Warfare: III. Public Health and War

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During the twentieth century, an estimated 110 million people lost their lives as a result of armed conflicts (WHO). If one includes the major episodes of "collective violence," such as the Stalinist terror of the 1930s and the famine associated with the Great Leap Forward in China (1958–1960), this figure reaches 191 million (Rummel), with approximately 60 percent of these deaths occurring among noncombatants.

Since the Second World War, approximately 190 armed conflicts have occurred affecting ninety-two countries (WHO; Federation of American Scientists). Most occurred in Asia, Africa, and Latin America; however, since 1990, four European conflicts—Chechnya, Azerbaijan, Georgia, and the former Yugoslavia—have caused more than 350,000 deaths. Some wars are still fought primarily between competing armies, such as the Iran-Iraq conflict (1980–1988), in which an estimated 450,000 military personnel died (Sivard), but the vast majority now take place within states.

Civilian populations have increasingly been the intentional targets of military actions, as can be seen in the shelling of urban centers during the conflicts in Bosnia and Herzegovina, Chechnya, Angola, Lebanon, and Somalia. In addition, modern weapons such as napalm, cluster bombs, and land mines do not discriminate between combatants and innocent civilians. In Mozambique the antigovernment forces killed approximately 100,000 civilians in 1986 and 1987 alone (Ugalde, Zwi, and Richards) and between 5 million and 6 million people were either internally displaced or fled to neighboring countries.

Since World War II there have been numerous episodes of massive human rights atrocities and genocide that defy the traditional characteristics of armed warfare. Examples include Pol Pot's killing fields in Cambodia; the Guatemalan government action against indigenous Mayan communities; the use of chemical and biological weapons against the Kurds in Halabja, Iraq; the genocide against Tutsis in Rwanda; and the civilian massacres following the referendum on independence in East Timor.

Public Health Impact of War

DIRECT IMPACT. The direct public health consequences of war include death, injury, sexual assault, disability, and psychological stress. Measuring the impact and hidden costs of conflict is complex for a variety of reasons. Even where huge numbers of people are involved, agreement on the magnitude of impact varies. Estimates of the number of victims of the Rwandan genocide are still imprecise and vary from 500,000 to one million (Murray, King, Lopez, et al.). Particularly high civilian death rates have been reported in Angola, Ethiopia, Liberia, Mozambique, Rwanda, Somalia, Southern Sudan, El Salvador, Guatemala, Afghanistan, Cambodia, Tajikistan, and Bosnia and Herzegovina (Zwi and Ugalde; Toole, Galson, and Brady).

Rape is increasingly recognized as a feature of internal wars, and it has been present in many different types of conflicts. In some conflicts, rape has been used systematically as an attempt to undermine opposing groups. In the former Yugoslavia, for example, estimates of the number of rape survivors have ranged from 10,000 to 60,000 (Swiss and Giller).

Estimates of mine-related disabilities are also sobering: 36,000 in Cambodia (one in every 236 persons in that nation has lost at least one limb), 20,000 in Angola, 8,000 in Mozambique, and 15,000 in Uganda. The costs are both physical and social and affect all age groups. Between February 1991 and February 1992, approximately 75 percent of the land-mine injuries treated worldwide were in children five to fifteen years old (Toole, Waldman, and Zwi).

Immeasurable psychological trauma has been caused by widespread human-rights abuses, including detention, torture, and forced displacement (institutionalized in the former Yugoslavia as "ethnic cleansing"). The extent of mental health "trauma" experienced during and in the aftermath of war and conflict is controversial, with some analysts identifying significant proportions of affected populations suffering from post-traumatic stress disorder, while others argue that this term and the response to it medicalizes an essentially social phenomenon.

INDIRECT IMPACT. The indirect public health consequences of war have been mediated by hunger, mass migration, and collapsed health services, especially in impoverished developing countries where basic services and food reserves are already inadequate. The intentional use of food deprivation as a weapon has become increasingly common (MacCrae and Zwi). For example, armed factions on all sides have obstructed food-aid deliveries in southern Sudan, resulting in mass hunger and, during 1993, death rates up to fifteen times those reported in nonfamine times. In 1992 widespread looting and banditry deprived millions of Somalis of much-needed food aid.

At the end of 2002 there were more than 15 million refugees worldwide, and an additional 22 million people internally displaced in their own countries (U.S. Committee for Refugees). Crude death rates (the number of deaths per 1,000 population per month) among refugees and internally displaced persons have ranged between five and twenty-five times baseline rates. Most deaths have been caused by preventable conditions such as malnutrition, diarrhea, pneumonia, measles, and malaria (Toole, Waldman, and Zwi). High death rates reflect the prolonged period of deprivation suffered prior to displacement, the often inadequate response to humanitarian crises by the international community, and problems of gaining access to provide relief assistance to war-affected communities. More than 50,000 refugees from Rwanda died within one month of fleeing into eastern Zaire in 1994, representing a death rate more than 25 times higher than the baseline rate in Rwanda (Goma Epidemiology Group).

