The recent history of war epidemiology
(originally published 11 October; updated 20 Oct because of new comments):
Today’s (i.e., 11 October) big public health news report is the article by a Johns Hopkins University research team published in The Lancet on-line edition on the number of war-related casualties in Iraq. “We estimate”, the authors conclude, “that as of July, 2006, there have been 654 965 (392 979–942 636) excess Iraqi deaths as a consequence of the war, which corresponds to 2,5% of the population in the study area”.
As Lancet’s editor, Richard Horton, points out in a comment, “this study adds substantially to the new field of conflict epidemiology, which has been evolving rapidly in recent years”. Unsurprisingly, US President George W. Bush questions the findings: “I don’t consider it a credible report”, he told a White House press conference (according to today’s Guardian ).
The Lancet’s report underscores the importance of the complex relations between war and (lack of) health throughout history.
True, the war-medicine topic has been investigated by a numer of historians of medicine in recent years, e.g., in Roger Cooter, Mark Harrison and Steve Sturdy’s collection War, Medicine and Modernity (1999), but nevertheless surprisingly few historians of 20th century medicine and public health have paid attention to the topic, despite the fact that it is probably among the most important global public health problems throughout the 20th century.
Today’s Lancet report emphasizes the importance of understanding the intertwining of global inequality, warfare and security with public health issues. Maybe this would be something for students at the School of Public Health and especially the Masters Program in International Health here in Copenhagen to pursue? There is much to do. For example, it would be quite interesting to know whether the changing global conflict pattern — from traditional regular inter-national warfare, to more diffuse, unorganised and distributed terrorist-ish war forms — also involves changes in the pattern of deteriorating health? Epidemiologists use to talk about the “epidemiological transition” — from (broadly speaking) infectious diseases to noncommunicable diseases, e.g. life-style diseases. Could one speak of another kind of epidemiological transition, from the effects of direct-contact warfare (wounds, shell-shock etc.) to the effects of large-scale destruction of the environment resulting in hunger, refugee problems, deteriorating sanitation, etc.?
20 Oct 2006 Thomas
Spännande! Jag tror att man inte bara kan sätta in medicinen i diverse militära och säkerhetspolitiska konjunkturer och sammanhang, utan man bör göra det.
Förutom de intressanta sammanhang mellan krig och försämrad folkhälsa du skriver om, har man förstås även en massiv koppling mellan krig/militär och den medicinska kunskapsutvecklingen. Grupper av beväringar och unga män som mönstrar har erbjudit stora empiriska material för delar av forskningen, militären har finansierat och drivit forskning och så vidare och så vidare. Biologisk krigföring är bara ett område; Brian Balmer skrev en rätt bra bok i ämnet på brittiskt källmaterial häromåret.
Sen har man en massa forskning om augmented reality, virtual reality, förstärkning av sinnen och sånt, som; mörkersynsutrustning, fjärrstyrda förarlösa flygplan, head up-displayer i (bemannade) flygplan, människa-maskininteraktion i stridsledningssystem, protesteknologier, LSD och så vidare: krig försätter människokroppen i diverse extrema situationer vilket gör att det finns forskning som kan vara intressant för historiker och andra humanister som jobbar med saker som sinnen, vad är en människa, cyborgperspektivet mm.
I en av mina kommande uppsatser laborerar jag med ett slags Braudelinspirerat tidsperspektiv, där en enskilde forskaren sätts i relation till mer strukturella konjunkturella förändringar på lite längre tidsskala; jag misstänker att för en medicinhistoriker skulle de militära sammanhangen kunna vara en sådan halv-långsam konjunkturell faktor.
The following was sent as an e-mail attachment from Ib Bybjerg, professor in international health at the University of Copenhagen, as a response to my post and Gustav’s comment on conflict & war-epidemiological transitions. He asked my to put it in the comment section because the blog has been down for a while for upgrading:
Direct and indirect effects of war may have changed over time from uniformed (semi-)professionals killing each other face to face, over increasing losses among civilians happening to be in the front-line, towards primarily losses of lives among civilians due to ‘imploding’ societies or even states, and reluctance of the international society to react properly and timely. I will leave this to military historians and political science to discuss in details.
