Peace through health

By 2020 the World Health Organization and the World Bank predict that war will be one of the top 10 causes of disability and death.¹ Recent events may well bring this date forward. “Is there anything that health professionals can do to prevent this?” was the key question addressed at the first international “Peace through Health” conference held last month at McMaster University (www.humanities. mcmaster.ca/peace-health).

Health professionals care for those wounded in war. The Red Cross was founded in 1864 specifically for this purpose. Other health agencies, such as the Nobel Prize winning Médecins Sans Frontières, have been involved in dealing not just with the immediate but also the long term consequences of war. The cost of war goes beyond the direct health effects of bombs and bullets. Economic and social systems are disrupted, famine and epidemics may follow, and resources are diverted to military rather than health goals—all of which make war a public health problem.²,³

The conference organisers have previously described war as a disease process.⁴ Like other diseases, war has risk factors. These can be prevented from developing (primordial prevention) or be modified (primary prevention), and the effects of war can be treated (secondary prevention). Once war has caused damage then rehabilitation is required (tertiary prevention). The conference proposed that healthcare workers, through health initiatives, could play important parts at every stage of the process of war as they do in disease.² But have there been any successful initiatives to date, or is this an example of health professionals thinking that they have an answer for every ill?

Evidence supporting secondary prevention comes from a systematic review of health initiatives in conflicts over the past 15 years.⁵ This found that ceasefires had been negotiated in seven countries to allow the delivery of humanitarian aid and immunisation programmes. The most striking example occurred three times each year in El Salvador between 1985 and 1992. Unicef, the Roman Catholic church, and other organisations negotiated such days of tranquillity and immunised 300 000 children, reducing the incidence of polio to zero.

An example of tertiary prevention is the peace through health programme in Bosnia-Herzegovina.⁶ After the war ended in 1985 the neglected health system, like many other domains, was divided between the Bosnian Croats and the Bosnian Serbs. WHO and the UK's Department for International Development (DFID) worked together on a programme to unify the staffing, service provision, training, and delivery of health care. This, they claim, reduced separatist attitudes.

While there are other examples of smaller, locally based health initiatives,⁷ none has been adequately evaluated. Even the WHO-DFID programme used anecdotal comments from field teams to say that volatility had reduced and social cohesion improved. The report admits that it could have been the wider peace process and post war fatigue felt by the population that brought about these changes. Their survey of 201 ethnically diverse health professionals in Bosnia-Herzegovina found a significant association between those who had been involved in interethnic activity and a willingness to collaborate in a unified health system. However, a cross sectional survey cannot support a causal relation between participation in interethnic activity and changes in attitudes.

The conference organisers have called for “peace through health” to become a new discipline that should be taught to health professionals.⁸ In the next two years they plan to form a collaborative network to further research. A new assessment tool could be an important step forward in evaluating the impact of aid on conflict.⁹

With few examples of peace through health initiatives, it is ideology that is driving the movement at present. Importantly, humanitarian aid has even worsened conflict at times. In Sudan in 1998, for example, large amounts of grain intended as aid were diverted to the military, thereby strengthening their capability.¹⁰ Peace through health can also be viewed as a form of political control. For example, participation in the peace through health programme in Bosnia-Herzegovina was a prerequisite for the delivery of aid. Health professionals could lose their status of neutrality and impartiality.

Taking place after military action started in Afghanistan, the conference had a sense of urgency and immediacy. However, health professionals are more likely to be persuaded that peace through health works by evidence, not ideology.