Medicine, Peace, and Public Policy

In this column, over the last two years, there have been many assertions about the role of health professionals in building peace. Some essays have dealt with grassroots peace work (for example, peace education for children in schools, or eliminating violent discipline of children). This essay will address the issue of public advocacy for peace by health professionals, ie, peace work at a high level, attempting to influence decision-makers.

Let me start with two examples of work from the health sector to influence public policy on issues of war and peace. One is pre-violence and the other is post-violence.

Iraq

In late 2002, it was apparent that there were plans for the USA to invade Iraq. Throughout the world citizens were exerting themselves to prevent this. Health professionals played a role in this, and were assisted by some remarkable research that had been done by a medical peace organization. Whereas most efforts to oppose this war were based on moral and principled arguments in the expectation that a war on Iraq would injure and kill many people and greatly damage nature and the economy of the region, the advocacy work by health professionals was based on what we could call “predictive epidemiology.”

A US-UK consortium of health professionals had worked from epidemiological data of mortality and morbidity from the first war against Iraq. They used knowledgeable predictions of likely war scenarios to predict impact on population deaths and injuries, impact on health services and infrastructure. They brought in the possibility of subsequent civil war and the further deterioration in health this would cause. Their predictions were in the order of hundreds of thousands of deaths and of the same order for wounded. They predicted serious impact on health and nutrition status of the population.

This material was picked up and used in the strong global campaign to prevent this war, the first ever preventive anti-war campaign, run before the war occurred. People could say not just that this war will do harm, but, within rough ranges, how much and what kind of harm, and which portions of the population would particularly suffer.

We know that some governments acquiesced to the US asking for troops, and other governments, catching the widespread political mood on this issue, did not involve their countries in this war. That political mood comprised a myriad of components, including a relatively clear picture of what the war would do to Iraqis. The efforts of health and peace workers to use such data did not prevent the suffering of Iraqis, but may have had a longer-term effect beyond denying further legitimacy to the belligerent states. The fact that the predictive epidemiology of this war turned out to be roughly right, that this effort from a Peace through Health framework to influence public policy was soundly-based, strengthens the hand of those who would delegitimize war as a means to deal with political problems. The possibility of now applying this methodology to a potential attack on Iran arises.

Afghanistan

The second story, of the McMaster Peace through Health project in Afghanistan, is one of evolution in the project goals, enabling access at progressively higher levels for policy input. We began with goals of mental health, social healing, and the culture of peace, directed at non-governmental organizations (NGOs) and children. People reacted positively to what we offered and remarked that we should present this material to decision-makers, politicians. So we did. We held large workshops with politicians across the spectrum of parties, including Taliban, before the 2001 attack by the US. We later offered workshops to various groups of opinion leaders as well. One was attended by the entire staff of the Ministry of Education. This Ministry adopted our curriculum materials, appointed our field-workers as full-time consultants and text-book writers, and mandated inclusion of peace education material for all grades of elementary school.

Further access to cabinet-level decision-makers in recent years has led to our former field-worker Dr Seddiq Weera’s being appointed to the National Commission on Peace-strengthening in Afghanistan, an embryonic National Reconciliation Commission. He is now the representative of this Commission to outside bodies, and has opportunity to speak to the President of Afghanistan, Hamid Karzai, on the issue of reconciliation. The group at McMaster has a small continuing role, feeding Dr Weera and the Commission research resources on reconciliation to assist its work and promoting ideas of peace processes in this conflict within Canada, which is militarily involved in Afghanistan.

Why do health professionals involve themselves in public policy on issues of war and peace?

I recall once being part of a small delegation from Physicians for Global Survival-Canada having a dialogue with officials from the Canadian Department of National Defense about Canada’s support of NATO’s nuclear weapons policy. One official, who clearly did not understand the nuclear weapons-health linkage said to me, “Why don’t you just focus on...on...cigarette smoking or something?” This is why.

War and other violence are major determinants of deficits in population health (Figure 1). War acts directly increasing mortality and morbidity and indirectly increasing the severity of other macro-determinants, such as economic insufficiency, poor governance, human rights abuses, ecological degradation, and the disintegration of communities and cultures. Once a country is caught in this vicious cycle, each turn of the wheel makes it poorer, with worse human rights abuse, worse governance, and so on. This is sometimes referred to as the “conflict trap” (1).

