Fragile States and Impacts on Healthcare

Frank Hutchins[1]

1. Universidad de Bellarmine, Estados Unidos

Doi: https://doi.org/10.23936/pfr.v7i3.253

PRÁCTICA FAMILIAR RURAL│Vol.7│No.3│Noviembre 2022│Recibido: 22/11/2022│Aprobado: 24/11/2022

Cómo citar este artículo
Hutchins F. Estados frágiles e impactos en la atención médica. PFR [Internet]. 29 de noviembre de 2022. 7(3). Disponible en: https://practicafamiliarrural.org/index.php/pfr/article/view/253

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Five years of climate-induced drought have left nearly half of Somalia’s population at the brink of starvation. Where rains have failed to fall, Improvised Explosive Devices (IEDs) - nearly all the work of Al-Shabaab extremists - have proliferated. This lethal combination of natural and social forces directly jeopardizes physical and mental health, leaving countries such as Somalia with some of the worst health indicators on the planet, including a life expectancy (56 years) nearly three decades short of Japan.

Keywords: violence, stress, climate change, allostatic charge

Estados frágiles e impactos en la atención médica


Cinco años de sequía a causa del cambio climatico han dejado a casi la mitad de la población de Somalia al borde de la inanición, a esto se suma la proliferación de artefactos explosivos improvisados (IED), producto del accionar de extremistas de Al-Shabaab. Esta combinación letal de fuerzas naturales y sociales pone directamente en peligro la salud física y mental, dejando  algunos de los peores indicadores de salud del planeta, incluida una esperanza de vida (56 años) casi tres décadas por debajo de Japón..

Palabras clave: violencia, estrés, cambio climático, carga alostática


The connections between state instability and health are extensive. This is particularly visible in social determinants of health, and the impacts these have on health equity in a particular country. Social stratification, and the effects of different rates of exposure, vulnerability, and the consequences of disease, result in increased suffering by certain groups based on race/ethnicity, gender, class, or other categories of difference. (Bornemisza, Ranson et al. 2010) While some of these determinants are the result of historical cultural, economic and political forces, others emerge from or are exacerbated by stressors on relatively weak governments. One visible area of stress is open conflict, such as that experienced in Ukraine, Syria, Yemen, or Afghanistan. But regionalized violence, such as that associated with cartels and gangs, can also produce significant stress on governments, and result in concomitant impacts on health. As this intersects with existing inequities, health care delivery is increasingly compromised. 

Somalia is the archetypical fragile state, defined by the Department for International Development as those states unwilling and/or incapable of delivering basic services to their population (DFID 2005). Such states are often conflict-ridden or, increasingly, significantly affected by poverty and climate change. The Fragile States Index (https://fragilestatesindex.org/) annually assesses countries across the globe, and gives each one a score that can be compared to indicators from earlier years to see whether a country is improving or worsening with regard to stability. The index looks specifically at: 

The Fragile States Index map of global instability colors much of the African continent with some shade of red on its Heat Map. A few other countries also show up as red or orange. In the Western Hemisphere, Venezuela and Haiti have that distinction. Other countries, such as Ecuador and Peru, are shaded yellow, putting them in the middle of the rankings of 179 countries in the index. (Peace 2022) For those fragile states shaded red, health services and indicators break down across multiple categories. As Mills says, developing countries generally have health care systems that are less established structurally, not as well organized, and less supported by public resources. (Mills 2014) In fragile states – which are not synonymous with developing states, but the links are more common – health disparities are intensified. Disparities are reflected in mortality and morbidity rates, epidemiological patterns, and medical education, and appear in states with High Intensity Conflict (such as Somalia, Syria, Ukraine, Afghanistan), Medium Intensity Conflict (such as Burkina Faso, Iraq, Myanmar), and High Institutional and Social Fragility (such as Burundi, Kosovo, Venezuela). (Landry, Giebel et al. 2021) 

For those countries ranked in the middle of the Fragile States Index – both developed and developing – metadata often suggest relatively efficient and effective health care systems. But narrowing the focus to specific regions reveals that some areas have problems similar to the more fragile states listed above. Ecuador, for example, is ranked 89th out of 179 states ranked by the 2022 Fragile States Index, with the most fragile state (Yemen) ranked number one. Life expectancy at birth increased by more than four years for women and nearly five years for men between 1990 and 2017. (Collaborators 2020) Universal Health Coverage has increased from 51.4% to 64.5% in 2019. (Collaborators 2020) Healthcare spending per person has gradually risen, while maternal and infant mortality rates have fallen. 

