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Article

Valire Carr Copeland and Daniel Hyung Jik Lee

Social reform efforts of the settlement-house movement have provided, in part, the foundation for today’s Maternal and Child Health Bureau’s policies, programs, and services. Planning, implementing, and evaluating policies and programs that affect the health and well-being of mothers and children require a multidisciplinary approach. Social workers, whose skills encompass direct services, advocacy, planning and research, community development, and administration, have a critical role to play in improving the health outcomes of maternal and child populations.

Article

Charles L. Robbins

The distribution of illness and its impact are not random occurrences. Social workers can prevent illness through education and behavioral change as well as mitigate its impact once it does occur, and social workers should be knowledgeable about illness and the health status of the people with whom they work. As advocates for our clients, it is important that we pursue policies and programs that address the inadequacies and injustices in health care. To accomplish this, we must be prepared with the necessary knowledge.

Article

The Slavevoyages website completed ten years of successful operation in 2018. Drawing on four decades of archival research on five continents, a revolution in computer-processing costs, and the more recent explosive growth of the worldwide web, the site currently offers public access to several databases on slave trading in the Atlantic World. The two most important of these are first, a database of 36,000 slave-trading voyages between Africa and the New World, and second, a database of 11,400 voyages from one port in the Americas to another—a traffic known as the intra-American slave trade. The time span covered is from the 16th to the late 19th century. The site also offers personal information on 92,000 Africans found on board some of those voyages, which is stored in a separate database, as well as an interface that permits users to explore our estimates of the overall size and direction of the transatlantic slave trade broken down by each of the 340 years of its existence. In other words, the site attempts to allow for voyages for which information has not survived. The site currently averages over 1,000 visitors per day, who consult a mean of eight pages per visit. It was one of the first web-based databases to use crowdsourcing to correct existing information and attract new contributions to its core database. These are currently refreshed on an approximately annual basis and earlier versions are made available to users on a download page. Slavevoyages has become the basic reference tool for anyone studying the transatlantic slave trade, and is used widely by teachers, genealogists, and scientists as well as historians and, more specifically, scholars of slavery and the slave trade.

Article

Nicole L. Pacino

During the pre-Columbian and colonial periods, Andean cosmological understandings shaped indigenous approaches to maternal health. Women typically gave birth at home with the assistance of a midwife (also called a partera or comadrona in Spanish). Birthing and post-partum care relied on local herbal remedies and followed specific social rituals. Women drank teas derived from anise or coca during the labor process, gave birth in a squatting position (toward Mother Earth, or Pachamama), and drank sheep soup after labor to replenish strength and warm the body. Rooms were kept dark because the common perception was that bright light injured newborn babies’ eyes. After labor, families buried or otherwise disposed of the placenta to keep the baby and mother healthy and facilitate lactation, as per Andean tradition. Changes in maternal health rituals began in the 18th century, as colonial rule became more consolidated. The rise of a distinct medical profession and government interest in population growth gradually shifted responsibility for maternal health from the Catholic Church and charitable organizations to the state. Throughout the 19th and 20th centuries, the growing power and authority of the state and the medical profession led doctors and urban-based reformers to attempt to change long-standing Andean birthing practices, which they considered archaic and unsanitary. These reforms emerged from a desire to reduce infant mortality rates and to replace traditional healers with medical professionals who were trained, licensed, and regulated by the state. As reformers looked to replace Andean maternal health and healing practices with new scientific understandings of the female body and birthing process, they also worked to discredit and displace midwives’ knowledge and practices. In particular, they encouraged women to give birth in newly constructed hospitals and to seek the guidance of medical professionals, like obstetricians. However, these reforms met with limited success. In the Andes today, midwives still attend to roughly 50 percent of all births, and in some remote areas, the figure is as high as 90 percent. It is also more common today to see the merging of biomedical and ritual practices to increase women’s access to and acceptance of health services and to reduce overall mortality rates.

