The arms industry as a commercial determinant of health in the Middle East: a call for research

SUMMARY POINTS.

• Public health research has mostly focused on firearm injuries in high-income contexts, leaving the broader arms industry largely unexamined.

• Little is known about the public health impacts of weapons production and trade, especially in the Middle East.

• This paper highlights the arms industry as a neglected commercial determinant of health beyond the narrow focus on firearms, identifying key pathways through which militarisation and weapons trade affect public health and the environment.

• Global health research needs to decentralise and recalibrate priorities by examining the arms industry as a commercial determinant of health through multidisciplinary, context-specific studies especially in conflict-affected regions such as the Middle East.

• Future work should scrutinise the political, economic and discursive strategies of the arms industry, including lobbying, narratives and cross-industry alliances, using rigorous methods and transnational research collaboration.

Introduction

The commercial determinants of health refers to the systems, practices and pathways through which commercial actors shape health and equity, a concept now broadened to include the manufacture and sale of small arms—an under-researched yet critical public health issue—shaped by profit motives and sustained demand amid complex historical, cultural, political, economic and geopolitical contexts.^{1 2} While there has been a recent increase in interest regarding the small arms industry, there is an urgent need for research on the wider arms industry as a distinct commercial determinant of public health. Unlike other health harming industries, it not only contributes directly to death, disability and destruction when its products are used as intended in wars and armed conflicts,^{3 4} but also indirectly shapes public health through upstream mechanisms, including state military spending on arms and the political and economic ties that develop between arms manufacturers and states. The recent BMJ series highlights the direct and long-term impacts of arms use in conflicts on both public and planetary health, noting the rise in armed conflicts worldwide since 2020 and the resulting deaths, most of which occur among women and children.⁵ Effective public health policy and advocacy rely on evidence from multidisciplinary research on the business strategies, tactics and stakeholders of the arms industry. In this analysis, we examine the characteristics of the arms industry through the lens of the commercial determinants of health, highlighting the key features and public health and environmental consequences of the arms trade, while identifying what distinguishes it from other health-harming industries. We situate this within perspectives from the Global South, which the recent BMJ special series on the arms industry has identified as a much-needed contribution,⁶ drawing on the case of the Middle East (ME) region as an example and a distinct political-economic arrangement. We conclude with implications for future research.

The arms industry

The arms industry is an international enterprise in which participants engage in the production, sales and maintenance of weapons, military technology and related equipment. This industry is deeply invested in research and development, engineering, manufacturing and servicing military materials, equipment and facilities. Companies operating in this sector—often referred to as defence contractors and collectively known as the defence industry—primarily produce weapons for the military forces of different countries.⁷ These conventional weapons include, among others, battle tanks, missiles, warships, and combat vehicles.⁸

At face value, the arms industry plays a role in addressing legitimate national and global security concerns by equipping governments with advanced military technology to maintain stability and protect their citizens from groups or states with political ideologies that pose threats to national security. Vestner suggests that when exporting arms, the industry establishes dependencies and mutual reliance between exporting and importing nations, and can enhance a country’s status and national pride, regional or global status; however, while most defence industries do not substantially boost national security, they consistently generate financial profits, resulting in industry economic benefits even without fully accomplishing their primary objective.⁹

Similar to other harmful industries, the arms industry acts as a commercial determinant of morbidity and mortality through integrated and sophisticated strategies designed to protect and promote its commercial interests, often at the expense of public health and the environment.¹⁰ Health-harming and planet-harming industries include more obvious and well-studied commercial actors, such as the tobacco, alcohol, pharmaceutical and ultra-processed food industries,¹¹ whose tactics, network of lobbyists, lawyers, tax advisers, media and marketing strategies support their operations and increase the consumption of their commodities.¹² However, the arms industry differs conceptually as a proximal determinant of death and injury through violence, and as a distal determinant, shaping multiple downstream health risks through influences on political decisions related to the purchasing and use of its weapons—which subsequently diminishes spending on social and health sectors.

