Peace building through health

War affects human health through the direct violence of bombs and bullets, the disruption of economic and social systems by which people use to address their health needs, the famine and epidemics that follow such disruptions, and the diversion of economic resources to military ends rather than health needs.1–8 In recent years war has been framed as a public health problem.9 This highlights the role of health workers in preventing and mitigating destructiveness but also raises questions regarding the constraints to their achievement of such objectives. Health work in zones of conflict can initiate and spread peace through conflict management, solidarity with indigenous health workers, strengthening of the social fabric, public dissent and restriction of the destructiveness of war there shall be preliminary evidence of effectiveness for some health-peace initiatives The transition towards peace in war-affected zones will often improve health care and health status of populations. But do health workers have a role in expanding peace? Progress towards more peaceful relationships, between large entities such as nations or small entities like community groups, requires multitrack actions at several levels. Does health care offer one such track? Only empirical data will answer this question, but our preliminary analysis of information suggests that health initiatives have indeed been successfully used as peace initiatives. Bases of health-peace mechanisms The five peace building mechanisms described below have been used by health care professionals. These mechanisms are appropriate to the unique characteristics of health care, which can be indicated through the terms “altruism”, “science,” and “legitimacy.” Altruism, a person's impulse to care about others, is found in every human society but is often expressed chiefly towards “in-groups,” with which a person identifies and feels a sense of community; the rest of humanity may be regarded as the “out-group,” towards which hostility or indifference may be directed. Such delimited altruism may be contrasted with extended altruism, which is associated with broader forms of identification, often connected to conceptions of “universal compassion or law. Extended altruism pushes beyond traditional in-group identities, challenging and extending the boundaries of care. Altruism is the basis of healthcare discourse and official policies. Although health care as practised is often based on delimited altruism (Lifton's The Nazi Doctors describes an extreme example14), its role as one means by which society institutionalises feelings of care and compassion; its association with humane, superordinate goals that transcend human differences; and its embodiment in international organisations such as the World Health Organization and non-governmental organisations such as Médecins sans Frontières (Doctors Without Borders) and International Physicians for the Prevention of Nuclear War make it a natural agent of the extension of altruism. Extended altruism puts much of traditional war making in question, for it entails refusing to accept hate-based identities and depersonalisation of the official enemy. The discourse of modern health care is also based on science. Value is accorded to systematic, empirical study that aims to achieve verifiable and replicable results. This valuation of supposedly objective “fact” is crucial to challenging key psychological processes of modern war. Ever since the rise of mass, citizen-based armies (roughly datable to the French revolution), the successful pursuit of war has depended on rousing a citizenry to determination and fervour through propaganda. Manipulation and suppression of information, as well as manufactured or exaggerated atrocity stories, have become pillars of modern war.15 Accurate and unbiased information about the health effects of policies, tactics, and weapons are rarely available, but act as an antidote to war propaganda and is essential to efforts to achieve a just peace. The third basis of health-peace initiatives is legitimacy. Unlike the two previous concepts, which refer to the discourse and culture of health professionals, this concept refers to the society within which health care is embedded. Healthcare workers are often accorded high legitimacy by society. In North America, for example, physicians have in recent years been consistently ranked by the public as among the most honest and ethical of all professionals. Although this may be inappropriate, and changing in many countries, they have been given a far higher rating than politicians,16–18 allowing them to exert considerable influence when they choose to do so. Health-peace mechanisms Conflict management: Conflict between contending groups may be resolved, lessened, or contained through the use of “medical diplomacy” or health oriented superordinate goals Solidarity: People and groups working to expand peace in difficult situations are supported by healthcare workers and groups with more power or freedom of action Strengthening the social fabric: The bonds uniting a population across diversities (of ethnicity, social class, and so on) may be restored or reinforced through methods of healthcare delivery as well as through reconciliation and healing Dissent: Using legitimacy, experience, or expertise derived from health care, a person or group disagreeing with the policies of the governing or dominant group expresses this disagreement in actions and words Restricting the destructiveness of war: Arguing on the basis of the health effects of military policies and weapons, and using expert knowledge and healthcare discourse, healthcare workers can argue for the restriction or abolition of these policies or weapons and work with others to have the restrictions embodied in international law Conflict management Doctors are able, at times, to gain access to the highest political offices in a nation (International Physicians for the Prevention of Nuclear War members spoke directly with Reagan and Gorbachev during