Case study: what really kills civilians when the systems fail
When a country is at war, or a disaster knocks out its infrastructure, most of the civilians who die are not shot, bombed or crushed. They die weeks and months later of dirty water, infections, hunger and medical care that stopped. A study of every armed conflict from 1990 to 2017 linked wars to 29.4 million civilian deaths. Only 2.4 million of them were injuries.
Our other case studies, on Weimar Germany and Yugoslavia and Bosnia, looked at what happens to money. This one looks at what happens to people's bodies when the water, sewers, food supply, power and clinics stop working.
The pattern: indirect deaths dwarf direct ones
In 2020, researchers at Imperial College London and partner universities published a panel study of 193 countries from 1990 to 2017 in BMC Medicine. They compared death rates in countries at war with what those countries would otherwise have expected.
| Cause of war-linked civilian death, 1990–2017 | Deaths | Share |
|---|---|---|
| Communicable disease, maternal and newborn deaths, malnutrition | 21.0 million | About 71% |
| Non-communicable disease (heart disease, diabetes and others) | 6.0 million | About 20% |
| Injuries, including violence | 2.4 million | About 8% |
| Total | 29.4 million |
Children under five saw the largest relative increase in deaths, and the largest absolute increases were among the youngest children and adults over 69. An earlier international review, the Geneva Declaration's Global Burden of Armed Violence in 2008, put it simply: studies show that between three and 15 people die indirectly for every person who dies violently.
Congo: violence was 0.4% of deaths
The wars in the Democratic Republic of Congo that began in 1998 drew in several neighboring armies and dozens of militias. The International Rescue Committee ran five nationwide mortality surveys and estimated 5.4 million excess deaths between August 1998 and April 2007. About 2.1 million came after the war formally ended in 2002.
In its last survey, covering 2006 and 2007, only 0.4% of deaths were attributed directly to violence. The killers were infectious disease, malnutrition, and problems of newborns and pregnancy. Earlier rounds named malaria, diarrhea, pneumonia and malnutrition. Children were 19% of the population but 47% of the deaths.
The total is disputed. In 2010 the Human Security Report argued that the IRC had used too low a baseline death rate and that the real figure could be as much as 60% lower. Nobody in that argument disputes the pattern: people died of preventable causes because clinics, roads, water and food supplies had collapsed.
Yemen: the cholera war
In November 2021 the UN Development Programme estimated that Yemen's war would have killed 377,000 people by the end of that year. About 60% of those deaths came from indirect causes such as hunger and preventable disease, not from fighting or air strikes.
The clearest marker is cholera, a disease spread by sewage in drinking water. From October 2016 to August 2019, Yemen's health ministry recorded 2,036,960 suspected cholera cases and 3,716 deaths. The Global Alliance Against Cholera called it the largest documented cholera epidemic of modern history. Bombing had damaged water and sanitation systems, and rising prices for fuel, food, water and medicine made the outbreak harder to stop.
The post-9/11 wars: death outlives the fighting
Brown University's Costs of War project estimated in May 2023 that the wars in Afghanistan, Pakistan, Iraq, Syria and Yemen caused 3.6 to 3.8 million indirect deaths. With direct deaths added, the total is at least 4.5 to 4.7 million and still rising. The report blames the damage to economies, public services, infrastructure and the environment, plus the spread of disease. It also counted more than 7.6 million children under five suffering acute malnutrition. These deaths keep coming long after the main fighting ends.
Leningrad: hunger and cold in a modern city
From September 1941 to January 1944, German and Finnish forces besieged Leningrad for about 872 days. Bombing destroyed water and sewer pipes and cut the city's utilities. In November 1941, after two cuts in one month, most civilians were allowed 125 grams of food a day.
Soviet authorities registered about 670,000 deaths, mostly from starvation, stress and exposure. Independent estimates run from 700,000 to 1.5 million, because many deaths were never registered. Most died of hunger and cold, not shells and bombs.
