Child Health & Conflict

in Cote d’IvoireCamelia Minoiu

IMF InstituteInternational Monetary

Fund

July 28th, 2011

Olga Shemyakina

School of EconomicsGeorgia Institute of

Technology

Motivation Large scale physical destruction arising from

armed conflicts and natural disasters Macro level studies suggest rapid catch-up

growth in physical capital and macroeconomic outcomes (Miguel & Roland, 2011; Davis and Weinstein, 2002)

However, the direct and indirect consequences of these events along human dimensions could be more persistent and serious than physical impacts.

War & Human Capital: Education

Europe: Loss in school attainment for individuals from war-affected

countries Germany & Austria vs. Sweden & Switzerland (Ichino & Winter-

Ebmer, 2004)

Tajikistan: 100,000 killed, hundred thousands displaced. Lower enrollment rates and completion of mandatory nine grades

of schooling by young women in Tajikistan (Shemyakina 2011)

Rwanda: 10% of population were killed Cohorts of children exposed to this conflict completed 18.3

percent fewer years of education. Non-poor, male individuals were more negatively affected.

(Akresh & de Walque, forthcoming)

War & Human Capital: Health

Burundi: Civil war and crop failure in Burundi (Bundervoet, Verwimp,

and Akresh, 2009) an extra month of war exposure decreases children’s

HAZ by 0.047 standard deviations compared to non-exposed children.

Rwanda: Effects of genocide in Rwanda (Akresh, Verwimp and

Bundervoet, forthcoming) Decrease in the stature of affected children

Nutrition and Health in Early Childhood There is no reversal of poor nutrition early in

life and the damage to health is permanent (Barker 1999).

Programming process: a fetus adjusts to short-term changes in his or her

environment and while such adaptation is beneficial in the short

run, it is detrimental to long-term health (Godfrey and Barker, 2000).

This study We use the 2002-2007 conflict in Cote d’Ivoire

as a quasi experiment to analyze the effect of the conflict on child’s health measured by height-for-age z-scores

while controlling for province of residence and year of birth

Main findings

Children from the northern regions of CIV that were controlled by the rebels and that were more affected by the war suffered health set-backs as compared to children from the lesser affected south.

The effect is especially pronounced for children born soon after the start of the conflict (born in 2003-2005) and who were exposed to the negative impacts of the conflict for a longer period of time, This is consistent with other studies (Bundervoet et al.,

2009).

2. Background of the Conflict

Civil war in CIV An unusually high international involvement by the

neighboring nations, the United Nations, France, and Burkina Faso.

Relatively small number of casualties: the best estimates of annual battle fatalities reaching about

600 in 2002 and 2003. Civilians affected by the conflict:

2.7 million, including the internally displaced and 4 million (includes foreign residents evacuated to Liberia

and Sierra Leone and those who fled to Mali, Guinea, Burkina Faso and elsewhere (UNOCHA, 2003)).

Figure 1 – Real GDP Growth Rate in Cote d’Ivoire,

1990-2010.

-4

-2

0

2

4

6

8

10

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Civil conflict

Source: World Economic Outlook (October 2010). The figure for 2010 is a projection.

The conflict: 2002-2007 Prelude:

Political unrest followed the death of long-standing President Felix Houphouet-Boigny in 1993, with a number of coups d’état taking place during the 1990s.

The start: September 19, 2002 multiple attacks in several cities (Abidjan in the

south, Bouake in the center, and Khorogo in the north)

by military forces protesting against plans towards demobilization.

The conflict: 2002-2007 Tension caused by

26% of population is of foreign origin (Burkina Faso, Sierra Leone)

Unemployment, return of many urban migrants to the fields that were tended by migrants

xenophobia: suppressed during the previous presidency “Ivorian” An economic downturn due to a deterioration of the terms

of trade between Third World and developed countries worsened conditions, exacerbating the underlying cultural and political issues.

Catalyst to the conflict

The law quickly drafted by the government and approved in a referendum immediately before the elections of 2000 required both parents of a presidential candidate

to be born within Côte d'Ivoire. This excluded the northern presidential

candidate Alassane Ouattara from the race. Ouattara represented the predominantly Muslim

north, particularly the poor immigrant workers from Mali and Burkina Faso working on coffee and cocoa plantations.

The conflict: 2002-2007 During the conflict:

After the initial attacks, the rebel forces retreated to the northern and western parts of the country, while the south was under government control.

The conflict ignited widespread harassment of foreigners in CIV, including migrant workers from the region and refugees from Liberia and Sierra Leone living on the outskirts of cities.

The end: The crisis ended officially with the March 2007

Ouagadougou Political Accord, although fighting had ceased about three years before that, with the interim period being marked by isolated bouts of violence and a tense atmosphere.

