War and Public Health

Veeral Shah
PM 565
Blog paper 2

An examination of the role of the Public Health Community in preventing armed conflict
War and terrorism have had and continue to have profound social, political, economic and health costs far beyond the official termination of conflict. Historically, the health care community comes to conflicts during or after the duration of conflict and usually not in a preventative sense. Although, this model is understandable given the unique circumstances surrounding conflict, the current model deals little with the concepts around whether health care professionals (HCP) on the ground can serve as preventative agents as well as curative agents in times of conflict. Obviously, in many cases, this should not be understood to mean that health care professionals bear full responsibility for alerting the public as to the potential human rights violations, but it does not absolve them either. Groups such as Doctors without Borders have continually sought support from the international community regarding medical aid to those in need, but in a twenty-first century framework more steps must be taken. It is difficult to assess how much power an organization outside the borders of a particular region can exert on the persons of that region and how ethical is it to impose the idea of one’s will, whether it be political or social, upon another, especially in situations where help is not explicitly requested. Governments have run into political quagmires as a result of such partisan, unilateral thought processes in most recent memory the United States and Iraq. When examining the enormous complexity faced by individuals seeking to make government’s yield to help those in need, an HCP understandably feels overwhelmed and powerless, thereby concluding that their respective actions have no impact on the government at large. However, in actuality, HCP’s are uniquely positioned to alert intra and extra governmental and non-governmental entities on the atrocities occurring on a grassroots level.
The indirect, or secondary, public health effects of conflicts have been caused by population displacement, food shortages, and collapsed basic health services. Recent examples of mass population movements that attracted widespread media attention have included the Kurdish exodus from northern Iraq in 1991; widespread internal displacement and migration to neighboring countries by Somalis in 1992–93; the displacement of several million persons in the former Yugoslavia between 1992 and 1995; and the migration of up to two million Rwandans in 1994. A new term–complex emergency–has been coined to describe situations affecting large civilian populations that usually involve a combination of factors including war or civil strife, food shortages, and population displacement, resulting in significant excess mortality.1 The evolution of complex humanitarian emergencies tends to follow a relatively consistent pattern:
1. Domination of government by one political faction
2. Discrimination against minority ethnic or religious groups or against majority groups by ruling minorities
3. Widespread human rights abuses leading to civil unrest, violence and open armed conflict.

The conflict eventually leads to a destruction of infrastructure, diversion of resources away from social services, especially prevention programs such as child immunizations and antenatal care. Naturally, hospitals and surgical centers in the areas surrounding conflict may be overwhelmed by the needs of war wounded and general medical services suffer from lack of staff and shortages in essential medical supplies.1
Primary prevention is the basic strategy of public health, and epidemiology is one of its essential tools. In situations of armed conflict, however, epidemiology can be practiced safely and reliably in very few areas. Hence, the traditional documentation, monitoring, and evaluation elements of disease prevention may be ineffective in these situations. The provision of adequate food, shelter, potablewater, sanitation, and immunization has proved problematic in countries disrupted by war. Primary prevention in such circumstances, therefore, means stopping the violence.
More effective diplomatic and political mechanisms need to be developed that might resolve conflicts early in their evolution prior to the stage when food shortages occur, health services collapse, populations migrate, and significant adverse public health outcomes emerge. The notion of national sovereignty embodied in the United Nations Charter has sometimes forced the international
community to stand by and watch extreme examples of human rights abuses until a certain threshold of tolerance has been crossed and strong action has been taken, as in the case of Somalia. By the time such action has been taken, however, the conflict has often advanced to a stage where any involvement by outside forces is costly and dangerous. Cautious, neutral, but determined diplomacy of the kind practiced by the Atlanta-based Carter Center in Ethiopia, Sudan, Haiti, and Bosnia-Herzegovina might serve as a model for future conflict resolution efforts.2 Epidemiologists and behavioral scientists might play a role in this process by systematically studying the dynamics and characteristic behaviors that sustain conflict situations and by seeking to identify measures that might reduce the level of tension between opposing sides.
