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Militarism and world health
Sot. Sci. Med. Vol. 34. No. Printed in Great Britain
7, pp.
719-724,
0277-9536192
1992
$5.00
+ 0.00
Pergamon Press plc
MILITARISM
AND WORLD
HEALTH
CHRISTIEW. KIEPER
Program in Health Science and Human Survival, University of California, Box 0848, San Francisco, CA 94143, U.S.A. Abstract-Militarism is a rapidly growing factor in that complex network of social, political and economic causes of ill health among the world’s poor. This complex of causes is driving a spiral of class inequality, political instability, and military repression in many less developed nations. These nations share a uniform security doctrine, which has major health impacts. Here five impacts are noted: diversion of resources, suppression of dissent, military classism, environment damage, and crime and terrorism. The demand stimulated by the recent Persian Gulf War for expensive, high-technology weapons may deepen Third World debt and fuel the cycle of poverty, ill health, social unrest, and military oppression. International health workers need to take account of the causes and effects of militarism in their studies of health problems. Their work could be aided by organizations that promote disarmament and environment preservation. Key words-violence,
military, poverty, social inequality, environment
As events in the Persian Gulf demonstrate, the goal of a more peaceful world continues to elude us in the post-Cold War era. In fact, militarism appears to be on the upswing, and its consequences for health are already serious both at home and abroad. Because of this trend, it may become increasingly difficult for us to have a positive impact on the health of humanity in the 21st century, even when there are no major wars being fought. It is time for health professionals to examine some of the salient causes and ‘peacetime’ health consequences of militarism. In the confusion that follows the Gulf War, a few things are clear. There will continue to be much suffering and death for many months, possibly even years, in the war-ravaged lands with their shattered public health, housing, food distribution and medical systems. There will be great political turmoil in Iraq, and possibly also in the neighboring states; turmoil that will take its toll in the disrupted livelihoods and neglected social needs of millions of innocent people. In the United States, an enormous war debt will further burden our already floundering health care system, differentially hurting the poor [I, 21. For the foreseeable future, then, the war may not move us closer to President Bush’s image of a peaceful ‘New World Order’, but in the opposite direction, toward increased chaos and misery. Was this situation necessary? Can it happen again? As professionals dedicated to the promotion of human health, we must ask ourselves these questions, and I am moved to offer a perspective on them. In my view, the Gulf War and its aftermath are the predictable results of a powerful trend in international relations-the tendency to view military technology as a way of solving political and economic problems. This trend, this militarism, not only contributes to the
likelihood of situations like the Persian Gulf, but it also has serious consequences for world health even in the absence of outright war. EXTENT OF MlLITARISSl
The word ‘militarism’ can mean any of three things, and I will be using the word here in all of its meanings-first, the leadership of society by a military class; second, the tendency to use military strategy in dealing with problems; and third, an aggressive tendency to prepare for war. To be a ‘militarist’ is to be a villain, and nobody in the world is going to admit to the epithet. Studying and preparing for war is always justified as a prudent precaution against the belligerence of others. In this sense, it resembles a character defect-subtle, destructive and hard to eradicate. There has been a vast increase in the number, the distribution, and the destructive power of weapons and men trained to use them throughout the world in the last 20 years, especially in the less industrialized nations. Let us first address the causes of this trend, then turn to its effects on human health-not just the effects of war itself, but also the effects of the purchase, transfer and stockpiling of weapons, and the training and employment of armed forces. First, how much militarism are we talking about? It is very hard to put a figure on it, but the world spends about a trillion dollars a year on military goods and services [3]. An estimated $340 billion dollars worth of arms were either given or sold to Third World countries between 1981 and 1988. Most of these arms were produced by the Soviet Union and the United States, with another substantial amount from Eastern and Western Europe, but there is
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a growing arms export market among developing nations too. Argentina, Brazil, China, Korea, India, Israel and South Africa have large arms exports [4]. The value of arms produced in Third World countries grew from about $2 million in 19.50 to $1.1 billion in 1984-over a 500-fold increase [4]. And where does this vast flood of weapons end up? In the 1980s more than half of it ended up in one area-the Middle East. Iraq alone got $50 billion worth [5]. In 1990, NATO and the Soviet Union began major reductions in conventional weapons and troops in Europe, and in October 1991, the United States and the Soviet Federation announced major reductions in their nuclear weapons arsenals. However, these developments should not be seen as a general reduction in world militarism. Not just the numbers of weapons, but the technology is increasing exponentially. Sixteen Third World countries now deploy ballistic missiles, with ranges up to 2000 miles. More and more are developing chemical and biological weapons, and several are edging toward nuclear capability 141. There were 22 wars in Third World countries in the 1980s [5], and in a growing list of countries the military holds ruling power, officially or unofficially [3]. The casualities are staggering. The Iran-Iraq War killed an estimated 1.25 million people [4]. Wars in Southern Africa (largely Mozambique and Angola) killed 1.6 million [6]. Nicaragua sustained 30,000 deaths and $15 billion worth of damage in the Contra war. We have heard about Pol Pot’s killing frenzy in Cambodia, and the terrible casualties in Ethiopia and the Sudan, but much of the killing has gone almost unnoticed in the United States. Some 430,000 have died in Tibet since the Chinese invasion of 1949 [7], and recent radio reports from Sri Lanka give the figure 40,000 for the known deaths in the present ethnic violence there. Two hundred and fifty thousand have died in recent wars in El Salvador, Chile, Guatamala and Argentina 131. The pace of arms transfers seems to be quickening in the 1990s. In August 1990, President Bush authorized the transfer to Egypt of $1 billion worth of F- 16s and to Saudi Arabia of $2.2 billion worth of tanks, aircraft and missiles, and in September, another $21 billion worth [8]. Between March and July, 1991, the United States sold another $15 billion worth in the Middle East [9]. CAL’SES OF MlLITARlSM
