The possibilities for the health sector to actively contribute to peace processes

The 20th century has been the bloodiest in the history of mankind. Two world wars and numerous smaller violent conflicts have resulted in more than 110 million deaths, 50 million displaced and the suffering of countless more. The World Bank and WHO estimate that war will be the 8th most common cause of morbidity and mortality in the year 2020 [1]. Despite the enormous human consequences of violent conflict, it is a relatively new thought that physicians and other health professionals can play an active role in prevention, resolution and reconciliation after violent conflicts. Since Henri Dunant in the 19th century founded the International Red Cross, health professionals have treated combatants and civilians in situations of violent conflict. Meanwhile health professionals have been engaged in peace work, but only as individuals and not as professionals. This changed in the last half of the 20th century when organizations such as International Physicians for the Prevention of Nuclear War (IPPNW) and Physicians for Human Rights (PHR) were founded with the purpose of preventing war, the use of weapons and human rights abuses, because of their grave consequences for human health. The association between violent conflict and health was further stressed in 1981 when the World Health Assembly passed a resolution that acknowledged the role of physicians and other health workers in the preservation and promotion of peace as the most important factor for the attainment of health for all [2]. In an article from 2000 a "health-peace initiative" is defined as any initiative that is intended to improve the health of a population and to simultaneously heighten that population's level of peace and security [3]. The purpose of this article is to give an overview of the growing academic field, concerning the contribution of health professionals to peace processes and war prevention.

The characteristics and health professionals

The values of the medical profession give health professionals a unique possibility to contribute to peace processes. The medical profession is associated with characteristics such as altruism, solidarity and credibility and with humanitarian values such as neutrality and impartiality. Also health workers have a wider access to the civilian population during violent conflict than most other professions [4]. These conditions give the medical profession a significant influence. On the other hand, health professionals are an integrated part of the local community and it can therefore be difficult for individuals to stay neutral under some circumstances.

The role of health professionals

The epidemiological, clinical and public health knowledge that health professionals posses due to their training can be of great value in medical peace work. The medical terminology has often inspired peace research and the analysis of violent conflict. The WHO definition of health as "a condition of complete physical, mental and social well-being" can be compared to a definition of peace as "a systemic way of engendering a state of integration and positive, nurturing, respectful and cooperative relationships" [4]. The term "etiology of conflict" is often used and it has been suggested that the terminology of prevention from public health can be applied to conflict prevention and resolution models. Primary prevention is action seeking to decrease the risk of illness or in this context preventing that violent conflicts erupt [5]. Examples of primary prevention in conflict are collection and dissemination of health data and promoting the understanding of any violent conflict as a humanitarian disaster. Violent conflict is often presented as the fight between good and evil. Refusing to accept such a justification of a conflict, health workers can help de-legitimizing it [6]. To do so successfully it is necessary to collect accurate data on mortality and morbidity and disseminate these widely. Organizations that have used this strategy in the past include IPPNW that have disseminated information on the health effects of nuclear weapons, the International Committee of the Red Cross (ICRC) that have collected data on the health effects of small arms and the International Campaign to Ban Landmines, which every second year publishes a report on the global human consequences of landmines. In addition to this, WHO and a number of renowned researchers have advocated for the systematic collection of data on health consequences of violent conflict [1, 7]. Amnesty International and PHR have likewise documented the damage to human health caused by human rights abuses. Finally, a newer example of documentation of direct and indirect health consequences of violent conflict is a series of reports on the war in Iraq, published by the British NGO Medact. These reports and studies on the war in Iraq published in The Lancet in 2004 and 2006 have received a lot of media attention [8].

Secondary prevention seeks to diagnose illness early so as to diminish the resulting suffering. This can be compared directly to health work during violent conflict [5]. Altruism, solidarity, citizen-diplomacy and non-cooperation are all examples of secondary prevention applied by health professionals during violent conflict [6]. Altruism is when health professionals help wounded civilians on both sides of a conflict. This is the principle underlying the work of ICRC and Doctors without Borders. Solidarity is characterized by a more active positioning and is based on concrete actions in support of victims of violent conflict and human rights abuses. Examples include the physicians' network of Amnesty International, which work in support of colleagues who refuse to treat torture victims and thereby become complicit in torture and a project coordinated by Danish Church Aid and IMCC (the Danish medical students' international organization) where medical students travel to Palestine and act as observers of human rights abuses on medical transports. Health can serve as a super-ordinate goal that can make different parties to a conflict cooperate because of the political neutrality of health. This has been used in so-called humanitarian ceasefires, which have in some instances led to peace negotiations in Asia, Africa and Latin-America [5]. However, there are also examples of how the use of humanitarian ceasefires has been harmful if the context of the violent conflict has not been taken into consideration. The knowledge of methods of conflict resolution and the use of citizen diplomacy has played a role in most of the projects mentioned in this article, and a number of organizations, including the WHO, train health workers in conflict resolution skills. One of the core methods of IPPNW is citizen diplomacy and advocacy. In 1987 the co-founders of IPPNW met with Gorbatjov, who has since explained that this meeting played a significant role in his decision to disarm Soviet nuclear weapons five years later [9]. Despite this, physicians have also contributed to torture and inhuman treatment and to the development of weapons throughout history. Therefore an important aspect of physicians' contribution to peace is non-cooperation when challenged to engage in human acts.

Tertiary prevention has the purpose of preventing relapse [5]. For instance health systems can contribute to civic identity and human security, which has been used in the reconstruction of post-conflict societies [6, 10]. Treatment after physical and psychological trauma is important for social rehabilitation of the community as well as for health. It has been suggested that health systems can contribute to rehabilitation by giving people a common identity, by being conveyors of trust and by meeting basic human needs. It is presumed that the population in a community with a common identity and where basic needs are being met equally is less susceptible to competing identity claims such as religion or ethnicity and the resulting fragmentation and destabilization of society [6]. WHO has throughout the 1990s coordinated projects in Mozambique, Croatia and Bosnia amongst other places, where all the parties to a violent conflict prioritize and plan health services in the local community together during the rehabilitation phase [10]. Treatment and rehabilitation of victims of trauma combined with reconciliation strengthens the peace after a violent conflict [6]. University and NGO-projects in Croatia, Afghanistan and Sri Lanka have taken advantage of that.

A new academic discipline?

The ideas presented in this article are based on the field work of numerous organizations, the projects and trainings of health professionals undertaken by WHO and research by academics in North American and European universities. The discipline has been called Peace through Health, Health as a Bridge for Peace and Medical Peace Work. Despite a continuing academic discussion about the theories and a large future task to evaluate and validate the field efforts, the thought that health professionals can contribute actively to peace work is gaining increasing recognition. A number of articles have been published on the topic in renowned international journals, the first university courses have been implemented in Canada and Norway and twelve European partners financed by the European Union are developing the world's first internet based university course in Medical Peace Work. The basis for an international network of academics, teachers and field workers have been made and three scientific conferences have taken place in Finland and Canada in 2001 and 2005 as well as a number of smaller meetings hosted by the UN, NGOs and universities with the purpose of building community and establishing common ground. Currently an international homepage is being developed as well as training material and a book summarizing the academic knowledge on the topic and a new open-access scientific journal on war and health has been inaugurated.

This article is based on a study first published in Ugeskr Læger 2006; 168:3049-51.