallel health systems organised during the war, and by conflicts between international funding agencies and national policy makers; the impact of war on policy making has not been adequately assessed Agencies focusing on post-conflict rehabilitation tend to overlook effects of war that are less visible and more difficult to assess The 1980–92 civil war in El Salvador was the culmination of decades of militarisation, intense political violence, and repression which produced thousands of victims.5–7 Violations of international codes of war conduct, mostly by the government's armed forces, routinely took place during the war. Horrifying descriptions of massacres of children, women, and elderly people; killings of wounded and sick in hospital wards; assassinations of civilians; and executions of prisoners have been reported by survivors. Estimates of war related casualties and physical …