More children die from the indirect impact of armed conflict in Africa than those killed in the crossfire and on the battlefields, according to a new study by Stanford researchers. 

The study is the first comprehensive analysis of the large and lingering effects of armed conflicts — civil wars, rebellions and interstate conflicts — on the health of noncombatants.

The numbers are sobering: 3.1 to 3.5 million infants born within 30 miles of armed conflict died from indirect consequences of battle zones between 1995 and 2005. That number jumps to 5 million deaths of children under 5 in those same conflict zones.

“The indirect effects on children are so much greater than the direct deaths from conflict,” said Stanford Health Policy's Eran Bendavid, senior author of the study published today in The Lancet.

The authors also found evidence of increased mortality risk from armed conflict as far as 60 miles away and for eight years after conflicts. Being born in the same year as a nearby armed conflict is riskiest for young infants, the authors found, with the lingering effects raising the risk of death for infants by over 30 percent.

On the entire continent, the authors wrote, the number of infant deaths related to conflict from 1995 to 2015 were more than three times the number of direct deaths from armed conflict. Further, they demonstrated a strong and stable increase of 7.7 percent in the risk of dying before age 1 among babies born within 30 miles of an armed conflict.

The authors recognize it is not surprising that African children are vulnerable to nearby armed conflict. But they show that this burden is substantially higher than previously indicated. 

“We wanted to understands the effects of war and conflict, and discovered that this was surprisingly poorly understood,” said Bendavid, an associate professor of medicine at Stanford Medicine.  “The most authoritative source, the Global Burden of Disease, only counts the direct deaths from conflict, and those estimates suggest that conflicts are a minuscule cause of death.”

Paul Wise, a professor of pediatrics at Stanford Medicine and a senior fellow at the Freeman Spogli Institute for International Studies, has long argued that lack of health care, vaccines, food, water and shelter kills more civilians than combatants from bombs and bullets. 

This study has now put data behind the theory when it comes to children.

“We hope to redefine what conflict means for civilian populations by showing how enduring and how far-reaching the destructive effects of conflict have on child health,” said Bendavid, an infectious disease physician whose co-authors include Marshall Burke, PhD, an assistant professor of earth systems science and fellow at the Center on Food Security and the Environment.

“Lack of access to key health services or to adequate nutrition are the standard explanations for stubbornly high infant mortality rates in parts of Africa,” said Burke. “But our data suggest that conflict can itself be a key driver of these outcomes, affecting health services and nutritional outcomes hundreds of kilometers away and for nearly a decade after the conflict event”. 

The results suggest efforts to reduce conflict could lead to large health benefits for children.

The Data

The authors matched data on 15,441 armed-conflict events with data on 1.99 million births and subsequent child survival across 35 African countries. Their primary conflict data came from the Uppsala Conflict Data Program Georeferenced Events Dataset, which includes detailed information about the time, location, type and intensity of conflict events from 1946 to 2016. 

The researchers also used all available data from the Demographic and Health Surveys conducted in 35 African countries from 1995 to 2015 as the primary data sources on child mortality in their analysis.

The data, they said, shows that the indirect toll of armed conflict among children is three-to-five times greater than the estimated number of direct casualties in conflict. The indirect toll is likely even higher when considering the effects on women and other vulnerable populations.

Zachary Wagner, a health economist at RAND Corporation and first author of the study, said he knows few are surprised that conflict is bad for child health.

“However, this work shows that the relationship between conflict and child mortality is stronger than previously thought and children in conflict zones remain at risk for many years after the conflict ends.” 

He notes that nearly 7 percent of child deaths in Africa are related to conflict and reiterated the grim fact that child deaths greatly outnumber direct combatant deaths.

“We hope our findings lead to enhanced efforts to reach children in conflict zones with humanitarian interventions,” Wagner said. “But we need more research that studies the reasons for why children in conflict zones have worse outcomes in order to effectively intervene.” 

