Violent conflict and the demand for healthcare: How armed conflict reduces trust, instills fear, and increases child mortality.

What are the health effects of violent conflict? It is well known that wars kill civilians away from the battlefield and long after the fighting has stopped. Yet why this happens remains only partially understood. While we have good evidence that factors such as the destruction of infrastructure, political neglect, and the out-migration of health workers - what may be called supply-side factors - negatively affect health outcomes, we know much less about how violence shapes the attitudes and behavior towards healthcare use among civilians exposed to violent conflict - what may be called demand-side factors. Here, I theorize that exposure to violence suppresses civilian demand for healthcare through two mediating channels - mistrust of government institutions and fear of future violence - with adverse consequences for health outcomes, particularly child health. To test this theory empirically, I combine information from over 80,000 interviews conducted in 22 conflict-affected countries in Africa with individual- and context-level measures of exposure to violent conflict. Exposure to violence is associated with significantly lower levels of political trust and increased fear of future violence, which in turn predict lower healthcare utilization, lower immunization rates, and higher infant and child mortality. To fully address the health consequences of armed conflict, it is essential that we better understand the attitudinal and behavioral correlates of exposure to violence.