The Role of Public Health Practitioners, Academics, and Advocates in Relation to Armed Conflict and War

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 training of public health practitioners, gathering and disseminating information to policymakers and the public, encouraging interagency coordination, and more. These include global entities such as the World Federation of Public Health Associations, state and local public health agencies in the United States, and military health entities.

Expanding the Public Health Research Base to Create New Tools for the Prevention of War and Armed Conflict
The public health knowledge base concerning the role of practitioners in war, preparation for war, and the aftermath of war, is entirely inadequate. Public health practitioners, academics, and advocates could have multiple roles in relation to armed conflict, but currently their set of responsibilities has been proscribed in a very narrow way—largely in relation to establishing systems to medically treat those affected by war, repairing health systems and health-supporting infrastructure after it has been destroyed, cleaning up water and sanitation systems to prevent the spread of disease, and perhaps assessing the scope of the damage. However, our methods of counting both direct and indirect deaths are inadequate, and the few methods at our disposal have been politicized and obfuscated by combatants.

Public health practitioners should expand their responsibilities in armed conflict situations to include all the traditional roles they would usually play in relation to any other problems responsible for widespread disease, illness, and poor health: primary, secondary, and tertiary prevention. As mentioned earlier, these new responsibilities require an expanded view of the prevention of war and its impacts as a public health issue, as well as training for public health workers in applying traditional public health skills to war and conflict. In addition, public health practitioners need to assist in the development of new knowledge and approaches, because the currently available tools are quite limited. There is a significant need to identify and fund a research agenda to support an expanded role for public health practitioners and educators in the area of expanding the knowledge base about effective strategies in primary, secondary, and tertiary prevention as they relate to war.

Primary Prevention
Probably the most contentious role for public health practitioners is, ironically, the role that is most traditional for public health professionals: primary prevention. To prevent armed conflict before it begins, public health practitioners need to be equipped with political and communication tools that work as effectively as, for instance, immunization campaigns. Primary prevention requires an understanding of the root causes of war, which are only partially understood.⁸⁷ WHO cites political (unequal access to power), economic (unequal distribution of resources), societal (inequality between groups), and demographic (rapid demographic change) factors as risk factors for collective violence.68 Research into the causes of war consistently and robustly indicates that the factor most strongly associated with war is poverty.¹⁵ Disease and environmental degradation have been separately shown to reinforce poverty and form a logical part of the causal chain leading to conflict.⁸⁸ However, some research has less clear results. Some reports suggest resource scarcity as a cause of violence in Rwanda, South Africa, Assam, Chiapas, Kenya, and Sudan, but empirical testing of ecoscarcity has produced mixed results.⁸⁹ If climate change grows as a public health problem, we may expect more conflicts to erupt as people seek “higher ground.” Moreover, the international community lacks a significant body of research on why similar structural factors result in conflict in some communities or countries, but not in others.

Recent trends indicate today’s violence may not have the same causes and patterns as past wars, and ongoing research into new causes and patterns is needed. For example, the Human Security Brief 2006 found that since 2000, 1-sided violence against civilians has increased despite a decline in the number of civil wars, with which these attacks are typically associated. The UN recently reported that it had little way of knowing whether the deadly threats to civilians are increasing or decreasing.⁹⁰

However, the UN noted in a 2004 report that “early warning is only effective when it leads to early action for prevention.”⁸⁸,p23 This is a rather disheartening conclusion when considered beside the later comment that the greatest hindrance to “collective security institutions has simply been an unwillingness to get serious about preventing deadly violence,” page 23 especially in the time period before full-blown conflict when prevention is a real possibility.88 The need for an effective understanding of the causes of conflict is matched and possibly outstripped by the need for coherent mechanisms for action by governments and multilateral organizations. Primary prevention would include active participation in the development of and advocacy for such mechanisms.