Article

There are three main topics in research on the effects of work on health. The first topic is workplace accidents where the main issues are reporting behavior and workplace safety policies. A worker seems to be less inclined to report a workplace accident for fear of job loss when unemployment is high or when the worker has a temporary contract that may not be renewed. Workplace safety legislation has intended to reduce the incidence and severity of workplace accidents but empirical evidence on this result is unclear. The second topic is employment and health where the focus is on how job characteristics and job loss affect health, in particular mental health. Physically demanding jobs have negative health effects. The effects of working hours vary and the effects of job loss on physical and mental health are not uniform. Job loss seems to increase mortality. The third topic concerns retirement and health. Retirement seems to have a negative effect on cognitive skills and short-term positive effects on overall health. Other than that, the effects are very inconsistent, that is, even with as clear a measure as mortality, it is not clear whether life expectancy goes up, goes down, or remains constant due to retirement.

Article

Education is strongly associated with better health and longer lives. However, the extent to which education causes health and longevity is widely debated. We develop a human capital framework to structure the interpretation of the empirical evidence and review evidence on the causal effects of education on mortality and its two most common preventable causes: smoking and obesity. We focus attention on evidence from randomized controlled trials, twin studies, and quasi-experiments. There is no convincing evidence of an effect of education on obesity, and the effects on smoking are only apparent when schooling reforms affect individuals’ track or their peer group, but not when they simply increase the duration of schooling. An effect of education on mortality exists in some contexts but not in others and seems to depend on (i) gender, (ii) the labor market returns to education, (iii) the quality of education, and (iv) whether education affects the quality of individuals’ peers.

Article

Valuing the benefit of reduced exposures to environmental health risks requires assessment of the willingness to pay for the risk reduction. Usual measures typically estimate individual local rates of substitution between money and the reduced probability of the adverse health impact. Benefit-cost analyses then aggregate individuals’ willingness to pay to calculate society’s willingness to pay for the health risk reduction benefit. The theoretical basis for this approach is well established and is similar for mortality risks and health outcomes involving morbidity effects. Researchers have used both stated preference methods and revealed preference data that draw on values implicit in economic decisions. Continuing controversies with respect to valuation of environmental health impacts include the treatment of behavioral anomalies, such as the gap between willingness-to-pay and willingness-to-accept values, and the degree to which heterogeneity in values because of personal characteristics such as income and age should influence benefit values. A considerable literature exists on the value of a statistical life (VSL), the local tradeoff between fatality risk and money, which is used to value mortality risk reductions. Many VSL estimates use data from the United States for regulatory analyses of environmental policies, but several other countries have distinct valuation practices. There are empirical estimates of the benefits associated with reducing the risks of many environmental health effects, including cancer, respiratory diseases, gastrointestinal illnesses, and other health consequences that have morbidity effects.

Article

Paola Sesia

Today, the death of women during pregnancy, childbirth or postpartum is considered simultaneously a public health, social inequality, and gender discrimination problem. In Mexico, approximately one thousand women die each year during pregnancy, childbirth, postpartum or from an unsafe abortion, experiencing a premature and sudden death in the midst of their most productive years, often with lasting consequences for their families and surviving children. As elsewhere, the great majority of these deaths would not have occurred if women had had prompt and unlimited access to quality emergency obstetric care, as well as easy access to contraceptives to prevent unwanted pregnancies. Most deaths are related to the substandard quality of available maternal healthcare services; services that are provided for free to most Mexican women in an overly saturated and underfunded public health system that also tends to overmedicalize and pathologize normal births. Their prematurity and abruptness, their occurrence in the process of giving life, the fact that these deaths exclusively affect women, and their avoidable nature make maternal mortality unacceptable in today’s social, political, and ethical arenas. From an historical perspective, deaths in childbirth were much more common in past centuries than today; these deaths were considered inevitable and were accepted as natural occurrences until the late 19th century. However, surrounding rituals, the meaning attached to these deaths, related notions of womanhood and motherhood, and practices to prevent or avoid them, underwent changes according to broader sociocultural, political and religious transformations from Pre-Hispanic times to the 20th century. As elsewhere, in Mexico maternal deaths declined considerably in the 1930s–1950s with the discovery of penicillin and the concomitant decline of puerperal fever; they reached a plateau in the 1960s and 1970s and began to slowly decline again in the 1980s–1990s with an even steeper decrease after the signature of the United Nations (UN) Millennium Development Goals in the year 2000; time when the reduction of maternal mortality became one of eight high-priority global public policy objectives, closely monitored by UN bodies. Maternal deaths are a reflection of ingrained multiple social inequalities that characterize Mexican society at large; poor, rural, marginalized and Indigenous pregnant women face a 2–10 times higher risk of dying than the rest of Mexican women, because their access to contraception and to prompt and high quality obstetric emergency care is more limited. Today, research in the field of maternal mortality etiology, measurement and reduction includes the call for women-centered respectful maternal care, the elimination of discrimination in the provision of obstetric services and the application of a human rights perspective to health policies, programs, and care.

