violence, conflict and health in africa

Sm. Sri. Med. Vol. 28. No. 7. pp. 649-657, 1989 0277-9536 89 $3.00+0.00 Prmted in Great Bntain. All rights resewed Copyright c 1989 Pergamon Press plc

VIOLENCE, CONFLICT AND HEALTH IN AFRICA

DENNIS A. ITYAVYAR' and LEO 0. OGBA?

‘Department of Sociology, University of Jos, Jos, Nigeria and 2Department of Government and Public Administration, University of Ilorin, Ilorin, Nigeria

Abstract-This study attempts to examine the impact of incessant violence and political conflicts on the development of health services in Africa. Specifically, how do violent activities and conflicts. such as wars. affect health care infrastructures and health policies in Africa? The paper further examines the consequences of violence and conflicts on the health of refugees.

The paper concludes that African states would develop better health policies for their citizens in the absence of violence and conflicts.

Key words-health. Africa, political violence, militarism

INTRODUCTION

Violence and conflict have become almost daily experiences in Africa. These upheavals include civil wars, peasant uprisings, religious riots, student demonstrations and labour unrest. Between 1960 and 1987 no less than 16 African countries have been involved in violence and political conflicts. Examples of these include those of Zaire, Mauritania, Algeria, Morocco, Ethiopia, Somalia, Kenya, Sudan, Chad and Nigeria in the 1960s and Zimbabwe, Uganda, Tanzania, Angola and Mozambique in the 1970s and 1980s. Several countries in Africa such as Chad, Angola and Ethiopia are currently engaged in civil wars.

Besides civil wars, other recurring cases of violence are religious disturbances such as those in Nigeria and Sudan; violent student demonstration in Liberia, Ghana and Burkina Fasso, and labour and civil unrest in South Africa.

In this paper, we examine the consequences of violence and conflicts on the development of health services, and specifically, the impact of violence on health policy in Africa.

VIOLENCE, CONFLICT AND HEALTH

Violence and conflicts have specific impact on health care policies of African States through:

(I) Increases in military spending that negate health care priorities.

(2) Physical destruction of social infrastructures such as hospitals. roads, industrial activities etc., all of which have substantial impacts on the formulation of long term health policies.

(3) Problems of refugees which create constant mobility of displaced persons by wars and other political violence; exacerbate problems of hunger and malnutrition and sometimes create long term health problems.

The biennial report of the Director General to the World Health Organization Assembly and the United Nations in 1984, focused on violence and conflict as they affect African health care. The report un- equivocally confirmed that many African states still

living through periods of civil wars and the destabilization policies of the South African apartheid system have experienced material and human damage which perpetuates their poverty and indirectly affects health care policies [ 11. The WHO report further emphasized that funds used by South Africa’s neighbouring countries to preserve their economic and political independence, as well as to cater for the acute increases of refugee movements across their borders, cannot be utilized for the health development efforts of these nations. These many aspects of insecurity caused by violence and conflicts in the African region must certainly affect the WHO’s target of health for all by the year 2000.

To more critically examine the extent to which cases of violence and conflicts affect health care policies in Africa, we analyse a number of conflicts in Africa occurring in the period 1960-1987. We also provide examples of violent riots that have occurred in some African countries. These examples will enable us to draw conclusions on how violence is directly or indirectly connected with the underdevelopment of health services in Africa.

Conflicts and wars became constant fratricidal escapades for most African states right from the time when the eradication of colonialism became an important agenda for most Africans. But as was opti- mistically expected, the post-independence era has not reduced the sad situation of Africa’s endless conflicts. However, our view of violence and conflict as used in this study covers only events in which African states were/are engaged with each other in confrontations in which there is the actual or possible use of force; conflicts or violence in which African Liberation Forces are consistently seeking to assert control or sovereignty over a particular territory in Africa, and in which large scale or limited use of force is applied against the colonial authorities involved and violent events in which rival groups or insurgent forces within one state have abandoned the political processes to use organized and prolonged military means to change the structure or the configuration of power within a particular state [2].

The scale of forces, mobility of persons, and the disruption of infrastructural facilities, that normally

649

650 DENNIS A. ITYAYYAR and LEO 0. OGBA

accompany the category of violence and conflicts considered here, are considerable enough to affect public policy as will be considered later in the case of health. The taxonomy of violence and conflicts considered here is exhaustive, and represents the types of conflicts that have occurred in African states.

For the purpose of the present study, coup d’etat and minor diplomatic disruptions between states, unless they are accompanied by social upheaval carrying the possibility of escalation and wide conflict, have not been considered. Although coup d’etats are becoming a common feature of the Afri- can political scene, their direct impact on public policy of African states cannot be easily generalized [3]. Violence also includes any activities that disturb peace such as religious riots and violent student demonstrations.