the Cold War) while maintaining high credibility with the general public. They also have, through shared medical research and professional organisations, wide international contacts with colleagues. They may be well placed to undertake diplomatic activities such as mediation, facilitation of dialogue, and high level advocacy, although they would require appropriate training to perform such tasks effectively. Superordinate goals transcend the interests of contending parties and are shared by both (or all) of them. Certain goals in population health may make it desirable to seek cooperation between contending parties in a region affected by war. This may create an opportunity to build a negotiating framework, to counter dehumanisation of the enemy, and sometimes to demonstrate the possibility of stopping the violence. Where the warring parties are, or aspire to be, the government, they may willingly espouse public health goals. Funding bodies may make grants conditional on the contending parties finding ways to work together. In the mid-1980s, Unicef, the Roman Catholic church, and other organisations negotiated “days of tranquility” in El Salvador. Fighting was suspended for the immunisation of children for three days each year from 1985 until the peace accords in 1992. Major gains in the health goals of the campaign were ostensibly achieved, with a total of 300 000 children immunised at several thousand sites each year. The incidence of measles, tetanus, and polio dropped dramatically, that of polio to zero. A negotiating framework between government, the army, and rebel forces, mediated by the church, was created at the national level and multiple local levels. This ostensibly contributed favourably to the achievement of the peace accords. Solidarity Individuals and groups in threatening situations may be struggling to survive, attempting to restrain an existing war or to prevent a possible war, or resisting abuses of state or rebel groups' power. Linkages with health sector groups outside the conflict area may provide much-needed resources, including knowledge. The vigilance intrinsic to such linkages, as operated by organisations like Amnesty International and Physicians for Human Rights, may provide protection against the persecution, disappearance, or death of workers. Solidarity linkages may also offer alternative, non-violent strategies for resolving disputes. The Medical Action Group in the Philippines comprises physicians, dentists, community development workers, nurses, and medical students. They travel in small teams to remote areas to treat people in communities displaced by war that would otherwise have no health services. They promote the peace and security of these communities by reporting on human rights abuses by the army, and they work for longer term peace and justice by advocating on behalf of affected communities. The army units in each area are always visited by the entering team. Human rights violations are thought to have diminished as a result of the teams' capacity to report and advocate. Strengthening the social fabric Health care is one of the chief means by which members of a society express their commitment to each other's wellbeing. An adequate healthcare system accessible to all members of society can promote feelings of security and of belonging to a broad, inclusive group that respects people and meets their common needs. This civic identity makes hate-based mobilisation of ethnic or other identity groups more difficult. In Uganda, for instance, renewed health structures have encouraged displaced people to return home, and it has become clear that rehabilitation of the healthcare system is linked to the wider process of social recovery from war. In many areas, ethnic and religious divisions may have been manipulated to foment war, and violence may have been propagated as a desirable solution to conflict. Social healing of these divisions is necessary to re-establish conditions for public health. This activity is sometimes combined with the tasks of physical and psychological rehabilitation.22 In Croatia a school based curriculum has been devised for children aged about 11 in areas seriously affected by war. It combines the opportunity to discuss sadness, anger, and stress symptoms with a cautious approach to reducing prejudice, learning about non-violent conflict resolution, developing a vision of reconciliation, and “peace living.” Evaluation of this programme has shown small positive changes in some relevant dimensions in both mental health and ethnic tolerance. Working with the idea, the World Health Organization and the UK Department for International Development mounted in Bosnia-Herzegovina “a concerted and intensive attempt to address the fundamental obstacles to peace through health sector development.”25 They show that their programme broke through ethnic barriers and enabled other non-governmental organisations to implement inter-ethnic programmes. Dissent Dissent from the policies of the governing or dominant group may take the form of protest, persuasion, non-cooperation, or intervention.26 Dissent by healthcare workers may draw on their legitimacy, experience, or expertise. Opposition to the Vietnam war by medical professionals included a variety of means and bases of dissent. Benjamin Spock, well known for his writings on the care of infants, drew on his formidable credibility with the American public to speak out against the US war effort.27 Claire Culhane, a Canadian nurse who had worked in a clinic in south Vietnam, protested Canada's involvement in the war through civil disobedience, speaking, and writing.28,29 Her actions were based less on high legitimacy than on personal experience of the health effects of military policies. Doctors who participated in the international war crimes tribunal held in Stockholm in 1967 under the auspices of the Bertrand Russell Peace Foundation, giving testimony against both weapons and actions taken by the US government in its pursuit of the Vietnam war, spoke primarily as scientific experts.