Article

Saskia Hin

People’s life courses are shaped by the complex interactions of contextual factors, of individual behavior, and of opportunities and constraints operating at the macro level. Demography studies these processes with a focus on particular transitions in the life course: birth, leaving home, marriage, and other transitions in civil status (divorce, remarriage, and transitions into widowhood), the birth and survival of offspring, migration, and finally the end of the life cycle—death.

Initial work on the ancient world focussed primarily on macro-level data, trying to establish overall trends in population development on the basis of census figures and other population estimates. This approach has received further impetus with the advent of survey demography (see Population Trends). More recently, attention has turned to single events in the life course. Core demographic studies have attempted to establish patterns and rates of marriage, fertility, migration, and mortality. Others have taken a complementary approach with a stronger focus on qualitative data. These support investigation of sociological, cultural, and economic aspects of demographic phenomena. The remainder of this article focusses on a concise evaluation of current understanding of marriage, fertility, migration, mortality, and population trends in the ancient Greco-Roman world.

Article

Saskia Hin

Roman population size and population trends have been debated for long by proponents of low and high counts; these have recently been joined by proponents of a middle count. Each is based on a different interpretation of the enigmatic Roman census figures. Different understandings of patterns of death and disease, of marriage, of childbearing, and of infanticide follow on from these interpretations. Recent studies have added new perspectives, drawing on archaeological finds, and have started to pay more attention to migration flows.

There are two different kinds of questions historians might wish to ask about the population of the Roman world: How large was it or any of its constituent parts? And what were the patterns and tendencies of birth rates, death rates, and migration rates, with their implications for overall growth or decline?

Five sources of information offer imperfect answers to the first kind of question: census figures, mostly but not exclusively, for the Roman Republic and early Empire, where they served for taxation, military recruitment, and political purposes; figures relating to the feeding of (part of) the population of the city of Rome; occasional references to the population of particular cities or areas, usually without any possibility of knowing on what they were based; figures for the carrying capacity of different areas of the Roman world in the earliest post-Roman periods for which reasonably reliable figures exist; and, finally, archaeological survey evidence that provides indications of change in land use, and implicitly of population change over time.

Article

Amira M. Khan, Zohra S. Lassi, and Zulfiqar A. Bhutta

Nearly 80% of the world’s population lives in low- and middle-income countries (LMICs) and these regions bear the greatest burden of maternal, neonatal, and child mortality, with most of the deaths occurring at home. Much of global maternal and child mortality is attributable to easily preventable and treatable conditions. However, the challenge lies in reaching the most vulnerable communities, especially the rural populations, making it imperative that maternal, newborn, and child health (MNCH) interventions focus on communities in tandem with facility-based strategies. There is widespread consensus that delivering effective primary health care (PHC) interventions through the continuum of care, starting from pregnancy to delivery and then to the newborn, infant, and the young child, is an integral component of health strategies in high-, middle- and low-income settings. Despite gaps in research, several effective community-based PHC approaches have been proven to impact MNCH positively. Implementation of these strategies is needed at scale in LMICs and in partnership with all stakeholders including the public and private sector. Community-based PHC, operating on the principles of community engagement and community mobilization, is now more critical than ever. Further robust studies are needed to evaluate certain strategies of community-based PHC and their impact on maternal and child health outcomes, such as the use of mobile technology and social franchises. Recognition of community health workers (CHWs) as a formal cadre and the integration of community-based health services within PHC are vital in strengthening efforts to impact maternal, neonatal, and child health outcomes positively. However, despite the importance of community-based PHC for MNCH in LMICs, the existence of a strong health system and skilled workforce is central to achieving positive health outcomes in these regions.