Independent African states have witnessed incessant conflicts with serious social consequences, Shortly after independence in 1960. the Congo (Zaire) erupted into a major civil war and set Africa on a major path of disequilibrium. Since that period Zaire has been forced into a series of other debilitating crises. Each time, the state abandoned pressing social development to concentrate on consolidation of sovereignty. In addition, the massive refugee situation, generated by the Zairean conflicts, has affected other African states, especially neighbouring Angola. Uganda and Tanzania. The experience of Zaire has been duplicated in other African conflicts that have occurred in Ethiopia, Chad. Angola, Zaire, Sudan, Somalia. Burundi, Nigeria, Zimbabwe, South Africa and many others.

The conflicts in Ethiopia, Somalia and Eritrea have been responsible for the building up of the largest (at least in personnel) military reserve in Africa. As a result of Ethiopia’s wars with its neighbours. its military force rose from 2500 in 1963 to 250.000 in 1982 [4]. At the same time the conflict in the Horn of Africa has been responsible for the high influx of refugees in that region since 1963. As a result of the EthiopianSomalia wars more than 1.5 million refugees have been affected. The Eritrean conflict alone produced 350.000 refugees between 1979 and 1981, most of whom were forced to seek asylum in Sudan

[Sl. Between 1965 and 1987. Chad has been torn by

incessant conflicts. Chad remains one of the poorest states of the world with very little investment on social policies. Extensive military assistance from France, Libya, and more recently. the United States continues to fuel the Chadian conflict. Each of these powers has sought to dominate the region. Chadian refugees have been a constant burden to neighbouring countries, notably Nigeria, Cameroun and Sudan. Between 1981 and 1982. members of the Organization of African Unity (OAU) raised about $236.71 million to maintain a peace force in Chad. What is interesting here is that this was more than the total fund which Chad allocated to health care in IO years. Nigeria’s share of $82.9 million spent in the peace-keeping operation to Chad was almost the equivalent of national health allocation for the 1981 fiscal year 161.

Sudan and Burundi also experienced internal violence since 1961. Even though these conflicts have

erupted intermittently. refugee problems have been more constant. Many people from the Tutsi and Hutu ethnic groups of Burundi have been forced to flee into Rwanda and Uganda. Also. in Sudan. Christians of the south continue a war of attrition and social deprivation with the government. While military spending and military policies have been given priority in Sudan, the country continues to depend on international assistance to support domes- tic policies [7].

The Nigerian civil war between 1967 and 1970 remains one of the fiercest internal conflicts in Africa, both in its human toll and social costs. During this war, Nigeria’s defence spending increased remark- ably, while social spending decreased. Social in- frastructure including hospitals, roads and industries were virtually destroyed, especially in the secessionist Biafra. In 1966 only 6.8% (N29.19million) of the national budget was devoted to defence. This rose to 24.1% (N 107.50 million) in 1968 when the civil war had started. As the war continued, defence budget rose to 32.3% (W 162.62 million) in 1969 and 42.6% (N359.91 million) in 1970. In the same period health expenditure fell from 3.7% (W 16.39 million) in 1967 to 0.8% (814.02million) in 1969 and 1.1% (W9.29 million) in 1970 [8]. The mass destruction of hospitals and clinics was accompanied by the most glaring problem of more than 2 million refugees created by the war.

Between 1976 and 1984, and before the Western Sahara declared itself an independent state of Saha- rawi Arab Republic (SADR). Morocco was involved with the POLISARO in a protracted war over West- ern Sahara. During this period, more than 70.000 refugees fled from the disputed territory into the neighbouring states of Mauritania and Senegal. Yet to carry on the war in the Western Sahara. Morocco’s military spendings between 1978 and 1984 averaged between 16 and 18% of gross government annual expenditure; at the same time the rising prices of food were causing intermittent riots in different cities of Morocco [9].

In Mozambique, the violent activities of the South Africa-supported Mozambique National Resistance (MNR) has been causing untold damage to the socialist policies of the Mozambique state. Rebel incursions have not only resulted in massive insecurity and increased military spending in Moz- ambique, but the rebels have prevented Mozambique farmers from cultivating crops and the national government from distributing seeds to millions of farmers. The result of such rebel activities is that millions of Mozambiquans in 1987 are reported to be facing death through starvation [IO, Ill.

The Academic Staff Union of Universities (ASUU) has recounted a fairly recent case of violence at ABU. Zaria, Nigeria involving police and students where between 20 and 30 people were killed, many people injured and much property destroyed [12]. The most recent of this category of violence is the religious disturbances which occurred in Kaduna State in Nigeria in March 1987. The violence involved a clash between Moslems and Christians and resulted in the loss of many lives and many injuries. More than 1000 churches in Kaduna State were burnt down by Moslems during the disturbance. Property such as

Violence, conflict and health in Africa 651

houses and cars were also destroyed by Moslem rioters. These riots have implications for health services in Africa [ 131. All those disasters and social consequences noted here are political and require resolution through political means.

Using African conflicts and violence as conceived here, we have tried to address the following questions:

(I) Do cases of African conflicts and violence increase military spendings of the affected states? How do these relate to the health care policies?

(2) How can damage resulting from wars and violence in Africa affect long term health care programming in African states?

