War is perhaps the most serious of all public health problems. Public health has been defined by the Institute of Medicine as "what we, as a society, do collectively to assure the conditions in which people can be healthy." Using this definition, war is clearly antithetical to public health. It not only causes death and disability among military personnel and civilians, but it also destroys the social, economic, and political infrastructure necessary for well-being and health. War violates basic human rights. As a violent method of settling conflicts, it promotes other forms of violence in the community and the home. War causes immediate and long-term damage to the environment. And war and preparation for war sap human and economic resources that might be used for social good.
DIRECT IMPACT ON HUMANS AND THE ENVIRONMENT
Worldwide, there were over 45 million deaths among military personnel during the twentieth century—a mean annual military death rate of 183 deaths per 1 million population. This rate was more than sixteen times greater than the reported rate for the nineteenth century, despite enormous progress in surgical treatment of war injuries and in the prevention and treatment of infectious diseases. In addition, since an increasing percentage of wars are civil wars or are indiscriminate in the use of weapons, civilians are increasingly caught in the crossfire. Civilian deaths as a percentage of all war-related deaths rose from 14 percent during World War I to 90 percent during some wars of the 1990s. Moreover, during civil wars civilians may find it difficult to receive medical care and may be unable to obtain adequate and safe food and water, shelter, medicinal care, and public health services. The physical, mental, and social impacts of war on civilians are especially severe for vulnerable populations, including women, children, the elderly, the ill, and the disabled. Further, war is responsible for many million refugees and internally displaced persons.
INDIRECT IMPACTS ON HUMANS AND THE ENVIRONMENT
War also has a severe, indirect impact on humans and the environment through the diversion of human and economic resources. The governments of many developing countries spend five to twenty-five times more on military than on health expenditures. From this culture of violence people learn at an early age that violence is the way to try to resolve conflicts. War and preparation for war use huge amounts of nonrenewable resources, such as fossil fuels, as well as toxic and radioactive substances that cause pollution of the air, water, and land.
INDISCRIMINATE HARM TO NONCOMBATANTS
Of particular concern to public health is the indiscriminate harm done to noncombatants. This includes not only the use of so-called weapons of mass destruction, such as nuclear, chemical, and biological weapons, but also some uses of conventional weapons. Examples of the latter include the carpet bombing of Warsaw, Rotterdam, Coventry, Dresden, Hamburg, Tokyo, and other cities during World War II; and collateral damage caused by bombs and missiles in recent conflicts in Iraq, Serbia, and Kosovo. Anti-personnel land mines also cause indiscriminate injury and death and, like biological and chemical weapons, have been banned by international convention.
Chemical and biological weapons have been used since antiquity. Chemical weapons, which are used to produce toxic effects rather than explosions or fire, include vesicant agents such as mustard gas; agents producing pulmonary edema such as chlorine and phosgene; agents affecting oxidizing enzymes such as cyanide; and anticholinesterase inhibitors known as nerve agents. Chemical weapons were used extensively in World War I, leading to the negotiation of the Geneva Protocol of 1925, which banned the use of chemical and bacteriologic weapons. During World War II, chemical weapons were stockpiled by several nations, but were little used. The Chemical Weapons Convention (CWC), which was opened for signature in 1993 and entered into force in 1997, bans the development, production, transfer, and use of chemical weapons. The Organization for the Prohibition of Chemical Weapons (OPCW), headquartered in The Hague, has broad enforcement powers under the CWC. The United States and Russia are proceeding with destruction of stockpiles of chemical weapons, but there remains controversy about the health consequences of the methods being used. In 1995, the Aum Shinrikyo sect in Japan released nerve agent gas in the Tokyo subway, resulting in a number of deaths and many injuries. This incident heightened the concern about future use of chemical weapons.
Biological weapons, which are used to cause disease in living organisms, were developed and stockpiled by the United States, Great Britain, and other nations during World War II, but saw only very limited use by Japan in China. In 1969 the United States unilaterally renounced the use of biological weapons and announced the destruction of its stockpiles. The Biologic Weapons Convention (BWC), which was opened for signature in 1972 and entered into force in 1975, is much weaker than the CWC. It permits "defensive" research, which has led to suspicion that offensive research and development is being done. Efforts are currently being made to strengthen the BWC. Concern has recently been raised about the possible use of biological agents by groups or individuals to attack civilian populations.