The question is, why? There are economic reasons and ideological reasons. Increasing populations and declining resources, the widening gap between the rich and the poor, the destruction of traditional cultures, and the spread-of information through the electronic media are trends throughout the world, leading to intense frustration and political instability, and from there to military repression. The superpowers also compete for economic
influence in the Third World, as do Third World countries themselves, and elites within these countries. In 1986 about half the world’s population lived in countries where the per person share of gross national product was less than $270. Fertility rates are highest in most of these countries, resulting in huge population growth rates. By the year 2000, there will be an additional 1.3 billion people in the world, and 87% of this growth will occur in the poorest i of the world [IO]. Poverty itself is the main engine driving this dynamic. Children under 5 years account for 4&60% of all deaths in countries where the great majority of labour is done by human bodies rather than machines. This in turn leads couples to strive for big families, in order to assure a continuous labor supply for the family. Moreover, poverty is actually increasing in much of the world. Each person’s share of the domestic economy is declining in Nicaragua, El Salvador, Jamaica, Bolivia and Chile, in Kuwait, Central African Republic, Somalia, Zaire, Tanzania, Mozambique, Madagascar, Zambia, Ghana, Niger, Liberia, Senegal, Uganda, Togo and Sudan, and probably in much of central and Southeast Asia and Eastern Europe as well. In those countries, nef poverty is increasing [IO]. In many other countries, including the United States, Brazil, and Mexico, by the way, large sectors are getting poorer, even though the upper classes are making advances. In the poorest countries, overpopulation is producing unsustainable pressure on rural land so that masses of people are moving from stricken rural areas to miserable urban slums, losing many of their cultural values in the process. I have witnessed this process in South Africa and Mexico. In South Africa the urban population has more than doubled since 1980, from 10 million to 22 million [l I]. I have seen unbelievably crowded squatter camps containing as many as half a million people, completely without sanitary services, newly sprung up around Durban, Capetown, Johannesburg and Pretoria in just a few years. In 1975 there were 90 towns in the Third World with populations of over a million, and by the year 2000 it is estimated there will be nearly 300. In the same period, the urban population in these countries is expected to grow from 28% of the total to 42% [12]. Why is all this happening, and exactly what does militarism have to do with it? The process is a complex one, but it has to do with the increasingly unequal distribution of resources. Figure 1, admittedly oversimple, gives some idea of the most common factors involved. I have already mentioned the relationship of widespread poverty and population growth. In an effort to break out of this poverty trap, Third World countries typically encourage foreign capital investments, both in the form of loans and foreign
Militarism and world health
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Fig. 1. Some interacting factors in the relationship of militarism and health.
of enterprises. This results in capital flight, as interest payments and profits on industry leave the Third World on a huge scale. Falling commodity prices and rising interest rates in the 1980s greatly worsened this problem. The estimated net transfer of wealth from the Third World to the First World in 1989 was $35 billion [13]. Each of the ten largest multinational companies has incomes larger than the gross national products of each of the world’s 80 poorest countries, and most of the big multinationals profit from militarism in one way or another [12]. In order to keep attracting foreign investment, poor countries must often meet the demands of foreign banks through structural adjustment, which may involve currency devaluation with attendant radical increases in food prices, wage freezes and layoffs in the public sector, and cutbacks in public services. Often, Third World governments are afraid to make badly needed reforms, such as land distribution, for the same reason-such reforms might hurt their ability to service their debts and attract foreign capital. Most of these processes result in the concentration of wealth in the hands of a managerial class, thereby widening class inequality and deepening political instability. Third World governments, encouraged by the multinational companies who benefit from the status quo, are tempted to turn to militarism and repression to maintain order. But this often leads to a further vicious circle, as: (1) military procurement can deepen foreign debt; and (2) violence by the military destroys local infrastructure, disrupts commerce, and angers the poor, who have little to lose in fighting back. But of course inequality isn’t the whole story. Rivalries based on nationality, religion, and culture fuel the flames of militarism on every hand. During the Cold War, the U.S. and the Soviet Union sold billions of dollars to client states in order to consolidate our spheres of influence in Asia, Latin America, Africa and the Middle East. Now, ethnic and religious rivalries in all these areas are a tremendous problem, as are political rivalries within states. The biggest arms purchasers are countries like Iraq and Israel, who can afford them, ownership
and who have long standing ethnic tensions to worry about. EFFECTS
OF MILITARISM
Now I turn to the effects of militarism on health. The foremost effect, of course, is the outright killing, maiming, refugeeism, and destruction of livelihood caused by war. There is no doubt that this costs more in civilian than in military lives. An estimated 74% of all war casualties were civilians in the 1980s and the proportion appears to be increasing as the destructive power of weapons increases. In the 1990s the estimate so far is 90% [3]. But aside from this main effect, I would like to describe five less obvious ones: the diversion of resources, the suppression of dissent, military classism, environmental damage, and crime and terrorism. Let’s look at the diversion of resources. As I mentioned earlier, world military spending runs about a trillion dollars a year-$1.7 million a minute. (Given the power that amount of money will buy, it seems clear enough why the world’s governments seem unable to slow the production of weapons, or stop the appalling slaughter they inevitably produce.) Only about 15% of this is spent by the developing countries, but this fails to illuminate the economic burden of these expenditures. If expenditures are indexed to per capita income in the country where they are incurred, we find that in 1988 the industrial nations spent the equivalent of 56 million personyears of income on the military, while the developing nations spent 187 million person-years, or nearly 4/S of the total [3]. The developed countries spend an average 5.4% of their GNPs on military, and 0.3%, or one eighteenth of that, on aid to developing countries. There are 800 million starving people in the world. Three out of 5 people in the Third World have no access to safe water, and 3 out of 4 no sanitation. At the world military spending rate, 35 set could build classrooms for 30,000 children, or feed 22,000 people for a year. Twelve minutes could build 40,000 village pharmacies. Two and a half hours equals the entire world budget of the World Health Organization.
