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J R Soc Med. 2002 April; 95(4): 214–215.
PMCID: PMC1279523

War or Health?

Since the shocking terrorist events of 11 September 2001, the world's attention has been drawn to issues of global conflict and vulnerability, and the challenge of living together in the era of globalization. The slaughter of thousands on one day in New York focused attention, if only briefly, on the toll of death and disease elsewhere in the world. For example the New Internationalist (November 2001) estimated that on that same day, worldwide, 2400 people died of hunger, 6020 children were killed by diarrhoea and 2700 children died of measles. Here are some other pertinent figures:

  • Number of malnourished children in developing countries, 149 million
  • Number of people without access to safe drinking water, 1100 million
  • Number of people without access to adequate sanitation, 2400 million
  • Number of people living on less than $1 per day, 1200 million
  • Number of African children under 15 living with HIV, 1.1 million
  • Number of children without access to basic education, 100 million
  • Number of illiterate adults, 875 million
  • Number of women who die each year in pregnancy and childbirth, 515 000
  • Annual average number of people killed by drought and famine 1972-96, 73 606
  • Annual average number of children killed in conflict 1990-2000, 200 000
  • Annual average number of children made homeless by conflict 1990-2000, 102 million

Much of this attrition, misery and death can be attributed, one way or another, to war and conflict—not only through its direct effects but also through its impact on development and people's opportunities to realize their full potential. In his introduction to a new and comprehensive book on this subject Kofi Annan, Secretary General of the United Nations puts the essential message simply: ‘when we ask “Why didn't someone intervene?” the question should not be addressed only to the United Nations. All of us have the obligation to halt or prevent injustice and suffering’.

War or Health?1—produced as a reader by an international group led by the Finn Ilkka Taipale, is a formidable offering. It covers the history of war and medicine, the impact of different weapons on populations, the wideranging effects of war on demographic structures with their profound implications for health which reverberate down the generations, the consequences of war on health services (not always negative) and on vulnerable groups such as women, children, the elderly, the disabled and the mentally ill (inevitably negative), and the long-term consequences for war veterans. Much of this came as a shock to me. Though I had prided myself on a well developed world-view, I was surprised by the gaps in my knowledge and understanding. I would guess that most people are unaware of the extent to which war has ravaged the environment, particularly in the last few decades. Woven through this magnum opus is a story of the epidemiology of war down the ages—of time and place and person—and the depressing realization that mankind has learned nothing. Indeed, in the twentieth century matters became much worse. Consider the estimates of average annual military deaths in wars, worldwide, by century, per million population:

  • 17th century 19.0 per million
  • 18th century 18.8 per million
  • 19th century 10.8 per million
  • 20th century 183.2 per million.

What this snapshot does not tell us is that, during the twentieth century, the ratios of military to civilian casualties reversed, so that it is no longer soldiers but civilians who are the main casualties of war. In the First World War, roughly 90% of those killed were soldiers and only 10% civilians. In the Second World War, even if we count all the victims of the Nazi deathcamps as war casualties, civilians made up about half of those killed. But in today's conflict ‘it is now conventional to put the proportion of civilian casualties somewhere in the region of 75%’.

Some soundbites:

‘In general soldiers are today the best protected people and the vast majority of victims in need of assistance are civilians.’

‘Doctors, nurses and other health workers, returning from the field have often seen the worst that a man can do to other human beings’.

‘The medical profession needs not only a good training in many new things—in the workings of international machinery, ethnology, politics, logistics, communication, negotiation, the handling of the media—but also a deep insight into its own historical role and a conviction of its importance... the medical profession and relief workers are often left alone to speak out for universal norms of humanity’.

The other recurrent message of this book is ‘prevention, prevention, prevention’, with the health professions in a leadership role. The challenge is not only primary prevention of war but also secondary prevention by conflict resolution and tertiary prevention by clinical work in war zones and intervention as honest brokers in achieving reconciliation. What became clear to me whilst reading this volume was that this is not just an issue ‘over there’ where the wars and genocide are often on a large scale. It is also for us ‘over here’, where the preconditions of civic breakdown—unemployment and social exclusion, massive social inequalities and resentment, and the development of extensive criminal elites and of a criminal underclass—have produced circumstances resembling the wars of old. Somehow we discount the significance of what is happening in our own neighbourhoods, and so fail to see the timeless role of healthcare workers as community leaders and healers in providing the leadership to address it.

I could go on—the dreadful waste of resources which prevents human development; the violation of women and children (‘the evil that men do lives after them’)—but more important is to ask what we should be doing personally in response to the threat to our children's future and the planet itself. After the events of 11 September last year, Prime Minister Blair told the Labour Party Conference:

‘The kaleidoscope has been shaken. The pieces are in flux. Soon they will settle again Before they do, let us reorder this world around us. Today, humankind has the science and technology to destroy itself or to provide prosperity to all. Yet science can't make that choice for us. Only the moral power of a world acting as a community can. By the strength of our common endeavour we achieve more together than we can alone’.

At that moment last October, Tony Blair appeared to capture the public mood yet, six months later the cynicism has begun to return. Can we afford to ignore the challenge presented to us in War or Health? Health workers have a prime duty and responsibility to spread tolerance, combat hatred and work towards reconciliation. These are not just warm words, they go to the heart of the ethical basis of our craft and our vocation. Now we have a reader which is tailor-made for educational courses. Let us put it to work and ensure that our role and contribution to peace is explicit and understood.

To finish with a quote from the American poet and librarian Archibald MacLeish (UNESCO Courier, October 1985):

‘Of course we can educate for world peace. I would be willing for my own part to say that there is no possible way of getting world peace except through education which means education of the peoples of the world. All you can do by arrangements between governments is to remove the cause of disagreement which may become, in time, causes of war. But peace as we are all beginning to realise, is something a great deal more than the absence of war. Peace is positive and not negative; peace is a way of living together which excludes war, rather than a period without war, in which peoples try to live together’.

It is impossible to do full justice to this volume. Those who wish to follow up this review will find in it examples of how physicians and health workers are contributing to the world peace movement, together with contact addresses.

References

1. Taipale I, et al., eds. War or Health? A Reader. London: Zed Books, 2001. [652 pp; ISBN 1-85649-950-2 (h/b), £55; ISBN 1-85649-951-0 (p/b), £16.95]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press