War, terror and mourning. Cultural memory in the inner dialogue.

This text compares four essays dealing with war, state terror in dictatorships, social violence such as racism, mourning and the avoidance of mourning. It shows that dictatorships share similarities in their techniques of manipulation, linguistic style and reference to history. They seek to exploit national myths through manipulative alienation. Myths are a central element of cultural memory, and their effect can be understood through a model of internal dialogue. This dialogue determines whether the regime's attempts at manipulation are successful.

Invasive fungal infections in wars, following explosives and natural disasters: A narrative review.

Infections are well-known complications in patients following traumatic injuries, frequently leading to high morbidity and mortality. In particular, trauma occurring in disaster settings, both natural and man-made, such as armed conflicts and explosives detonation, results in challenging medical conditions that impede the best management practices. The incidence of invasive fungal infections (IFI) is increasing in trauma patients who lack the typical risk factors like an immune compromised state or others. This narrative review will focus on IFI as a direct complication after natural disasters, wars, and man-made mass destruction with a summary of the available evidence about the epidemiology, clinical manifestations, risk factors, microbiology, and proper management. In this setting, the clinical manifestations of IFI may include skin and soft tissue infections, osteomyelitis, visceral infections, and pneumonia. IFI should be considered in the war inflicted patients who are exposed to unsterile environments or have wounds contaminated with soil and decaying organic matter.

Comparative analysis and evolution of civilian versus combatant mortality ratios in Israel-Gaza conflicts, 2008-2023.

Background: There is a need for statistical methodologies that scrutinize civilian casualties in conflicts, evaluating the degree to which the conduct of war affects civilians and breaches the laws of war. Employing an epidemiological method, this study introduced, developed, and applied a novel approach for investigating mortality of civilians versus combatants in conflicts. Methods: A deterministic mathematical model, structured by age and sex, was developed to describe the process of conflict-related deaths among both combatants and civilians. The model was calibrated using demographic and conflict-related data from different Israel-Gaza conflicts. To quantify the extent of the impact on civilians and determine whether they are the primary focus of a conflict, a statistical metric, the index of killing civilians, along with associated criteria, was devised. Results: The model-estimated proportion of deaths in Gaza categorized as combatants was 62.1% (95% uncertainty interval (UI): 57.6-66.2%), 51.1% (95% UI: 47.1-54.9%), and 12.7% (95% UI: 9.7-15.4%) in the 2008-2009, 2014, and 2023 Israel-Gaza conflicts, respectively. The index of killing civilians was 0.61 (95% UI: 0.51-0.74), 0.96 (95% UI: 0.82-1.12), and 7.01 (95% UI: 5.50-9.29) in the 2008-2009, 2014, and 2023 conflicts, respectively. These index values indicate strong evidence for civilians being an object of war in the 2008-2009 and 2014 conflicts, but combatants were still identified as the primary focus of the conflict. In the 2023 conflict, there is robust evidence for civilians being an object of war, with civilians identified as the primary focus of the conflict. Conclusion: Findings imply a progressive shift in Israel's rules of engagement over time, with a trend towards higher acceptance of casualties among civilians. The 2023 conflict stands apart from preceding Israel-Gaza conflicts, with civilians identified as the primary focus of the conflict.

Maintaining the mental health of Ukrainians in time of war: searching for a mechanism to provide a comprehensive system of psychosocial support and mental health awareness.

OBJECTIVE: Aim: To substantiate the possibilities of developing a comprehensive system of psychosocial support for Ukrainians during and after the war through thedevelopment of an integrated model of psychosocial service provision in the community, which promotes cross-sectoral interaction and expands the possibilities of integrating and scaling up multiple levels of mental health interventions. PATIENTS AND METHODS: Materials and Methods: The article is based on the use of bibliosemantic analysis of scientific works on the topic of mental health and mental health during the war. CONCLUSION: Conclusions: It is emphasised that in developing a comprehensive system of psychosocial support, it is necessary to: ensure accessibility of services for those in need; integrate services into the general health and social protection system; use a multisectoral approach, involving various organisations, institutions and professionals; train professionals to work in war conditions; develop and implement psychoeducation and psychological support programmes; monitor and evaluate the effectiveness of programmes. Particular attention is paid to psychoeducation as a technology that can be used at different levels of psychological intervention by both mental health professionals and other specialists involved in the provision of social services in communities. The spread of the impact of psychoeducational programmes will contribute to the development of community resilience in the face of social and psychological risks provoked by the war. A mechanism for scaling up the capabilities of the Technical Working Group on Mental Health and Psychosocial Support (MHPSS TWG), an association of leading international and Ukrainian NGOs specialising in mental health, established in Ukraine with the support of the WHO and the Ministry of Health of Ukraine, is proposed. The idea of creating a network of Resilience Centres in communities with the aim of forming a comprehensive system of psychosocial support at the state and community levels is substantiated.

