Genocide is the deliberate and systematic destruction of a group of people defined by their nationality, or by their ethnic, cultural, or religious background. While public health has long been
Genocide may include a direct assault on public health as it did in Bosnia-Herzegovina. There, public health came face to face with genocide when acts were committed to destroy the public health of the population, thereby threatening to destroy people through inflicting serious harm to their health. Food, fuel, electricity, running water, and medical supplies were cut off from Sarajevo and its environs during the siege of that city. Since many things are essential to public health, including housing, nutrition, sanitation, and access to public health, any acts committed to destroy or seriously undermine the conditions needed for health are potentially acts of genocide if they are committed against a specific population. For instance, during the siege of Sarajevo, waterborne diseases such as hepatitis A increased because the sanitation systems no longer worked properly, 10 percent of the city's population was moderately malnourished, and the combined effects of malnutrition, cold, and lack of adequate medical care led to increased illness and deaths. In the case of Bosnia-Herzegovina, genocide disproportionately affected the most vulnerable Bosnians—the very young, the elderly, women, the chronically ill, and the disabled.
Genocide may also include indirect assaults on public health, as it did in Rwanda in 1994. There, massive displacement of persons from their homes created large-scale health risks to the internally displaced and refugees. While the high morbidity and mortality in the Rwandan refugee population was recognized as a public health crisis, it was also the product of genocide. Refugees from the genocide who were living in camps did not contract cholera solely because of the infectious agent, but also because they were forced to flee their homes and encounter grossly unsanitary conditions due to their status as members of an ethnic group (the Tutsi) and resultant attacks by the Hutu government.
GENOCIDE AND OTHER FORMS OF MASS VIOLENCE
Genocide is a particular type of mass violence perpetrated against a large population. Other threats to the survival of a population, such as arbitrary imprisonment, discrimination, mass and systematic rape, torture, cutting off essential civilian supplies, and forced migration, can perpetrate large-scale harm against that population and have many of the same implications for public health as overt genocide. However, since 1946, when the United Nations General Assembly declared that genocide is "a crime under international law," genocide is recognized as distinct from other forms of mass violence. The Convention on the Prevention and Punishment of the Crime of Genocide, enacted in 1951, defines genocide as:
Any of the following acts committed with intent to destroy, in whole or in part, a national, ethnical, racial or religious group as such: (a) killing members of the group; (b) causing serious bodily harm to members of the group;(c) deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part; (d) imposing measures intended to prevent births within their group; or (e) forcibly transferring children of the group to another group.
This distinction between genocide and other forms of mass violence is as significant to public health as it is to international law. First, when public health professionals name mass violence "genocide," they can invoke the Genocide Convention in their calls for action of intervention from the international community. Second, genocide is a punishable crime under the Genocide Convention. Since many health professionals believe that justice and legal accountability facilitate both the healing of victims and primary prevention of future genocides, determining that mass violence constitutes genocide invokes legal mechanisms for punishing the perpetrators under the Genocide Convention.
THE ROLE OF PUBLIC HEALTH
The precursors, processes, and consequences of genocide are increasingly being understood, and public health contributes to this understanding in a distinct manner from other disciplines, such as the law profession and the human rights field. Specifically, public health brings to the study of genocide the unique tools of epidemiology, which is the study of the distribution of disease and the factors associated with a disease within a population. Since public health views a specific population or group of human beings in an ecological model that includes the institutions (e.g., paramilitary organizations) and the objects (e.g., weapons of genocide) they have created, it is only natural that public health views genocide in this manner, too. Thus, public health professionals can examine genocide as a disease, along with social and behavioral factors that correlate with the disease, and may even cause it.
The work that public health professionals do to examine, prevent, and mitigate genocide can be understood in terms of the three traditional core functions of public health: assessment, policy development, and assurance of services. Assessments can be performed through data collection and analysis intended to identify, document, and notify the public about potential or ongoing genocide. Here the public health principles of disease and injury surveillance can be applied to violence against a population, and the traditional tools of public health—such as case reports and surveillance studies—are well suited to this function. A genocide may have early warning signs that public health professionals can detect, such as escalating violence, increased refugee flows out of a country, and increasing systematic discrimination. In those cases where a war strategy targets the health of an entire group of people, public health professionals are best able to recognize the nature of the genocide.