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Seven days could eradicate world hunger, and twelve days could create water supplies for the entire Third World [ 141. Turning to the United States. we are well aware of the tradeoffs between military and health expenditures. In the last IO years, military budgets have reached an all-time high, while programs for primary health care, prenatal care, and nutrition have been cut [2]. Estimates of the cost of the buildup and war in the Persian Gulf vary from S28 to $86 billion, and the president’s 1992 military budget, at $290.8 billion (excluding war costs), shows no decline from 1991 [I]. In addition to the indirect effects through resource diversion, there is a devastating, direct effect of militarism on health that we rarely hear about. In militaristic countries, health care is a scarce resource, and the control of it is seen as a crucial element of power. Accordingly, in many militarized health workers and health facilities nations, are primary targets of military operations. As a medical anthropologist, I have spontaneous, direct reports from health workers in Guatemala, Chile, El Salvador, Honduras and the Philippines that the local governments have killed and tortured many rural health workers and destroyed their clinics, in order better to control the people served by the health workers. In Nicaragua and Mozambique, I have seen the effects of the same policies, carried out by guerillas with foreign military backing. In Mozambique between 1982 and 1988 the South African-backed Renamo guerillas killed an estimated 100,000 civilians and destroyed 484 health centers, serving 2 million people [IS]. According to political scientist George Lopez, there is throughout the Third World a “unified national security doctrine” that targets health and human rights workers, and a direct correlation between the degree of militarization of a government, and its level of human rights violations [ 161. Then there is the problem of military classism. In many poor countries, it is very difficult for a poor family to reach middle class security and comfort by legal means. A military career may be one of the few avenues of upward mobility, since it can give one the raw power needed for extralegal operations. In many places, military officers do get rich through extortion, bribery and graft, eventually forming an elite class in their own right. This has the effect of further siphoning off scarce resources, such as land, into the hands of the military, and worsens the health conditions of the poor. A good example is El Salvador, where the military is supported with massive U.S. aid. There, 2% of the population owns 60% of the land, and many campesinos have little or none. The military, however, owns vast tracts in both rural and urban areas, which they use to generate income for their pension fund. Lopez continues: What is unique in current Third that military leaders are becoming
World conflicts is extremely wealthy.
This is tied to certain corrupt practices, such as protection practices by businesses, patronage by other officers, and so forth. [16]. Turning to the environment, militarism has disastrous effects here in all its phases-weapons production, supplying and training an army or navy, war itself, and the refugeeism caused by war. Production and operations use large quantities of toxic chemicals and metals, which are often left behind to pollute the environment. A 1986 General Accounting Office report concluded that U.S. military facilities produce a minimum of 500,000 tons of hazardous waste per year. In California alone, 40 military bases have been cited by the Environmental Protection Agency for Class I violations of environmental law [l7]. In modern war, massive use of defoliants combines with cratering, burning, and chemical and oil spills to lay waste large tracts of land. Some areas of Vietnam are still uninhabitable, due to use by the United States of some 100,000 tons of defoliants there in the 1960s and 70s. That war produced some 25 million craters, leading to problems of insect control and water sanitation [l8]. In El Salvador, formerly a heavily forested country, defoliants have helped reduce the forest cover to only 7% of total acreage, and 77% of the land is now heavily eroded, according to a 1989 report of the San Francisco-based Environmental Project on Central America. Largely as a result of the Iran-Iraq War of 1981-1987, during which tankers and drilling platforms were destroyed in the Persian Gulf, that body of water is the most polluted of its size in the world. The recent war with Iraq not only produced disasterous oil fires and spills, but also: (a) severely disrupted the desert ecosystem, which depends on a fragile “crust of microorganisms, ephemeral plants, salt, silt and sand,” (b) depleted the Saudi Arabian water supply, (c) seriously polluted Iraq’s water supplies, contributing to thousands of deaths from infectious disease [18]. War-related refugeeism has significant environmental effects as well. Displaced populations lack the resources and facilities to feed and house themselves over long periods, or to dispose of their wastes. Finally, let us look at the way in which militarism contributes to crime and terrorism. Although the mainstream press usually treats drug-running, banditry, and politically motivated crime as problems unrelated to ‘legitimate’ military weapons transfers, this is far from the case. As the supply of weapons held by armed forces increases throughout the world, the black market in weapons also grows. Weapons like automatic rifles, explosives, mines, small rockets and rocket launchers and electronic communication and detection equipment are often stolen for sale by troops with access to military stores, or simply sold on the black market by those war deserters in the Third World who do not simply turn to crime as a livelihood themselves. Needless to say, it is difficult to get reliable figures on such sales, but evidence indicates the extent of
Militarism and world health covert trading is great. Civil liberties watchdog groups like the Christic Institute report large, routine covert transfers by the CIA [19]. An African economic newsletter reports on the sale of contraband AK47 military assault rifles as follows: “. . . The Economist, a British magazine, was quoted U.S. $80 in Thailand from deserting Cambodians, U.S. $75 in Honduras from former Nicaraguan Contras, and U.S. $50 in Pakistan from Afghan rebels [20]“. The same article reports that Mozambiquan ex-soldiers and ex-rebels sell AK47s at the South African border for 20 Rand (about U.S. $7), or the equivalent in maize. Thanks to the extreme poverty in South Africa’s black townships, most of the ethnic violence there has been carried out with homemade firebombs, spears and knives. But in March 1991, a houseful of people in the Johannesburg township of Alexandra were murdered with AK47 rifles. Some of these weapons are probably purchased by otherwise law-abiding people, for hunting (an indirect environmental impact of militarism) or self-protection, but there is also a strong relationship between illegal arms trading and violent crime. The growth of highly organized and well armed drug cartels in Latin America, for example, parallels the growth of weapons transfers to the Third World. Note that the brisk trade in assault rifles mentioned above involves three of the world’s major drug producing areas.