Secondary prevention involves the early detection of evolving conflict-related food scarcity and population movements, preparedness for interventions that mitigate their public health impact, and the development of appropriate public health skills to enable relief workers to work effectively in emergency settings. Disaster detection activities in the form of early warning systems have existed for some time; however, these systems have tended to focus on monitoring natural rather than man-made hazards. Such systems, implemented by a range of United Nations agencies and US Government–supported programs, routinely monitor crop yields, food availability, staple cereal prices, rainfall, and household income in a number of African countries, as well as conducting periodic vulnerability assessments. The information generated is published and disseminated widely in periodic bulletins and has proven useful in predicting natural disasters, such as drought throughout southern Africa in 1992.3 Nevertheless, these systems have generally not developed early indicators related to human rights abuses, ethnic conflict, political instability, and migration. Other groups such as Africa Watch, Physicians for Human Rights, Amnesty International, and African Rights have conducted assessments of vulnerability in countries, such as Burundi, relatively early in the evolution of civil conflict. The problem with such assessments is that the results are often ignored by the governments of those nations able to intervene unless their security interests are perceived to be threatened. Early in 1992, for example, reports by several nongovernmental organizations (NGO) on the deteriorating situation in Somalia were largely ignored by the international community. Epidemiologists might play an important role in developing and field testing the sensitivity and predictive value of a broad range of early public health emergency indicators.
The inability of the world to promptly address the explosive epidemic of cholera among Rwandan refugees in eastern Zaire, in July 1994, underscored the lack of emergency preparedness planning at a global level.3 This epidemic highlighted the inadequate reserves of essential medical
supplies and equipment for establishing and distributing safe water, as well as revealing a lack of technical consensus on the most appropriate interventions. Agencies that did have the appropriate skills and experience, such as Oxfam and MSF, lacked the necessary resources, and those agencies with the resources and logistics, such as the United States military, lacked the technical experience in emergency relief. Preparedness planning needs to take place both at a coordinated international level and at the level of countries where complex emergencies might occur. Relief agencies need resources to implement early warning systems, maintain technical expertise, train personnel, build reserves of relief supplies, and develop their logistic capacity. At the country level, all health development programs should have an emergency preparedness component that should include the establishment of standard public health policies (e.g. immunization and management of epidemics), treatment protocols, staff training, and the maintenance of reserves of essential drugs and vaccines for use in disasters.4
Front-line relief workers in complex emergencies are often volunteers recruited by NGOs who sometimes lack specific training and experience in emergency relief. They require knowledge and practical experience in a broad range of subjects, including food and nutrition, water and sanitation, disease surveillance, immunization, communicable disease control, epidemic management, and maternal and child health care. They should be able to conduct rapid needs assessments, establish public health program priorities, work closely with affected communities, train local workers, coordinate with a complex array of relief organizations, monitor and evaluate the impact of their programs, and efficiently manage scarce resources. In addition, they need to function effectively in an often hostile and dangerous environment; such skills are specific to emergencies and are not necessarily present in the average graduate of a medical or nursing school. Therefore, relief agencies need to allocate more resources to relevant training and orientation of their staff, as well as providing adequate support in the field. Indigenous health workers in emergency-prone countries, while often familiar with the management of common endemic diseases, also need training in the particular skills required to work effectively under emergency conditions.
Tertiary prevention involves prevention of excess mortality and morbidity once a disaster has occurred. The health problems that consistently cause most deaths and severe morbidity as well as those demographic groups most at risk have been identified. Most deaths in refugee and displaced populations are preventable using currently available and affordable technology. Relief programs, therefore, must channel all available resources toward addressing measles, diarrheal diseases, malnutrition, acute respiratory infections, and, in some cases, malaria, especially among women and young children. The challenge is to institutionalize this knowledge within the major relief organizations and to ensure that relief management and logistical systems provide the necessary resources to implement key interventions in a timely manner. Initially, both refugees and displaced persons often find themselves in crowded, unsanitary camps in remote regions where the provision of basic needs is highly difficult. Prolonged exposure to the violence of war and the deprivations of long journeys by refugees cause severe stress. Upon arrival at their destination, refugees–most of whom tend to bewomen and children–may suffer severe anxiety or depression, compounded by the loss of dignity associated with complete dependence on the generosity of others for their survival. If refugee camps are located near borders or close to areas of continuing armed conflict, the desire for security is an overriding concern. Therefore, the first priority of any relief operation is to ensure adequate protection and camps should be placed sufficiently distant from borders to reassure refugees that they are safe. To diminish the sense of helplessness and dependency, refugees should be given an active role in the planning and implementation of relief programs. Nevertheless, giving total control of the distribution of relief items to so-called refugee “leaders” may be dangerous. For example, leaders of the former Hutucontrolled Rwandan government took control of the distribution system in Zairian refugee camps in July 1994, resulting in relief supplies being diverted to young male members of the former Rwandan Army.5 Surveys indicated that households headed by single women had diminished access to food and shelter material, leading to elevated malnutrition rates among children in those
households.
