This position paper addresses the role of public health practitioners, academics, and advocates in response to war and armed conflict. This paper provides the scientific basis and justification for an acknowledgment that war has been among the most important public health problems of the last 100 years, and there is little evidence its importance is waning.
We who have committed our careers to promoting public health need to change our framework to encompass war as 1 of the most significant threats to the health of people in every demographic group and in every country. Practitioners, educators, and other workers in public health can play powerful roles in preventing war itself, as well as mitigating the public health consequences of war.
Problem Statement and Evidence
War has profound public health consequences, and it is an entirely preventable source of some the world’s worst public health catastrophes.
Mortality
Death and disability from violent confrontations are the most apparent and direct effects of war, although they are not always accurately measured. Estimates of deaths secondary to armed conflict in the 20th century range from 110 million to 149 million (an average of about 1 million to 1.5 million deaths per year).1,2 Some researchers claim additional deaths resulting from genocide, forced enslavement, famines, and other events associated with war and conflict could bring the total to approximately 231 million for the entire century.2 By comparison, approximately 19 million people died of AIDS between 1990 and 2007.3 In 2006, tuberculosis caused fewer than 2 million deaths,4 and malaria caused fewer than 1 million deaths.5
Morbidity
Although morbidity resulting from war and conflict is perhaps even more difficult to quantify than mortality, clearly the number of injuries dwarfs the number of deaths. For example, without even considering civilians, the official number of fatalities among US armed forces in the current Iraq War exceeds 4,200, whereas injuries as of February 2009 exceed 30,0006 (although some estimates indicate the number of injured may be as high as 60,000).7 High-tech body armor used by western militaries and improved battlefield medicine have saved lives that might otherwise have been lost, but survivors have more severe and multiple injuries (now called polytrauma), such as amputations and traumatic brain injury, which result in a range of effects, including dizziness, blurred vision, headaches, seizures, trouble with memory, loss of coordination, sleep disturbance, and behavior or mood changes.7,8 Combat exposure to a variety of substances causes new and unexplained problems; for instance, the US Research Advisory Committee on Gulf War Veterans’ Illnesses only recently confirmed that Gulf War syndrome is a recognized condition experienced by more than 175,000 veterans of the 1991 Gulf War, likely caused by use of pyridostigmine bromide, to protect against nerve gas, and the use of pesticides.9
Psychological harm inflicted on combatants includes posttraumatic stress disorder (PTSD), depression, alcohol misuse, and anxiety disorders, all of which can persist for years after the end of combat.10–12 Additional injury or even death can result from violent behaviors associated with PTSD in combat veterans, including intimate partner violence and suicide. Although PTSD has been clinically defined only since the Vietnam War, mental illness secondary to conflict exposure is not new; the US military lost more than 500,000 combat personnel resulting from psychiatric collapse in World War II.10 More recently, rising suicide rates among US military personnel have been reported at epidemic levels: 24 soldiers committed suicide in January 2009, the highest monthly suicide total since recording began in 1980 and exceeding the number of combat deaths during the same month.13
Civilians
Although armies tend to report and track the numbers among their ranks who are killed in conflict settings, less clear responsibility is assigned for reporting deaths and injuries among civilians. Collecting information on the human cost of war is “a complex and often contested business.”14, p18 Civil wars tend to have the highest rates of civilian mortality resulting from direct violence, although, in general, the majority of deaths caused by war are civilian.15 According to some (imperfect) calculations, the 25 largest conflicts in the 20th century are reported to have resulted in the deaths of approximately 33 million civilians, compared with approximately 39 million dead soldiers.1 The 2008 Global Burden of Armed Violence reported that between 3 and 15 times as many people die “indirectly” for every person who dies violently in conflict.16 Targeting civilians to terrorize populations and force capitulation has been a tactic of war since ancient times, and the advancement of more high-tech and larger-impact weaponry has made the killing of bystanders increasingly more likely.17,18 For example, German Zeppelins during World War I dropped 6,000 bombs on nonmilitary targets in Britain and killed or injured 2,000 civilians.19 Several decades later, area bombings leading up to and during World War II caused hundreds of thousands of civilian deaths, ending with the US incendiary raids and atomic bombs dropped on Japan that killed at least 780,000 people.17,20