THE ROLE OF THE HEALTH
PROFESSIONAL
The trend toward militarization of the developing countries is likely to continue, for two principal reasons. First, the liberalization and decentralization of the Soviet Union and former Warsaw Pact countries, while it may produce limited civil and border wars, is likely to reduce the need for massive military expenditures in the industrial countries. As I have detailed earlier, this is leading arms manufacturers in those countries to look toward the Third World as a major market. Second, as the Gulf War showed, the growing dependence of the industrial economies on Third World labor, commodities, and markets creates an incentive for militarily advanced nations to establish hegemony, by arms transfers and/or war, in less developed nations. The Gulf War may represent a dramatic acceleration of the process described here. Rochlin and Demchak have summarized the ‘lessons’ of that war as follows: The apparent success of the United States and its coalition partners has been attributed to our use of sophisticated electronic defenses and reconaissance, and precision-guided munitions. Iraq’s defeat, likewise, is seen to result from their failure to counter these. Governments throughout the world, including the less developed nations: will seek to acquire, at enormous cost, both American-style ‘brilliant’ weaponry, and the technology with which to defeat it. Ballistic missiles, even of the crude Scud variety, will also be in demand. Because of the international concern generated by Iraq’s Scuds, such weapons are now seen as a
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form of military threat affordable by Third World countries 1211. The increasingly sophisticated and costly militarization of the Third World will both divert large sums that might have been used for health promotion, and increase the power of militarist regimes, with the unhealthy effects I have noted. International health assistance programs, conducted either under United Nations auspices, or through bilateral aid agreements, are not likely to affect this trend much. The agencies involved in such projects must work within the military and foreign relations policies of their governments, and the health professional will have no choice but to see much of his work undone by the effects of those policies. For example, a recent World Bank policy study on financing health services in developing countries lists three main barriers to effective health care delivery in those countries, and recommends four measures to combat these. The barriers are: (a) insufficient spending on cost-effective activities like immunization and contraception, (b) internal inefficiency of public programs, and (c) inequality in the distribution of benefits. The suggested remedies are: (a) charging fees to those who can pay for government health facilities, (b) providing insurance accounts to cover major health risks, (c) encouraging private sector providers, and (d) decentralizing government health services [22]. This typical analysis, which I cannot present in detail here, has many merits, but it also has the great shortcoming of which I speak: It addresses the symptoms-poor health care-almost without reference to their broad political context. In order for the reforms recommended by the study to improve access to health care, the governments in question would have to: (a) spend the savings from increased fees and increased efficiency on services for the poor, (b) support the community empowering activities of primary health workers in poor areas, (c) refrain from seriously degrading the environment, and (d) fend-off attempts by the affluent to profit from the health care sector. In many countries, these things are unlikely to happen due to militaristic priorities, and even if they do happen, their effects are likely to be swamped by the contrary effects of military activity. This same World Bank report points out that Third World health care expenditures have been shrinking, as a percentage of national budgets. To summarize all these points, two possibly useful conclusions about the role of the health worker emerge: (1) that military policies affecting client populations are at least as much a part of the health environment as local health policy, or the presence of disease agents, and (2) given the recent severe increase of militarism, it is the work of health professionals to document the specific effects of this factor on health, to disseminate this information to clients and the health science community, to search for countermeasures against it, and to promote prophylactic measures
12.8
CHRISTIE W. KIEFEA
that will reduce the prevalence of militarism in the health environment. This is obviously a gigantic undertaking, and I cannot begin to specify here what it would entail. However, health scientists already have many of the skills and resources needed to undertake this work (epidemiological and program evaluation research skills, access to granting agencies and publishing sources. teaching positions, access to public records reasonably
and
human strong
populations, public
credibility,
travel
funds,
to name
and
a few).
of us could make substantial contributions to this effort by changing the focus of our activities only moderately. We also would be able to draw on the well developed resources of a wide range of organizations devoted to disarmament and environmental preservation. Greenpeace, the Natural Resources Defense Council, the Union of Concerned Scientists, the Center for Defense Information, the Stockholm International Peace Research Institute, Physicians for Social Responsibility, the International Peace Research Association, the Worldwatch Institute, the Institute for Policy Studies, and many more, regularly publish useful material for the project I am recommending. A look at Sivard’s World Military and Social Espenditurrs [3] gives some notion of the richness of raw information available. One way to tap these resources would be to promote, aggressively, joint projects linking health science, disarmament and environmentalist organizations. Many
5 6 7 8 9 10 II 12 13 14 15
I6 17. 18.
19. 20. 21.
REFERENCES I. Council on a Livable World.
Military Budget Summary: A Brief Analysis of the Fiscal Year 1992 Military Budget, Council Fact Sheet. 1991.
22.
Side1 V. The health and social costs of the weapons race. ;\fobius 4. (I), 5666, 1984. Sivard R. World Military and Social E.rpenditures. p. 7. World Priorities, Washington, DC, 1991. Klare M. Wars in the 1990s: growing firepower in the Third World. Bull. Atomic Scient. 46, (4), 9-14, 1990. Lyons P., Fitzgerald K. and Reinbolt R. Militarizing the Third World. Nuclear Times 8, (2). 27-29. 1990. Towfard Freedom Newsletter. p. 7, Jan. 1991. San Francisco Chronicle, 18 February, 1991. Klare M. Fueling the fire: how we armed the Middle East. Bull. Afomic Scient. 47, (I), 19-26. 1991. Hartung W. The boom at the arms bazaar. Bull. Atomic Scienl. 47, (8). 14-20, 1991. World Bank. The Development Data Book, 2nd edn, pp. 7, 9. World Bank, Washington, DC. 1988. Fitzgerald J. Fuelling the future. Vlieende Springbok, pp. 1399146, 1990. Sanders D. The Struggle for Health. p. 67. Macmillan, Houndmills, 1985. S/D-USA Newsleffer, p. 15, Winter 1990. Barnaby F. (Ed.) The Gain Peace Atlas, pp. 1088114. Doubleday, New York, 1988. Werner D. The yellow bulldozer, or, some good things are happening in South Africa. Newsletter from the Sierra Madre, No. 19, p. 4. Lopez G. Why the generals wage war on the people. Bull. Atomic Scient. 46, (4). 30-33, 1990. Bloom S. California Military Toxics Facr Sheet. Arms Control Research Center. San Francisco. 1990. Political Ecology Group. War in the Gulf, An Encironmen/al Perspective, p. 3. Political Ecology Group, San Francisco, 199 1. Sheehan D. Affidavit of Daniel P. Sheehan. Christic Institute, Washington. DC, 1987. Beira Corridor Group. The kalashnikov killing. BCG Bull. No. 22, p. 3, 1991. Rochlin G. and Damchak C. Lessons of the Gulf War: ascendant technology and declining capability. Survical 23, (3), May/June, 1991. World Bank. Financing Health Sewices in Developing Countries: An Agenda for Reform. World Bank, Washington, DC, 1987.