Such dissent may be furthered by “redefinition of the situation” by dissenting parties. By redefining the situation, parties attempt to gain control over issues that have been defined by those with formal political power as “none of their business” or “outside their field of expertise.” Healthcare workers have at times been successful in redefining war as a public health problem rather than a strictly political problem, thereby creating a space for the exercise of their knowledge and opinion. Given their generally high legitimacy with the public, they have in this way been able to exercise considerable influence. The strategies used by International Physicians for the Prevention of Nuclear War to redefine nuclear war as a public health issue are a classic example; another is the efforts of the International Study Team to raise doubts about claims that advanced technology was being used to fight a humane war in Iraq. Restricting the destructiveness of war In the West, war has long been restricted by banning weapons deemed abhorrent. The notion goes back at least as far as the second Lateran Council of 1139, when the crossbow was outlawed for use against Christians (a fine example of delimited altruism). Where proposals for the abolition of particular weapons or tactics are framed on the basis of health effects, these become health-peace initiatives. Arguments against the use of napalm and other incendiaries, nuclear weapons, cluster bombs, and antipersonnel landmines on the basis of their horrific health effects belong to this category, as do similarly framed arguments against food and crop destruction, deliberate starvation, and physical and mental torture. There is a risk in such efforts, since legal restrictions on war are always interpreted in some quarters as evidence that war is a civilised, professional activity that can be waged in rule-based and even humane ways. But for people committed to diminishing or abolishing war, gradual suffocation through graduated restriction is one possible route. The International Committee of the Red Cross has recently developed criteria for an objective, medically based definition of “superfluous injury or unnecessary suffering” (wording from the 1977 additional protocol I to the Geneva Conventions of 1949, one of several international agreements aimed at restricting the methods used to wage war) so that some weapons now in use can be eliminated and abhorrent new weapons can be banned before they are deployed. Evaluation of peace outcomes is difficult. In many situations use of a control group is impossible. Measures before and after intervention, for all their flaws, may be the best achievable—for example, counts of human rights violations against a group before and after a solidarity action. For some hoped-for peace outcomes, the only way of evaluating the health-peace linkage may be through the direct reports of key decision makers. Mikhail Gorbachev, for example, reported that his foreign policy, which enabled a shift away from the Cold War, was influenced by the analyses and policies of International Physicians for the Prevention of Nuclear War. An example of evaluation using a control group design was the health-peace intervention with Croatian school children described above. As well as measures of psychological symptoms (health), the children's degree of antipathy to other ethnic groups was measured, as were their attitudes and behaviour regarding violence and conflict resolution (peace).14 A control group of schools received no intervention, and the evaluation researchers were a separate team from those who provided the intervention. The battery of tests was given immediately before and after intervention and to control and intervention groups a year after the end of the intervention. This desirable study design is not always achievable in war zone fieldwork. The recent surge of interest in “peace building” as a theme of foreign policy is leading to advances in thinking in evaluation, and recent studies have begun to develop indicators for the peace and conflict impact of development projects, including health initiatives, in conflict zones.