(3) Can the reduction in the incidences of war refugees in Africa improve health care services of host and affected states?

(4) Is a regional policy of conflict reduction in Africa of any relevance to health care policies, and how?

These questions inform our proceeding discussion. Table 1 provides further examples of specific cases

of violence and political conflicts in Africa between 1960 and 1987. Each violent activity contained in the table has serious implications for health services development in Africa. First, it leads to uncontrolled defence expenditure to the neglect of the social sector. Secondly, and as stated earlier, victims of violence are often treated in hospitals by medical professionals with drugs and equipment which would have been put to better use.

Also, as a result of violence and conflicts in which refugee problems have become a feature of the Afri- can continent, a new imposition on social policies of states have emerged. The Council of Ministers of the OAU recognized this problem when it noted:

One thing that is clear is that the concept of African traditional hospitality which has enabled hundreds of thousands of African refugees to find asylum in many African countries, has reached a saturation point. Unless the refugee exporting countries look more seriously at the human toll, the misery and the loss and wastages of human and material resources involved, we run the calculated risk of getting used to an q/r situation In Africa [l4].

Human waste. superfluous military spendings and the problem of refugees are issues related to violence and conflict in the past three decades in Africa (see Table I).

MILITARY SPENDINGS AND HEALTH POLICIES OF AFRICAN STATES

Defence expenditure has increased spectacularly over the years. developing out of the security forces in the colonial periods. African armies have become more sophisticated and more destructive, and be- cause of these three times as much is expended on them in real terms than about three decades ago [IS]. These massive increases in expenditures and size of African armies can be related to three main factors. These are: increased national resources, perceived security needs, and real threat of violence or actual involvement in a conflict. In most instances, the growing sizes of African armies and their military spendings have failed to buy security. Instead, these

have produced more frightening consequences that detract from the goals of peace and security. For example, most African countries that have experienced great changes in size of military spendings and strength, have also been involved in one conflict or the other. Such countries have also been known to be preparing to play some active role in some existing conflict in their region; or were recovering from recent involvement in a violent activity. All these are symptoms of national insecurity and have implications for social policies.

Between 1963 and 1982, African states that were involved in any form with violence and conflicts showed dramatic changes in their military strength. Among such countries were Algeria, Ethiopia. Libya, Morocco, Nigeria. Somalia, Sudan. Tanzania, Zaire. Zimbabwe and South Africa (see Table 2). All such increases in military strength were particularly accompanied by massive importation of arms and the consequent waste of national resources. For example, between 1977 and 1979. as a result of the Ethiopian-Somalia conflict. both states spent more on arms imports (more than 10% of their national income) than did all the Nordic countries plus the Netherlands [ 161.

As Tables 2 and 3 demonstrate. the strength of most African armies as well as military expenditures and military consumption of national resources, all increased dramatically in the periods between 1963 and 1982. This period also coincides with the era of escalating conflicts in Africa as shown in Table 1. However, the link between military consumption of resources and health care priorities is less clear. One reason for this must be related to the fact that most analysts cannot agree that funds from reduced military spendings can be transfered to improved social spending, especially health. Table 4 indicates that countries (such as Ethiopia) involved in violence and conflicts, or are recovering from conflicts have been characterized by high defence spending and low social expenditures, especially in the health sector during the same period.

Between 1972 and 1978 when the Chadian conflict was raging, increases in defence spending rose by 28.2%, while that of health rose only by 3.9%. Also in Somalia and Ethiopia during the same period, defence increases rose by 17.9 and 42.6%, respectively; while those of health remained at 5.3 and 4.2%, respectively [ 171. Other African states such as Burundi which was involved in internal ethnic violence with its neighbour Rwanda, Tanzania which was involved in a border conflict with Uganda and Nigeria which was involved in post-war reconstruction and at the same time playing an active role in regional conflict management, all showed the same high priority given to defence and less regard to increasing health funding. Almost all African countries that were not involved in some form of violence or conflict experienced a more balanced growth in defence and health expenditure. These occurred without regard to the nature of the regime in power, whether military or civilian. For example. Ivory Coast, Mauritius, Liberia and Ghana all experienced a low, but uniform growth in defence spending and a slightly higher growth in health allocations during the period between 1972 and 1978. These states were

Tab

le

I. V

iole

nce

an

d

oo

litlc

al

con

fhct

s in

A

fric

a.

196&

19X

7

I. M

auri

tan

ia

con

flic

t,

1961

2.

Co

ng

o

Bra

uav

ille

con

flic

t.

1960

(t

wic

e)

3.

Zai

rian

(C

on

go

) co

nfl

ict,

19

60-1

964

4.

Alg

eria

n

-Mo

rocc

o

con

fbct

, 19

63

5 E

thlo

pla

S

om

alia

co

nfl

ict.

19

63

19X

2

6.

Ken

ya

So

mal

i co

nfl

tct.

19

63

7.

Su

dan

ese

con

flic

t,

1963

19

88

8 S

pan

ish

S

ahar

a (W

esle

rn

Sah

ara)

co

nfl

ict.