Article

Martin Karlsson, Tor Iversen, and Henning Øien

An open issue in the economics literature is whether healthcare expenditure (HCE) is so concentrated in the last years before death that the age profiles in spending will change when longevity increases. The seminal article “aging of Population and HealthCare Expenditure: A Red Herring?” by Zweifel and colleagues argued that that age is a distraction in explaining growth in HCE. The argument was based on the observation that age did not predict HCE after controlling for time to death (TTD). The authors were soon criticized for the use of a Heckman selection model in this context. Most of the recent literature makes use of variants of a two-part model and seems to give some role to age as well in the explanation. Age seems to matter more for long-term care expenditures (LTCE) than for acute hospital care. When disability is accounted for, the effects of age and TTD diminish. Not many articles validate their approach by comparing properties of different estimation models. In order to evaluate popular models used in the literature and to gain an understanding of the divergent results of previous studies, an empirical analysis based on a claims data set from Germany is conducted. This analysis generates a number of useful insights. There is a significant age gradient in HCE, most for LTCE, and costs of dying are substantial. These “costs of dying” have, however, a limited impact on the age gradient in HCE. These findings are interpreted as evidence against the red herring hypothesis as initially stated. The results indicate that the choice of estimation method makes little difference and if they differ, ordinary least squares regression tends to perform better than the alternatives. When validating the methods out of sample and out of period, there is no evidence that including TTD leads to better predictions of aggregate future HCE. It appears that the literature might benefit from focusing on the predictive power of the estimators instead of their actual fit to the data within the sample.

Article

Low- and middle-income countries (LMICs) bear a disproportionately high burden of diseases in comparison to high-income countries, partly due to inequalities in the distribution of resources for health. Recent increases in health spending in these countries demonstrate a commitment to tackling the high burden of disease. However, evidence on the extent to which increased spending on health translates to better population health outcomes has been inconclusive. Some studies have reported improvements in population health with an increase in health spending whereas others have either found no effect or very limited effect to justify increased financial allocations to health. Differences across studies may be explained by differences in approaches adopted in estimating returns to health spending in LMICs.

Article

Cristina Bellés-Obrero and Judit Vall Castelló

The impact of macroeconomic fluctuations on health and mortality rates has been a highly studied topic in the field of economics. Many studies, using fixed-effects models, find that mortality is procyclical in many countries, such as the United States, Germany, Spain, France, Pacific-Asian nations, Mexico, and Canada. On the other hand, a small number of studies find that mortality decreases during economic expansion. Differences in the social insurance systems and labor market institutions across countries may explain some of the disparities found in the literature. Studies examining the effects of more recent recessions are less conclusive, finding mortality to be less procyclical, or even countercyclical. This new finding could be explained by changes over time in the mechanisms behind the association between business cycle conditions and mortality. A related strand of the literature has focused on understanding the effect of economic fluctuations on infant health at birth and/or child mortality. While infant mortality is found to be procyclical in countries like the United States and Spain, the opposite is found in developing countries. Even though the association between business cycle conditions and mortality has been extensively documented, a much stronger effort is needed to understand the mechanisms behind the relationship between business cycle conditions and health. Many studies have examined the association between macroeconomic fluctuations and smoking, drinking, weight disorders, eating habits, and physical activity, although results are rather mixed. The only well-established finding is that mental health deteriorates during economic slowdowns. An important challenge is the fact that the comparison of the main results across studies proves to be complicated due to the variety of empirical methods and time spans used. Furthermore, estimates have been found to be sensitive to the use of different levels of geographic aggregation, model specifications, and proxies of macroeconomic fluctuations.

Article

Towns and cities generally exhibit higher temperatures than rural areas for a number of reasons, including the effect that urban materials have on the natural balance of incoming and outgoing energy at the surface level, the shape and geometry of buildings, and the impact of anthropogenic heating. This localized heating means that towns and cities are often described as urban heat islands (UHIs). Urbanized areas modify local temperatures, but also other meteorological variables such as wind speed and direction and rainfall patterns. The magnitude of the UHI for a given town or city tends to scale with the size of population, although smaller towns of just thousands of inhabitants can have an appreciable UHI effect. The UHI “intensity” (the difference in temperature between a city center and a rural reference point outside the city) is on the order of a few degrees Celsius on average, but can peak at as much as 10°C in larger cities, given the right conditions. UHIs tend to be enhanced during heatwaves, when there is lots of sunshine and a lack of wind to provide ventilation and disperse the warm air. The UHI is most pronounced at night, when rural areas tend to be cooler than cities and urban materials radiate the energy they have stored during the day into the local atmosphere. As well as affecting local weather patterns and interacting with local air pollution, the UHI can directly affect health through heat exposure, which can exacerbate minor illnesses, affect occupational performance, or increase the risk of hospitalization and even death. Urban populations can face serious risks to health during heatwaves whereby the heat associated with the UHI contributes additional warming. Heat-related health risks are likely to increase in future against a background of climate change and increasing urbanization throughout much of the world. However, there are ways to reduce urban temperatures and avoid some of the health impacts of the UHI through behavioral changes, modification of buildings, or by urban scale interventions. It is important to understand the physical properties of the UHI and its impact on health to evaluate the potential for interventions to reduce heat-related impacts.