But all are not well in Ecuador. Violence, especially related to cartel activity, debt servicing stress, indigenous unrest, refugee waves, and climate change disasters, affect healthcare delivery and equity. Cartel violence in particular has grown dramatically in recent years, with The Guardian in a November 2022 article referring to Ecuador as teetering “on the edge of becoming a narco-state.” The article referred to multiple prison massacres, and a general rise in violent deaths as local criminal gangs join Mexican cartels in controlling geographical and social territory in coastal Ecuador. (Collyns 2022) States of emergency were declared in Guayas, Santo Domingo, and Esmeraldas provinces at various times in 2022. The murders of policemen in Guayaquil and Esmeraldas were behind the most recent declarations. The growing power of cartels and criminal gangs can lead to the “weaponization of health care” as power shifts to extra-state groups that can affect the provision of health services and control large sums of contract money that sustain public health systems. (Haar, Read et al. 2021) 

Servicing the foreign debt also diverts considerable resources away from other areas, such as healthcare. Ecuador’s external debt accounted for 54% of Nominal GDP in 2021, up from about 18% in 2012. (CEIC 2022) While international loans can theoretically be used for social projects, such as healthcare, they can also constrain options for such projects as public monies are used to pay principal and interest on loans. Government-imposed austerity measures, or those demanded by lenders such as the IMF, can lead to deep cuts to healthcare. The Guardian reported that Ecuador’s Ministry of Health dismissed 3,680 workers in 2019, just before the COVID-19 pandemic slammed the country. (Corkery, Chiriboga-Tejada et al. 2020) Predictably, the healthcare infrastructure buckled under the pressure. Horrific pictures of the bodies of COVID victims left on sidewalks and outside morgues and hospitals in Guayaquil circulated worldwide. 

Contributions to government instability emerge as well from regional and global problems, such as refugee movements and climate change. According to UNHCR, there were over 100,000 refugees in Ecuador in 2020, along with 26,000 asylum seekers. (UNHCR 2022) This was among the highest number of recognized refugees in Latin America, creating a further strain on health services and public spending. Climate change, particularly in the form of weather extremes that lead to both flooding and drought, damages infrastructure and increases the numbers of Internally Displaced Persons. The World Health Organization predicts an additional quarter million deaths per year from 2030-50 from climate-related malnutrition, vector-borne diseases, diarrhea, and heat stress. Under a high-emissions model, the World Bank Group predicted a significant increase in the Number of Very Hot Days (>35°C) and Tropical Nights (>20°C) in Ecuador through the end of the century. The propagation and transmission of vector diseases such as dengue, malaria, and leishmaniasis – currently common at lower elevations – will impact people at higher elevations as temperatures rise. (Group 2021) Respiratory problems are also expected to rise as air quality deteriorates in urban areas.  

The concept of “fragile” or “weak” states provides us with tools to define and analyze the consequences of fragility for key social sectors, such as healthcare. This increases the power of epidemiological models to predict and track the impacts of conflict, debt loads and environmental disasters on specific populations within regions or countries. Fragile governments with limited resources and legitimacy struggle to meet the health needs of their populations. This has clear implications for their citizenry, but also for global health as contagions have no respect for political boundaries. Beyond states formally labeled as “fragile,” there are multiple countries with varying degrees of instability that also impacts healthcare. The darker shadows of globalization are haunted by specters, such as narco- and necro-states that operate with virtual impunity. (Díaz-Barriga and Dorsey 2020) Violence associated with cartels and gangs can be analyzed at the individual level, connecting myriad stressors with chronic diseases, the breakdown of immune systems, and mental health issues. Violence and the circulation of dark money can also be analyzed at larger scales, as bureaucrats and police forces are compromised, and governments pumping money into security have less to support public health and pay those providing health services. 

It is essential that an intersectional approach be used to assess and predict health patterns at various scales. Research from biological sciences must be married to social science research to deepen our understanding of complex problems that emerge from the intersection of health with social, political, and economic breakdown. Multidisciplinary analyses offer greater sophistication and accuracy in tracing out these intersections, which is especially important in places where over-stressed public institutions cannot or will not provide critical services such as healthcare. The outbreak and movement of both infectious and chronic diseases can be more effectively monitored and controlled, and the distribution of medicines, medical technology, and human resources can be more equitable, with this approach. 


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CEIC (2022). Ecuador. CEIC. 

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Collaborators, G. U. H. C. (2020). "Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019." The Lancet 396(10258): 1250-1284. 

Collyns, D. (2022). Headless bodies and deadly bombs: cartel violence escalates in Ecuador. The Guardian

Corkery, A., et al. (2020). Austerity is killing Ecuador. The IMF must help end this disaster. The Guardian

DFID (2005). "Why we need to work more effectively in fragile states." London: DFID

Díaz-Barriga, M. and M. E. Dorsey (2020). Fencing In Democracy, Duke University Press. 

Group, W. B. (2021). Climate Risk Country Profile: Ecuador. 

Haar, R. J., et al. (2021). "Violence against healthcare in conflict: a systematic review of the literature and agenda for future research." Conflict and Health 15(37). 

Landry, M. D., et al. (2021). "Health system strengthening in fragile and conflict-ridden states: a call to action." BMC Health Services Research 21(726). 

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UNHCR (2022). "Refugee Data Finder." Retrieved Nov. 28, 2022, from https://www.unhcr.org/refugee-statistics/download/?url=8Jf2oQ