19

64

1980

s

9.

Ch

adia

n

con

flic

t.

1965

-198

7

IO.

Rw

and

an-B

uru

nd

i co

nfli

cl

I I.

Nig

eria

ci

vil

war

. 19

67-1

970

12.

Zim

bab

wea

n

con

flic

t,

197&

19X

0

13.

Ug

and

a-T

anza

nia

co

nfl

ict,

19

79

14.

So

uth

ern

A

frxa

n

con

flic

ts

(Nam

lbla

an

d

apar

thei

d

m

So

uth

Afr

ica)

15.

An

go

la,

1970

-197

6

16.

Zai

re

(Sh

aba)

an

d

con

flic

t,

1977

an

d

1978

Tri

bal

d

iwd

ents

se

ek

auto

no

my

Tri

bal

d

issi

den

ts

seek

au

ton

om

y

A

mu

tin

y o

f C

on

go

lese

so

ldie

rs

agai

nsl

B

elg

ian

o

ffic

ers

led

to

fore

ign

in

terv

enti

on

. L

ater

it

esca

late

d

to

civi

l w

ar

and

succ

essi

on

o

f K

atan

ga

Ter

rito

rial

cl

aim

s

Ter

rilo

rtal

an

d

irre

den

tist

cl

aim

s le

d

to

reg

ula

r b

ord

er

war

s

Ter

rito

rial

cl

aim

5

Inte

rnal

vi

ole

nce

b

etw

een

M

osl

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of

the

no

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an

d

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rist

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f th

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uth

re

sult

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into

in

term

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nl

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auto

no

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con

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wee

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PO

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o

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M

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b

etw

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n

ort

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n

Mo

slem

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d

sou

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civi

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ar

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w

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lord

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d

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into

su

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d

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led

to

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zan

ian

inva

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w

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and

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b

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b

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PL

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UN

ITA

and

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tem

pt

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w

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to

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d

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and

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of

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, co

nst

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into

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(CA

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and

in

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m

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spen

din

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ou

t 70

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re

fug

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fled

to

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and

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re

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e cr

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the

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s in

to

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, R

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of

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incr

ease

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Ab

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Reg

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(B

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mili

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cala

tin

g

mili

tary

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din

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for

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eria

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000

refu

gee

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ed

into

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amb

ia,

Zai

re,

Tan

zan

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zam

biq

ue

and

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iger

ia.

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rup

tio

n

of

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no

mic

an

d

soci

al

life

in

mo

st

of

the

Fro

ntl

ine

Sta

tes

Th

ou

san

ds

of

refu

gee

s fl

ed

into

K

enya

an

d

Zai

re.

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ill-o

ver

of

soci

al

chao

s co

nti

nu

e in

U

gan

da.

H

igh

mili

tary

co

sl

for

Tan

zan

ia

Ref

ug

ee

infl

ux

into

B

ots

wan

a.

Les

oth

o,

Zim

bab

we,

Mo

zam

biq

ue,

et

c.

So

cial

an

d

mili

tary

co

sts

for

the

Fro

nth

ne

Sta

tes

and

fo

r S

ou

th

Afr

ica

400.

000

refu

gee

s fl

ed

into

Z

aire

, Z

amb

ia,

Nig

eria

et

c.

So

cial

and

m

ilita

ry

spen

din

g

incr

ease

d.

An

go

la

rem

ams

a F

trif

e-to

rn

stat

e

Th

ou

san

ds

of

refu

gee

s R

ed

Zai

re

into

A

ng

ola

, U

gan

da,

an

d

Su

dan

. S

oci

al

and

m

ilita

ry

cost

s

So

urc

es:

Ref

s 12

. 51


Table 2. Military expenditures of African states, 1963 and 1977-1980. a comuarison (milbons %U.S.)*

Country 1963 1977 1978 1979 I980

66 471 527 602 705 Algeria Benin (Dahomey) Botswana Burundi Camcroun Central African Republic Chad Congo Brazzaville Equatorial Guinea Ethiopia Gabon Ghana

I.1 9 - -

1.2 I3 I5 50 2.1 9 1.5 24 3.7 36

- 17.9 2.5

35.3 5.8 8.7 6

I35 18 42 21 60

148 7

I40 43 I5 II

731 49

8

IO I5 21 55 IO 37 34

6 I59 49 60 23 79

189 9

439 47 23 28

I6 27 25 88 14 40 52 6

349 69 60

22 33 35 82 I3 22 61

6 447

74 50 9

I25 IO0 26

503 94 55 39

II20 I60

22:: 64 I4

I05

Guinea Ivory Coast

Kenya Liberia Libya Madagascar Malaw Mauritania Morocco Mozambique Niger Nigeria Senegal Sierra Leone Somalia South Africa Sudan Tanzania Togo Tunisia Uganda Upper Volta (Burkina Faso) Zaire Zambia Zimbabwe

;.I 14.0 9

4 93 - 34 28 9 2.2 3.9

219 21.5

1.3

326 83

8 2040

56

- Il.4

I.5 2.8

IO

44 6

21:: 228 133

16 I60 97 22

I65 300

2269 2320 199 200

40 2185 216 172

I9 I85 146 27

-

98 291

I3 500 82 47 30

396 II4 I2

1991 59 8

95

250 23

337 I25 35

200 -

267 23

363 I61 32

I10 294

263 223 516

- 203 221 427 478

*The dollar value used in this table is not constant. Values expressed for each year represent dollar prices at the ruling exchange rate for the years.

