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Unaccounted long-term health cost of wars on wartime children

Summary:
Editors' note: This column is part of the Vox debate on the economic consequences of war. Across the world, armed conflicts continue to pose a serious threat to the lives of millions of people. They significantly burden all facets of economic and social life in conflict-torn nations due to their toll on human life and long-term detrimental effects on physical and mental health and human capital, as well as institutional capacity, social capital and economic growth. A 2022 World Bank report predicts that, by 2030, between two-thirds and three-quarters of extremely poor people will live in conflict settings. Conflicts account for 80% of all humanitarian needs. Further, many countries ravaged by conflict are caught in cycles of violence. Over 90% of the 39 countries that had civil

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Editors' note: This column is part of the Vox debate on the economic consequences of war.

Across the world, armed conflicts continue to pose a serious threat to the lives of millions of people. They significantly burden all facets of economic and social life in conflict-torn nations due to their toll on human life and long-term detrimental effects on physical and mental health and human capital, as well as institutional capacity, social capital and economic growth. A 2022 World Bank report predicts that, by 2030, between two-thirds and three-quarters of extremely poor people will live in conflict settings. Conflicts account for 80% of all humanitarian needs. Further, many countries ravaged by conflict are caught in cycles of violence. Over 90% of the 39 countries that had civil wars in the 21st century also had civil wars in the last three decades. 

The 2022 Russian invasion of Ukraine and war atrocities once again place at the centre of the public attention the enduring impacts of armed conflict on populations, especially children (Justino 2022). The Russian invasion caused millions of Ukrainian children to leave their homes and schools and seek refuge in bomb shelters, underground metro stations, parking lots, and at times in other countries as refugees (Angrist et al. 2022, Becker 2022).

There has been a long-held view that short-term fluctuations in income and consumption from armed conflict result in temporary losses in welfare but not permanent harm (Davis and Weinstein 2002, Brakman et al. 2004, Miguel and Roland 2011). Over the past decade, however, evidence is mounting that adverse transitory shocks, especially those experienced early in life, can have profound long-term effects. Children are particularly vulnerable to the impact of armed conflicts, given the age-specific nature of human capital and physical and mental health investments, as well as the extreme distress caused by exposure to armed conflicts during children’s formative years (Angrist 2022, Brück et al. 2022). 

Additionally, it has been shown that wartime resources, as well as post-war mitigating investments, lead to significant long-term heterogeneity among wartime children. Considering that 426 million children worldwide are being affected by armed conflicts (Østby et al. 2020) in addition to the millions of Ukrainian children in war zones, understanding the potential long-term effects of warfare on children in war-torn countries worldwide is of paramount importance.

Examining historical episodes of conflicts, existing studies provide robust causal evidence on the potential long-term legacies of in utero and early childhood exposure to warfare on human capital, health, and labour market outcomes of wartime children. Studies have, for example, examined the effects on German children of the Allied Air Forces’ extensive bombing in WWII. In the Allied Air Force (AAF) Bomber Command’s offensive area campaign, more than one and a half million tonne of mostly high-explosive bombs were dropped over Germany (Davis 2006). It significantly disrupted daily life, exacerbated by the uncertainty of the aerial attacks and the destruction of homes, schools, hospitals, and other public spaces. 

However, the intensity of the bombing varied significantly across cities, as shown in Figure 1. In fact, targeted cities were not necessarily chosen for their significance for the war effort, but rather for their visibility from the air, determined by weather conditions or noteworthy landmarks such as cathedrals. Furthermore, the distance to the RAF’s air bases in Mildenhall, UK – also used later in the war by American aircraft – significantly contributed to the bombing intensity in a given town.

Figure 1 WWII destruction across regions in West Germany

Unaccounted long-term health cost of wars on wartime children

Note: The darker the region, the more wartime destruction it experienced.
Source: Data on regional boundaries is taken from the Federal Office for Building and Regional Planning (Bundesamt für Bauwesen und Raumordnung, BBR).

Leveraging a unique historical city-level dataset on bombing intensity and the resulting destruction of Germany in WWII and individual data from various waves of the German Socio-Economic Panel, in a pair of papers (Akbulut-Yuksel 2014, 2017) I exploit plausibly exogenous city-by-cohort variation in the intensity of in utero and early childhood exposure to the aerial attacks by the Allied Air Forces. The treatment variable in this research design is an interaction between the wartime destruction in a given city and an indicator for being under the age of five during WWII, ages that are fundamental for long-term health outcomes.

In Akbulut-Yuksel (2014), I find that large-scale physical destruction had detrimental effects on education, health, and labour market outcomes even after 40 years. Significant destruction of schools and disruption of the educational system resulted in wartime children in the most severely affected areas having completed 0.8 fewer years of school. Moreover, as adults, these wartime children are over a centimetre shorter; war exposure wiped out a half a century’s improvement in individual height. 