Cardiac surgery during wartime in Israel.

BACKGROUND: The war that began on October 7th, 2023, has impacted all major tertiary medical centers in Israel. In the largest cardiac surgery department in Israel there has been a surprising increase in the number of open-heart procedures, despite having approximately 50% of surgeons recruited to military service. The purpose of this study is to characterize this increase in the number of operations performed during wartime and assess whether the national crisis has affected patient outcomes. METHODS: The study was based on a prospectively collected registry of 275 patients who underwent cardiac surgery or extracorporeal membrane oxygenation (ECMO) during the first two months of war, October 7th 2023 - December 7th 2023, as well as patients that underwent cardiac surgery during the same period of time in 2022 (October 7th, 2022 - December 7th, 2022). RESULTS: 120 patients (43.6%) were operated on in 2022, and 155 (56.4%) during wartime in 2023. This signifies a 33.0% increase in open-heart procedures (109 in 2022 vs. 145 in 2023, p-value 0.26). There were no significant differences in the baseline characteristics of patients when comparing the 2022 patients to those in 2023. No significant differences between the two groups were found with regards to intraoperative characteristics or the type of surgery. However, compared to 2022, there was a 233% increase in the number of transplantations in the 2023 cohort (p-value 0.24). Patient outcomes during wartime were similar to those of 2022, including postoperative complications, length of stay, and mortality. CONCLUSIONS: Patients who underwent cardiac surgery during wartime presented with comparable outcomes when compared to those of last year despite the increase in cardiac surgery workload. There was an increase in the number of transplants this year, attributed to the unfortunate increase in organ donors.

It matters what you see: Graphic media images of war and terror may amplify distress.

Media exposure to graphic images of violence has proliferated in contemporary society, particularly with the advent of social media. Extensive exposure to media coverage immediately after the 9/11 attacks and the Boston Marathon bombings (BMB) was associated with more early traumatic stress symptoms; in fact, several hours of BMB-related daily media exposure was a stronger correlate of distress than being directly exposed to the bombings themselves. Researchers have replicated these findings across different traumatic events, extending this work to document that exposure to graphic images is independently and significantly associated with stress symptoms and poorer functioning. The media exposure-distress association also appears to be cyclical over time, with increased exposure predicting greater distress and greater distress predicting more media exposure following subsequent tragedies. The war in Israel and Gaza, which began on October 7, 2023, provides a current, real-time context to further explore these issues as journalists often share graphic images of death and destruction, making media-based graphic images once again ubiquitous and potentially challenging public well-being. For individuals sharing an identity with the victims or otherwise feeling emotionally connected to the Middle East, it may be difficult to avoid viewing these images. Through a review of research on the association between exposure to graphic images and public health, we discuss differing views on the societal implications of viewing such images and advocate for media literacy campaigns to educate the public to identify mis/disinformation and understand the risks of viewing and sharing graphic images with others.

Trauma care in crisis: war trauma and mental health funding.

Background: Israel is currently under a state of continued unrest and state of war. There has been an influx of financial aid to treat the mental health fallout both from within Israel and abroad. Despite increased research into resilience, treatment and wide-scale interventions, there is a concern that this is not significantly influencing mental health aid allocation.Objective: This letter to the editor aims to describe the current situation and address current difficulties in regard to the relevant literature from recent conflicts and national traumatic events.Method: A consortium of national and international trauma experts pooled together their knowledge to produce a working statement based on evidence from clinical and research findings.Results: As opposed to wider, short-term psychological interventions which have limited long-term proven efficacy, lessons from previous war zones, wide-scale exposure to trauma and current war-torn countries highlight the importance of targeting and assessment, addressing barriers to care, strengthening existing systems and promoting community resilience and care.Conclusions: In addition to acute care, funding should be allocated to long-term care, enhancing treatment accessibility and community follow-up and additionally support long-term research to assess effectiveness and contribute to international knowledge.

