Children under the age of 15 living in countries affected by protracted conflict are, on average, almost three times more likely to die from diarrheal diseases caused by a lack of safe water, sanitation and hygiene than by direct violence, UNICEF said in a new report released on Thursday.

The report looks at mortality rates in 16 countries going through prolonged conflicts and finds that, in most of them, children under the age of five are more than 20 times more likely to die from diarrheal-related deaths linked to lack of access to safe water and sanitation than direct violence.

“The odds are already stacked against children living through prolonged conflicts – with many unable to reach a safe water source,” said UNICEF Executive Director Henrietta Fore. “The reality is that there are more children who die from lack of access to safe water than by bullets.

“In Nigeria, conflict has created huge challenges for people living in the North-East of the country, where violence has affected their ability to access water and sanitation, leading to diseases such as cholera,” said Mohamed Fall, UNICEF Nigeria Representative.

“More than 3.6 million people are in need of water, sanitation and hygiene services – 1.1 million of these are internally displaced (IDPs), having fled their homes due to violence and conflict. Many of them are out-of-reach, in remote areas still impacted by conflict. About 800,000 people are in hard-to-reach areas and 79 percent of these are children and women,” said Mohamed Fall.

In North-East Nigeria, 5,365 people were affected by cholera, with 61 dying in 2017, while 12,643 people were affected and 175 died of cholera in 2018.

UNICEF is working to scale-up lifesaving responses, especially in IDP camps, to ensure quality and sustainability of WASH services and facilities, minimize the risk of WASH-related diseases, and to provide preventive measures against cholera and other water-borne diseases.

Without safe and effective water, sanitation and hygiene services, the report noted, children are at risk of malnutrition and preventable diseases including diarrhea, typhoid, cholera and polio.

Girls are said to be particularly affected: they are vulnerable to sexual violence as they collect water or venture out to use latrines. They deal with affronts to their dignity as they bathe and manage menstrual hygiene, and they miss classes during menstruation if their schools have no suitable water and sanitation facilities.

These threats, the report also observed, are exacerbated during conflict when deliberate and indiscriminate attacks destroy infrastructure, injure personnel and cut off the power that keeps water, sanitation and hygiene systems running. Armed conflict also limits access to essential repair equipment and consumables such as fuel or chlorine – which can be depleted, rationed, diverted or blocked from delivery. Far too often, essential services are deliberately denied.

“Deliberate attacks on water and sanitation are attacks on vulnerable children,” said Fall, as “water is a basic right. It is a necessity for life.”