This essay confronts the collision of two potential global threats: the outbreak of infectious pandemics and the outbreak and protraction of civil wars. Specifically, it addresses the potential that civil wars can elevate the risk that an infectious outbreak will emerge; the possibility that civil wars can reduce the capacity to identify and respond to outbreaks; and the risk that outbreaks in areas of civil conflict can generate political and security challenges that may threaten regional and international order. Both global health governance and international security structures seem inadequate to address the health and security challenges posed by infectious outbreaks in areas of civil conflict. New approaches that better integrate the technical and political challenges inherent in preventing pandemics in areas of civil war are urgently required.

Most civilian casualties in war are not the result of direct exposure to bombs and bullets; they are due to the destruction of the essentials of daily living, including food, water, shelter, and health care. These “indirect” effects are too often invisible and not adequately assessed nor addressed by just war principles or global humanitarian response. This essay suggests that while the neglect of indirect effects has been longstanding, recent technical advances make such neglect increasingly unacceptable: 1) our ability to measure indirect effects has improved dramatically and 2) our ability to prevent or mitigate the indirect human toll of war has made unprecedented progress. Together, these advances underscore the importance of addressing more fully the challenge of indirect effects both in the application of just war principles as well as their tragic human cost in areas of conflict around the world.