The direct health effects of the arms industry are most visible in situations of armed conflict, where the production and use of weapons translate immediately into death and injury. Since 2020, the number of conflicts worldwide has nearly doubled, accompanied by a corresponding rise in civilian deaths, including increasing numbers of women and children.^{13 14} Explosive weapons, such as missiles, rockets, artillery shells, bombs and landmines are particularly dangerous when used in populated areas, where most victims are civilians,¹⁵ causing immediate deaths from blasts, shrapnel and burns, while many survivors suffer life-changing injuries, including amputations, spinal cord damage, traumatic brain injuries and other permanent disabilities. Escalating and disproportionate impacts can be seen, for example, in 2023, when 47 476 people were killed or injured worldwide, 73% of whom were civilians, while in 2024, the number of casualties increased dramatically to 67 026.¹⁵

Beyond the direct injuries and fatalities that the arms industry’s weapons inflict, population health is impacted indirectly through mechanisms that disrupt healthcare systems, livelihoods and environmental conditions. Healthcare system disruptions in times of armed conflicts impair access to essential care and hinder preventive programmes, leading to the resurgence of preventable diseases and prolonged healthcare recovery.^{1 16} Bellis and colleagues discuss the multiple strategies used by the arms industry across several upstream levels, including political, financial, marketing, corporate social responsibility, global supply chain benefits and lucrative employment practices.⁴ We discuss selected examples to illustrate these dynamics.

Arms industry strategies and tactics

Outside conflict settings, the industry continues to market its products in ways that normalise its routine ownership and use.¹⁷ This marketing operates through multiple channels, including pervasive media consumed daily by youth,¹⁸ embedding military equipment and arms narratives within entertainment—facilitated through the provision of this military equipment and filming locations.^{19 20} The industry also promotes corporate social responsibility initiatives in academic settings, such as supporting research and university partnerships, which in turn influence how research agendas are set and how they shape knowledge and policy environments; these tactics also fall within the ‘disinformation playbook’ where industries establish credibility and recruit allies that can control scientific evidence to align with their interests.^{11 21} As individual small arms become more available and accessible, they become an asset that facilitates transnational organised crime, including illicit drug trafficking, which is accompanied by armed criminal activity that results in further injury, death, fear and disruption of community systems.²²

The arms industry’s global military expenditure was estimated in 2023 to be US$2443 billion²³ if divided by the estimated world population of 8.05 billion, amounts to over US$300 spent per person on military activities, exceeding expenditure on all Sustainable Development Goals.²⁴ Though it can be tempting to ascribe this scale of spending to geopolitics, the arms industry itself represents a potential key node of influence in driving the norms, nature and scale of arms spending as it persuades nations to acquire weapons through a network of intermediaries, or by bribing leaders to secure government purchases.²⁵ The UK-based Campaign Against Arms Trade²⁶ argues that the arms industry exacerbates conflicts, supports regimes that violate human rights and wastes essential resources. This industry operates with the full endorsement of governments worldwide, as it has deeply embedded itself within government operations by maintaining a close relationship through, for example, advisory boards in the UK and revolving doors between the industry, the military and government, thereby creating a conflict of interest.²⁶

Defence aerospace firms use the US federal government’s massive defence spending to justify substantial campaign contributions. They influence key congressional committees by donating to members, hiring former officials as lobbyists and exerting political influence through contributions to election campaigns; for example, the US Defence Aerospace spent US$57 457 455 in the 2024 elections.²⁷ By framing military responses as the only solution to political conflicts and portraying armed action as inevitable, the military shapes media coverage to gain public support for war, justifies arms spending and during wartime, enforces censorship to align public information with its interests.²⁸

The relatively scarce literature that exists does not accurately represent the global nature of the arms industry harms, nor does it account for the important arms trade. Wiist,²⁹ for example, draws attention to the ‘war industry’, which consists of weapons manufacturing, sales, combat support services, lobbying and job creation, as well as governmental, international and multilateral organisations, labour markets and international trade. However, this framework does not capture the controversial role of other industries or alliances between them that may profit from wars. With the spread of armed conflicts in non-European low-income countries in the 21st century, this has become one of the most significant contemporary global challenges to public health and the international system, due to its devastating impacts and external parties benefiting from defence contracts and arms sales. Despite extensive writing on armed conflicts, there is limited scholarly focus or engagement on the accountability frameworks for war profiteering,³⁰ a term used to describe excess profit gains resulting from military conflict by non-state actors, such as financial institutions, energy and extractive companies and private military companies who lobby to secure contracts during wars.³¹ During the wars in Iraq and Afghanistan, for example, the USA depended on several corporations for warfare to supply drones, helicopters, planes, trucks, weapons, catering, construction, information technology and logistics.³² Greenpeace³³ argues that gas companies are currently capitalising on the Russia–Ukraine war to weaken regulations and push new proposals for increasing liquefied gas imports.