Another author, Sam Heft-Neal, PhD, is a research fellow at the Center for Food Security and the Environment and in the Department of Earth Systems Science. He, Burke and Bendavid have been working together to identify the impacts of extreme climate events on infant mortality in Africa.

There are a billion guns in the world today. Those firearms took the lives of about 251,000 people in 195 countries in 2016, according to new research. 

That’s a lot of guns and fatalities, mostly by homicide, suicide and accidents with firearms.

About 35 percent of those gun deaths were by Americans committing suicide.

In the most comprehensive investigation of its kind, the findings, published this week in the Journal of the American Medical Association (JAMA), show 64 percent of firearm-related deaths were homicides, 27 percent were suicides and 9 percent were unintentional deaths.

And in all but one year of the 27-year study period — 1994 due to the Rwandan genocide — firearm deaths were more common along sidewalks than on the battlefields.

“This constitutes a major public health problem for humanity,” said Stanford Health Policy’s David Studdert, a professor of medicine and professor of law.

In an accompanying editorial alongside the research by a consortium of public health experts, the Global Burden of Disease 2016 Injury Collaborators, Studdert and his co-authors write:

“Injuries and deaths from firearms are increasingly part of modern consciousness, particularly in some countries. In the United States, gun-related massacres at schools, places of worship, workplaces, night clubs, and recreational venues have seared images of innocent victims in the minds of the populace. In the United States and elsewhere, acts of terrorism committed with firearms and other lethal means have changed the way people live, work, travel, and play.”

But Studdert and his co-authors — firearms and public health experts Frederick P. Rivara at the University of Washington and Garden J. Wintemute at the University of California, Davis — argue that the deaths from these headline-generating mass shootings and terrorist attacks are only a fraction of the public health burden of firearm-related murders and suicides.

“Mass shootings and terrorism perpetrated with guns are the most visible forms of firearm violence,” Studdert told SHP. “But most firearm deaths are private tragedies. They are homicides and suicides that occur behind closed doors, leaving families and communities devastated.”

The global burden of firearm mortality is highly concentrated, according to the research. In 2016, six countries in the Americas — Brazil, the United States, Mexico, Columbia, Venezuela and Guatemala — accounted for slightlymore than 50 percent of all deaths.

An estimated 32 percent of the deaths occurred in just two countries, Brazil and the United States, with Brazil accounting for one-fourth of all firearm homicides and the United States 35 percent of all firearm suicides.

“For individuals living in the United States, where the national policy debate has focused largely on interpersonal violence, the study provides a reminder of the importance of firearm suicide. In 2016, there were 2 firearm suicides for every firearm homicide, a margin that has widened over the past decade as suicide rates have increased and homicide rates have been relatively flat. Older white non-Hispanic men are at greatest risk of firearm suicide. Research and prevention efforts in the United States should proceed from a more inclusive definition of firearm violence.”

The authors believe more robust methods for estimating the number and distribution of firearms — as well as a better understanding of access — are critically important in determining which policies and prevention strategies are most effective and how best to implement them.

Studdert and his fellow researchers said research on firearm violence and public health has been impeded by the Dickey Amendment, the 1996 bill that mandated “none of the funds made available for injury prevention and control  at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”

“In the absence of this funding, several private foundations have stepped in to fill the void," they wrote. "However, real progress in addressing the vast public health problem that the Global Burden of Injury Collaborators document will depend on sustained action from governments in both research and policy.”

Malaria claims nearly half-a-million lives worldwide each year — and yet we still know so little about the immunology of the disease that has plagued humanity for centuries.

There were 216 million cases in 2016, according to the World Health Organization. Sub-Saharan Africa carries 80 percent of the global burden of the mosquito-borne infectious disease which devastates families, disrupts education, and promotes the vicious cycle of poverty.

It is particularly brutal to pregnant women, who are three times more likely to suffer from a severe form of the disease, leading to lower birthweight among their newborns and higher rates of miscarriage, premature and stillborn deliveries.