Sources: Compiled from Sivard R. L. World Military and Social Expendirures. 198lL1983. World Priorities, Washington, DC.; and Weeks G. The armies of Africa. Ajrica Rep. 9.3-21, January 1964. See also Ref. (2, p. 3171.

also relatively free of internal violence and external conflicts. Kenya and Sierra Leone (relatively stable states) both experienced a rise in defence spending during the period between 1972 and 1978, which corresponded with increased health care allocation.

It is important to note here that increases in defence expenditure, even in those countries which are free of internal violence and external conflicts, shows an emerging trend of the position of the military in African politics. In many African countries top military officers are part of the ruling class and also control the government. As a result of this they have considerable influence on state policy and especially the vote to the defence sector where they derive direct benefit in forms of comparatively high salaries and other privileges.

The importance of the military in politics has also led to increases in the size of African armies and consequently the size of the officer corps. Besides her large size of serving officers, Nigeria now has more than 50 retired and young military generals who still draw salaries from the Ministry of Defence. This, added to the rapid promotion in the army leads to increased budgetary allocation to the defence sector. Expenditures in the defence sector are not just for

weapons, in fact, sometimes a large part is for salaries and allowances. For these reasons countries such as Ivory Coast, which have not experienced any violence or conflicts, still have high and increasing defence expenditures.

This discussion so far shows only how conflict and violence influence expenditures in African countries. We now turn to a discussion on how violence influences health policies in Africa.

VIOLENCE AND HEALTH POLICY

Conflicts and violence have direct effects on health policies of African states. Existing health infrastructures destroyed in riots, conflicts and violence often have to be replenished. This takes away the attention of policy-makers from other areas of health care that would be the focus of health policy if existing health infrastructures had not been destroyed in riots.

The physical destruction of hospitals, dispensaries, clinics and even personnel such as doctors affect health policy as it does not give room for growth and development in the health sector. In African countries (such as Chad and Angola) involved in war, new health policies must first take cognisance of infrastructures destroyed by war before any new ones may be considered.

The use of medical services to treat soldiers and other victims of political conflicts and riots convinced policy-makers in such countries to consolidate their belief in policies informed by the medical model. In the medical model, health services are conceived mostly in terms of hospitals, dispensaries, doctors and nurses and not in terms of other factors such as food, housing, water etc., which may affect health and well-being. In times of war more medical personnel, especially surgeons, are employed and additional items of medical equipment are purchased with war victims in mind. Thus, in war-time health policies of African states become narrow and unidimensional, focusing as it were, on soldiers and perhaps a few people in the privileged classes. Rural and urban poor are, in these circumstances ignored or at best given only very basic services. Countries such as Chad and Ethiopia which have been involved in political conflicts for many years now may not want to focus their health policies on rural and urban people, but rather on war victims.

The resources voted for health in times of war may be small and only enough to meet the need of soldiers and a few others. It is not therefore possible for health policy in a war situation to concurrently embark on heavy defence spendings and a popular based health care system.

The impact of violence on health policy is perhaps best demonstrated in the case of the Nigerian civil war of 1967-1970. During the civil war. health programmes started earlier were abandoned and others destroyed. Many hospitals and medical equipment and even a medical school were destroyed. The Enugu medical school and the University of Nigeria, Nsukka were destroyed and this put a halt on training of medical personnel for at least 3 years. Physi- cians, nurses and other health personnel lost their lives while many hospitals not destroyed were mobi-

654 DENNIS A. ITYAVYAR and LEO 0. OGBA

Table 3. Changes in African military power, a comparison 1963-1982.