The arms trade and its impacts on the Middle East

The arms trade involves the sale, export or import of weapons, ammunition and spare parts, as well as logistical support, through legal and illegal transactions among governments, private firms and militias—exchanges that occur in formal, black and grey markets and may take the form of gifts, sales or subsidies.³⁴ In recent decades, as military budgets in industrialised nations have tightened, arms companies have sought to expand into new markets, often in regions highly susceptible to armed conflict, instigating regional and interstate instability and wars.^{35 36} The global weapons trade is mostly maintained by a high demand for weaponry in the ME and Asia, the world’s two main arms importers.³⁷

This worldwide supply of weaponry is supported by the development of a proficient globalised arms industry,³⁸ whose trade is regulated by Transnational Legal Orders consisting of a variety of legal instruments and institutions working together to establish rules that govern trade,³⁹ such as import and export certificates.^{35 39} Globally, the Arms Trade Treaty (ATT), the United Nations’ first legally binding agreement to establish universal regulations for the global arms trade, was adopted in 2014 with 112 state parties, 29 of whom are signatory.⁴⁰ While ATT has the potential to reduce civilian harm from explosive weapons in populated areas, its effectiveness is significantly hindered by state violations, transparency issues and a disconnect between commitments and actions—particularly among major importers. The Treaty lacks effective enforcement power, as some signatory states—including the UK, France, China, Serbia and Bulgaria—continue to export explosive weapons in ways that may breach the Treaty, supplying them to countries where their use has been associated with significant civilian harm.⁴¹

The arms trade has placed an uneven burden on low- and middle-income countries (LMICs).^{42 43} Weapons used in armed conflicts and wars, made available through the global legal and illegal trade of arms, cause significant injuries, death, suffering, long-term health impacts, the spread of diseases, and adverse environmental consequences.

The ME region presents not only a paradigmatic typical case of arms-related health harms, but also a distinct political-economic configuration that extends and complicates the commercial determinants of health model developed by scholars in the Global North. The ME region varies in economic prosperity, industrialisation, political systems and governance. Several states in the region suffer from high levels of social and political fragmentation, violent conflicts, war and persistent foreign interventions.⁴⁴ There are industrialised high-income countries, such as Saudi Arabia and the United Arab Emirates (UAE), and low-income countries, for example, Lebanon, Syria and Yemen. Despite evidence pointing to a global decrease in interstate conflict after the Second World War, such patterns of conflict have actually remained stable or have even increased in the ME in the past 30 years,⁴⁵ with Lebanon, Syria and Yemen actively enduring these crises,^{46 47} in addition to the Occupied Palestinian Territories which have been in protracted crisis since the establishment of the state of Israel in 1948.⁴⁸ At the time of writing, there are 110 active armed conflicts around the world, with the ME and Africa collectively hosting 80 of them,⁴⁹ and this excludes the recent US–Israel war on Iran. The number of casualties is a vast underestimation of reality as indirect impacts of conflict are often under-recorded and underestimated,⁵⁰ and does not include the current war on Gaza, whose toll was estimated at the time of writing this paper as 2 million internally displaced people, at least 65 500 Palestinians killed, and 167 000 injured in Gaza strip.⁵¹