“Pregnant women and their unborn children are more susceptible to the adverse consequences of malaria, so we are working to investigate new strategies and even lay the foundation for a vaccine to prevent malaria in pregnancy,” said Prasanna Jagannathan, MD, an assistant professor of medicine who is this year’s recipient of the Rosenkranz Prize.

Jagannathan, an infectious disease physician who is also a member of Stanford’s Child Health Research Institute, said the $100,000 stipend that comes with the prize will allow his lab members to ramp up their research in Uganda. A member of the nonprofit Infectious Disease Research Collaboration in Kampala, his team is particularly interested in how strategies that prevent malaria might actually alter the development of natural immunity to malaria.

“With support from the Rosenkranz Prize, we hope to identify maternal immune characteristics and immunologic targets that are associated with protection of malaria in pregnancy and infancy,” Jagannathan said.

The Dr. George Rosenkranz Prize for Health Care Research in Developing Countries is awarded each year by the Freeman Spogli Institute for International Studies and Stanford Health Policy to a young Stanford researcher who is trying to improve health care in underserved countries. It was established in 2009 by the family or Dr. George Rosenkranz, a chemist who first synthesized cortisone in 1951, and later progesterone, the active ingredient in oral birth control pills.

“My father has held a lifelong commitment to scientific research as a way to improve the lives and well-being of communities around the world,” said Ricardo T. Rosenkranz, MD. “In particular, he has always sought to improve the health of at-risk populations. Dr. Jagannathan’s work offers the very sort of innovative ingenuity that characterized my father’s early research, as well as his vision towards the future.”

Jagannathan and his collaborators at UCSF and in Uganda are currently conducting a randomized control trial of 782 Ugandan women who are receiving intermittent preventive treatment with a fixed dose of dihydroartemisinin-piperaquine(or IPTp-DP), a medication that has dramatically reduced the risk of maternal parasitemia, anemia, and placental malaria. Their preliminary data suggests that among 684 infants born to these women, maternal receipt of IPTp-DP may lead to a reduced incidence of malaria in the first year of life.

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“Having the discretionary support of the Rosenkranz Prize will allow us to generate some preliminary ideas from this trial that could lead to larger studies, to push this agenda further along,” Jagannathan said.

That agenda is to create a vaccine that targets pregnant women to prevent malaria both during pregnancy — but also potentially preventing malaria in infants, giving them a better start in life.

“We’re not the first ones to think of this, but we have the opportunity to test these hypotheses in incredibly unique settings, with really well-studied cohorts that have real-world implications in terms of what we find,” Jagannathan said. “I’m hopeful that the data that’s generated over the new few years will allow us to keep moving forward.”

Jagannathan has been traveling to Uganda for a decade to study malaria. He’s seen firsthand the relentless, gnawing impact the disease has on daily life.

“Before I went to Uganda I really didn’t understand the burden that malaria causes in communities — and it’s just incredible,” he said. His first study was on children aged 5 and under who had on average six episodes of malaria a year.

“They just get it over and over again, and the toll on society is enormous,” he said. The clinics are overwhelmed and a parent or sibling must miss work or school to stay home with that child.

Yet, in highly endemic settings, children eventually develop an immunity that protects against the adverse outcomes from malaria. If he and his colleagues can understand how pregnant women and children develop this clinical immunity to malaria, it could lead to better treatments and preventative strategies.

“If we understand the mechanisms that underlie naturally acquired immunity, that would offer some clues as to how we can develop a vaccine that actually allows either that immunity to occur more quickly or prevents us from developing immunity that allows for the parasite to persist without symptoms,” he said.

There is currently a malaria vaccine undergoing testing in Africa. The vaccine, known as RTS,S, was developed by GlaxoSmithKline and the PATH Malaria Vaccine Initiative, with support from the Bill and Melinda Gates Foundation. Decades in the making, four doses of the vaccine are required to reduce malaria infection in humans.