Further, exposure to WWII destruction caused children from disadvantaged families to have a four-percentage-point higher mortality rate later in life (Akbulut-Yuksel 2014). Their satisfaction with their health is six percentage points lower and they earn 9% less. The estimated adverse health effects of warfare were severest for wartime girls, people with lower socioeconomic status, and those who lost their parents during the war years and were residing in the hardest-hit cities, suggesting that resources available during wartime are essential to reduce the enduring effects of war (Akbulut-Yuksel and Yuksel 2017, Justino 2022).

The long-term adverse health effects of prenatal and early postnatal exposure to warfare have also been documented in a wide array of physical and mental health outcomes, even 60 years after the war. In Akbulut-Yuksel (2017), I find that individuals who were exposed to WWII destruction during gestation or early childhood have higher BMI and obesity as adults due to significant nutritional deficiencies in their formative years. Further, these individuals also show an elevated incidence of chronic health conditions in adulthood, such as stroke, hypertension, diabetes, and cardiovascular disorder. 

In a recent paper with Erdal Tekin and Belgi Turan (Akbulut-Yuksel et al. 2022), we further demonstrate that early childhood exposure to war negatively affects not only physical health but also long-term mental health. We found that an increase of one standard deviation in the destruction caused by war during a person’s first five years of life is associated with about a 10% decline in standardised mental health scores when they are in their 60s and 70s. This also translates into an increase of 3.3 percentage points in the likelihood of being diagnosed with clinical depression.

Similar evidence of the adverse long-term physical and mental health effects of war on children has also been found among survivors of the Vietnam War. We show that Vietnamese wartime children, especially girls, who were exposed to war before their teen years are significantly more likely to have functional and physical limitations as adults in their daily activities (Akbulut-Yuksel et al. 2022). Additionally, our results indicate that wartime girls later in life suffer from PTSD more often than their older counterparts, who did not experience war as children, supporting the findings from WWII studies that show enduring physical and mental health legacies of childhood exposure to war.

These studies provide mounting and alarming evidence on the potential impact that the Russian invasion may have on the human capital and physical and mental health outcomes of the Ukrainian children who are being exposed to war and large-scale destruction (also see Brück 2022, Angrist 2022, Becker 2022, Justino 2022). Even though countries can be successfully rebuilt with humanitarian aid and post-war reconstruction efforts, the physical and mental health effects linger for a long time, even in countries with strong post-war institutions that may mitigate some of these adverse effects (Becker 2022). 

There is little doubt that the trauma, fear, and anguish Ukrainian children are experiencing will have a tremendous effect on their physical and mental health, an effect that may last for life. Taken together, the findings from WWII, the Vietnam War, and other historical episodes underscore the importance of policies that prioritise the child (Brück 2022, Angrist et al. 2022). Such policies are essential not only to improve the wellbeing of the wartime children and their children, who are also impacted by warfare, but also to facilitate peacekeeping operations.

References

Akbulut-Yuksel, M (2014), “Children of war the long-run effects of large-scale physical destruction and warfare on children”, Journal of Human Resources 49(3): 634–62.

Akbulut-Yuksel, M (2017), “War during childhood: The long run effects of warfare on health”, Journal of Health Economics 53: 117–30.

Akbulut-Yuksel, M, and M Yuksel (2017), “Heterogeneity in the long-term effect of the warfare”, Economics and Human Biology 27(Part A): 126–36.

Akbulut-Yuksel, M, E Tekin and B Turan (2022), “WWII blues: The long-run effects of warfare on mental health”, mimeo.

Akbulut-Yuksel, M, Z Zimmer, S Pandey and T K Toan (2022), “Untold story of wartime children: Results of the Vietnam Health and Aging Study”, mimeo.

Angrist, N, S Djankov, P Goldberg and H Patrinos (2022), “The loss of human capital in Ukraine”, VoxEU.org, 27 April.

Becker, S (2022), “Lessons from history for our response to Ukrainian refugees”, VoxEU.org, 29 March.

Brakman, S, H Garretsen and M Schramm (2004), “The strategic bombing of cities in Germany in World War II and its impact on city growth”, Journal of Economic Geography 4(1): 1–18.

Brück, T, M Di Maio and S Miaari (2022), “Learning the hard way: The effect of conflict on education”, VoxEU.org, 19 April.

Davis, D, and D Weinstein (2002), “Bones, bombs, and break points: The geography of economic activity”, American Economic Review 92(5): 1269–89.

Davis, R G (2006), Bombing the European Axis powers. A historical digest of the combined bomber offensive 1939 – 1945, Maxwell Air Force Base, AL: Air University Press.

Justino, P (2022), “The war in Ukraine: Civilian vulnerability, resilience, and resistance”, VoxEU.org, 14 April.

Miguel, E, and G Roland (2011), “The long run impact of bombing Vietnam”, Journal of Development Economics 96(1): 1–15.

Østby, G, S A Rustad and A F Tollefsen (2020), Children affected by armed conflict, 1990–2019, Oslo: Peace Research Institute Oslo.

World Bank (2022), Fragility, conflict and violence.

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