Inflicting deliberate harm on civilian populations, however, does not require weapons. The Ethiopian government’s policies of civilian starvation as a weapon of war killed hundreds of thousands of Eritreans during their war for independence in the 1980s.21 The United Nations estimated that more than 300,000 people have been killed in the Darfur region of Sudan, and another 2.4 million people have been displaced.22
Despite the 1949 Geneva Convention (IV) and subsequent protocols to define rules for the protection of civilians during wartime, civilians are increasingly targeted because conflict is less frequently characterized as state-sponsored industrial warfare, but rather more often as civil conflict and episodic confrontation without declaration of war.23,24 Since 1989, the numbers of state-based conflicts (1 or more parties in the conflict are governments) and nonstate conflicts active in a given year have declined overall, whereas the number of “1-sided violence” campaigns (actions by governments or rebel groups targeting civilians) has increased by 37% in the same time period.15 The type of weapons used, as well as where and by whom they are used, influences the effects on civilians. Combatants heedless of international law will often seek out targets in crowded urban settings, and indiscriminate explosive devices can kill and maim more civilians than do bullets.25– 27
In addition to direct attacks, civilians face further risk from infectious disease and malnutrition when conflicts destroy infrastructure and obstruct humanitarian aid. In studying 22 months of violent conflict in the eastern Democratic Republic of the Congo, researchers found that of 2.5 million excess deaths between 1998 and 2001, only 350,000 were attributable to violence, with the balance attributed to increased mortality from diarrhea, febrile diseases (largely malaria), and malnutrition.28
Displacement further exacerbates these effects on civilians, who either leave the country as refugees (approximately 10 million worldwide, according to the United Nations High Commissioner for Refugees, although the actual number may be somewhat higher)29 or remain within the country’s borders as internally displaced persons (approximately 24.5 million in 52 countries).30 These populations suffer further from infectious diseases (including diarrheal disease, measles, acute respiratory infections, malaria), chronic conditions left untreated (cardiovascular disease, cancer, kidney disorders), nutritional deficiencies, sexual assault, and other forms of interpersonal violence.31
In addition, the psychological impact of war on civilians is immense. People in a variety of countries and settings exposed to conflict-related traumatic events have been reported to display symptoms of PTSD (15–42%), depression (16–68%), anxiety (60–72%), and other mental distress.32 The neurobiology of PTSD indicates that it is a global disorder, with conflict-related PTSD thriving in developing and developed countries. Coping responses and availability and acceptability of treatment do vary by cultural setting.10 Symptoms of PTSD, including “anger outbursts, emotional numbing, isolation and despair, distrust and paranoia, hypervigilance and preoccupation with an enemy,” if highly prevalent in a society, can lead to perpetuation of conflict.10 page 65
Women and Children
Three-quarters of all refugees are women and children, who are disproportionately affected by war and conflict.33 Because women rely on men for security and support in many societies, they are more vulnerable when men are killed or absent from home during conflict.33 Women face torture, rape, sexual slavery, and forced impregnation as part of genocidal destruction of a society. A study examining the immediate and long-term effect of conflict on mortality found that even though men tend to suffer more of the immediate mortality caused by war (civil or interstate), the aftermath of severe conflict negatively affects women’s mortality as much as men’s over the long term.34
Children, in addition to suffering the effects of malnutrition during war, are often targeted during ethnic cleansing and are more likely to be killed or seriously disabled by landmines than adults.35 Children also experience severe psychological effects from war, including anxiety, depression, PTSD, anger, and hopelessness.24,35 War violence can translate to family violence and parental substance abuse, which place additional stress on children’s mental health.36 Exposure to community violence, even only witnessing atrocities rather than being victims, can result in aggression and antisocial behavior in children at the time as well as years after the exposure.37 Approximately 300,000 child combatants participate in active conflict at any given time, often through abduction, and both experience and perpetrate violent acts.38 Some studies further suggest that psychological harm can be transmitted from parents to children, especially from parents with PTSD, extending the trauma of war into the next generation.39