Military forces Average military expenditure as 3. of central

Country 1963 1982 government cxpendtturc 1975-1982

Algeria 48.000(l) 101.000 (4) 7.6 (23) Benin 1000 (2) 3150(3l) 15.3(12) Burundi 800 (24) 5200 (24) 22.2 (4) Burkina Faso 1000 (22) 3700 (29) 18.2 (9) Cameroun 2700(14) 7300 (22) 9.9 (20) Central African Republic 500 (27) 2300 (32) 8.9 (22) Chad 400 (29) 4200 (28) Congo Brauaville 700 (25) 8700 (20) 11.: (13, Ethiopia 2500 (16) 250.000 (I ) 42.6(l) Gabon 700 (25) 3200 (30) I.1 (31) Gambia none 475 (34) 0 Ghana 8000 (6) 12,600(17) 3.7 (29) Guinea 4800 (9) 990+(18) “:a Ivory coast 4OOO(ll) 5070 (26) 3.6 (30) Keny 25OO(l6) 16.000 (14) 12.9 (16) Liberia 3500(12) 5520 (23) 5 I (25) Libya 5000 (8) 53.000 (8) 4.5 (27) Malagasy Republrc 2600(15) 2l,lc0(13) 13.5(15) Mali 3100(13) 4650 (27) 20.5 (7) Maurltama 500 (27) 8170(21) 25.9 (2) Morocco 34.000 (2) ll7,000(3) 17.8 (IO) Mozambique - 12.650(16) 20.8 (5) Niger 1200 (21) 2150(33) 4.8 (26) Nigeria 8000 (6) 133,000 (2) 93(21) Senegal 1850(20) 9700(19) ll.4(19) Somalia 4600(10) 62,550 (7) 18.4 (8) South Africa 25.000 (3) 78,OQO (5) 13.9(14) Sudan ll.OoO(5) 68,000 (6) 12.2 (18) Tanzania 2000(18) 40,000 (IO) 16.3(11) Togo 250 (30) 5080 (25) 7.0 (24) Tumsia 20.000 (4) 29,ooO(ll) 4.5 (27) Uganda 2000 (IS) 15,000(15) 20.6 (6) Zaire “:a 42.000 (9) 12.4(17) Zimbabwe 24,000 (12) 25.9 (2)

‘The rankmg for each state m this comparison is given in parentheses. Sources: The Milirary Balance. 197&/984lntemational Institute of Strategic Studies. London; Weeks G. The African

armies. .4frico Rep. &2l. January 1964.

lized for the wounded soldiers. The atmosphere of war never allowed the development of commerce, industry and even farming. No wonder Nigeria was affected by famine during and after the civil war. The magnitude of physical and psychological destruction

Table 4. Increase on military and health expenditure. 1972-1978. by country

Defence Health statea (O/o) ( % I Botswana IO.3 60 Burkma Faso 30.4 33 Burundi 12.0 3.6 Chad 28.2 3.9 Ethiopia 42.6 42 Ghana 4.7 75 Ivory coast 7.5 77 Kenya 20.5 72 Liberia 1.6 4.6 Malaw 15.1 51 Maurltlu, 0.4 7.6 Mozambique 69.4 “‘a Nigeria 14.6 2.0 Slerra Leone 14.9 II 4 Somalia 17.9 5.3 South Africa 6.8 “.a Sudan 9.5 0.2 Tanzania 10.2 57 Zambia n/a 83

Sources: Compiled from The World Bank. Accelerared Developmenr in Sub-Sahara

Africa. An Agenda /or Action, p. 185. World Bank, Washington, D.C 1983. ,

was so great that it affected public policy and especially health policy during and after the war.

After the civil war ended in 1970, the then Head of State, General Gowon, embarked on a programme of reconciliation and reconstruction. The implication of the reconstruction policy on health policy was obvi- ous. The renovation of hospitals and clinics destroyed during the war became the focus of policy in the period 1970-1975. Had there not been a war, health policy in the period 197&1975 would have been directed perhaps to rural health care. But as a result of the war, it was not until 1975. after reconstruction was completed, that a new health policy was initiated. This time health policy shifted from a predominantly curative one of the civil war to the introduction of Basic Health Services Scheme (BHSS). In the edu- cational sector too Universal Primary Education (UPE) was introduced. Both programmes targeted the rural and urban poor. These policies are likely to have been introduced earlier had resources not been diverted to war.

The Nigerian example is applicable to many other African countries engaged in political conflicts. In their situation of war, such countries lack the stability to think of popular based health policies that would encourage immunization, health education, oral re- hydration therapy, child and welfare clinics and training of public health workers.

The effect of violence on health policy, to be sure, is not limited to civil war. The 10 violent religious


riots which occurred in Nigeria between May 1980 and March 1987 destroyed several hospitals, clinics, drug stores, hotels, cars, schools and churches which the government has to renovate or compensate victims. This kind of violence affects health policy in the sense that resources voted for programmes such as health education, child welfare and immunization are again shifted to hospitals to provide cure to victims or to replenish destroyed hospitals. This does not allow the growth of public health policy while curative medicine continues to thrive.

The incessant cases of violence and political conflicts have contributed to the consolidation of curative health policy in Africa. Victims of war or riots, policy-makers argue, cannot be treated with primary health care, but in hospitals. On the other hand, policy-makers need to know that infectious diseases which are common killers in Africa cannot be prevented by building new hospitals, but can only be combated by a comprehensive public health policy that emphasizes good housing, water, food and an hygienic environment.

HEALTH PDLICIES AND REFUGEES

Refugee problems are not new to Africa, but their upsurge and consistency since the 1960s has been disturbing. The number of refugees in Africa has doubled every 5 years since that time. In 1965, for example, the estimated refugee population of Africa was half a million; in 1970 it was one million; in 1975 two million; in 1978 four million; and by the end of 1980, it had reached the level of five million [18, 191. This figure is more than the total population of more than the 10 smallest African states [19, p. 81. By 1984, it was being argued that half of the then 10 million of the world’s refugee population were living in Africa under distressing circumstances.