7, pp.
719-724,
0277-9536192
1992
$5.00
+ 0.00
Pergamon Press plc
MILITARISM
AND WORLD
HEALTH
CHRISTIEW. KIEPER
Program in Health Science and Human Survival, University of California, Box 0848, San Francisco, CA 94143, U.S.A. Abstract-Militarism is a rapidly growing factor in that complex network of social, political and economic causes of ill health among the world’s poor. This complex of causes is driving a spiral of class inequality, political instability, and military repression in many less developed nations. These nations share a uniform security doctrine, which has major health impacts. Here five impacts are noted: diversion of resources, suppression of dissent, military classism, environment damage, and crime and terrorism. The demand stimulated by the recent Persian Gulf War for expensive, high-technology weapons may deepen Third World debt and fuel the cycle of poverty, ill health, social unrest, and military oppression. International health workers need to take account of the causes and effects of militarism in their studies of health problems. Their work could be aided by organizations that promote disarmament and environment preservation. Key words-violence,
military, poverty, social inequality, environment
As events in the Persian Gulf demonstrate, the goal of a more peaceful world continues to elude us in the post-Cold War era. In fact, militarism appears to be on the upswing, and its consequences for health are already serious both at home and abroad. Because of this trend, it may become increasingly difficult for us to have a positive impact on the health of humanity in the 21st century, even when there are no major wars being fought. It is time for health professionals to examine some of the salient causes and ‘peacetime’ health consequences of militarism. In the confusion that follows the Gulf War, a few things are clear. There will continue to be much suffering and death for many months, possibly even years, in the war-ravaged lands with their shattered public health, housing, food distribution and medical systems. There will be great political turmoil in Iraq, and possibly also in the neighboring states; turmoil that will take its toll in the disrupted livelihoods and neglected social needs of millions of innocent people. In the United States, an enormous war debt will further burden our already floundering health care system, differentially hurting the poor [I, 21. For the foreseeable future, then, the war may not move us closer to President Bush’s image of a peaceful ‘New World Order’, but in the opposite direction, toward increased chaos and misery. Was this situation necessary? Can it happen again? As professionals dedicated to the promotion of human health, we must ask ourselves these questions, and I am moved to offer a perspective on them. In my view, the Gulf War and its aftermath are the predictable results of a powerful trend in international relations-the tendency to view military technology as a way of solving political and economic problems. This trend, this militarism, not only contributes to the
likelihood of situations like the Persian Gulf, but it also has serious consequences for world health even in the absence of outright war. EXTENT OF MlLITARISSl
The word ‘militarism’ can mean any of three things, and I will be using the word here in all of its meanings-first, the leadership of society by a military class; second, the tendency to use military strategy in dealing with problems; and third, an aggressive tendency to prepare for war. To be a ‘militarist’ is to be a villain, and nobody in the world is going to admit to the epithet. Studying and preparing for war is always justified as a prudent precaution against the belligerence of others. In this sense, it resembles a character defect-subtle, destructive and hard to eradicate. There has been a vast increase in the number, the distribution, and the destructive power of weapons and men trained to use them throughout the world in the last 20 years, especially in the less industrialized nations. Let us first address the causes of this trend, then turn to its effects on human health-not just the effects of war itself, but also the effects of the purchase, transfer and stockpiling of weapons, and the training and employment of armed forces. First, how much militarism are we talking about? It is very hard to put a figure on it, but the world spends about a trillion dollars a year on military goods and services [3]. An estimated $340 billion dollars worth of arms were either given or sold to Third World countries between 1981 and 1988. Most of these arms were produced by the Soviet Union and the United States, with another substantial amount from Eastern and Western Europe, but there is
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CHRISTIEW. KIEFER
a growing arms export market among developing nations too. Argentina, Brazil, China, Korea, India, Israel and South Africa have large arms exports [4]. The value of arms produced in Third World countries grew from about $2 million in 19.50 to $1.1 billion in 1984-over a 500-fold increase [4]. And where does this vast flood of weapons end up? In the 1980s more than half of it ended up in one area-the Middle East. Iraq alone got $50 billion worth [5]. In 1990, NATO and the Soviet Union began major reductions in conventional weapons and troops in Europe, and in October 1991, the United States and the Soviet Federation announced major reductions in their nuclear weapons arsenals. However, these developments should not be seen as a general reduction in world militarism. Not just the numbers of weapons, but the technology is increasing exponentially. Sixteen Third World countries now deploy ballistic missiles, with ranges up to 2000 miles. More and more are developing chemical and biological weapons, and several are edging toward nuclear capability 141. There were 22 wars in Third World countries in the 1980s [5], and in a growing list of countries the military holds ruling power, officially or unofficially [3]. The casualities are staggering. The Iran-Iraq War killed an estimated 1.25 million people [4]. Wars in Southern Africa (largely Mozambique and Angola) killed 1.6 million [6]. Nicaragua sustained 30,000 deaths and $15 billion worth of damage in the Contra war. We have heard about Pol Pot’s killing frenzy in Cambodia, and the terrible casualties in Ethiopia and the Sudan, but much of the killing has gone almost unnoticed in the United States. Some 430,000 have died in Tibet since the Chinese invasion of 1949 [7], and recent radio reports from Sri Lanka give the figure 40,000 for the known deaths in the present ethnic violence there. Two hundred and fifty thousand have died in recent wars in El Salvador, Chile, Guatamala and Argentina 131. The pace of arms transfers seems to be quickening in the 1990s. In August 1990, President Bush authorized the transfer to Egypt of $1 billion worth of F- 16s and to Saudi Arabia of $2.2 billion worth of tanks, aircraft and missiles, and in September, another $21 billion worth [8]. Between March and July, 1991, the United States sold another $15 billion worth in the Middle East [9]. CAL’SES OF MlLITARlSM
The question is, why? There are economic reasons and ideological reasons. Increasing populations and declining resources, the widening gap between the rich and the poor, the destruction of traditional cultures, and the spread-of information through the electronic media are trends throughout the world, leading to intense frustration and political instability, and from there to military repression. The superpowers also compete for economic