With regard to ‘war and public health’, the International Red Cross (ICRC) published a handbook with that title in 1996. MSF has a textbook on ‘Refugee Health’, first published in 1997, while the major Non-Governmental Organizations (NGOs) in 1997 issued the first version of ‘The Sphere Project’: ‘Humanitarian Charter and Minimum Standards in Disaster Response’, which besides of practical advice on management includes ‘10 commandments’ or a Code of Conduct for NGOs.
At our Center for International health & development, CISU, Copenhagen University, we have adopted a similar code of conduct re. research in vulnerable societies and populations – see http://www.cisu.dk/.
All this reflects the need for taking human health more serious in conflict situations, whether civil or military – or increasingly, mixes hereof, not forgetting the professionals supposed to help populations most in need. It is not enough to be ‘good’ – you need to be good at it!
The above mentioned responses were primarily prompted by the genocide in Rwanda, 1994, where about 800.000 died the ‘Kain & Abel way’, while about 25.000 died from bacterial dysenteria – unfortunately resistant to the prescribed antibiotics, and another 25.000 from cholera, among others, because various agencies’ water-pumps, tubes and fittings did not fit, while several thousands died from malaria, also resistant to the prescribed drugs. All these mistakes – including the withdrawal of the UN forces - were thoroughly reviewed by an international commission, much helped by Danida leadership, and published as a 5-volume report: ‘The international response to conflict and genocide: lessons from the Rwanda experience’, ODI Publications 1996.
Acknowledging the need for better understanding and managing human health in complex emergencies, I convened some people and agencies to a meeting in Switzerland in 1998, among others Johns Hopkins University’s Gilbert Burnham (the co-author of the Lancet article on war-related casualties in Iraq) and ICRC, UNHCR, WHO, and the European association of institutes teaching tropical medicine and international health, www.troped.org, advocating for better training and research into these areas.
In 1999/2000 when the Copenhagen University Masters in International Health started www.pubhealth.ku.dk/mih_en/, a module on disasters management and refugee health was launched. Such courses are also run in Liverpool and Dublin, as well as at Johns Hopkins – by Gilbert Burnham, whose lecture notes, issued together with the International Federation of Red Cross and Red Crescent Societies: ‘Public health guide for emergencies’ we are permitted to use at our local course.
Learning from experience is not always straightforward: The Tsunami about 10 years after the Rwanda Genocide disclosed that the Code of Conduct and Minimum Standards in Disaster Response were far from being lived up to. Again, an international commission, among others with Danida support, issued a critical report, on 14. July this year, advocating for better understanding and management and cooperation – from early warning to walking out. To complicate matters, the natural disaster hitting Sri Lanka and Banda Ache came upon the ongoing civil war: Why did the natural disaster help ending the man-made conflict in Indonesia, but made the one in Sri lanka worse?
Interestingly, upsurge of diarrhoeal diseases, malaria etc. wrongly anticipated – among others by myself! - did not come true. The same was the case in Iraq, where I happened to predict on Danish TV – wrongly again -, that maybe 30.000 would die in hostilities in the acute phase, while 100.000 might die from diseases in the chronic phase. The Johns Hopkins people have clearly demonstrated that deaths are primarily from Sunnis killing Shiits and vice versa. So yes, there is a great need for cross-disciplinary research in health and conflicts, with the high hopes that we may learn from experience – though history tells us that we still behave more like Joseph and his brothers than Jesus and his disciples. P.S. CISU, together with psychology, CU, the Danish Civil Defence, Danida, NGOs and INSEAD are right now planning a 1 year Masters in Disaster Management – for details see www.MDM.ku.dk
Ib Bygbjerg