Assessment is equally important after a genocide occurs. The methods, effects, and outcomes of all public health interventions must be assessed objectively. Epidemiologic studies to determine and quantify the public health impact of genocide can be performed, as has been done in numerous studies of international and civil wars. The public health impact of genocide goes beyond the number of people killed. It must also be understood for its long-term effect on public health, including the destruction of medical facilities; the killing and flight of physicians, nurses and other health care professionals; the psychological impact on the survivors; and the interruption of programs for immunizations, infectious disease prevention, and prenatal care. Public health can also inform other types of assessments, such as retrospective studies to determine and identify the conditions, risk factors, and precursors that led to genocide.
Policy development may include recommending courses of action to prevent or mitigate a genocide. Again, policy development is an established function of public health in response to situations that threaten the health and safety of an exposed population. For instance, public health programs such as vaccination campaigns are proposed when large numbers of people living in a defined geographic area are at risk for illness or death from a contagious disease that vaccination would protect against. Similarly, public health policy proposals can advocate to protect groups at risk of genocide. Whenever there is a threat or occurrence of genocide, public health officials can advocate strongly for immediate international action. The principles of public health, coupled with the protests of public health professionals, can influence governments regarding the need, timing, and level of intervention required to protect a group from genocide.
Assurance of services may include designing and implementing programs that address the efforts at genocide. In the event of genocide, health care professionals can provide emergency services and physical and psychological treatment and rehabilitation of survivors. Interventions for complex humanitarian emergencies must be implemented as quickly as possible and made available to refugees and internally displaced persons.
Public health can play an important role in determining the truth about events of mass violence. Much of the work regarding genocide in the fields of human rights, law, and history revolves around determining the truth of claims for and against an occurrence of genocide. Public health contributes to these efforts through the powerful tool of epidemiology. With its methods for systematic compilation, consolidation, and assessment of data, epidemiology can be used by war crime tribunals to argue that specific war violations occurred on a scale consistent with crimes against
S. Swiss and J. Giller have demonstrated how public health methods are critical to defining the nature of a particular mass violence, such as the systematic use of rape in Bosnia-Herzegovina. They estimated that "based on the assumption that 1 percent of acts of unprotected intercourse result in pregnancy, the identification of 119 pregnancies, therefore, represents some 11,900 rapes." They stress that the goal is not to arrive at a final number of events but rather to determine its magnitude and extent, since evidence of a systematic pattern is critical to determining whether rape constituted part of a policy of genocide. This is because the Genocide Convention prohibits even intent or attempts to commit genocide. Though proof of thousands of rapes is useful evidence when prosecuting a case under the Genocide Convention, the Genocide Convention focuses on the perpetrator's intent to destroy a social group in whole or in part. The degree to which a genocidal plan is successfully carried out is not part of the law of the Genocide Convention. Thus, behind the inevitable complexities that surround questions of the responsibility of the different nationality or ethnic group involved in the violence, public health can analyze a genocide from a public health perspective and can contribute to the prevention of genocide and the healing of its survivors.
DAVID P. EISENMAN
Convention on the Prevention and Punishment of the Crime of Genocide. Available at http://www.unhchr.ch.html/menu3/b/p_genoci.htm.
Geller, G. A. (1995). "Humanitarian Responses to Mass Violence Perpetrated against Vulnerable Populations." British Medical Journal 311:995–1001.
Human Rights Watch (1993). War Crimes in Bosnia-Hercegovna, Vol. 2: Helsinki Watch. New York: Author.
Levy, B. S., and Sidel, V. W., eds. (1997). War and Public Health. New York: Oxford University Press.
Mann, J. M.; Gruskin, M. A.; and Annas, G. J., eds. (1999). Health and Human Rights: A Reader. New York: Routledge.
Staub, E. (1984). The Roots of Evil: The Origins of Genocide and Other Group Violence. Cambridge, UK: Cambridge University Press.
Swiss, S., and Giller, J. (1993). "Rape as a Crime of War: A Medical Perspective." Journal of the American Medical Association 270:612–613.