Immediately following widescale attacks, national disasters and outbreaks of war there is a tendency for an outpouring of aid, and in recent years, mental health aid.Despite an increase in research in the field there are still significant gaps in the literature and a disconnect between the evidence and economic and philanthropic policy with short-term initiatives often favoured over long-term strategic planning.It is recommended that greater attention be paid to targeting and assessment, addressing barriers to care, strengthening existing systems and promoting community care.

The environment as the first victim: The impacts of the war on the preservation areas in Ukraine.

The war in Ukraine has had a devastating impact on the environment. Military actions have caused the release of hazardous substances into the environment, such as pollutants and toxic chemicals, that have contaminated the water, soil, and air, posing a threat to both human health and the environment. This has resulted in widespread destruction and contamination of natural habitats and resources and has disrupted wildlife populations and ecosystems. The impacts of military activity on the soils of protected areas are particularly critical, as they are the basis of biotic and landscape diversity and require special management and scientifically based monitoring measures even in peaceful conditions. In this context, this communication paper aims to provide an overview of the impacts of the war on the soils in four Ukrainian protected areas, namely Chornobyl Radiation and Ecological Biosphere Reserve; Desniansko-Starohutskyi National Nature Park; Holosiivskyi National Nature Park, and Hetmanskyi National Nature Park. To address these aspects, this paper combined GIS analysis and secondary data including soil samples obtained during field expeditions, to provide evidence of how ground battles, occupation, terrestrial land mines, and explosions can severely impact the soils. Practical and theoretical implications of the military actions are also discussed.

The impact of PTSD symptoms on suicide ideation in time of terror and war: A nationwide prospective study on the moderating role of loneliness.

The terrorist attack of October 7, 2023, and its accompanying war have increased the risk for posttraumatic stress symptoms (PTSS) and suicide ideation (SI). In this national prospective cohort study, we examined the extent to which a sense of loneliness moderates the association between PTSS and SI in the wake of the October 7th attack and the Israel-Hamas war. A representative sample of 710 Israeli adults (362 female, 51.1 %) aged 18-85 (M = 41.01, SD = 13.72) participated in a longitudinal study assessing depression, current SI, and loneliness at two time points: T1, one month before the attack (August 2023) and T2 (November 2023), one month after the attack. We found two significant interactions in which a sense of loneliness at T2 moderated the link between both PTSS at T1 and T2 and current SI at T2. Specifically, the level of PTSS contributed to current SI at T2 more strongly among individuals reporting higher loneliness levels than those reporting low loneliness levels. Clinicians treating individuals coping with high PTSS levels should attend to their patients' sense of loneliness, as it comprises a significant risk factor for current SI and may be considered an important target in treatment.

Impact of the War in Ukraine on the Ability of Children to Recognize Basic Emotions.

Objectives: This study assessed emotion recognition skills in school-age children in wartime conditions in Ukraine. Methods: An online survey based on the concept of basic emotions was administrated to a sample of 419 schoolchildren from Ukraine and a control group of 310 schoolchildren from the Czech Republic, aged 8 to 12. Results: There is no difference in judging the intensity of anger and fear by Ukrainian children, compared with the control group. There is no evidence that the emotions of anger, fear, and sadness were better recognized in the Ukrainian group. Children from Ukraine were better at recognizing positive emotions than Czech children. Conclusion: Increased risks of threats and wartime experience do not impair the accuracy of identification of emotions like fear or the assessment of intensity of basic emotions by children who experience war in Ukraine. Still, it is important to continue studying the long-term consequences of military conflicts in order to deepen the understanding of their impact on human mental functioning.

Game-theoretic agent-based modelling of micro-level conflict: Evidence from the ISIS-Kurdish war.