“It’s a remarkable vaccine in that it’s effective in the beginning, but the problem is that the efficacy wanes very rapidly,” Jagannathan said, noting that some studies show that beyond three years, the effectiveness drops to 15-20 percent.

“That’s the big issue and why people are really interested in trying to find new strategies and new approaches for a next-generation malarial vaccine,” he said. “That’s the overarching aspect of what motivates my work.”

Stanford scientists found that the global economy is likely to benefit from ambitious global warming limits agreed to in the United Nations Paris Agreement.

Failing to meet climate mitigation goals laid out in the U.N. Paris Agreement could cost the global economy tens of trillions of dollars over the next century, according to new Stanford research. The study, published in Nature, is one of the first to quantify the economic benefits of limiting global warming to levels set in the accord.

The agreement commits 195 countries to the goal of holding this century’s average temperature to 2 degrees Celsius above levels in the pre-industrial era. It also includes an aspirational goal of pursuing an even more stringent target of limiting temperature rise to 1.5 degrees. To date, the economic benefits of achieving these temperature targets have not been well understood.

 “Over the past century we have already experienced a 1-degree increase in global temperature, so achieving the ambitious targets laid out in the Paris Agreement will not be easy or cheap. We need a clear understanding of how much economic benefit we’re going to get from meeting these different targets,” said Marshall Burke, assistant professor of Earth system science in the School of Earth, Energy & Environmental Sciencesand lead author of the study.

To develop this understanding, a team of Stanford researchers studied how economic performance over the past half-century correlated with changes in temperature around the world. Then, using climate model projections of how temperatures could change in the future, they calculated how overall economic output is likely to change as temperatures warm to different levels.

The researchers found a large majority of countries – containing close to 90 percent of the world’s population – benefit economically from limiting global warming to 1.5 degrees instead of 2 degrees. This includes the United States, China and Japan – the three largest economies in the world. It is also true in some of the world’s poorest regions, where even small reductions in future warming generate a notable increase in per capita gross domestic product.

“The countries likely to benefit the most are already relatively hot today,” said Burke. “The historical record tells us that additional warming will be very harmful to these countries’ economies, and so even small reductions in future warming could have large benefits for most countries.”

The projected costs from higher temperatures come from factors such as increases in spending to deal with extreme events, lower agricultural productivity and worse health, the scientists said.

Previous research has shown that the actual climate commitments each country has made as part of the Paris Agreement add up to close to 3 degrees of global warming, instead of the 1.5–2 degrees warming goals.

Given this discrepancy, the researchers also calculated the economic consequences of countries meeting their individual Paris commitments, but failing to meet the overall global warming goals of 1.5–2 degrees. They found that failing to achieve the 1.5–2 degrees goals is likely to substantially reduce global economic growth.

Percentage gain in GDP per capita in 2100 from achieving 1.5 degrees Celsius global warming instead of 2 degrees.

Percentage gain in GDP per capita in 2100 from achieving 1.5 degrees Celsius global warming instead of 2 degrees. (Image credit: Marshall Burke)

“It is clear from our analysis that achieving the more ambitious Paris goals is highly likely to benefit most countries – and the global economy overall – by avoiding more severe economic damages,” said Noah Diffenbaugh, professor of Earth system science and paper co-author.

The authors note the study may underestimate the total costs of higher levels of global warming. That’s especially true if catastrophic changes such as rapid melting of the ice on Greenland or Antarctica come to pass, or if extreme weather events such as heatwaves and floods intensify well beyond the range seen in historical observations. A recent studyby Diffenbaugh and his colleagues showed that even with reduced levels of global warming, unprecedented extreme events are likely to become more prevalent.