The seriousness of refugeeism in Africa must be considered in light of the fact that every case of protracted violence and conflict in Africa has produced refugee victims. In 1957, the first batch of African political refugees numbering 200,000 fled Algeria into Morocco and Tunisia as a result of the Algerian war of independence with France. In 1961, about 15 1,000 Angolan refugees fled into Zaire as a result of the beginning of the war of liberation with Portugal. This figure grew higher between 1961 and 1977, reaching 400,000 by 1970. By 1972, the influx of Burundi refugees into Tanzania and Zaire had reached 25.000 and 28,000 respectively. In 1979, about 200,000 Zimbabwean refugees were settled all over Africa, especially in the Frontline States. Other surveys also show that since 1965, more than 250,000 Chadians fled their territory into Cameroun, Central African Republic and Nigeria to avoid the scourge of war. By 198 1, there were 1.5 million refugees living in Somalia alone; 490,000 in Sudan and 400,000 in Zaire. Other countries which reported more than 100,000 refugees in their territory were Cameroun (266,000) Burundi (234,000), Tanzania (140,000), Uganda (112,400) and Nigeria (110,000) [20]. There are also thousands of political refugees from South Africa in the Frontline States.

As at 1988 the exact figure of refugees in Africa is not known. But there is no doubt that the figures

recorded in 1981 have been reduced as a result of voluntary repatriation and assimilation of refugees by their host countries. Also major activities to reduce the impact of refugeeism on the host countries by the international organizations and voluntary agencies have declined since 1981. At the same time, the health issues of refugeeism remain largely un- resolved.

Refugees suffer from death, disease and hunger. The rate of crude mortality of Eritrean and Tigrayan refugees in Sudan, for instance, was estimated at 105/1000; while malnutrition was found to be 52% (for children under 5 years with less than 80% weight per standard height). Incidence of infectious diseases such as malaria, yellow fever and typhoid are also reported in all refugee camps in Africa [21]. The problem of infectious diseases is even compounded by the nature of housing available for refugees. Many of them use makeshift housing and have problems obtaining water. A larger percentage of African refugees are housed in UN refugee camps. However, housing availability is usually smaller than the population of refugees to be accommodated. The condition is even worse in camps run by national African governments, as they experience constant shortages of food, water and clothing. In general, refugee camps run by UN and religious groups are better than public camps under the responsibility of African governments.

The living and the health conditions of refugees vary widely on the basis of camps where they are accommodated. Thus, while there may be im- provements in the health and living conditions of some camps such as Eritrean and Tigrayan refugees in Sudan, it may not be the same with those in Zambia and Angola [22].

Health issues such as infectious diseases, stress, poor health care, poor sanitation, lack of water and food immediately begin to develop as refugees embark on the journey outside their homes as a result of violence and conflicts. Refugees that spontane- ously move across international borders, or evacuate far away from their homes, are most often accommodated in temporary houses and makeshift huts. From there, they begin immediately to face emergency programmes of feeding and health. Where large numbers have been involved, the camps have often been squalid and accompanied by malnutrition with high mortality rates of llO/lOOO or more in some camps. Hanne Cristensen in her study of the settlement of refugees in Africa found high incidences of disease and death in refugee camps in Zambia, Sudan and Angola in different periods of conflict [23]. T. F. Betts has also argued that most refugee camps in Africa have a tendency to dump large numbers of newly arrived refugees on existing settlement sites without changing existing food supply and health care facilities [24].

Under such conditions certain diseases become more rampant. These include communicable disease, anaemia, and nutritional deficiencies (notably kwash- iorkor), septic abortion, complications of pregnancies and perinatal deaths. Suicide and other degenerative diseases such as peptic ulcer, nephrosis, diabetes and bronchitis also tend to increase under camp pressure and anxiety. Though the quality of statistical data

656 DENNIS A. ITYAVYAR and LEO 0. OGBA

regarding the health of refugees in Africa is limited, casual observation in most camps by some medical doctors, especially those that were involved in the refugee camps in Biafra during Nigeria’s civil war, point to the high concentration among refugee children of such ailments as pneumonia, tuberculosis, diptheria, smallpox, meningitis, whooping cough and measles [25].

Medically, it has also been stated that severe malnutrition which persists in most African refugee camps (e.g. in Zambia and Sudan) may result in clinical complications either in the long or short run. Persistent diarrhoea, neurological involvement in pel- lagra and beriberi, bone malformation in acute cases of ricket, and blindness in final stage of vitamin A deficiency are common in refugee children. All these health problems that refugees go through may not be uncommon in normal conditions but when they are the results of acute violence and conflicts. they impose serious strains on the health facilities of host countries, or on the area of refugee concentration. This, certainly affects health care services and health care programming of the concerned areas. Refugees also strain the health resources of host countries especially in cases where international agencies such as UNICEF do not assist, and also where the health resources of the host countries are already inadequate. According to Ibrahim Dagash, of the OAU Information Division, the refugee camps in the Horn of Africa:

are living examples of waste. misery and homelessness. The only way to identify them is that they are refugees from whom only God. the Almighty knows what the future holds. How those refugees manage to live in their present camps under such conditions of poverty with their children not having anywhere to go is a miracle [25].