This article delves into the dynamics of a dyadic political violence case study in Rojava, Northern Syria, focusing on the conflict between Kurdish rebels and ISIS from January 1, 2017, to December 31, 2019. We employ agent-based modelling and a formalisation of the conflict as an Iterated Prisoner's Dilemma game. The study provides a nuanced understanding of conflict dynamics in a highly volatile region, focusing on microdynamics of an intense dyadic strategic interaction between two near-equally- powered actors. The choice of using a model based on the Iterated Prisoner's Dilemma, though a classical approach, offers substantial insights due to its ability to model dyadic, equally-matched strategic interactions in conflict scenarios effectively. The investigation primarily reveals that shifts in territorial control are more critical than geographical or temporal factors in determining the conflict's course. Further, the study observes that the conflict is characterised by periods of predominantly one-sided violence. This pattern underscores that the distribution of attacks, and target choices are a more telling indicator of the conflict nature than specific behavioural patterns of the actors involved. Such a conclusion aligns with the strategic implications of the underlying model, which emphasises the outcome of interactions based on differing aggression levels. This research not only sheds light on the conflict in Rojava but also reaffirms the relevance of this type of game-theoretical approach in contemporary conflict analysis.

[Microbiological challenges in the treatment of war injuries]. / Mikrobiologische Herausforderungen bei der Versorgung von Kriegsverletzungen.

The treatment of war injuries represents a continuing and recurrent challenge in modern reconstructive surgery. Previously, tumor resections and sepsis-related resections were mainly responsible for lengthy bone defects in Germany. In recent years another picture has increasingly emerged, particularly caused by the medical support of Ukraine. Aspects of military surgery are also becoming more important in civil hospitals, especially in the treatment of gunshot and explosion injuries. In Germany, war injuries are currently secondarily treated, as the distribution of patients is carried out according to the cloverleaf principle, weeks or months after the occurrence of the primary injury. In addition to complex bone and soft tissue defects of the extremities following such injuries, which often affect neural and vascular structures, reconstruction is often complicated by an increasing spectrum of multidrug-resistant pathogens. The definition of microbiological terms, such as contamination, colonization, critical colonization, local and systemic infections are important in the clinical routine in order to initiate a targeted treatment, especially in treatment with antibiotics. Wound swabs for determination of the spectrum of pathogens and the optimal testing of resistance are important for selecting the appropriate antibiotic agents. The concept of antibiotic stewardship (ABS) is established in many hospitals to improve the quality of antibiotic treatment and to minimize the formation of resistance. The selection of the method of reconstruction depends on the condition of the patient, the overall clinical constellation and the function to be expected after completion of treatment. The treatment of injuries due to violence and terrorism necessitates clear concepts and an interdisciplinary approach, especially with respect to microbiological challenges and increasing resistance situations.

[Challenge of limb care after violence and war with a special focus on imaging procedures]. / Herausforderung der Extremitätenversorgung nach Gewalt und Krieg mit besonderer Betrachtung bildgebender Verfahren.

BACKGROUND: Injury patterns in the area of the extremities following violence and war harbor many special features and require special attention. Destructive and complex defect injuries are often present, which necessitate elaborate and special reconstruction approaches, predominantly as part of a staged and multistaged procedure. RESEARCH QUESTION: In this context, special attention must be paid to the diagnostic options as an essential aspect, as a clear diagnosis means that targeted treatment steps can be planned and implemented. MATERIAL AND METHOD: The authors' experience in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia, as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of interdisciplinary cooperation with radiological and, in particular, nuclear medicine disciplines are taken into account in the daily routine. RESULTS AND DISCUSSION: Extremity injuries in the context of violence and war are accompanied by complex bone and surrounding soft tissue defects due to the high energy impact. The principles of reconstruction familiar from everyday life can only be transferred one-to-one to a limited extent. The treatment pathways are often very long and complex and the questions of infection and tissue vitality must be answered again and again in stages. Interdisciplinary collaboration with the disciplines specialized in imaging procedures, particularly in the field of nuclear medicine, is one of the key building blocks for a successful treatment pathway.