influence in the Third World, as do Third World countries themselves, and elites within these countries. In 1986 about half the world’s population lived in countries where the per person share of gross national product was less than $270. Fertility rates are highest in most of these countries, resulting in huge population growth rates. By the year 2000, there will be an additional 1.3 billion people in the world, and 87% of this growth will occur in the poorest i of the world [IO]. Poverty itself is the main engine driving this dynamic. Children under 5 years account for 4&60% of all deaths in countries where the great majority of labour is done by human bodies rather than machines. This in turn leads couples to strive for big families, in order to assure a continuous labor supply for the family. Moreover, poverty is actually increasing in much of the world. Each person’s share of the domestic economy is declining in Nicaragua, El Salvador, Jamaica, Bolivia and Chile, in Kuwait, Central African Republic, Somalia, Zaire, Tanzania, Mozambique, Madagascar, Zambia, Ghana, Niger, Liberia, Senegal, Uganda, Togo and Sudan, and probably in much of central and Southeast Asia and Eastern Europe as well. In those countries, nef poverty is increasing [IO]. In many other countries, including the United States, Brazil, and Mexico, by the way, large sectors are getting poorer, even though the upper classes are making advances. In the poorest countries, overpopulation is producing unsustainable pressure on rural land so that masses of people are moving from stricken rural areas to miserable urban slums, losing many of their cultural values in the process. I have witnessed this process in South Africa and Mexico. In South Africa the urban population has more than doubled since 1980, from 10 million to 22 million [l I]. I have seen unbelievably crowded squatter camps containing as many as half a million people, completely without sanitary services, newly sprung up around Durban, Capetown, Johannesburg and Pretoria in just a few years. In 1975 there were 90 towns in the Third World with populations of over a million, and by the year 2000 it is estimated there will be nearly 300. In the same period, the urban population in these countries is expected to grow from 28% of the total to 42% [12]. Why is all this happening, and exactly what does militarism have to do with it? The process is a complex one, but it has to do with the increasingly unequal distribution of resources. Figure 1, admittedly oversimple, gives some idea of the most common factors involved. I have already mentioned the relationship of widespread poverty and population growth. In an effort to break out of this poverty trap, Third World countries typically encourage foreign capital investments, both in the form of loans and foreign
Militarism and world health
721
Fig. 1. Some interacting factors in the relationship of militarism and health.
of enterprises. This results in capital flight, as interest payments and profits on industry leave the Third World on a huge scale. Falling commodity prices and rising interest rates in the 1980s greatly worsened this problem. The estimated net transfer of wealth from the Third World to the First World in 1989 was $35 billion [13]. Each of the ten largest multinational companies has incomes larger than the gross national products of each of the world’s 80 poorest countries, and most of the big multinationals profit from militarism in one way or another [12]. In order to keep attracting foreign investment, poor countries must often meet the demands of foreign banks through structural adjustment, which may involve currency devaluation with attendant radical increases in food prices, wage freezes and layoffs in the public sector, and cutbacks in public services. Often, Third World governments are afraid to make badly needed reforms, such as land distribution, for the same reason-such reforms might hurt their ability to service their debts and attract foreign capital. Most of these processes result in the concentration of wealth in the hands of a managerial class, thereby widening class inequality and deepening political instability. Third World governments, encouraged by the multinational companies who benefit from the status quo, are tempted to turn to militarism and repression to maintain order. But this often leads to a further vicious circle, as: (1) military procurement can deepen foreign debt; and (2) violence by the military destroys local infrastructure, disrupts commerce, and angers the poor, who have little to lose in fighting back. But of course inequality isn’t the whole story. Rivalries based on nationality, religion, and culture fuel the flames of militarism on every hand. During the Cold War, the U.S. and the Soviet Union sold billions of dollars to client states in order to consolidate our spheres of influence in Asia, Latin America, Africa and the Middle East. Now, ethnic and religious rivalries in all these areas are a tremendous problem, as are political rivalries within states. The biggest arms purchasers are countries like Iraq and Israel, who can afford them, ownership
and who have long standing ethnic tensions to worry about. EFFECTS
OF MILITARISM
Now I turn to the effects of militarism on health. The foremost effect, of course, is the outright killing, maiming, refugeeism, and destruction of livelihood caused by war. There is no doubt that this costs more in civilian than in military lives. An estimated 74% of all war casualties were civilians in the 1980s and the proportion appears to be increasing as the destructive power of weapons increases. In the 1990s the estimate so far is 90% [3]. But aside from this main effect, I would like to describe five less obvious ones: the diversion of resources, the suppression of dissent, military classism, environmental damage, and crime and terrorism. Let’s look at the diversion of resources. As I mentioned earlier, world military spending runs about a trillion dollars a year-$1.7 million a minute. (Given the power that amount of money will buy, it seems clear enough why the world’s governments seem unable to slow the production of weapons, or stop the appalling slaughter they inevitably produce.) Only about 15% of this is spent by the developing countries, but this fails to illuminate the economic burden of these expenditures. If expenditures are indexed to per capita income in the country where they are incurred, we find that in 1988 the industrial nations spent the equivalent of 56 million personyears of income on the military, while the developing nations spent 187 million person-years, or nearly 4/S of the total [3]. The developed countries spend an average 5.4% of their GNPs on military, and 0.3%, or one eighteenth of that, on aid to developing countries. There are 800 million starving people in the world. Three out of 5 people in the Third World have no access to safe water, and 3 out of 4 no sanitation. At the world military spending rate, 35 set could build classrooms for 30,000 children, or feed 22,000 people for a year. Twelve minutes could build 40,000 village pharmacies. Two and a half hours equals the entire world budget of the World Health Organization.