Article

Infancy and young childhood are characterized by rapid cognitive, emotional, and physical development. Each year is marked by specific developmental tasks. Infants need positive parenting, a safe environment, and attention to their basic physical needs. A strong bond with caregivers is also necessary, as this lays the foundation for trust, allowing infants to explore their world. Many of the risk factors, such as prenatal exposure to alcohol and drugs, malnutrition, and abuse and neglect, can be remedied. Interventions such as home visiting, family leave, and nutrition programs are inexpensive and effective, and should receive more attention from social work. Infancy and young childhood are the most crucial periods in a child's development. There is a dynamic and continuous interaction between biology and experience that shapes early human development. Human relationships are the building blocks of healthy development, and children are active participants in their own development.

Article

David S. Jones

Few developments in human history match the demographic consequences of the arrival of Europeans in the Americas. Between 1500 and 1900 the human populations of the Americas were traBnsformed. Countless American Indians died as Europeans established themselves, and imported Africans as slaves, in the Americas. Much of the mortality came from epidemics that swept through Indian country. The historical record is full of dramatic stories of smallpox, measles, influenza, and acute contagious diseases striking American Indian communities, causing untold suffering and facilitating European conquest. Some scholars have gone so far as to invoke the irresistible power of natural selection to explain what happened. They argue that the long isolation of Native Americans from other human populations left them uniquely susceptible to the Eurasian pathogens that accompanied European explorers and settlers; nothing could have been done to prevent the inevitable decimation of American Indians. The reality, however, is more complex. Scientists have not found convincing evidence that American Indians had a genetic susceptibility to infectious diseases. Meanwhile, it is clear that the conditions of life before and after colonization could have left Indians vulnerable to a host of diseases. Many American populations had been struggling to subsist, with declining populations, before Europeans arrived; the chaos, warfare, and demoralization that accompanied colonization made things worse. Seen from this perspective, the devastating mortality was not the result of the forces of evolution and natural selection but rather stemmed from social, economic, and political forces at work during encounter and colonization. Getting the story correct is essential. American Indians in the United States, and indigenous populations worldwide, still suffer dire health inequalities. Although smallpox is gone and many of the old infections are well controlled, new diseases have risen to prominence, especially heart disease, diabetes, cancer, substance abuse, and mental illness. The stories we tell about the history of epidemics in Indian country influence the policies we pursue to alleviate them today.

Article

Life-cycle choices and outcomes over financial (e.g., savings, portfolio, work) and health-related variables (e.g., medical spending, habits, sickness, and mortality) are complex and intertwined. Indeed, labor/leisure choices can both affect and be conditioned by health outcomes, precautionary savings is determined by exposure to sickness and longevity risks, where the latter can both be altered through preventive medical and leisure decisions. Moreover, inevitable aging induces changes in the incentives and in the constraints for investing in one’s own health and saving resources for old age. Understanding these pathways poses numerous challenges for economic models. The life-cycle data is indicative of continuous declines in health statuses and associated increases in exposure to morbidity, medical expenses, and mortality risks, with accelerating post-retirement dynamics. Theory suggests that risk-averse and forward-looking agents should rely on available instruments to insure against these risks. Indeed, market- and state-provided health insurance (e.g., Medicare) cover curative medical expenses. High end-of-life home and nursing-home expenses can be hedged through privately or publicly provided (e.g., Medicaid) long-term care insurance. The risk of outliving one’s financial resources can be hedged through annuities. The risk of not living long enough can be insured through life insurance. In practice, however, the recourse to these hedging instruments remains less than predicted by theory. Slow-observed wealth drawdown after retirement is unexplained by bequest motives and suggests precautionary motives against health-related expenses. The excessive reliance on public pension (e.g., Social Security) and the post-retirement drop in consumption not related to work or health are both indicative of insufficient financial preparedness and run counter to consumption smoothing objectives. Moreover, the capacity to self-insure through preventive care and healthy habits is limited when aging is factored in. In conclusion, the observed health and financial life-cycle dynamics remain challenging for economic theory.