Health Care and Health-Supporting Infrastructure
Infrastructure crucial to health and well-being is often targeted and destroyed during war, including health care facilities, electricity-generating facilities, water treatment and sanitation systems, transportation and communication systems, and food supply systems.40 In addition to the destruction of health care facilities, health care services break down when drug supplies are interrupted and health care workers migrate or die.35,41 In some situations, combatants deliberately target health workers, such as in Chechnya, Kosovo, Mozambique, Nicaragua, and Afghanistan.42–46 Moreover, in the name of fighting enemies, the immunity of health workers to provide health services to wounded combatants irrespective of political affiliation is not respected, and some countries, including the United States, have deemed providing health care a form of material support to terrorists and thus a crime. The effects continue after conflicts, when government funding for health is compromised, and the training system for new health workers is weakened or stopped. Addressing these damages, however, is rarely a priority in peace-making activities and postconflict reconstruction.
In addition, emergency situations call for a radical readjustment in the approach to health care provision and survival support that goes beyond standard health care infrastructure. Vulnerable populations—the very young and very old, women, and those ill or disabled—experience a multifold risk of morbidity and mortality. The need for active outreach and provision of basic human needs, including food, shelter, clothing, and sanitation, demands urgent attention by multiple sectors as well as negotiation at political and international levels.
Human Rights
Violation of human rights, including torture, the erosion of free speech, and detention, are common during war and ultimately compromise health and well-being. In some cases, these violations constitute both war crimes and crimes against humanity, especially when committed through widespread attacks on civilians.47 Amnesty International estimated that forms of torture are prevalent in at least 81 countries worldwide.48 The history of maltreatment of prisoners and civilians in the 20th century included unlawful detention, physical and psychological torture, and public policing of daily life. In 1948, the United Nations adopted the Universal Declaration of Human Rights, stipulating that no human being should be subjected to any form of torture. This declaration was followed by other international antitorture agreements, including the Geneva Conventions of 1949, and the protection from torture described in the United Nations Declaration on the Protection of All Persons From Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment of 1975.49 Like prohibitions against targeting civilians, however, they are still routinely ignored by state and nonstate combatants.
Government surveillance, heightened in the United States since the USA PATRIOT Act passed in October of 2001 in response to the terrorist attacks of September 11, 2001, can amplify public perception of risk and result in increased anxiety, avoidance of crowds and public places, and increased suspicion.50 Imprisonment and detention as a means of control of populations is costly and often results in mental and physical harm to detainees, increasing social insecurity.51
Environment
The environmental impact of war is severe and long lasting. Combatants destroy fields and forests, contaminate or divert water supplies, and release pollutants through fires.52 Military equipment uses nonrenewable resources and emits pollutants, such as carbon monoxide; diesel particles; and oxides of nitrogen, hydrocarbons and sulfur dioxide. The production and testing of weapons has caused severe pollution and habitat destruction, with continued pressure to expand testing throughout the world while undermining species protection safeguards. Approximately 80 million antipersonnel landmines in 80 countries account for 15,000 deaths and many severe injuries each year and make large land areas uninhabitable and unusable.53 Nuclear facilities produce chemical and radioactive waste, and nuclear weapons testing results in significant environmental contamination and increased incidence of some types of cancer.54 Battlefields are often condemned as dangerous wastelands because of their legacy of unexploded or toxic munitions and dangerous abandoned equipment. The production and use of chemical and biological weapons can also contaminate the environment and affect living beings.52
Diversion of Resources