The research agenda for primary prevention would provide methods for public health practitioners to educate policymakers and the public about the anticipated consequence of war and to advocate for alternative resolutions to conflict. One example of health practitioners organizing against war is the International Physicians for the Prevention of Nuclear War (IPPNW), founded in 1980 by doctors in the United States and Soviet Union to document the medical and environmental harm of nuclear weapons and bringing this information into the public and political dialogue.⁹¹ IPPNW was awarded a Nobel Peace Prize in 1985, and now has affiliates in 62 countries, including the US affiliate Physicians for Social Responsibility. More recently, Medact, the British affiliate of IPPNW, in 2002 undertook to predict the number of deaths in Iraq as a consequence of a US invasion.⁹² Medact wrote, Credible estimates of the total possible deaths on all sides during the conflict and the following three months range from 48,000 to over 260,000. Civil war within Iraq could add another 20,000 deaths. Additional later deaths from post-war adverse health effects could reach 200,000. . . . In all scenarios the majority of casualties will be civilians.⁹²

Medact went on to discuss the expense of the anticipated war, with the understanding that the diversion of these resources from the determinants of health would have both direct and indirect effects on health:

The financial burden will be enormous on all sides, with arms spending, occupation costs, relief and reconstruction possibly exceeding $150–200bn. The U.S. is likely to spend $50bn - $200bn on the war and $5bn - 20bn annually on the occupation.” As the report points out, “$100bn would fund about four years of expenditure to address the health needs of the world’s poorest people.⁹²

Even these best-guess scenarios by Medact were, however, underestimates of the toll of this most recent widespread multinational, cross-regional conflict. Researchers used well-established population-based survey methods to estimate 655,000 excess Iraqi deaths between 2002 and 2006.^93,94 Public health tools for generating preconflict estimates, as well as for conducting ongoing monitoring during conflicts, must be more refined and more effective. In addition, the need for public health professionals to carry out these assessments, often under significant personal risk, needs to be widely supported and protected to obtain the most objective information by which policymakers are held to account for knowingly taking decisions that have predicted consequences.

Secondary Prevention
The most important role of public health practitioners after the commencement of armed conflict is the mitigation of as much morbidity and mortality as possible, as well as a tabulation of the injuries, illnesses, and deaths that do occur. Although professionals have experience with harm reduction in other settings of high risk behavior (such as drug use and unsafe sex), experience with thinking of public health workers as requiring “harm reduction” skills and tools in the case of armed conflict is limited. There is thus a compelling need to learn how best to apply traditional skills to this new role.

As evident in all recent armed conflict, the period immediately after the onset of hostilities is a time of immense confusion, with the potential for significant harm to all in the vicinity, especially the most vulnerable of noncombatants. This is when hospitals are looted, suspicions are high enough to prompt “shoot first” behaviors, and usual sources of medical care for preexisting health problems are interrupted. In this phase of war, our role turns to protecting medical care and public health systems from destruction and disintegration. This role requires skills and methods to protect both physical infrastructure and the health workers themselves.

In addition to that role, however, public health workers must prepare for the grim task of counting deaths in a systematic, epidemiologically sound manner—even when the hostilities have not yet abated. This role is rarely well received by the combatants, especially the initial aggressor.⁹⁵ Public health workers engaged in the counting of injuries, illnesses, and deaths need not only the best epidemiological tools, but also the best political and communications tools to ensure their counts are received in a way that ensures credibility. An important contribution to the field, therefore, would be well-researched new methods to count injuries, illnesses, and deaths. Public health workers can also contribute with epidemiological studies of human rights violations during conflict. In addition to new tools, health workers who engage in this work also need physical protection while completing their work and respect for their findings when it is complete.

Tertiary Prevention
When victims of combat overwhelm the health care systems, health workers are maximally stressed to provide services in the settings of insufficient supplies, broken equipment, too few beds, inadequate and dangerous transport systems, and too few health workers. The role of public health turns to triage, maintaining communication among health facilities and suppliers to ensure the best possible care for patients, promoting the human rights of the victims of combat, and encouraging the cessation of hostilities.

Although the public health community has accumulated experience and training for the first 2 of these functions (triage and communication within the health system), largely in the setting of natural disasters, work toward the cessation of hostilities is usually left to the political arena. Public health workers could effectively take on more of this role, however, because they are in the best position to discuss the consequences to the health of the public of failing to achieve a cease fire. Multilateral organizations, especially the UN and its various affiliated agencies, would especially benefit from a deliberate effort by public health workers to bring more tools and a new voice to the urgent need to end violence once it has begun.

As an example, the International Committee of the Red Cross (ICRC) serves as an independent, neutral organization ensuring humanitarian protection and assistance for victims of war and armed violence. In the December 2008 to January 2009 Gaza conflict, ICRC needed to engage in significant political negotiations and press communications to attempt to bring humanitarian and medical relief to civilians in the Israeli-occupied Palestinian territories, because the invading force was preventing the delivery of services to injured civilians. These negotiating and communication skills are not traditionally thought of as falling within the public health arena, and few practitioners are prepared with the training and tools necessary for this role.