Figure 3 - The « buffer zone » separating the rebel-held north and the government-controlled south in Cote

d’Ivoire, 2002–2007

3. Data

3. Household and Individual Data The cross-sectional 2002 and 2008

Household Living Standards Surveys (HLSS)

The National Institute of Statistics

Detailed information on households and individuals, including socio-economic characteristics

3. Household and Individual Data Anthropometric measures for children

ages 0-5 years (0- 60 months) at the time of the survey Height Weight

Focus on height: a long-term measure of health

WHO Multicentre Growth Reference Study Height for age (HAZ):

the study population lived in the favorable socio-economic conditions and where the mobility was low;

80+% followed WHO feeding guidelines Cross-sectional and longitudinal component New dataset

Brazil Ghana India Norway Oman USA

3. The key dependent variable Height for Age Z-score (deviation from the mean score

based on WHO standards): (Measured Value - Average Value in the reference

population)/ Standard Deviation of the reference population

Ranges HAZ> - 2 s.d.– not malnourished -3 s.d. <HAZ < -2 s.d. – moderately malnourished HAZ< - 3 s.d. – severely malnourished

-2< HAZ < 2 – 95% of reference population

3. WHO guidelines The use of -2 Z-scores as a cut-off implies that 2.3%

of the reference population will be classified as malnourished even if they are truly "healthy" individuals with no growth impairment. Hence, 2.3% can be regarded as the baseline or expected prevalence.

% of population with HAZ < -2 SD: <20% - low prevalence of malnourishment 20-29 – medium 30-39 – high 40+ - severe

Descriptive data HAZ by province of residence and age group Historical HAZ by gender and year HAZ by gender, year and conflict exposure

Table 1 - Overview of nutritional status and poverty in CIV, by region HAZ range

Definition of malnourishment

All Conflict (North)Non-Conflict

(south)

2002 2008 2002 2008 2002 2008

>-2 Not 47.9 57.4 47.3 53.4 48.3 59.2

[-3, -2] Moderate 21.3 15.4 20.7 15.3 32.0 15.5

<-3 Severe 30.8 27.2 32.0 31.4 29.9 25.3

  Average -2.0 -1.53 -2.04 -1.68 -1.96 -1.46

Table 1 - Overview of nutritional status and poverty in CIV, by region HAZ range

Definition of malnourishment

All Conflict (North)Non-Conflict

(south)

2002 2008 2002 2008 2002 2008

>-2 Not 47.9 57.4 47.3 53.4 48.3 59.2

[-3, -2] Moderate 21.3 15.4 20.7 15.3 32.0 15.5

<-3 Severe 30.8 27.2 32.0 31.4 29.9 25.3

  Average -2.0 -1.53 -2.04 -1.68 -1.96 -1.46

Table 1 - Overview of nutritional status and poverty in CIV, by region HAZ range

Definition of malnourishment

All Conflict (North)Non-Conflict

(south)

2002 2008 2002 2008 2002 2008

>-2 Not 47.9 57.4 47.3 53.4 48.3 59.2

[-3, -2] Moderate 21.3 15.4 20.7 15.3 32.0 15.5

<-3 Severe 30.8 27.2 32.0 31.4 29.9 25.3

  Average -2.0 -1.53 -2.04 -1.68 -1.96 -1.46

Table 1 - Overview of nutritional status and poverty in CIV, by region HAZ range

Definition of malnourishment

All Conflict (North)Non-Conflict

(south)

2002 2008 2002 2008 2002 2008

>-2 Not 47.9 57.4 47.3 53.4 48.3 59.2

[-3, -2] Moderate 21.3 15.4 20.7 15.3 32.0 15.5

<-3 Severe 30.8 27.2 32.0 31.4 29.9 25.3

Failure to improve as much

Figure 4 – Long-term perspective on child health in CIV: Percentage of children with HAZ < - 2 s.d.

Years 1994, 1998, 2002, 2006, and 2008.

0

10

20

30

40

50

60

1994 1998 2002 2006 2008

Females Males

Sharp increase in malnourishment rates in 2002

Figure 5 – Long-term perspective on child health in CIV: Percentage of children with HAZ < - 3 s.d. Years 1994, 1998, 2002, 2006, and 2008.

0

5

10

15

20

25

30

35

1994 1998 2002 2006 2008

Females Males

Figure 6 - War vs. non-war affected areas:

Percentage of children with HAZ < - 2 s.d.

0

10

20

30

40

50

60

Total Females Males

2002 Non-war 2008 Non-war 2002 War 2008 War

Figure 6 - War vs. non-war affected areas:

Percentage of children with HAZ < -2 s.d.