War and the preparation for war divert resources to military purposes while reducing expenditures for public health, health care, and the determinants of health.40 World military expenditures in 2006 exceeded $1.2 trillion.55 In 2009, the US Department of Defense base-funding request was $500 billion; various military expenditures in other programs (including nuclear weaponry in the Department of Energy), the supplemental request for current wars, and the servicing of past military debts bring the total annual military spending closer to $1 trillion.56 Defense represents more than half of all discretionary spending in the 2009 US Federal Budget, not including the wars in Iraq and Afghanistan.57 Even when large entitlement programs (Medicaid and Medicare) are included in the analysis, current and past military spending absorbed 42% of collected income taxes in 2007.58 Various accounting and budgeting strategies can obscure the high costs of war from the public and policymakers; for instance, the George W. Bush administration kept expenditures for the wars it launched “off the books” by consistently requesting war funds through supplementary appropriations processes rather than incorporating them into regular annual budget requests.59,60
Trends indicate the proportion of the budget being spent on current wars and clean up from past ones is likely to grow; the amount spent on the military in the United States increased more rapidly than any other area of the federal budget from 2001–2008. Even excluding spending on the wars in Iraq and Afghanistan and the “global war on terror,” defense spending has grown at an average annual rate of 4.8% in those 7 years, twice as fast as federal expenditures on Social Security, Medicare, and Medicaid grew in the same period.61 Noted and Nobel prize-winning economists have conservatively estimated that the current wars in Iraq and Afghanistan will cost the United States. $3 trillion over time, enough to build 8 million housing units, hire 15 million teachers, and provide health insurance for 530 million children for a year.60 The diversion of these resources is felt profoundly in all aspects of life, as evidenced by the response of nearly 200 national, regional, state and local unions and other labor organizations representing millions of working people who have organized to oppose the war and advocate for resource allocation consistent with the well-being of their constituents.62
Effects of War on Domestic Public Health Work
Wars on the planet, even those in which the United States is not a combatant or a financier, create burdens for local US communities and public health systems. Vulnerable populations, such as combat veterans and refugees, place a strain on the social service and public health safety net, whereas funding for war- and security-related priorities reduces the resources for other community needs.
In January 2009, 23.4 million veterans were living in the United States, and the impact of their experiences extends to their immediate family members and larger community.63 US veterans are already disproportionately represented among the homeless (representing 26% of the homeless population), and frequently battle mental health, substance abuse, and difficulties with social reintegration, which make it difficult to maintain employment and housing.64 The US Department of Veterans Affairs, tasked with providing federal benefits, including health care to veterans and their families, expects to spend $93.4 billion in fiscal year 2009 (7% over budget), including $40 billion for health care, $47 billion for benefits, and $230 million for the national cemetery system.63 These expenditures are not likely to meet the needs of all veterans and their families, placing a burden on nonmilitary social service organizations such as health clinics, soup kitchens, homeless shelters, and housing programs. Military families often face stress caused by the financial strain of medical expenses or the loss of reliable income following deployment, in addition to disability and other readjustment challenges.65 For example, evidence exists that “payday loan” operations seek to locate near military bases because their predatory lending practices are best marketed to populations of low-ranking soldiers and their families.66
The United States admitted 48,217 people as refugees in 2007, the majority under the age of 25.67 An additional 25,000 people were granted affirmative or defensive asylum. More than half of these refugees settled in 10 states—California, Texas, Minnesota, New York, Florida, Washington, Arizona, Illinois, North Carolina, and Georgia. In addition to any physical or emotional trauma carried from the violence in their country of origin, refugees face the emotional distress of displacement, language barriers, and cultural isolation. Social service and health care providers may be ill-equipped to meet the needs of these populations, particularly children, without additional resources and training.