Political economy analysis of the arms industry in the ME

Underlying determinants, such as militarisation and securitisation are major drivers of arms use. Increased militarisation, the extent to which civil society is organised around preparations for war and focused military spending, seems to be a process that all modern societies engage in,⁵² and the ME region is no exception. The ME region imports are among the top 20% in the global militarisation index.⁵³ Five of the 10 countries with the highest level of militarisation, according to the 2022 Global Militarisation Index, are in the ME and include in descending order: Israel, Kuwait, Oman, Bahrain and Saudi Arabia. In 2021, Israel spent about US$22.5 billion on military expenditure (5.2% of gross domestic product (GDP)), and Kuwait US$8.7 billion equivalent to 6.7% of GDP.⁵⁴ The major manufacturers and exporters to these countries have been the USA, France, Russia, Israel and China.⁵⁵ Between 2014 and 2017, the majority of weapons recovered from ISIS forces turned out to be manufactured and/or imported from Eastern Europe, China and Iran.⁵⁶ Hence, ME countries and armed groups engaged in conflict have been the main consumers and recipients of arms from industries both within and outside the region for many decades. To lessen such dependency on the Global North, many countries have started manufacturing weapons (ie, Saudi Arabia, Qatar, UAE and Egypt) for use as well as for sale.⁵⁷

Arms transfers to the Arabian Peninsula function less as narrow defence tools and more as political instruments embedded in a broader regional and global political economy. A key driver of Gulf arms procurement has been the strategic aim of maintaining close ties with Western security guarantors, particularly the USA, the UK and France, by channelling substantial investments into their defence industries, thereby reinforcing long-standing alliances rooted in geopolitical and energy-security interests.⁵⁸ For exporting states, arms sales are driven primarily by political and strategic considerations rather than market logic, increasingly shaped by private defence corporations, whose expanding influence blurs the line between state and industry interests. The shift toward an ‘arms bazaar’ model, characterised by competitive exhibitions and intensified private-sector involvement, illustrates how commercial, geopolitical and security objectives converge.^{58 59}

Military spending also plays a significant role in maintaining internal authoritarian power structures rather than addressing external threats, with high levels of military expenditure negatively associated with indicators of democracy and political reform.⁵⁹ The specific dynamics of the ME are rooted in post-colonial dependencies, and play out in military spending and emerging production. The UAE is currently relying on mineral extraction coined ‘green militarization’⁶⁰ to diversify its economy and to develop renewable energy sources for military facilities, making most of its mining as investments in Africa, Latin America and South Asia.⁶¹

Policing and the development and circulation of lethal technologies originated in colonial contexts and have been reproduced across time and geographical regions, becoming central to the political and economic core of the state.⁶² Colonial practices that persist after independence are embedded in modern military institutions.⁶³ For example, the British Mandate’s counterinsurgency practices (1936–1939) using military force were institutionalised and later consolidated under the State of Israel after 1948 as a continuation and adaptation of earlier colonial modes of rule, grounded in organised violence, including targeting of civilian spaces, coercive interrogation and repression practices.⁶⁴ This militarised governance was not limited to Palestine but also manifested in other Middle Eastern countries, such as Egypt, particularly in its responses to dissent. The Egyptian military played a central role in ‘maintaining political order’ during the 2011 Arab spring, particularly through conducting mass arrests, military trials of civilians and the use of live ammunition to disperse protest camps, including in incidents resulting in mass casualties.⁶⁵

The defence relations between Arab Gulf countries and Western nations are based on networks of people, consultants and companies that work as a ‘revolving door’. For example, retired military officers and former government officials from Western nations, such as the USA and European countries, work as consultants or advisors for Gulf governments or defence companies, which gives them power over decisions made after their retirement.⁶⁶ Lobbying networks are also responsible for Gulf nations’ influence on Western nations’ decisions, particularly regarding the sales of weapons to the UAE and Saudi Arabia.⁶⁷ Western consultants, such as McKinsey and the Big Four, are responsible for influencing the development of various government plans and projects in the Arab region without much input from locals.⁶⁸ Overall, these networks of consultants, former officials and companies connect governments and private interests, making defence cooperation more complex and international.

