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Defining the limits of public health
EDITORIAL
THE LANCET Volume 355, Number 9204
Defining the limits of public health How should doctors respond when civilians become targets in war? A serious recent example is the gratuitous Russian annihilation of the Chechen capital, Grozny. And Israel has just vented its impatience by breaking agreed (and UN-monitored) terms of engagement with Syrian-backed Hizbollah guerrillas in Israeli-occupied southern Lebanon. That 1996 agreement—reached after Israeli operations had left 160 civilians dead and 340 injured—is now in tatters. At least 17 Lebanese civilians were injured in the latest Israeli raids. The most well-researched instance of disregard for civilian safety was revealed last week in a report published by Human Rights Watch on the 1999 NATO air campaign in former Yugoslavia. At the time, NATO officials emphasised their wish to limit civilian casualties. However, the Human Rights Watch report concluded that during the 78-day bombing campaign, 500 Yugoslav civilians were killed in at least 90 incidents. Although legitimate military locations were targeted in most cases, nine attacks were directed at non-military targets—Serb radio and television headquarters, a heating plant, and seven bridges that did not provide vital transportation routes. Of the attacks on military installations, 33 took place in heavily populated urban areas where civilian casualties were likely. The use of cluster bombs by the USA and UK was an especially deadly aspect of the air campaign, accounting for up to 150 civilian fatalities. After one NATO cluster-bomb incident that went badly wrong in May, 1999 (in Nis, including hits on a health centre and near a pathology building), there were 14 civilian deaths. The US government secretly ordered its forces to cease using these weapons. However, British military commanders continued to use cluster bombs. Why were cluster bombs deemed so essential? Because they were, according to this new report, “part of a psychological warfare strategy of harassment undertaken without regard to the greater risk to the civilian population”. Human Rights Watch concluded “that NATO violated international humanitarian law”. The effects of targeting civilian populations fall directly on local health services. For example, the 1996 conflict in south Lebanon produced injuries that had serious, and frequently forgotten, longterm consequences. Early relief efforts did provide THE LANCET • Vol 355 • February 19, 2000
valuable aid to these casualties, but much needed additional rehabilitative medical services were often missing (J Epidemiol Community Health 2000; 54: 35-39). Doctors have an important advocacy role in bringing the needs of those affected by war to the attention of politicians. There is another role for health workers and, again, the fields of Yugoslavia provide the evidence. The WHO Regional Office for Europe’s Peace Through Health programme, designed in collaboration with the UK’s Department for International Development, aims to use medicine as a direct means to reconciliation. Their report, published last year, finds that “the health sector has been the most progressive in terms of reconciliation”. How so? The idea, conceived in March, 1997, was simple: to promote cooperation between governments and local populations on matters of health policy. Projects among the different ethnic communities of Bosnia and Herzegovina included: promotion of primary and mental health services; tuberculosis control; anti-tobacco policies; and provision of children’s dental health. This work is impressive. WHO’s report argues that, “For WHO, to view contributions to peace-building as extraneous to our technical role is at best myopic, at worst negligent”. Doctors have a vital role in the prevention of conflict, as well as in the care and cure of its consequences. The only remaining argument is the limit of the preventive reach of public health. One new sphere of influence has already opened up. WHO has, through its Commission on Macroeconomics and Health, made economics a central strand in its strategy for sustainable development. But physicians also have individual parts to play. It is, after all, the individual alone who can lead, act, or persuade. And here one arrives at the ultimate political and economic risk to the public’s health— namely, the sale of weapons between nations. The tragic irony of the latest Israeli-Lebanese conflict is that Israeli soldiers were probably killed by American missiles originally supplied by Israel to Iran. Cold logic thus insists that doctors must oppose this grotesque traffic in human misery. And they must do it now. The Lancet 587
THE LANCET Volume 355, Number 9204
Defining the limits of public health How should doctors respond when civilians become targets in war? A serious recent example is the gratuitous Russian annihilation of the Chechen capital, Grozny. And Israel has just vented its impatience by breaking agreed (and UN-monitored) terms of engagement with Syrian-backed Hizbollah guerrillas in Israeli-occupied southern Lebanon. That 1996 agreement—reached after Israeli operations had left 160 civilians dead and 340 injured—is now in tatters. At least 17 Lebanese civilians were injured in the latest Israeli raids. The most well-researched instance of disregard for civilian safety was revealed last week in a report published by Human Rights Watch on the 1999 NATO air campaign in former Yugoslavia. At the time, NATO officials emphasised their wish to limit civilian casualties. However, the Human Rights Watch report concluded that during the 78-day bombing campaign, 500 Yugoslav civilians were killed in at least 90 incidents. Although legitimate military locations were targeted in most cases, nine attacks were directed at non-military targets—Serb radio and television headquarters, a heating plant, and seven bridges that did not provide vital transportation routes. Of the attacks on military installations, 33 took place in heavily populated urban areas where civilian casualties were likely. The use of cluster bombs by the USA and UK was an especially deadly aspect of the air campaign, accounting for up to 150 civilian fatalities. After one NATO cluster-bomb incident that went badly wrong in May, 1999 (in Nis, including hits on a health centre and near a pathology building), there were 14 civilian deaths. The US government secretly ordered its forces to cease using these weapons. However, British military commanders continued to use cluster bombs. Why were cluster bombs deemed so essential? Because they were, according to this new report, “part of a psychological warfare strategy of harassment undertaken without regard to the greater risk to the civilian population”. Human Rights Watch concluded “that NATO violated international humanitarian law”. The effects of targeting civilian populations fall directly on local health services. For example, the 1996 conflict in south Lebanon produced injuries that had serious, and frequently forgotten, longterm consequences. Early relief efforts did provide THE LANCET • Vol 355 • February 19, 2000
valuable aid to these casualties, but much needed additional rehabilitative medical services were often missing (J Epidemiol Community Health 2000; 54: 35-39). Doctors have an important advocacy role in bringing the needs of those affected by war to the attention of politicians. There is another role for health workers and, again, the fields of Yugoslavia provide the evidence. The WHO Regional Office for Europe’s Peace Through Health programme, designed in collaboration with the UK’s Department for International Development, aims to use medicine as a direct means to reconciliation. Their report, published last year, finds that “the health sector has been the most progressive in terms of reconciliation”. How so? The idea, conceived in March, 1997, was simple: to promote cooperation between governments and local populations on matters of health policy. Projects among the different ethnic communities of Bosnia and Herzegovina included: promotion of primary and mental health services; tuberculosis control; anti-tobacco policies; and provision of children’s dental health. This work is impressive. WHO’s report argues that, “For WHO, to view contributions to peace-building as extraneous to our technical role is at best myopic, at worst negligent”. Doctors have a vital role in the prevention of conflict, as well as in the care and cure of its consequences. The only remaining argument is the limit of the preventive reach of public health. One new sphere of influence has already opened up. WHO has, through its Commission on Macroeconomics and Health, made economics a central strand in its strategy for sustainable development. But physicians also have individual parts to play. It is, after all, the individual alone who can lead, act, or persuade. And here one arrives at the ultimate political and economic risk to the public’s health— namely, the sale of weapons between nations. The tragic irony of the latest Israeli-Lebanese conflict is that Israeli soldiers were probably killed by American missiles originally supplied by Israel to Iran. Cold logic thus insists that doctors must oppose this grotesque traffic in human misery. And they must do it now. The Lancet 587