Public Health and War: Hope Among the Horrors?

“War is a man-made public health problem,” argued the Turkish Medical Association when the Turkish army attacked Kurdish areas in Afrin, Syria.¹ The American Public Health Association (APHA) placed war “among the most important public health problems of the last 100 years,” with “little evidence that its importance is waning.”² Barry S. Levy, in his new book From Horror to Hope: Recognizing and Preventing the Health Impacts of War, agrees, and speaks of war as a “public health catastrophe.” What more can be said?

TIMELY AND ACCOMPLISHED

A lot more, as Levy’s work shows. Levy is a physician with the Department of Public Health and Community Medicine, Tufts University School of Medicine, and former APHA president. His publications cover social injustice, environmental health, climate change, terrorism, and war, from a public health perspective. From Horror to Hope brings together what has preoccupied Levy throughout his professional life. He describes how war affects population health in different forms and dimensions, ranging from injuries, mental and reproductive health, to (non)communicable diseases, and he identifies subpopulations at particular risk, from children to military personnel. He covers the effects of different types of weapons, as well as legal and ethical aspects of war. Importantly, Levy proposes what role public health professionals can play in preventing war and promoting peace. His book will be of interest to public health students and practitioners wishing to obtain an overview of these long-neglected topics.

The breadth of the topics Levy covers is impressive. In some places, more in-depth technical details could inform the actions and practices of public health professionals. For example, there is an extensive list of chemical agents used in weapons of mass destruction, yet it remains open how their health effects can be treated, and what public health resources this would require. The section on nuclear weapons rightly focuses on the risk of total mutual destruction. Yet Russia’s President Putin, his invasion of Ukraine failing, may resort to “low-yield” tactical nuclear warheads. Levy does not provide much detail of a public health response—which would be quite different in the two scenarios. It would range from explicitly warning the public that no health workers and infrastructure will be left to assist survivors of an all-out nuclear war to detailed advice on how to avoid physical and radiation injury, building on the dubious “duck and cover” campaigns in the 1950s. Public health workers face a dilemma here: claiming that they can alleviate a population’s suffering after a nuclear attack would be unethical—but so would declining to prepare for nuclear war.

MORE DILEMMAS AND AMBIGUITIES

Dilemmas and ambiguities abound in the context of 21st century wars—for example, those relating to when a war starts, and what constitutes a weapon. Levy describes new weapons such as drones and cyberattacks. One could add here weaponized health communication, which may be deployed well before military action is taken. Broniatowski et al. provide evidence of Russian Twitter bots and Internet trolls amplifying a debate on measles vaccination in Ukraine in 2014, thereby compounding vaccine supply problems.³ Vaccine uptake among Ukrainian children declined dramatically, as Figure 1 shows, followed by an outbreak with tens of thousands of cases in 2018 and 2019. Substantial public health resources were and are required to make up for the ensuing loss of trust, extending to the COVID-19 pandemic.

FIGURE 1—

Measles Vaccination Coverage Among Children in Ukraine in Percentages, 2000–2021

Note. Black line: first vaccine dose; gray line: second vaccine dose. Source. WHO Immunization Dashboard Ukraine (https://immunizationdata.who.int/pages/profiles/ukr.html).

An additional public health dilemma, which is often neglected, pertains to “othering” processes in times of war. To legitimize weapon use, territorial war, or regime change, the attacking party will construct an “other,” such as a purported Nazi regime in Ukraine as Russia’s justification for its war of aggression; or a regime allegedly hoarding weapons of mass destruction, as in the second Iraq war. A core element of othering processes is a power asymmetry.⁴ This asymmetry manifests in terms of military, economic, or knowledge power. In a war of aggression, the aggressor makes use of these power asymmetries, and subsequently attacks in the respective fields—not necessarily, or not only, in the military field.

In othering processes, the equal worth of individuals is challenged from a position of power. In a war, othering leads to dehumanization, which rarely remains one-sided, even in an asymmetric war.⁵ In Ukraine, for example, the enemy forces are called “russians” (with a small “r”) and labeled as nonhuman, monstrous creatures. Additional forms of othering associated with war scenarios include the detainment of population groups in camps.⁴ In these scenarios, public health practitioners face yet another dilemma. On the one hand, they need to identify, publicize, and help to reduce economic and knowledge asymmetries between groups and between nations, emphasizing again and again the equal value of all human beings, and to reject attempts at othering particular groups. On the other hand, they have to concede that nations need defense systems that are able to balance asymmetries in military power to protect populations and their health from aggressors, such as Russia, that ruthlessly break international law. Democratic societies with a realist view of world politics will conceive a well-funded military as a means of primary prevention of war. Even when striving for disarmament, they will concede, for the time being, a need for the very weapons, including nuclear weapons, that inevitably turn war into a public health catastrophe.

CHALLENGES

Levy prefers other means of preventing war, which he discusses in the concluding chapter. Diplomacy and reconciliation are core elements of promoting peace, and Levy recommends, for example, “speaking truth to power.” Yet activists against war incur high personal risks. Members of the Turkish Medical Association were sentenced to prison terms after their protests and freed only after international expressions of solidarity.^1,6 Russian citizens who protest against their government’s war in Ukraine lack a comparable visibility, institutional backup, and supportive lobby.

That does not mean that public health scientists and practitioners should give up idealist positions, or that they should stop actively opposing war. First, they need to continue documenting direct and indirect war-related health consequences, as Levy and colleagues such as Victor W. Seidel have impressively done over the past decades.⁷ Levy portrays several more doctors, activists, and scientists in his book who contribute to this endeavor. Second, public health scientists and practitioners must find a balance between pointing out the limitations they are facing, being unable to protect population health in all-out wars; and explaining means of mitigation and prevention. And third, they need to identify, and aim at reducing, othering processes in and between societies early on, thus helping to stop divisiveness and hatred.

“From Horror to Hope” is a fitting motto these days, when the future looks precarious: humanity may well eradicate itself—and many other species—through unmitigated climate change or in an all-out war. Far too little has been done to protect the future.⁸ Public health scientists and practitioners ought to spend substantially more time and resources assessing and communicating these horrors and their health consequences—helping to keep them at bay, and thereby investing in the future from a position of hope. In other words, they should follow Barry Levy’s remarkable example.