[Initial in-hospital treatment of patients with penetrating trauma due to violence and war]. / Innerklinische Erstversorgung von Patienten mit penetrierendem Trauma nach Gewalt und Krieg.

BACKGROUND: Current political and social developments have brought the topics of violence, in this context attributable to terrorism and sabotage, and since February 2022 awareness of war in particular has again greatly increased. This article aims to present the contextualized dealing with penetrating injuries in terms of initial in-hospital treatment. OBJECTIVE: The question remains to be answered as to what extent penetrating injuries require special attention and to what extent the treatment priorities, options and strategies as well as surgical treatment require adaptation of the usual approach in routine clinical practice in Germany. MATERIAL AND METHOD: The experience of the authors in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of a comprehensive systematic literature review and current data from a national evaluation on the topic of preparing hospitals in Germany for such scenarios are taken into account. RESULTS AND DISCUSSION: The clinical systems need to be well-prepared for such casualties, especially if they require treatment in large numbers. This is precisely so because the majority of patients are in a relevantly threatening situation (usually in the sense of a hemorrhage), treatment must be very urgently provided and in such scenarios a lack of resources must always be overcome, at least temporarily, especially for example for blood transfusions.

Governance in times of war: Public procurement in Ukraine.

Wars increase the importance of government functions, yet they also constrain their ability to fulfill these functions. In particular, wars hinder economic activity, thereby limiting governments' capacity to raise the revenues required to maintain stability and meet the heightened needs of citizens. Effective governance is therefore severely undermined in times of war. However, empirical research on how wars affect government procurement is limited. We address this gap by exploring procurement dynamics using over one million public purchases of goods and services in Ukraine between January 2021 and October 2022, corresponding to the Russian invasion of the country. We document a large fall in the total number of purchases since the invasion and an increase in the share of successfully completed procurements. This higher success rate comes at the cost of efficiency, with the government paying more to source their goods. This can be attributed to the decline in the share of government purchases via online auctions and the reduced competition. Thus, the prioritization of the quick acquisition of goods and services forced governments to sacrifice cost-effectiveness. In summary, the war did not lower the successful purchasing of private goods and services, and transparency was not decreased. However, the trade-off of speed and transparency for greater costs may become increasingly problematic with the growing budget constraints resulting from the war. This article contributes to our understanding of the Ukrainian government choices during the early phase of the war. The results also highlight the importance of ensuring procurement efficiency and transparency when the war ends as reconstruction efforts will require substantial increases in government procurements.

Exploring perceived challenges, adoption, and assessment of Western values of democracy and human rights in Palestine in the 2023 War on Gaza.

This study delved into the dynamics of perceived challenges, adoption, and assessment of Western values of democracy and human rights among university students in Palestine, particularly in the aftermath of the 2023 War on Gaza. A mixed-methods strategy was used in the research, with a participant pool of 384 students representing a range of demographics. By exploring the impact of geopolitical events, the results revealed a positive link between perceived challenges and the assessment of Western values. Although there is a notable gender and geographic difference in the assessment and adoption of Western values, females and those living in cities and villages are shown to have greater perceived challenges with these values. The qualitative component, including interviews with 12 students, provided valuable insights into the postwar evolution of Palestinian perspectives, highlighting a notable shift in attitudes, initially characterized by belief in the superiority of Western values, followed by a decline in faith during the war. This decline is attributed to traumatic events, biased media narratives, and the contradiction between idealized standards and harsh realities. In conclusion, the study emphasizes the need for a comprehensive understanding of the multifaceted influences on Palestinian perceptions of Western values.

Can trade and security alliance help reduce interstate war?

This study explains how the gap between theory and empirical research hinders scientific progress in the area of international political economy. To demonstrate this point, I use Chen's Extended Dependence Theory, which challenges liberal peace theory but fails to provide supporting empirical evidence. Chen contends that it is not trade dependence between two states that fosters peace but a challenger's trade relations with the defense-pact partners of the target. Although Chen criticizes liberal peace proponents whose primary concern is how to deter war, his empirical analysis is confined to how to decrease (fatal) militarized disputes short of war. I argue that for his theory to succeed, it must be validated against the most severe and intense form of conflict. Using statistical tests and substantive significance, I uncover no peace-building effect, with regards to war, attributable to Extended Dependence. It appears that the Extended Dependence variable exhibits a ceiling effect. Future research should explain why economic ties and security institutions fail to work together to lower the risk of the most destructive form of conflict.