72’
CHRISTIEW. KIEFER
Seven days could eradicate world hunger, and twelve days could create water supplies for the entire Third World [ 141. Turning to the United States. we are well aware of the tradeoffs between military and health expenditures. In the last IO years, military budgets have reached an all-time high, while programs for primary health care, prenatal care, and nutrition have been cut [2]. Estimates of the cost of the buildup and war in the Persian Gulf vary from S28 to $86 billion, and the president’s 1992 military budget, at $290.8 billion (excluding war costs), shows no decline from 1991 [I]. In addition to the indirect effects through resource diversion, there is a devastating, direct effect of militarism on health that we rarely hear about. In militaristic countries, health care is a scarce resource, and the control of it is seen as a crucial element of power. Accordingly, in many militarized health workers and health facilities nations, are primary targets of military operations. As a medical anthropologist, I have spontaneous, direct reports from health workers in Guatemala, Chile, El Salvador, Honduras and the Philippines that the local governments have killed and tortured many rural health workers and destroyed their clinics, in order better to control the people served by the health workers. In Nicaragua and Mozambique, I have seen the effects of the same policies, carried out by guerillas with foreign military backing. In Mozambique between 1982 and 1988 the South African-backed Renamo guerillas killed an estimated 100,000 civilians and destroyed 484 health centers, serving 2 million people [IS]. According to political scientist George Lopez, there is throughout the Third World a “unified national security doctrine” that targets health and human rights workers, and a direct correlation between the degree of militarization of a government, and its level of human rights violations [ 161. Then there is the problem of military classism. In many poor countries, it is very difficult for a poor family to reach middle class security and comfort by legal means. A military career may be one of the few avenues of upward mobility, since it can give one the raw power needed for extralegal operations. In many places, military officers do get rich through extortion, bribery and graft, eventually forming an elite class in their own right. This has the effect of further siphoning off scarce resources, such as land, into the hands of the military, and worsens the health conditions of the poor. A good example is El Salvador, where the military is supported with massive U.S. aid. There, 2% of the population owns 60% of the land, and many campesinos have little or none. The military, however, owns vast tracts in both rural and urban areas, which they use to generate income for their pension fund. Lopez continues: What is unique in current Third that military leaders are becoming
World conflicts is extremely wealthy.
This is tied to certain corrupt practices, such as protection practices by businesses, patronage by other officers, and so forth. [16]. Turning to the environment, militarism has disastrous effects here in all its phases-weapons production, supplying and training an army or navy, war itself, and the refugeeism caused by war. Production and operations use large quantities of toxic chemicals and metals, which are often left behind to pollute the environment. A 1986 General Accounting Office report concluded that U.S. military facilities produce a minimum of 500,000 tons of hazardous waste per year. In California alone, 40 military bases have been cited by the Environmental Protection Agency for Class I violations of environmental law [l7]. In modern war, massive use of defoliants combines with cratering, burning, and chemical and oil spills to lay waste large tracts of land. Some areas of Vietnam are still uninhabitable, due to use by the United States of some 100,000 tons of defoliants there in the 1960s and 70s. That war produced some 25 million craters, leading to problems of insect control and water sanitation [l8]. In El Salvador, formerly a heavily forested country, defoliants have helped reduce the forest cover to only 7% of total acreage, and 77% of the land is now heavily eroded, according to a 1989 report of the San Francisco-based Environmental Project on Central America. Largely as a result of the Iran-Iraq War of 1981-1987, during which tankers and drilling platforms were destroyed in the Persian Gulf, that body of water is the most polluted of its size in the world. The recent war with Iraq not only produced disasterous oil fires and spills, but also: (a) severely disrupted the desert ecosystem, which depends on a fragile “crust of microorganisms, ephemeral plants, salt, silt and sand,” (b) depleted the Saudi Arabian water supply, (c) seriously polluted Iraq’s water supplies, contributing to thousands of deaths from infectious disease [18]. War-related refugeeism has significant environmental effects as well. Displaced populations lack the resources and facilities to feed and house themselves over long periods, or to dispose of their wastes. Finally, let us look at the way in which militarism contributes to crime and terrorism. Although the mainstream press usually treats drug-running, banditry, and politically motivated crime as problems unrelated to ‘legitimate’ military weapons transfers, this is far from the case. As the supply of weapons held by armed forces increases throughout the world, the black market in weapons also grows. Weapons like automatic rifles, explosives, mines, small rockets and rocket launchers and electronic communication and detection equipment are often stolen for sale by troops with access to military stores, or simply sold on the black market by those war deserters in the Third World who do not simply turn to crime as a livelihood themselves. Needless to say, it is difficult to get reliable figures on such sales, but evidence indicates the extent of
Militarism and world health covert trading is great. Civil liberties watchdog groups like the Christic Institute report large, routine covert transfers by the CIA [19]. An African economic newsletter reports on the sale of contraband AK47 military assault rifles as follows: “. . . The Economist, a British magazine, was quoted U.S. $80 in Thailand from deserting Cambodians, U.S. $75 in Honduras from former Nicaraguan Contras, and U.S. $50 in Pakistan from Afghan rebels [20]“. The same article reports that Mozambiquan ex-soldiers and ex-rebels sell AK47s at the South African border for 20 Rand (about U.S. $7), or the equivalent in maize. Thanks to the extreme poverty in South Africa’s black townships, most of the ethnic violence there has been carried out with homemade firebombs, spears and knives. But in March 1991, a houseful of people in the Johannesburg township of Alexandra were murdered with AK47 rifles. Some of these weapons are probably purchased by otherwise law-abiding people, for hunting (an indirect environmental impact of militarism) or self-protection, but there is also a strong relationship between illegal arms trading and violent crime. The growth of highly organized and well armed drug cartels in Latin America, for example, parallels the growth of weapons transfers to the Third World. Note that the brisk trade in assault rifles mentioned above involves three of the world’s major drug producing areas.