Building a meaningful role for public health in the recovery of populations after conflict has ended will require expanded skills and resources for managing the health effects of migration and displaced people, managing the reintroduction of combatants into society after significant insults to mental health, enabling populations to avoid the effects of remaining land mines or other continuing effects of the conflict, and reconstructing damaged health systems. More long-term effects will require public health interventions, such as managing intergenerational effects of trauma. This tertiary prevention role for public health workers during and in the aftermath of conflict settings should not be limited to a few specialized organizations such as the ICRC. As previously identified in this paper, unacknowledged and by default, public health workers are coping every day with the fallout of war in our clinics, communities, and resource-weakened organizations. In addition, because political peace may not equate to social and community peace, especially where paramilitary or guerilla activity is prevalent, public health workers may play a useful role in peacekeeping efforts long after the political process declares peace.

Public health practitioners need significantly more skills and research to prepare themselves to carry out these roles. Limited funding is available for research and practice for public health professionals prepared to prevent and mitigate the effects of war, and too few avenues for dissemination on the public health consequences of war exist. According to McDonnell et al.,
[a] possibly more respected method for bringing awareness of local health and social issues to national and international levels is publishing research in credible journals. Peer-reviewed work can be a tool to facilitate negotiations between governments, NGOs and communities, and to influence international and national policy-makers.⁸⁰, p6 of 9

Using these avenues for dissemination allows the realities of war and the accompanying consequences to reach a wide audience and extends the knowledge base.

Strengthening the Infrastructure to Promote Peace
Whereas governmental and civil society infrastructures are well equipped to promote and support war and militarism, infrastructures to promote and support peace are weak. The significant resources and structures that many countries devote to preparing for war, including vast bureaucratic resources in each country’s department of defense (or its equivalent), enhance the likelihood that countries will move toward war rather than its many alternatives. The human and financial resources invested in training and preparing military personnel, developing and testing weapons systems, honing our capacity to enter war, and maintaining military facilities and bases are so large that they produce a tremendous material interest and societal momentum toward war as a means of solving geopolitical problems. At the same time, investments in international diplomacy, exchange programs, and international collaborative enterprises such as the UN, are so paltry they are dismissed as ineffectual tools in resolving international conflict.

Vast Expenditures in Preparation for War, Few for Peacekeeping and Securing Weapons
In 2007, world military expenditures totaled $1.3 trillion—a 6% increase in real terms over 2006 and a 45% increase over 1998. Although the bulk of this growth results from US spending, some areas of the world saw more rapid relative growth; conservative estimates indicate that between 1997 and 2006, not including spending by nonstate actors, sub-Saharan Africa’s military expenditures rose 55%, South Asia’s rose 57%, and Eastern Europe’s rose 61%.⁵⁵

One obvious side effect of this spending is the proliferation of both conventional and nuclear weaponry. Small arms and light weapons, which are primary weapons of civil wars, continue to be sold and traded at alarming rates, whereas efforts to limit their availability have faltered.88,96 Meanwhile, approximately 60 countries currently operate or are constructing nuclear power or research reactors, at least 40 countries possess infrastructure that could provide the basis for developing nuclear weapons in the future, and 9 countries possess about 27,000 nuclear weapons.⁹⁷

Investments in peacekeeping and securing weapons are starkly lower. The share of US income taxes spent on defense in 2007 was more than 30 times the portion invested in diplomacy and foreign aid.⁵⁸ In 2008, the US budget for preventing the spread of nuclear material was only $1.4 billion—approximately 1% of total estimated defense spending.⁹⁸ Internationally, the UN spends $15 billion annually on its programs, including peacekeeping operations, as well as development and assistance programs (but not including the World Bank, International Monetary Fund, or International Fund for Agricultural Development).⁹⁹ Within this amount is the allocation to the agency entrusted with reducing the threat of nuclear war and nuclear terrorism—the International Atomic Energy Agency—with a regular budget of less than $275 million.⁸⁸

In addition to being underfunded, peacekeeping operations rarely have sufficient personnel. The United States, with 4% of the world population and some of the largest military forces, provides personnel equivalent to only 0.5% of the UN’s current peacekeeping force.100,101 Even where peacekeeping forces are available, few nations have the logistic capacity to transport and adequately support them.⁸⁸