Magnitude of psychological distress and associated factors among war survivor women in Northern, Ethiopia, 2022: a community-based cross-sectional survey.

BACKGROUND: Civilian war and internal conflicts increase the incidences of mental health conditions among war survivors. It is crucial to assess war-related psychological consequences in war-affected areas in Ethiopia to intervene in the future. Thus, this study aimed to determine the magnitude of psychological distress and associated factors of psychological distress among war survivor women in Northern, Ethiopia. METHODS: A community-based cross-sectional survey was conducted, and 1596 war survivor women were recruited to participate using a face-to-face interviews with a census sampling technique from May 1-30, 2022. The psychological distress was assessed using a Kessler psychological distress scale (K10). Bi-variable and multi-variable logistic regression analyses were used, and variables with a p-value less than 0.05 in the multivariable analyses were considered statistically significant. RESULT: In this study, the response rate was 100% and the prevalence of psychological distress was 44.90% at a 95% CI: (42.40, 47.40). Psychological distress was significantly associated with the education of ability to read and write (AOR = 2.92; 95% CI: 2.12, 4.01), primary education and above (AOR = 3.08; 95% CI: 2.09, 4.54), housewife (AOR = 5.07; 95%CI: 2.64, 9.74), farmer (AOR = 8.92; 95%CI: 4.03, 19.70), emotional violence (AOR = 1.52; 95%CI: 1.05, 2.18), physical violence (AOR = 3.85; 95%CI: 2.37, 6.26) and sexual violence (AOR = 3.25; 95%CI: 1.98, 5.33) whereas being separate was protective for psychological distress (AOR = 0.38; 95%CI: 0.16, 0.92). CONCLUSION: The prevalence of psychological distress was found to be high. Therefore, women who are housewives, married, farmers, educated, and who have experienced violence must be the focus of governmental and private collaborative interventions to prevent war-related psychological morbidity and mortality.

Struggling to resume childhood vaccination during war in Myanmar: evaluation of a pilot program.

BACKGROUND: After the military coup in Myanmar in February 2021, the health system began to disintegrate when staff who called for the restoration of the democratic government resigned and fled to states controlled by ethnic minorities. The military retaliated by blocking the shipment of humanitarian aid, including vaccines, and attacked the ethnic states. After two years without vaccines for their children, parents urged a nurse-led civil society organization in an ethnic state to find a way to resume vaccination. The nurses developed a vaccination program, which we evaluated. METHODS: A retrospective cohort study and participatory evaluation were conducted. We interviewed the healthcare workers about vaccine acquisition, transportation, and administration and assessed compliance with WHO-recommended practices. We analyzed the participating children's characteristics. We calculated the proportion of children vaccinated before and after the program. We calculated the probability children would become up-to-date after the program using inverse survival. RESULTS: Since United Nations agencies could not assist, private donations were raised to purchase, smuggle into Myanmar, and administer five vaccines. Cold chain standards were maintained. Compliance with other WHO-recommended vaccination practices was 74%. Of the 184 participating children, 145 (79%, median age five months [IQR 6.5]) were previously unvaccinated, and 71 (41%) were internally displaced. During five monthly sessions, the probability that age-eligible zero-dose children would receive the recommended number of doses of MMR was 92% (95% confidence interval [CI] 83-100%), Penta 87% (95% CI 80%-94%); BCG 76% (95% CI 69%-83%); and OPV 68% (95% CI 59%-78%). Migration of internally displaced children and stockouts of vaccines were the primary factors responsible for decreased coverage. CONCLUSIONS: This is the first study to describe the situation, barriers, and outcomes of a childhood vaccination program in one of the many conflict-affected states since the coup in Myanmar. Even though the proportion of previously unvaccinated children was large, the program was successful. While the target population was necessarily small, the program's success led to a donor-funded expansion to 2,000 children. Without renewed efforts, the proportion of unvaccinated children in other parts of Myanmar will approach 100%.