Even public health workers who do not engage directly with veterans or refugees see the effects of a culture infused with a heightened level of violence in daily life. The norms of everyday behavior are altered by a government policy of engaging in high levels of violence as a matter of public policy. In applying the ecological model to violence, the World Health Organization (WHO) asserted that societal-level factors that influence violence include cultural norms that support violence as an acceptable way to resolve conflict and norms that support political conflict.68
Finally, war and militarism can distort public health priorities by channeling federal funds into areas that align with military or security goals but may not be consistent with community needs. This influx of resources can apparently provide benefit, such as the US government’s current “all-hazards approach” to bioterrorism preparedness that has enabled some communities to invest in disease surveillance, communications, and laboratory functions that benefit all public health efforts.69 However, local public health agencies struggle to balance spending time and resources in preparation for an unlikely terrorist attack while immediate and existing needs in their community go unmet. In addition, although influxes of resources to local agencies that increase capacity for specific programs are often not maintained over time, the public expectation for these services can persist, forcing public health agencies to prioritize unfunded high-profile, low-benefit programs at the expense of core public health services and staff. In addition, expansion of “biodefense” programs throughout the United States that conduct ambiguous research with lethal organisms, potentially in violation of the Biological Weapons Convention, pose hazards to surrounding communities, while raising the stakes for a global biological arms race.70
Advocating for an Expanded Public Health Role in Preventing War and Its Effects
A New Framework: Putting the Prevention of War Into the Public Health Agenda
For the most part, discussion of war and its impacts is missing from the public health agenda. War does not even appear on “top 10” lists of global or domestic public health challenges, when clearly its influence on health is overarching. Public health professionals have tended to set aside this problem as an inevitable force in the world that seems impossible to change, with the direct and indirect effects on our daily work easily hidden from view. That mindset must change.
Although core public health principles, approaches, and skills could be beneficially applied to prevent conflict and mitigate its consequences, the profession has not yet embraced this role. The classic public health framework of primary, secondary, and tertiary prevention of health problems is discussed in detail here. Public health professionals are skilled at defining problems, identifying risk and protective factors, developing and testing prevention strategies, and implementing and monitoring programs. These skills and approaches, as well as additional areas of expertise, could be cultivated and lent to the efforts to end wars and build lasting peace.71 One example of a collaborative approach across multiple disciplines is the emergence in the late 1980s of the field of “transitional justice,” which incorporates law, public policy, economics, history, psychology, and the arts to find solutions for reconciliation after human rights violations.72,73 Similarly, collaborations between public health, psychiatry, law enforcement, and public policy have resulted in harm reduction strategies and networks.74 A notable common thread in both examples is the involvement of activists on a variety of issues, from human rights to AIDS, in developing these approaches and advocating for their adoption.
Health professionals are already engaged in the downstream activities of conflict epidemiology, logistical support, and emergency response. The real strength of the public health approach, however, is to shift the focus to upstream causes. In the case of state-sponsored war or armed conflicts erupting from more informally organized insurgency groups, the root causes often include deep underlying structural problems of unresolved justice issues related to land distribution, disputes over water or other natural resources, historical animosity related to ethnic group discrimination, or poverty. Public health workers can bring a similar focus to conflict prevention efforts. In addition, efforts to evaluate conflict prevention programs have been described as “in a state of methodological anarchy” because of the lack of models and theories specific to the field.75 Public health professionals can bring the skill of conducting effective evaluations in difficult and diverse settings into the field of conflict management.
Role of the WHO in Preventing War
Health as a Bridge for Peace is one of the only programs administered by the WHO and its partners that aims to assist health workers around the world to contribute to peace, to bring about stability and reconstruction as conflicts end, and to help conciliation in divided and strife-torn communities.76 The program attempts to integrate peace-building principles, strategies, and practices into health relief and health sector development and notes the importance of encouraging public health workers to view peace building as an essential component of good public health practice. Additional tools are needed to assist with conflict analysis, conflict resolution, communication, and negotiation.