0

10

20

30

40

50

60

Total Females Males

2002 Non-war 2008 Non-war 2002 War 2008 War

Figure 6 - War vs. non-war affected areas:

Percentage of children with HAZ < -2 s.d.

0

10

20

30

40

50

60

Total Females Males

2002 Non-war 2008 Non-war 2002 War 2008 War

Figure 6 - War vs. non-war affected areas:

Percentage of children with HAZ < -2 s.d.

0

10

20

30

40

50

60

Total Females Males

2002 Non-war 2008 Non-war 2002 War 2008 War

Failure to lower as much malnour. rates in conflict areas by 2008

Figure 6 - War vs. non-war affected areas:

Percentage of children with HAZ < -2 s.d.

0

10

20

30

40

50

60

Total Females Males

2002 Non-war 2008 Non-war 2002 War 2008 War

Worse rates for females in 2008 in conflict areas

Failure to improve for males in conflict ares

Figure 7 – War vs. non-war affected areas:

Percentage of children with HAZ < -3 s.d.

0

5

10

15

20

25

30

35

40

Total Females Males

2002 Non-war 2008 Non-war 2002 War 2008 War

Figure 7 – War vs. non-war affected areas:

Percentage of children with HAZ < 3 s.d.

0

5

10

15

20

25

30

35

40

Total Females Males

2002 Non-war 2008 Non-war 2002 War 2008 War

Worsening of extreme malnourishment for men and women

Regression Results

4. Regression framework

Dependent variable: HAZ score of a child

Independent: Residence in the conflict affected area Gender

Controls: Birth cohort dummies Province dummies

Table 2 – Determinants of anthropometric outcomes in Cote d’Ivoire (children born b/w)  Children born in 2003-2004 2003-2005

  (1) (2) (3) (4)

1=Conflict-area -0.535*** -0.614*** -0.804*** -0.836***

1=Female x Conflict   0.188   0.068

1=Female 0.127 0.071 0.136 0.114

Region FE yes yes yes yes

Cohort FE yes yes yes yes

Observations 912 912 1524 1524

R-squared 0.054 0.054 0.043 0.043

Table 2 (cont-ed)– Determinants of anthropometric outcomes in Cote d’Ivoire  Children born in 2003-2006 2003-2007

  (5) (6) (7) (8)

1=Conflict-area -0.714*** -0.753*** -0.747*** -0.732***

1=Female x Conflict   0.088   -0.035

1=Female 0.175* 0.148 0.218** 0.228**

Region FE yes yes yes yes

Cohort FE yes yes yes yes

Observations 2010 2010 2326 2326

R-squared 0.044 0.044 0.048 0.048

Table 3 - Determinants of anthropometric outcomes in Cote d’Ivoire. OLS Regressions. Dependent Variable: Children’s Height for Age Z-Score.

 

Children born in 1997-2003

Children born in 1997-2004

Children born in 1997-2005

  (1) (2) (3) (4) (5) (6)

1=Born>09/02*Conflict -0.863** -0.745* -0.599*** -0.471** -0.423** -0.289

Interaction term *Female   -0.223   -0.283   -0.299

1=Female 0.459*** 0.459*** 0.459*** 0.459*** 0.458*** 0.458***

Region FE yes yes yes yes yes yes

Cohort FE yes yes yes yes yes yes

Observations 5015 5015 5622 5622 6234 6234

R-squared 0.051 0.051 0.051 0.051 0.051 0.051

Table 3 (cont’ed)- Determinants of anthropometric outcomes in Cote d’Ivoire. OLS Regressions. Dependent Variable: Children’s Height for Age Z-Score.

 

Children born in 1997-2006

Children born in 1997-2007

  (7) (8) (9) (10)

1=Born>09/02*Conflict -0.256 -0.160 -0.176 -0.055

Interaction term*Female  -0.216   -0.273

1=Female 0.458*** 0.458*** 0.458*** 0.458***

Region FE yes yes yes yes

Cohort FE yes yes yes yes

Observations 6720 6720 7036 7036

R-squared 0.051 0.051 0.051 0.051

5. Discussion

5. Main findings Lower HAZ rates in the rebel-controlled North Greater impact on children who were born

when the conflict started No significant negative impact on female HAZ

once we control for the year of birth and province of residence

5. Limitations and Future Work Potential selection:

Only children who were alive at the time of the survey

Results do not account for migration

Future work: Account for the selection issues Add household characteristics Exploit individual variables of exposure to conflict

Policy implications Early intervention is important

School feeding programs? Support for families with young children

Loss in child health is cumulative, children stagnate and follow on a different growth path

Research shows that: Shorter individuals complete fewer years of

schooling Earn lower wages in the developing countries,

especially this is true for males

Thank you!!!