The Anti-Personnel Landmine Convention (ALC) was opened for signature in 1997 and entered into force in 1999, setting precedents both for the speed of its ratification and for the work of nongovernmental organizations in bringing it about. The International Campaign to Ban Landmines and its leader, Jody Williams, were awarded the 1997 Nobel Peace Prize. By February 2000 the ALC had been signed by 137 governments, but not by the United States, Russia and the other states of the former USSR, and most countries of the Middle East. The ALC, in addition to banning any further production or placement of mines, calls for destroying stockpiles, removing mines from the ground, and helping landmine survivors.
Nuclear weapons were used by the United States in 1945 to destroy the Japanese cities of Hiroshima and Nagasaki. In each city, a bomb of explosive power equivalent to about 15 kilotons of TNT caused approximately 100,000 deaths within the first few days. Nuclear weapons have not been used in war since, but enormous quantities of nuclear and thermonuclear weapons have been stockpiled by the United States and the Soviet Union. Explosive tests of these weapons have been conducted by these two nations and by the United Kingdom, France, China, South Africa, and, in 1998, India and Pakistan. There have been 518 tests documented in the atmosphere, under water, or in space and, after the signing of the 1963 Limited Nuclear Test Ban Treaty, approximately 1,500 tests underground. The U.S. National Cancer Institute estimated in 1997 that the release of Iodine-131 in fallout from U.S. atmospheric nuclear test explosions was responsible for 49,000 excess cases of thyroid cancer among U.S. residents. Another study estimated that radioactive fallout from nuclear test explosions would be responsible for 430,000 cancer deaths by the year 2000. A Comprehensive Test Ban Treaty was negotiated in 1997, but a number of nations, including the United States, have refused to ratify it.
There are now approximately 35,000 nuclear weapons stockpiled in the seven nations that have declared possession—the U.S., Russia, the United Kingdom, France, China, India, and Pakistan. Israel is also widely believed to possess nuclear weapons. The declared nuclear-weapons nations agreed in the 1970 Nuclear Non-Proliferation Treaty (NPT) to work toward elimination of these weapons, but progress has been slow. The International Court of Justice in a unanimous advisory opinion in 1996 ruled that the nuclear weapons states were obligated under the NPT "to pursue in good faith … negotiations leading to nuclear disarmament." The International Physicians for the Prevention of Nuclear War was awarded the 1985 Nobel Peace Prize for its work to reduce the risk of nuclear weapons use by the United States and the Soviet Union. With the dissolution of the USSR, there has also been concern about leakage of nuclear weapons to other nations, to groups, and even to individuals.
THE ROLE OF HEALTH WORKERS AND ORGANIZATIONS
Physicians, nurses, and other health care personnel clearly have an ethical duty to care for the victims of war. But medical and public health workers, many believe, also have an ethical duty to prevent war and its consequences. Since membership in the armed forces of a nation seems to imply participation in a war effort, the question arises whether medical and public health personnel can ethically play such a military role.
Alternate ways for medical and public health workers to care for the casualties of war are available through organizations such as the International Red Cross, Doctors Without Borders (which received the 1999 Nobel Peace Prize), and Doctors of the World, as well as various associations that seek to alleviate the causes of war and to promote nonviolent conflict resolution. Such associations include the American Public Health Association, Physicians for Social Responsibility, Physicians for Human Rights, the International Physicians for the Prevention of Nuclear War, and Amnesty International.
Public health professionals can help to reduce and eliminate the causes of war, such as discrimination, poverty, and disease. They can educate and raise awareness about the health and social consequences of war and preparation for war; establish surveillance systems to detect wars, or the circumstances that lead to war, at an early stage; advocate for policies and treaties to ban weapons of indiscriminate destruction; encourage and support mediation and other forms of nonviolent conflict resolution; and work with all groups in society to promote a "culture of peace."
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