Getting health care has never been simple in the Central African Republic, where there’s a 16 percent chance a baby won’t make it past his or her fifth birthday and life expectancy tops out at age 50. But as violence has escalated in the wake of a coup in March, workers have fled government health clinics and many of the humanitarian organizations that have been propping up the country’s medical system have withdrawn from the country or cut back services.

At the same time, people who were forced from their homes by marauders are living in fields, where food is hard to come by and mosquitoes are plentiful. Malnutrition is rife, according to a new report  from Médecins Sans Frontières. Cases of malaria, a leading cause of death, are climbing at an alarming rate.

Children have been hardest hit, said Ellen van der Velden, who heads up MSF’s head of mission in the Central African Republic. But that’s not surprising — research shows children who grow up in war-torn countries are more likely to be malnourished and more susceptible to disease. Eight of the 10 countries with the world’s highest child mortality rates are engaged in conflict. The Central African Republic ranks number six.

“For children, the biggest casualties of war are not caused by bullets,” said Philip Verwimp, an associate professor of development economics at the Université Libre de Bruxelles in Belgium. “Children are far more likely to die from malnutrition, exposure to infectious disease or lack of access to health care.”

During the first quarter of 2013, MSF treated 33 percent more malaria cases in the Central African Republic than during the same period last year. Among children, the infection rate is nearly twice as high as in 2012. As the country rolls into peak malaria season this month, MSF estimates it may be heading into one of the “most acute malaria crises of recent years.”

Even in the best of times, only about 50 percent of children in the Central African Republic had access to routine vaccinations, like measles, meningitis and whooping cough. Since the fighting started in earnest in December of 2012, though, van der Velden said, “It is safe to say most babies aren’t getting vaccinated.” The government recently cancelled the rollout of an anti-malaria program that would have outfitted a large number of families with insecticide-treated bed nets to protect their children from disease-carrying mosquitos.

“The law of the jungle reigns,” Verwimp said. “People cannot trust the government, cannot trust police or fellow citizens. The usual economic health services all break down because of lack of governance.”

In times of peace, poor girls are most vulnerable. Children from wealthier families generally have better health outcomes because they are more likely to be well fed and can afford medical care, Verwimp said. Boys are less likely to die, he added, because when resources are scarce, male children get dinner first.

But in high-conflict areas, all children suffer.

“When dealing with a drought or a bad harvest, parents will see trouble coming and make preparations to make sure their children get enough food,” Verwimp said. “In a conflict setting, this is isn’t possible. They are caught off guard. They have to flee and leave their assets behind. They are not able to protect their children.”

Instability has aggravated pre-existing food shortages in the Central African Republic, van der Velden said. Stocks were already low and prices already high. Now, bandits, capitalizing on the chaos, are making their way through villages. Families have lost not only the food they harvested to feed their families, but also the grain stores they set aside for next year’s planting season.

“So many families are living hand to mouth,” said van der Velden. In MSF’s clinics, doctors are seeing babies with bloated bellies and spindly, bony limbs. 

Children carry the health effects of war with them long after the fighting has ceased, said Richard Akresh, an economics professor at the University of Illinois at Urbana-Champaign who studies how war affects child health. In his research in Burundi, Ethiopia and Nigeria, Akresh found that adults who were exposed to fighting as children were substantially shorter in height than those who weren’t.

Akresh can’t pinpoint exactly why children who grow up in war zones don’t grow as tall as their peers. It’s most likely, he said, an effect of malnutrition, exposure to disease or drinking bad water. What he does know for certain, though, is that stunted growth is connected to a slew of lasting problems. In general, men and women who grew up amidst conflict perform worse in school. Men earn less money because they are less productive. Women have more difficulty in childbirth. Their children are more likely to die.

“Everyone is so excited that there is less fighting in Africa — certainly, 20 to 30 years ago there was more — but even if the war is over, there is a group of kids who are going to be suffering for a long time,” Akresh said. “It’s important not to forget about them.”

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