Public health impacts of the arms industry on Middle Eastern populations

Armed conflicts in the Middle East produce long-lasting health consequences that persist well beyond the cessation of violence. The use of conventional and unconventional weapons, forced displacement, exposure to extreme stress and the disruption of food systems contribute to a high burden of chronic physical and mental health conditions among civilian populations. These impacts are often intergenerational, affecting not only those directly exposed to violence but also children and communities living in protracted conflict or post-conflict areas.^{42 69}

This context of long-lasting crises has caused considerable forced migration and population movements within and across national borders. In 2019, 45.7 million people were considered to be internally displaced globally, one-third of which originated from Syria, Yemen and Afghanistan.⁴⁵ The Syrian conflict of 2011 created a humanitarian crisis, internally displacing 6.5 million citizens and up to 5 million Syrian refugees in other countries,⁷⁰ while 10.8 million people were uprooted in Sudan and 2 million people displaced in the Gaza Strip.⁷¹

The burden of infectious diseases

The disruption and/or the complete annihilation of infrastructure and healthcare systems have also led to the decreased capacity of afflicted countries to fight infectious diseases,⁴⁵ exacerbating health inequalities even further. A well-documented example is the long-term health impact on the 1988 attack in Halabja, where clinical reports revealed that 75% of the residents developed respiratory problems, 57% ophthalmological conditions and 50% dermatological problems, with most experiencing multiple conditions simultaneously.⁷² Among the children in the area, 70% were found to have chronic conditions, including visual impairment (55%), skin disorders (36%) and respiratory diseases (51%).⁷³

Conflict-related breakdowns in public health infrastructure have contributed to outbreaks of cholera, hepatitis, polio and the amplified spread of Ebola have been cited in South Sudan, Yemen, Palestine and Syria as a result of prolonged violence.^{74 75} Since the start of the cholera outbreak in South Sudan (September 2024), 98 372 cases and 1624 deaths have been reported nationwide, including 347 new cases and 13 deaths in just the 2 weeks, highlighting the severe humanitarian and public health crisis.⁷⁶

Maternal and child health impact

Food insecurity is a key indirect pathway linking armed conflict to maternal and child health. Conflict disrupts agricultural production, food supply chains and markets, reducing access to nutritious food and increasing household vulnerability to hunger.⁷⁷ Pregnant women are particularly affected, as undernutrition during pregnancy increases the risk of adverse birth outcomes, including low birth weight and impaired foetal growth.⁴⁵ Children are also disproportionately impacted, facing higher risks of stunting, weakened immunity and mortality in conflict settings.⁷⁸ In Yemen, prolonged conflict has contributed to one of the world’s most severe food crises, with widespread acute malnutrition among children under 5 years of age.⁷⁷ Similarly, recent reports from Gaza have documented increasing levels of child malnutrition associated with shortages of food, clean water and humanitarian assistance.⁷⁹

Armed conflict can also adversely affect maternal and child health through environmental degradation resulting from military activities, including the destruction of infrastructure and contamination of air, water and soil. In particular, pregnant women and children can be at higher risk of these exposures due to their increased susceptibility to environmental toxins.⁸⁰ Research in Iraq following the Fallujah conflict of 2004 indicated that there was an increase in congenital anomalies, infant mortality and paediatric cancers, suggesting possible adverse effects on reproduction and children’s health from exposure to war environmental contaminants.⁸¹

Long lasting health impacts

Chronic mental and behavioural health effects have also been observed among populations displaced by conflict in the ME. Refugees living in Sweden, particularly those escaping social and political instability and armed conflict in countries like Lebanon, Iraq, Syria, Egypt and Morocco, reported exposure to imprisonment, torture, rape, kidnapping, life-threatening situations and forced separations; their children were found to have more depressive symptoms, somatisation and behavioural disorders than a comparison group.⁸²

Explosive remnants of war have endangered at least 82 countries, with millions of landmines still active in 58 nations across Africa and Asia, where unexploded ordnance has caused approximately 77 000 casualties, half of them children, in countries such as Iraq and Afghanistan, particularly affecting farmers and children playing or tending animals.⁸³

In addition, conflict-affected areas have also experienced famine, characterised by high mortality rates and malnutrition associated with the weaponisation of food, recording over 50 000 deaths between 1990 and 2019, the consequences of which can also still be seen in countries with a history of conflict, such as Yemen and South Sudan that are currently facing an acute food security crisis.⁸⁴