If African refugeeism has strained social infrastructures (notably health) of the host countries, how has this problem been dealt with? Integration or voluntary repatriation of refugees have been regarded as the best alternative solutions. However, these options require the fulfilment of two prerequisites;

(I) There must be the political will by the host state to remedy the plight of refugees in the short run before repatriation, and this must involve taking responsibility for the health care of refugees.

(2) Integration must demand the reprogramming and maintenance of existing social infrastructures such as health facilities. if refugees are to receive the same quality of medical attention as citizens or residents of their area of refuge. This of course depends on the economic strength of the host country to provide health services to all citizens as well as refugees to be integrated.

Whether the host countries or the place of refugee opia in 1984/85 can be partly explained by the asylum adopt a policy of voluntary repatriation of pressure of returnee refugees produced by the disas- refugees or integration. increased social spending in trous Ogaden wars. This situation was merely wors- the area of health must accompany budgetary poli- ened by the scourge of natural disaster. Also, in 1987 cies if states are to have any effect on refugees’ an outbreak of cholera has been reported in Uganda. welfare. Where the countries of asylum are visibly Experts relate this recent health development in poor or facing economic readjustments, as most Uganda to the debilitating condition of protracted African states now do, constant mobility of refugees conflict in the country and the decaying social ser- across borders can no longer be ignored as isolated vices. Mozambique has also been experiencing starv- questions in social policies of African states especially ation which may affect about three million people in in the area of health. This becomes more demanding 1987. South Africa’s constant destabilization of Moz-

in the face of declining international concern for African refugees.

More recently, funds from external donors to assist host countries to cope with the social consequences of refugeeism, have been drying up. The reasons for donors’ weariness over African refugee problems include the following:

(I) Many donors now believe that some African countries see refugee situations as some kind of industry through which money can be obtained for other pressing social services in their states. This accusation came out of the realization that donations to Ethiopean refugees were diverted to other projects,

(2) Donors have also become skeptical about unrealistic projects submitted by host countries of refugee asylum, in which the basis of improving refugee welfare are not clearly reflected in existing social policies. Some U.S.A. and Canadian donors prefer to participate in distributing their donations to refugees so as to forestall any diversion as was the case in the wake of the Ethiopian hunger crisis of 1985.

(3) And lastly, many donors are concerned that African countries are doing very little to address the political issues that in the first place lead to refugees in Africa [25, p. 51.

The views presented here vividly point to the fact that refugee problems hinder health policies of African states in a way that makes the problem a regional issue. An attempt to further understand Africa’s refugee problems and how it affects the health policies of African states must therefore be premised on a regional policy focusing on the management of African conflicts and attempts to minimize violence, as well as the diversion of funds for social and health programmes into security matters. Addressing the root of this problem must not be ignored by African states and forms a basis for their stabilized social policies. As Jake Miller put the refugee problem:

No sound is more distressing than the plea of the homeless. Their cry expresses the plea of hunger. thirst and disease. and denotes the fear of death, insecurity and repression. The cry is not a pretence, but a reflection of grim reality. It is an expression of tragedy occurring daily through the world, but especially in Africa where one out of every two refugees resides [26].

Where African conflicts do not directly cause refugee problems, they make the health problems associ- ated with it more difficult to cope with. Diseases and hunger now emerging in Ethiopia, Mozambique and Uganda are not isolated from the series of protracted conflicts that have occurred in these countries in the nast two decades. The starvation that rocked Ethi-


ambique has contributed in no small measure to the deteriorating social condition in that state. Inability to find solutions to violence and conflicts in Africa means that Africa may continue to endanger the health status of its inhabitants.

CONCLUSION

In this paper, we have tried to chart the direct and causal relationship between Africa’s many cases of violence and conflicts on the one hand and health care policies of African states on the other. Specifically, we have examined the impact of African conflicts and violence on military expenditure and how these relate to health care. We posit that damage resulting from wars and other violence in Africa affect long term health programming.

This paper has also considered the issue of refugees which these conflicts have created. We have considered the health and living conditions in various camps. While health conditions of refugees in some camps (e.g. those of UN in Eritrea) may be improving, others such as those in Zambia are not. On average, the social and health condition of refugee camps under the responsibility of African national governments are poorer than those by religious groups and international relief agencies. The common health problems of refugees include communicable diseases, anaemia, malnutrition, complicated pregnancies, stress etc.

The reduction in the incidence of war refugees in Africa may lead to the improvement of health care services in host states and other affected states, as health policies would be based on the nature of health problems rather than on the needs of war victims.

We conclude that no state, however humane or prepared can effectively take care of the health demands of its citizens in the wake of political insecurity, violence and conflicts. It will be even more difficult when national resources are heavily skewed in favour of defence expenditure.

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