The new research helps shed light on the overall economic value of the Paris Agreement, as well as on the Trump administration’s decision to withdraw the U.S. from the accord because of concerns that it is too costly to the U.S. economy. The researchers calculated that the overall global benefits of keeping future temperature increases to 1.5 degrees are likely in the tens of trillions of dollars, with substantial likely benefits in the U.S. as well. They note that these benefits are more than 30 times greater than the most recent estimates of what it will cost to achieve the more ambitious 1.5 degrees goal.

“For most countries in the world, including the U.S., we find strong evidence that the benefits of achieving the ambitious Paris targets are likely to vastly outweigh the costs,” said Burke.

Burke is also a fellow at the Center on Food Security and the Environment, the Stanford Woods Institute for the Environmentand the Freeman Spogli Institute for International Studies. Diffenbaugh is also the Kara J Foundation Professor, the Kimmelman Family Senior Fellow in the Stanford Woods Institute for the Environment and an affiliate of the Precourt Institute for Energy. Additional co-authors include W. Matt Davis, a former researcher at the Center on Food Security and the Environment. The research was supported by the Erol Foundation.

Media Contacts

Marshall Burke, School of Earth, Energy & Environmental Sciences: mburke@stanford.edu, (650) 721-2203
Noah Diffenbaugh, School of Earth, Energy & Environmental Sciences: diffenbaugh@stanford.edu, (650) 223-9425
Michelle Horton, Center on Food Security and the Environment: mjhorton@stanford.edu, (650) 498-4129

In March 2011, a post-earthquake tsunami triggered nuclear meltdowns, hydrogen-air explosions and the release of radioactive materials from the Fukushima Daiichi Nuclear Power Plant in Fukushima Prefecture, Japan. The Fukushima disaster has been called the most significant nuclear incident since the 1986 Chernobyl disaster. Professor Rodney C. Ewing, Frank Stanton Professor in Nuclear Security and co-director at the Center for International Security and Cooperation (CISAC) in the Freeman Spogli Institute for International Studies (FSI), as a member of a team of Japanese researchers, today published a report on the details of what exactly — at the particle level — was released into the air after the disaster.

In the discussion that follows, Ewing explains the team’s findings and why they are important for health and environmental safety.

Why did you decide to study the Fukushima disaster?

The Fukishima Daiichi event surprised me. I now teach a freshman seminar on this event. I am particularly interested to understand why the accident occurred and what the long-term impact will be on the environment. This research paper reflects my interest in answering these questions.

We’ve heard lots about possible health effects from contaminated water after the Fukushima disaster, but less about particulates in the air. What did you find?

During the core melt-down events at Fukushima Daiichi, radioactivity was released as fine particulates that traveled in the air, sometime for distances of tens of kilometers, and settled onto the surrounding countryside.

In order to understand the health risk, it is very important to understand the form and chemistry of these particulates.

Recently, in a previous paper we have described a new type of particulate that is Cs-rich (some Cs isotopes are highly radioactive). The highly radioactive Cs-rich particles formed in the reactor by condensation from a silica-rich vapor, formed from the melting of core and concrete structures. In this paper, we describe the first identification of fragments of the melted core that were entrapped by the Cs-particles and transported away from the reactor site, some 4 kilometers. This is an important discovery because this provides us with samples of the fuel and melted core.

This is a special contribution because it uses very advanced electron microscopy techniques that allow for imaging of individual atoms or clusters of atoms. This advanced technique is required because the particles are so small — nanometers in size.

How did you come to work with your collaborators in Japan?

I have had long standing collaborations with Japanese scientists for decades. The lead researcher for the group, Professor Satoshi Utusunomiya, was once a member of my research group when I was at the University of Michigan. We have always collaborated on topics that involve radioactive materials and the use of electron microscopy. This collaboration is an entirely natural outgrowth of previous collaborations.

What, if any, policy recommendations would you suggest based on your findings?

The most direct result would be to design monitoring systems so that we have a good record of released particulates. Also, we need to push the development of advanced analytical techniques so that these particulates can be quickly identified and characterized.