THE ROLE OF THE HEALTH
PROFESSIONAL
The trend toward militarization of the developing countries is likely to continue, for two principal reasons. First, the liberalization and decentralization of the Soviet Union and former Warsaw Pact countries, while it may produce limited civil and border wars, is likely to reduce the need for massive military expenditures in the industrial countries. As I have detailed earlier, this is leading arms manufacturers in those countries to look toward the Third World as a major market. Second, as the Gulf War showed, the growing dependence of the industrial economies on Third World labor, commodities, and markets creates an incentive for militarily advanced nations to establish hegemony, by arms transfers and/or war, in less developed nations. The Gulf War may represent a dramatic acceleration of the process described here. Rochlin and Demchak have summarized the ‘lessons’ of that war as follows: The apparent success of the United States and its coalition partners has been attributed to our use of sophisticated electronic defenses and reconaissance, and precision-guided munitions. Iraq’s defeat, likewise, is seen to result from their failure to counter these. Governments throughout the world, including the less developed nations: will seek to acquire, at enormous cost, both American-style ‘brilliant’ weaponry, and the technology with which to defeat it. Ballistic missiles, even of the crude Scud variety, will also be in demand. Because of the international concern generated by Iraq’s Scuds, such weapons are now seen as a
723
form of military threat affordable by Third World countries 1211. The increasingly sophisticated and costly militarization of the Third World will both divert large sums that might have been used for health promotion, and increase the power of militarist regimes, with the unhealthy effects I have noted. International health assistance programs, conducted either under United Nations auspices, or through bilateral aid agreements, are not likely to affect this trend much. The agencies involved in such projects must work within the military and foreign relations policies of their governments, and the health professional will have no choice but to see much of his work undone by the effects of those policies. For example, a recent World Bank policy study on financing health services in developing countries lists three main barriers to effective health care delivery in those countries, and recommends four measures to combat these. The barriers are: (a) insufficient spending on cost-effective activities like immunization and contraception, (b) internal inefficiency of public programs, and (c) inequality in the distribution of benefits. The suggested remedies are: (a) charging fees to those who can pay for government health facilities, (b) providing insurance accounts to cover major health risks, (c) encouraging private sector providers, and (d) decentralizing government health services [22]. This typical analysis, which I cannot present in detail here, has many merits, but it also has the great shortcoming of which I speak: It addresses the symptoms-poor health care-almost without reference to their broad political context. In order for the reforms recommended by the study to improve access to health care, the governments in question would have to: (a) spend the savings from increased fees and increased efficiency on services for the poor, (b) support the community empowering activities of primary health workers in poor areas, (c) refrain from seriously degrading the environment, and (d) fend-off attempts by the affluent to profit from the health care sector. In many countries, these things are unlikely to happen due to militaristic priorities, and even if they do happen, their effects are likely to be swamped by the contrary effects of military activity. This same World Bank report points out that Third World health care expenditures have been shrinking, as a percentage of national budgets. To summarize all these points, two possibly useful conclusions about the role of the health worker emerge: (1) that military policies affecting client populations are at least as much a part of the health environment as local health policy, or the presence of disease agents, and (2) given the recent severe increase of militarism, it is the work of health professionals to document the specific effects of this factor on health, to disseminate this information to clients and the health science community, to search for countermeasures against it, and to promote prophylactic measures
12.8
CHRISTIE W. KIEFEA
that will reduce the prevalence of militarism in the health environment. This is obviously a gigantic undertaking, and I cannot begin to specify here what it would entail. However, health scientists already have many of the skills and resources needed to undertake this work (epidemiological and program evaluation research skills, access to granting agencies and publishing sources. teaching positions, access to public records reasonably
and
human strong
populations, public
credibility,
travel
funds,
to name
and
a few).
of us could make substantial contributions to this effort by changing the focus of our activities only moderately. We also would be able to draw on the well developed resources of a wide range of organizations devoted to disarmament and environmental preservation. Greenpeace, the Natural Resources Defense Council, the Union of Concerned Scientists, the Center for Defense Information, the Stockholm International Peace Research Institute, Physicians for Social Responsibility, the International Peace Research Association, the Worldwatch Institute, the Institute for Policy Studies, and many more, regularly publish useful material for the project I am recommending. A look at Sivard’s World Military and Social Espenditurrs [3] gives some notion of the richness of raw information available. One way to tap these resources would be to promote, aggressively, joint projects linking health science, disarmament and environmentalist organizations. Many
5 6 7 8 9 10 II 12 13 14 15
I6 17. 18.
19. 20. 21.
REFERENCES I. Council on a Livable World.
Military Budget Summary: A Brief Analysis of the Fiscal Year 1992 Military Budget, Council Fact Sheet. 1991.
22.
Side1 V. The health and social costs of the weapons race. ;\fobius 4. (I), 5666, 1984. Sivard R. World Military and Social E.rpenditures. p. 7. World Priorities, Washington, DC, 1991. Klare M. Wars in the 1990s: growing firepower in the Third World. Bull. Atomic Scient. 46, (4), 9-14, 1990. Lyons P., Fitzgerald K. and Reinbolt R. Militarizing the Third World. Nuclear Times 8, (2). 27-29. 1990. Towfard Freedom Newsletter. p. 7, Jan. 1991. San Francisco Chronicle, 18 February, 1991. Klare M. Fueling the fire: how we armed the Middle East. Bull. Afomic Scient. 47, (I), 19-26. 1991. Hartung W. The boom at the arms bazaar. Bull. Atomic Scienl. 47, (8). 14-20, 1991. World Bank. The Development Data Book, 2nd edn, pp. 7, 9. World Bank, Washington, DC. 1988. Fitzgerald J. Fuelling the future. Vlieende Springbok, pp. 1399146, 1990. Sanders D. The Struggle for Health. p. 67. Macmillan, Houndmills, 1985. S/D-USA Newsleffer, p. 15, Winter 1990. Barnaby F. (Ed.) The Gain Peace Atlas, pp. 1088114. Doubleday, New York, 1988. Werner D. The yellow bulldozer, or, some good things are happening in South Africa. Newsletter from the Sierra Madre, No. 19, p. 4. Lopez G. Why the generals wage war on the people. Bull. Atomic Scient. 46, (4). 30-33, 1990. Bloom S. California Military Toxics Facr Sheet. Arms Control Research Center. San Francisco. 1990. Political Ecology Group. War in the Gulf, An Encironmen/al Perspective, p. 3. Political Ecology Group, San Francisco, 199 1. Sheehan D. Affidavit of Daniel P. Sheehan. Christic Institute, Washington. DC, 1987. Beira Corridor Group. The kalashnikov killing. BCG Bull. No. 22, p. 3, 1991. Rochlin G. and Damchak C. Lessons of the Gulf War: ascendant technology and declining capability. Survical 23, (3), May/June, 1991. World Bank. Financing Health Sewices in Developing Countries: An Agenda for Reform. World Bank, Washington, DC, 1987.