Adverse environmental impacts

Armed conflicts also impart significant loss to the natural environment. Chemicals used in military ammunition and explosives have devastating impacts on ecosystems by contaminating soil and waterways. Since the Anglo-American occupation in 2003, Iraq has experienced significant environmental degradation due to the use of illegal weaponry, including depleted uranium, which has caused widespread radioactive contamination, higher rates of cancer and birth defects, and the breakdown of environmental protection systems.⁸⁵ The Israeli war on Lebanon in 2023 has led to substantial environmental repercussions, especially in bombardment concentration regions. Extensive use of white phosphorus munitions, as reported by Kallab and Mouawad⁸⁶,⁸⁶ has contaminated soil, crops and water sources, making agricultural land hazardous and diminishing local food production. Significant environmental damage includes burned farmland and olive trees, widespread soil degradation and potential long-term harm to human and animal health from chemical exposure. Key crops, including olives, grains and carob, are severely affected, while livestock losses further undermine food security and local livelihoods. Post-war reconstruction can also have adverse environmental impacts. For Gaza alone, such an endeavour is estimated to require 46–60 million tons of carbon dioxide equivalent, increasing the carbon footprint in the process, expected to exceed the annual emission of over 135 countries.⁸⁷

Implications for global health research

The substantial regional variation in the nature and scale of the arms industry’s influence on public health demands greater decentralisation of research priorities and agendas.^{2 88} This is particularly relevant to the ME, where protracted crises, wars and armed conflicts continue to plague several countries, highlighting the intersections between geopolitics and commercial determinants of health and growing international trade.⁸⁹

We therefore call for a recalibration of global public health research priorities to give greater attention to the arms industry as an upstream commercial determinant of health, particularly in LMICs. The ME represents an important setting for such research because it encompasses both LMICs and continues to experience multiple overlapping crises.

A forward-looking research agenda should examine the arms industry’s political economy, its incentive structures, commercial strategies and ownership, framing practices and direct and indirect harms. As a commercial actor, the arms industry warrants greater scrutiny regarding its lobbying activities and influence on policymaking at global, regional and national levels. Such work would benefit from engagement with scholarship beyond public health, including political science, economics, law, ethics and development studies. Research could explore the financial and political drivers of the arms trade, stakeholder networks, alliances and links to other industries, particularly in the ME, where economic development, industrial capacity, geopolitical relationships and involvement in the global arms trade vary considerably.

Further research is also needed to understand how the arms industry shapes social norms and public discourse around conflict, security and the use of arms. Important questions remain regarding the influence of marketing strategies, corporate social responsibility initiatives and political activities on public narratives, legislation and local cultures, as well as the complex relationships between arms production and regional politics.

Addressing these gaps will require a broader range of rigorous and interdisciplinary methodologies, particularly in the Global South where evidence remains limited. Relevant approaches include evidence synthesis, as well as methods increasingly used in commercial determinants of health research, such as network analysis, systems mapping and documentary analysis. Importantly, this research agenda would incorporate meaningful participation from communities most affected by armed conflict to ensure that research is relevant, feasible and contextually appropriate. Participatory and digital methods, including photovoice and video-based approaches, may also help document lived experiences and track the longer-term impacts of conflict and arms-related policies.

Conclusion

Just as research on the commercial determinants of health continues to evolve, there is a pressing need to better understand the commercial drivers of armed conflict, particularly the role of the arms industry. As with other major health challenges, this includes examining how commercial actors in the arms industry use non-market strategies, adapt to and benefit from broader contextual factors. Advancing this line of inquiry would help fill critical gaps in our understanding of a key, yet underexplored, determinant of health. For example, the role of lobbying, the nature, incentives and evolution of the arms industry over time, its funding of political parties and university departments, potential interlocking directorates or revolving door dynamics with government, and its framing of threats, security, technology and climate harms could all be valuable areas for future enquiry of high relevance to global health equity.

Such research is warranted given the extensive and often long-lasting health consequences associated with armed conflict and militarisation. Beyond direct injury and mortality, these include the spread of infectious diseases through displacement and the destruction of health and public health infrastructure; adverse maternal and child health outcomes resulting from disrupted healthcare, food insecurity and social instability; and enduring physical, mental, social and economic harms that can persist across generations. The environmental impacts of conflict and military activities- including pollution, ecosystem degradation and damage to essential infrastructure—further compound these effects and threaten population health and sustainable development. Developing a stronger evidence base on the commercial determinants of armed conflict is therefore critical for informing policies that promote peace, health equity and planetary health.