WHO also collects data and reports on deaths from violence generally; a recent report estimated that 1.6 million deaths in 2000 were attributable to violence.77 Although the report acknowledges collective violence as 1 type of violence, WHO programs focus more on violence perpetrated against vulnerable individuals, including women, children, and the elderly, rather than populations. Moreover, its methodologies do not account for the deaths caused by war’s effect on infrastructure and environment that increase rates of disease, malnutrition, and other disorders. To help harness the largely untapped role of public health workers in preventing war, WHO could take a more prominent role in tracking and reporting on worldwide deaths caused by conflict and expand its resources for public health workers.
Role of Schools of Public Health and Educational Programs in Public Health in Preventing War
Schools of public health and educational programs in public health often avoid activities that could prevent war because they are deemed too controversial or political. Many traditional public health activities, however, are essentially peacemaking functions, even if not typically characterized that way. As the effects of war become increasingly appreciated as 1 of the most important of all public health problems in the world, schools of public health and educational programs in public health must strive to impart this understanding to a new generation of students. To this end, they should infuse their curricula with training in the public health consequences of war and the prevention of war. Schools of public health and educational programs in public health have a tradition of responding to the needs of conflict situations,78 but their role in mitigating impacts of war needs updating and strengthening. After the attack on Pearl Harbor, schools of public health were charged with assisting branches of the armed forces by developing courses in subjects like parasitology, tropical medicine, and sanitation for members of the military and the government during the war effort.78 In recent years, schools have focused on curricula for training students and professionals in emergency preparedness for infectious disease, natural disasters, and terrorist attacks. Pathobiologists continue their work of investigating new strategies for mitigating the effects of natural and human-made pathogenic threats to soldiers and civilians, as well as strategies for targeting enemy combatants.79 However, prevention or mitigation of war receives little to no attention in course offerings, despite the fact that students of public health have a great deal to offer in the fields of conflict prevention and stand to gain from the lessons of academic disciplines already engaged in the study of war and peace.
Public health workers would benefit from additional training in other disciplines and could contribute to the development of new standards and methods. Demographic skills would assist with collecting data in the field to help assess the status of health before, during, and after a conflict situation.80 In addition, public health practitioners could develop indicators related to public health and performance of health services, strengthen data collecting and surveillance techniques to address health status in conflict-affected populations, and devise and improve methods to analyze the impact of conflicts on health systems and how best to respond.
In addition to the WHO Health as a Bridge to Peace program, several university-based programs exist to serve as potential models for simultaneous training in conflict, peace building, and health. Peace studies programs include curricula that can be easily transferable to a public health curriculum on war and peace. For example, Cornell University’s Peace Studies program is devoted to research and teaching on the problems of war and peace, arms control and disarmament, and, more generally, instances of collective violence.81 New offerings would also expand knowledge of public health professionals on topics such as human rights and international law, qualitative research methods, innovative ways to gather reliable population information during conflict, and effective methods to communicate this information.68
The University of San Diego offers an interdisciplinary program in peace and justice that seeks to produce graduates who can engage in “real world problem-solving involving regional and international conflict” while pursuing scholarly agendas that examine the dynamics of justice and peacebuilding.82 Australia’s University of New South Wales has a Health and Conflict and Peacebuilding program that examines policies “at the intersection of health systems, conflict prevention, post-conflict recovery and peacebuilding.”83 Its first major project involved international collaboration to develop tools to rapidly assess peace-building and conflict prevention components or impacts of health initiatives.84 The Conflict and Health program at the London School of Hygiene and Tropical Medicine conducts research on public health issues in fragile states and engages in teaching and in-country capacity-building efforts.85 Some of its projects include training in mental health in complex emergencies and the development of resources such as an online guide to epidemiological tools for conflict-affected populations.86
These programs and resources can serve as models for schools of public health and educational programs in public health seeking to build the skills of health practitioners in contributing to peace building and responding to war.
Role of Other Public Health Organizations
Many other agencies could contribute to an expanded public health role in preventing war and its effects, whether through