Health facilities have been intentionally destroyed by armed factions in Afghanistan, Angola, Bosnia, Mozambique, and other war-stricken countries. In addition, the high costs of both maintaining military forces and treating the wounded have often led to insufficient funding for basic health services. In the Bosnian province of Zenica, for example, the proportion of surgical cases related to war injuries rose from 22 percent to 78 percent between April and November 1993, resulting in the cessation of almost all preventive health services (Toole, Galson, and Brady).

Perhaps the most significant consequence of war on public health relates to the tremendous cost of preparing for war. Military budgets throughout both the industrialized and developing worlds have diverted precious resources from public health and other social development programs. For example, in April 2002 the U.S. Congress approved $85 billion to fund the initial stages of the war in Iraq. In comparison, the total global expenditure on the fight against HIV/AIDS in low- and middle-income countries was $1.5 billion in 2001. Moreover, the destruction of environmental resources, such as water sources, agricultural land, livestock, and housing has had a major impact on public health in numerous countries affected by war.

Ethical Issues

Modern warfare has increasingly involved flagrant violations of the Geneva Conventions related to the protection of civilian persons in time of war (ICRC). Ethnic cleansing, detention of civilians, summary executions, and torture are clearly illegal under international law. The unrestricted ability of combatants to target civilians is fostered by the officially sanctioned international arms trade. The International Committee of the Red Cross (ICRC), the custodian of the Geneva Conventions, has often been deprived of access to civilians in countries such as Somalia, Sudan, and Bosnia and Herzegovina. Further, providing humanitarian assistance has become more dangerous. Between 1985 and 1998, over 380 deaths occurred among humanitarian workers (Sheil et al.).

Although violations of human rights law and international humanitarian law are crimes, the legal systems for punishing the perpetrators and compensating the victims are grossly inadequate. To date, international tribunals have been established to prosecute war criminals from the former Yugoslavia and from Rwanda. While these courts help to move the punishment of war criminals from theory to practice, they have been very slow to act and very expensive to implement. The establishment of an International Court of Justice is another step towards strengthening what has, in many respects, been a legal system without law enforcement capability.

International public opinion has increasingly supported the use of force by the United Nations to ensure delivery of humanitarian aid in situations either where governance has completely collapsed (e.g., Somalia and Liberia) or where governments consciously hinder access by relief agencies(e.g., Sudan and Bosnia and Herzegovina). However, there are no clear guidelines that might promote a consistent deployment of force to achieve humanitarian objectives (Dewey). The U.N. Charter prohibits interference in the affairs of a sovereign nation, thereby giving more weight to the rights of the state than to individual citizens.

Two contradictory examples from 1992 illustrate the ethical dilemmas inherent in the use of force to save lives from hunger and disease. In Bosnia and Herzegovina, European soldiers deployed to ensure the safe delivery of humanitarian supplies were powerless to prevent flagrant abuses of human rights committed in their presence (Jean). In contrast, the international armed contingent dispatched to Somalia in late 1992 to ensure the safe delivery of relief supplies eventually became a party to the internal conflict. This led to battles between U.N. troops and one local armed faction in heavily populated areas of the capital, Mogadishu, with high civilian casualty rates (Brauman). Thus, well-motivated intervention by the international community may inadvertently increase the risks to the intended beneficiaries.

Once access to an affected area is assured, health personnel have a critical role to play in accurately documenting the public health impact of war on civilian populations, thereby acting as effective advocates for a prompt and adequate response. Relief programs may pose a difficult choice for health workers: between the provision of individual curative care and the implementation of more effective, community-based programs such as childhood immunization.


Modern warfare has exacted a devastating toll on civilian populations. High mortality, morbidity, and disability rates have resulted directly from traumatic injuries and indirectly from hunger and mass displacement. Since the end of the Cold War, the potential for a more unified and coherent "international community" has emerged. The United Nations has a responsibility to carefully monitor the public health consequences of evolving conflicts and to apply aggressive diplomacy early to seek solutions. When conflicting parties obstruct access to civilians by relief agencies, the world needs to respond in a consistent and effective manner, and clearer guidelines on the use of force to deliver humanitarian aid in conflict settings need to be developed.

Relief programs will be more effective if they reflect the real needs of affected populations, rather than the availability of surplus commodities in donor countries. With a proper and timely scientific assessment of public health needs and careful monitoring of health and nutrition trends, those who are suffering are more likely to receive the aid they require. Primary prevention is the basic strategy of public health; consequently, in war settings, public health practitioners need to recognize that primary prevention means stopping the violence, as well as actively exploring methods for promoting sustainable peace.

michael j. toole (1995)

revised by author

SEE ALSO: Bioterrorism; Epidemics; Healthcare Resources, Allocation of; Health Policy;Public Health; and other Warfare subentries


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