Figure 1.

Macro-determinants of ill-health.

Importance of acting at political level

An analysis of 26 cases of peace work trying to understand what factors increase the probability of efficacy showed that whether peace work begins at a grassroots level, or at a opinion-leader level (for example, with religious leaders), it must, to attain efficacy, reach a political level (2). It is not enough to work merely at an individual level. These principles are very similar to those of public health.

Assets and limitations of health workers

If health workers are to engage in public advocacy on issues of war and peace, we should take stock of their assets and limitations in doing so. Their assets are their dedication to sustaining or improving health and ability to speak on this basis, and the fact that their work is science-based, which engenders trust in their assertions. Furthermore, they are ethically enjoined to have an impartial interest in the well-being of all, irrespective of political, ethnic, or other identity. Also, their ethical commitments, where they can be seen to hold fast in the general moral deterioration caused by war, are associated with public trust. The limitation lies in that health professionals have no formal education in political issues, peace studies, or public policy.

Modes of action of health professionals in public advocacy concerning war and peace

The overarching framework in this work is redefinition of the issue as a public health problem.

Dialogues with decision-makers

For many years now, delegations of physicians from International Physicians for the Prevention of Nuclear War have engaged in annual dialogues with officials in the Nuclear Weapons division of NATO in Brussels. Some of the dialogue partners made clear that they enjoyed these meetings, and used them as a source of new ideas on a bogged-down issue. It was commented that the meetings remind them of the moral quandary of having a two-tier nuclear weapons world. The next in this series of dialogues will focus on removing US nuclear weapons from Europe and the possibility of a nuclear weapons-free Europe.

A strikingly successful accomplishment in global public policy resulted from cooperative work between governments and NGOs. This was the Landmines Treaty, initiated by health NGOs – the International Committee of the Red Cross/Red Crescent and others, and before long International Physicians for the Prevention of Nuclear War. The former Canadian foreign minister, Lloyd Axworthy, is to be credited with hitching the energy and creativity of NGOs to the capacity of governments to create an international agreement. It felt like a great triumph when the treaty was achieved.

In some countries, a respected NGO may have access to both politicians and public servants who work in the area of interest. A well-prepared dialogue with such people may be very productive.

Advocacy to the public via the media

Health professionals engaged in advocacy need to skillfully direct their messages to the mass media, as vehicles of transmission directly to decision-makers and indirectly through an aroused public. Letters to the editor and opinion pieces in newspapers and radio and television interviews are some of the means used. There are skills to be acquired in using the media well. Some physician groups use paid consultation to improve those skills.

Action to influence decision-makers via an informed public

The hard work of speaking to concerned groups of people, in schools, universities, churches, professional groups, and service groups such as Rotary International will always be part of advocacy work. It is usually possible to urge participants to take political action – write to or visit their parliamentary representative. Work in all three of these modalities has been part of all advocacy campaigns, such as the abolition of landmines and currently, the efforts to get the issue of nuclear weapons back on the table of the UN Conference on Disarmament.

Research-policy gap

“Since the 1950’s, a steadily increasing amount of research and scholarly attention has been paid to the resolution of violent conflict. Today this has become the foundation of a robust body of knowledge focusing on non-military approaches to preventing, managing and ending conflicts. Despite this, the public and political perception of force as the primary response to conflict remains” (3).

There are lessons to be learned about how to present to decision-makers the knowledge that we have about the impact of war on health and the possibilities of peace:

• In developing knowledge, bear in mind its policy potential;

• Develop an understanding of the policy-maker’s context (eg, little time for reading long documents);

• Engage with potential users of the knowledge;

• Develop feasible action options the policy-maker could conceivably choose;

• Present knowledge in a user-friendly way; and

• Use windows of opportunity (3).

Engagement of health sciences students

Many students are longing for opportunities for meaningful engagement in the larger issues affecting health. Health workers are to be encouraged to engage students alongside them in such endeavors, and better still, to create opportunities for students themselves to put their talents to use in this field. Recently, medical students from International Physicians for the Prevention of Nuclear War conducted a dialogue with NATO nuclear weapons officials. Students leap at the opportunity to see their learning as relevant to the real world, and to practice translating what they learn into policy. They are learning to see themselves as actors in public policy, and evolving as global citizens.