Article

Jan Reinhardt, Binhua Fu, and Joseph Balikuddembe

A public health disaster occurs when the adverse health effects of an event such as a natural hazard or threat exceed the coping capacity of the affected human population. The coping capacity of the affected population is hereby dependent on available resources including financial and human resources, health infrastructure, as well as knowledge, planning and organizational capabilities, and social capital. Disasters therefore disproportionally affect lesser resourced regions and countries of the world and pose specific challenges to their health systems as well as to the international humanitarian community in terms of dealing with mortality and injuries, communicable and noncommunicable disease, mental health effects, and long-term disability. Challenges for healthcare delivery in disaster situations in lesser resourced settings include deficiencies in the construction of resilient healthcare facilities, the lack of disaster response plans, shortage of specialized medical personnel, shortcomings regarding training in disaster response, and scarcity of resources such as medicines and portable medical devices and supplies. Other challenges include the absence of appropriate algorithms for the distribution of scarce resources; lack of coordination of medical teams and other volunteers; limited awareness of particular health issues such as mental health problems or disability and rehabilitation; and lack of plans for evacuation, sheltering, and continuation of treatment of those with pre-existing health conditions. Many challenges lesser resourced settings face with regard to healthcare delivery after disasters such as the organization of mortality management, triage and treatment of the injured, or the delivery of rehabilitative and mental health care cannot be reduced to the lack of baseline resources in terms of health infrastructure, technology, and personnel but are related to the absence of proper planning for future disaster scenarios including implementation strategies and simulation exercises. This not only encompasses the formal drafting of disaster preparedness and response plans, contingency planning of hospitals, and the provision of disaster-related training to health personnel but in particular the identification and involvement of the potentially and traditionally affected communities and especially vulnerable groups in all the process of disaster risk reduction.

Article

Jaclyn M. Johnson and Clayton L. Thyne

The devastating Syrian civil war that began after the Arab Spring in 2011 has reminded the international community of the many consequences of civil war. However, this conflict is simply one of many ongoing conflicts around the globe. Civil war has a number of effects on individual lives, the country experiencing the conflict, as well as the international system more broadly. The humanitarian costs of civil war are steep. Individuals are negatively impacted by civil war in a myriad of ways. Three main areas of research are of interest: mortality, physical and mental trauma, and education. Several factors increase the number of deaths in a civil war, including a lack of democracy, economic downturns, and foreign assistance to combatants. Even if civilians survive conflict, they are likely to endure trauma that affects both mental and physical health. Strong evidence indicates that civil war spreads infectious diseases and severely diminishes life expectancy. Mental health is also likely to suffer in the face of conflict, as individuals often must overcome debilitating trauma. Finally, children are particularly susceptible in civil war settings. Children are often unable to continue their education as a consequence of civil war because combatants often target schools strategically or the state is unable to fund education as a result of funneling resources to the conflict. Civil wars also pose a number of threats to the state itself. First, a state that has experienced a civil war is much more likely to have another civil war in its future. Conflict recurrence has been explained through the type of settlement that concludes the initial civil war, institutions that may prevent recurrence like proportional representation, and the role of third parties in providing peace-ensuring security guarantees. Beyond recurrence of war, scholars have looked at the impact that civil wars have on state-level institutions, including democratization. While most state-level effects of civil war seem to be deleterious, there may also be positive effects, specifically in terms of female representation. Civil war in sub-Saharan Africa has been shown to increase the number of female representatives, perhaps providing an avenue for gender equality. Civil wars have ripple effects that impact neighboring countries and the international system more broadly. Proximate states are often challenged with an influx of refugees that may burden social programs or facilitate the spread of diseases and illicit arms. However, positive consequences of hosting refugees may include trading opportunities or economic growth from remittances. Moving beyond proximate states, civil wars have consequences for the entire globe. For example, civil wars have been demonstrated to spur international terrorism. The civil war literature has explored the various effects of conflict at the individual, state, and interstate level.