Disasters in rich countries: Puerto Rico after Hurricane Maria
The same pattern shows up on a smaller scale after natural disasters, even in wealthy places. Hurricane Maria hit Puerto Rico in September 2017. For months the official death toll was 64. An independent study by George Washington University estimated 2,975 excess deaths in the six months after the storm, with the poor and the elderly most at risk.
A separate household survey published in the New England Journal of Medicine estimated about 4,645 deaths. It found that interrupted medical care caused about a third of them, and 31% of households reported that their medical care was disrupted. The storm killed directly. The months without reliable power, roads and clinics killed more.
What this means for you
Almost everything that kills in the “after” phase can be prepared for at home, cheaply.
- Water is the first line. Ready.gov asks for one gallon per person per day for several days. Store more, and have a way to treat what you collect. See our water storage guide.
- Sanitation is half the job. Cholera and other diarrheal diseases spread when sewage gets into drinking water. Keep garbage bags, ties, soap and hand sanitizer, and plan where waste and trash will go if the sewers stop.
- Learn to make oral rehydration solution. The Rehydration Project's home recipe is 6 level teaspoons of sugar and half a level teaspoon of salt in 1 litre of clean or boiled-and-cooled water. Measure carefully, since too much salt is dangerous, and get medical help if diarrhea lasts more than 3 to 4 days.
- Protect the medicines you depend on. In Puerto Rico, a third of the deaths came from interrupted care. Keep your prescriptions organized, ask your doctor about keeping a buffer, and write down what everyone in the house takes.
- Food and warmth come next. Leningrad shows what hunger and cold do to a modern city. See how many days of food and water governments recommend and how to stay warm without power.
How this plays out in Finton
- The WATER need drains first. Raw creek water makes your family sick unless you filter or boil it.
- Trash in the house makes people ill. Burn it, bury it, or watch your family's health fall.
- The hospital doesn't last. In the grid scenarios it runs on generators, then fails, then closes. Earn Dr. Patel's radio call sign while you still can.
- Medicine is worth more than ammunition. First aid kits, antibiotics and rehydration salts save more lives than a fight.
Sources
- Jawad et al., Estimating indirect mortality impacts of armed conflict in civilian populations, BMC Medicine, 2020 — the 193-country study: 29.4 million deaths and the breakdown by cause.
- Geneva Declaration, Global Burden of Armed Violence 2008, executive summary (PDF) — three to 15 indirect deaths for every violent death.
- International Rescue Committee: Mortality in the Democratic Republic of Congo — 5.4 million excess deaths, 0.4% from violence, children 47% of deaths.
- Congo Research Group: How many people really died in Congo? — the Human Security Report challenge to the IRC estimate.
- Al Jazeera: UNDP report on Yemen war deaths (November 2021) — 377,000 deaths by the end of 2021, 60% indirect.
- ReliefWeb: Cholera situation in Yemen, August 2019 — 2,036,960 suspected cholera cases and 3,716 deaths since October 2016.
- Global Alliance Against Cholera: Cholera epidemic in Yemen — “the largest documented cholera epidemic of modern history.”
- Savell, How Death Outlives War, Costs of War, Brown University, May 2023 — 3.6 to 3.8 million indirect deaths in the post-9/11 war zones.
- Wikipedia: Effects of the siege of Leningrad — registered deaths, independent estimates and the 125-gram ration.
- NPR: Hurricane Maria caused 2,975 deaths, independent study estimates — the George Washington University estimate and the official count of 64.
- Harvard GHELI: New study, Hurricane Maria death toll exceeds official estimates — interrupted medical care as about a third of deaths.
- Rehydration Project: homemade oral rehydration solution — the recipe and its cautions.
- Ready.gov: Build a kit — water, sanitation and prescription medicine in a home kit.
This article is general information for preparedness and history. It is not medical advice. Follow official guidance and your local emergency managers, and call 911 in an emergency.