Still, the UN has conducted 63 peacekeeping operations since 1946, with a dramatic increase in the 1990s.¹⁰² The number of state and nonstate conflicts also declined, although it is unclear whether this is a causal relationship.⁹⁰ The 1990s were also the first decade in which more conflicts ended in negotiated settlement (42) than in victory (24).¹⁰¹ Although this trend is encouraging, negotiated settlements leave both sides of the conflict with some means and some motivation to reengage in conflict, thereby requiring continuing investments in ensuring the conditions required to preserve the peace. When negotiated settlements attract the necessary resources, the results are quite promising. A study of 23 civil wars found that 11 of 12 settlements that contained a third-party security guarantee were successful, whereas only 2 of 11 settlements without such a guarantee were sustained.⁹⁰ Conversely, failures can be devastating; the UN estimates that millions of deaths could have been prevented in the 1990s if the Bicess Agreement (pertaining to the conflict in Angola) and the Arusha Accords (Rwanda) had been successfully implemented.⁸⁸

Despite the critiques of peace operations thus far, the ability of these operations to produce any positive results while consistently suffering from “inadequate resources, ineffective coordination, inappropriate mandates and lack of political support,” argues for the potential for improvement in collective global security if the international community can muster better designed, resourced, and implemented initiatives.¹⁵page 6. In addition to contributing to peacebuilding efforts before conflicts escalate to the point of needing peacekeeping troops and working to create successful settlements, public health practitioners can also add their voices to those advocating for more resources for peacebuilding and peacekeeping rather than war.

The Responsibility to Protect
Although public health should aim to end war and armed conflict, some people argue for armed intervention in the absence of alternatives in situations of compelling human need. The genocides in Cambodia, Rwanda, Bosnia, and Darfur, as well as humanitarian disasters in Somalia, Zimbabwe, Kosovo, and East Timor have demonstrated massive failures by the international community to respond to human rights violations.

World leaders at the UN 2005 World Summit committed to several global actions and priorities, including the Responsibility to Protect.¹⁰³ The Responsibility to Protect advocates for countries to accept that national sovereignty entails a responsibility to protect its populations. In turn, the international community of nations must accept its responsibility to protect populations when crises reach a certain threshold, such as genocide and other large-scale killing, ethnic cleansing, war crimes, crimes against humanity, or serious violations of international humanitarian law. Governments working collectively can intervene (while being in compliance with international law) in regions where sovereign governments have proved powerless or unwilling to prevent such crises.⁸⁸

The framers of the Charter of the United Nations recognized that force may be necessary for the “prevention and removal of threats to the peace, and for the suppression of acts of aggression or other breaches of the peace.”⁸⁸page 53 The principle of nonintervention in internal affairs cannot be used to justify failing to prevent genocidal acts or other atrocities, such as large-scale violations of international humanitarian law or ethnic cleansing, which can properly be considered a threat to international security and as such provoke action by the Security Council.⁸⁸ Action may include coercive measures such as sanctions and international prosecution and, in extreme cases, military intervention. Military intervention for human protection purposes must be regarded as a policy failure, an exceptional and extraordinary measure exercised only as a last resort when all peaceful means of conflict resolution have been exhausted and demonstrated to be inadequate to prevent gross violations of human rights. Public health workers can play a role in these settings as well, in tertiary prevention of harm to populations.

APHA’s Longstanding Commitments and Evolving Role
APHA has taken stands over the years to oppose individual outbreaks of armed conflict, preparation for military intervention, and investments in weaponry. These statements include the following:

• 2007: Opposition to US Attack on Iran¹⁰⁴
• 2006: Opposition to the Continuation of the War in Iraq¹⁰⁵
• 2005: Condemning the Cooperation of Health Professional Personnel and Torture of Military Prisoners and Detainees¹⁰⁶
• 2003: Strengthening the Fiscal Viability and Independence of Public Health While Responding to Terrorism¹⁰⁷
• 2003: Opposition to United States Plans for New Nuclear Weapons Development and Pre-emptive War¹⁰⁸
• 2002: Opposing War in Central Asia and the Persian Gulf¹⁰⁹
• 2002: Call for the United States to Support a Strengthened Biological Weapons Convention¹¹⁰
• 2001: Opposition to National Missile Defense and the Militarization of Space¹¹¹
• 2000: Prevent, Response, and Training for Emerging and Re-emerging Infectious Diseases, including Bioterrorism¹¹²
• 2000: Preventing Genocide¹¹³
• 1999: Anthrax Immunization¹¹⁴
• 1999: Opposing War in the Middle East¹¹⁵
• 1999: Nuclear-Weapon-Free World¹¹⁶
• 1999: Taking Nuclear Weapons Off Alert¹¹⁷
• 1998: Cessation of Continued Development of Nuclear Weapons¹¹⁸
• 1997: Implementation of the Chemical Weapons Convention¹¹⁹
• 1997: Support for a Ban on Antipersonnel Landmines¹²⁰
• 1996: Cessation of Nuclear Testing and Abolition of Nuclear Weapons¹²¹
• 1993: A Ban on Antipersonnel Landmines¹²²
• 1992: Reducing and Monitoring the Use of Toxic Materials in Production by the Departments of Defense and Energy¹²³
• 1991: Continuing Consequences of the Vietnam War¹²⁴
• 1989: Delay of Waste Isolation Pilot Plant (WIPP), A Nuclear Waste Repository, Until Safety Is Assured¹²⁵
• 1989: Public Health Hazards at Nuclear Weapons Facilities¹²⁶
• 1987: End to Nuclear Weapons Testing and the Strategic Defense Initiative (SDI)¹²⁷
• 1985: The Health Effects of Militarism¹²⁸
• 1984: The New Threat to Nicaragua and World Peace¹²⁹
• 1983: Nuclear Testing and Dumping of Nuclear Waste Materials in the Pacific Ocean¹³⁰ 
• 1981: Nuclear War and Nuclear Weapons¹³¹
• 1979: World Peace and the Military Budget¹³²
• 1974: Chemical and Biological Methods of Warfare¹³³
• 1969: Chemical and Biological Methods of Warfare¹³⁴

This comprehensive statement on the relationship between war and public health creates the foundation for a theoretical and value-based approach to the topic of war generally and will provide a reference point for future statements that address individual conflicts, war policy, or weapons systems. Because war affects all public health workers, both foreign and domestic, in profound and wide-reaching ways, it is critical that the they embrace their responsibility to take a stand on how the profession of public health can help solve this most important of public health problems.

Actions
The public health consequences of war are massive and leave few if any areas of public health practice untouched. Thus, war is 1 of the greatest obstacles to realizing APHA’s vision of “a healthy global society.” Therefore, public health practitioners, academics, and advocates have an essential role to play in preventing war. To that end, public health professionals and international and domestic organizations should:

1. Recognize the prevention of war as a local, national, and global public health priority and highlight the essential role of all public health practitioners in the prevention of war and its public health consequences. 
2. Educate public health professionals, policymakers, and the public about the anticipated consequences of war and advocate for alternative resolutions to conflict. Engage public health professionals in advocacy such as on legislation related to the arms trade, ratification of treaties and protocols related to war, military expenditures, financial and political engagement in multilateral peace operations, and international development programs that address structural causes of war. Encourage public health professionals and professional journals to focus on the impact of war on public health.
3. Encourage and support research and advocacy relating to the structural causes of conflict, trends in risk to civilians from state and nonstate actors, assessment of impacts anticipated from wars that have not yet started, comprehensive monitoring and surveillance of public health impacts in conflict zones, factors in successful settlement, the rapid rebuilding of health systems infrastructure as part of postconflict reconstruction, and identifying ways to prevent war and to mitigate its health consequences. Encourage academic and government research on these and related topics, including by the National Institutes of Health, the Centers for Disease Control and Prevention, Health Resources and Services Administration, the military health services, and other public health funders. Attempt to engage the nation’s academic war training institutions in the study of public health impact assessments for armed conflicts.
4. Foster dialogue on the issue of war and build partnerships with international public health stakeholders, including the World Federation of Public Health Associations, WHO, and its regional entities, education institutions in other countries, international professional organizations and civil society organizations.
5. Improve the competency of the global public health workforce to prevent and mitigate the impacts of war. Work with the Association of Schools of Public Health, and directly with domestic and international schools, to promote and develop curricula addressing war and peace in a public health framework, including incorporating newer skill sets such as political negotiation, communication, and surveillance in crisis situations.

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