In the absence of conflict resolution, those communities that are totally dependent
on external aid for their survival because they have either been displaced from their homes or are living under a state of siege must be provided the basic minimum resources necessary to maintain health and well-being. The provision of adequate food, clean water, shelter, sanitation, and warmth will prevent
the most severe public health consequences of complex emergencies. It would seem that the temporary location of refugees in small settlements or villages in the host country would have fewer adverse public health consequences than their placement in crowded, often unsanitary camps. Although studies to compare health outcomes among refugees in camps and in free settlements have not been possible, surveillance data from Guinea and Malawi indicate that refugees in local villages have fared better than those in camps.6
During the past decade, much progress has been made among the major relief agencies in standardizing approaches and procedures in public health emergencies (ie Sphere Project). Training courses designed specifically for public health in emergency settings have been developed in Europe, the United States, and Australia. Standard guidelines and essential drugs lists have been developed and are routinely used in emergencies. The role of military forces in providing security and in directly providing emergency assistance has grown rapidly in recent years. Military forces have played a prominent role in relief operations in northern Iraq, Somalia, the former Yugoslavia, Zaire, Rwanda, and Haiti.6 The involvement of the military is often ambiguous, confusing the various tasks of peace-keeping, peace-enforcing, and providing relief. No one would doubt the logistical advantages of the military; however, this is not always matched with appropriate experience in the technical aspects of a relief operation. Furthermore, military assistance is expensive and because it depends on political decisions by national governments, it cannot always be integrated into disaster preparedness planning.
Relief management decisions need to be based on sound technical information, and assistance programs need to be systematically evaluated–not merely for their quantity and content, but also for their impact and effectiveness. Responsibilities for technical coordination and implementation of relief programs should increasingly be shared with proven, competent, and experienced NGOs. Greater resources need to be allocated to personnel training, emergency preparedness planning, and the maintenance of regional reserves of essential relief supplies. These activities need to include government and nongovernment agencies in countries where emergencies are likely to occur. Recent emergencies have followed a predictable pattern of political unrest, civil war, human rights abuses, food shortages, and, finally, mass population displacement. There has been almost no preparedness for these emergencies within the public health community. Agencies involved in health development projects need to be aware of political realities in certain regions of the world and should integrate preparedness planning into all aspects of public health programs. Health information systems should incorporate plans to simplify and focus on major health problems in the event of emergencies. Immunization, diarrheal disease control, and community health worker training programs should likewise incorporate emergency contingency plans. Finally, increased attention needs to be given to the challenges of rehabilitation of national health services following the cessation of armed conflict and the repatriation of large numbers of refugees to their country of origin.

References
1.B.S. Levy and V.W. Sidel, “Preface,” in B.S. Levyand V.W. Sidel, eds., War and Public Health (New York:
Oxford University Press, 1337).
2. World Health Organization. World Report on violenceand Health (Geneva: World Health Organization,
2006).
3. RJ. Rummel. Death by Gomment: Genocideand MmMurderSince lWO(New Brunswick, NJ, and London
4. Transaction Publications, 1334). A. Zwi, A. Ugalde and P. Richards. “The Effects of War and Political Violence on Health Services’’ in L. Kurtz, ed., Encyclopedia of Violence, Peace and Conflict (San Diego, CA: Academic Press 1999): 679-690.
5. R.M. Garfield and A.I. Neugut, “The Human Consequences of War”, in B.S. Levy and V.W. Sidel, eds., War and Public Health, supra note 3.
6. V.W. Sidel, “The Impact of Military Preparedness and Militarism on Health and the Environment”, in J.E.
Austin and C.E. Bnich, ecls., Be Environmental Comequences of War (New York: Cambridge University Press,2000).