“The only eventuality that is truly worse than winning a war is losing a war!” — Duke of Wellington
The central role of health workers during and after an armed conflict has always been a matter of debate. As a medical practitioner and a health worker who has been involved in providing medical relief in conflict zones at different stages of my career, what has always puzzled me is how little consideration is given to the health consequences both at the time when the war is being prosecuted and following the termination of armed conflict.
When I worked in Bahr-el Ghazal in the then undivided Sudan, the armed conflict had led to a terrible famine. That was never taken into account by either party and the consequences were just too gruesome to adumbrate.
What is even more perplexing is the absence of an effective lobby that can influence the policymakers effectively to prioritize the healthcare dimension when planning an armed conflict.
My own position vis-a-vis armed conflict between two states is guided by a simple non-negotiable doctrine:
A just peace can never be indifferent to the preventable death of a three-year-old from pneumonia or a woman in childbirth when these deaths are the result of a catastrophic disruption of civilian life by war.
There is a need to find ways to delimit the indirect effects in order to navigate the margins of where the human costs of unjust war give way to the human costs of unjust peace. Humanitarian strategies are helpful, as they are in all wars. Yet a critical reading of just war criteria seems most essential when war-fighting and peacemaking defy traditional boundaries, when conflict is prolonged and conceptually muddled. This may be of special concern when standoff weapons, such as high-altitude bombing or the use of armed drones, allow one side to extend combat operations over long periods of time without significant risk to their soldiers. The indirect effects of this protracted violence, in terms of both injury and mental well-being, can be profound. The failure to critically implement just war criteria when war phases are confused can create an analytic vacuum that can too often permit the chronicity of damage and time itself to obscure bonds of responsibility and permit the indirect effects of war to recede from public view.
Recent US and allied interventions have found it far easier to eliminate a regime than to protect its civilians in the aftermath. The regimes of Saddam Hussein in Iraq and Gaddafi in Libya, while predatory and oppressive, also made general provisions for food and water supplies, public health, and hospitals. Although no one would suggest that these services were adequate or efficient, they did exist and generated health outcomes that were at least as good as surrounding states.
The central human consequence of war has always been violent death. The destruction of human life through direct exposure to combat has long been the dominant preoccupation of both generals and philosophers. However, war also generates death, illness, and hardship through the destruction of the means of human survival. As noted in the US Army’s Civilian Casualty Mitigation Manual: “In addition to the inherent risks from combat, a society disrupted by armed conflict will have other vulnerabilities, particularly if large numbers of civilians lack food, water, shelter, medical care, and security. Disease, starvation, dehydration, and the climate may be more threatening to civilians than casualties from Army operations.” The fact that this manual exists is in itself worthy of note. However, its inclusion of these “indirect” mechanisms of impact also underscores the relevance of events that lie more distally along the causal chain between war and human suffering.
If the protection of innocent life is a fundamental ambition of a just war, it is useful to first consider the fate of the modern embodiment of innocence, the newborn infant, in societies plagued by war. Health workers are the ultimate inheritors of failed social order. Sooner or later, a breakdown in the bonds that define collective peace, indeed that ensure social justice, will find tragic expression in the clinic, on the ward, or in the morgue. This reality has always given health workers the opportunity, if not the responsibility, to provide a human narrative of suffering in addition to the technical requirements of care and comfort. Yet, for the most part, this narrative has not been adequately crafted or at least advanced in the deliberation of what has always been the most extreme challenge for health workers: the human consequences of war and its impact upon health of the society.
Specific estimates of the indirect effects of war have varied. Much of this variation has been due to the difficulties in ascertaining mortality and morbidity data in areas of poor security and highly mobile populations. Significant numbers of indirect deaths have been documented in a variety of settings, including in Iraq, Darfur, Afghanistan, Angola, the Democratic Republic of the Congo, Kosovo, and Guatemala. One summary study reported that the indirect health consequences of civil wars between 1991 and 1997 throughout the world were twice that associated with direct, combat related effects. A report published by the Geneva Declaration Secretariat suggested that for every violent death resulting from war between 2004 and 2007, four died from war-associated elevations in malnutrition and disease. Global health scholar Amy Hagopian and her colleagues reported that approximately one-third of all deaths in Iraq were due to indirect causes. Prior studies have also suggested significantly elevated rates of indirect deaths, although the precise proportion varied with different methodologies and points in time. In Kosovo, overall mortality more than doubled during the height of the fighting, but most of this increase was due to direct, traumatic injury. Beyond mortality considerations, indirect effects can include substantial numbers of disabilities, developmental disorders in children, and of special concern, long-standing mental health conditions. There is substantial evidence that the exposure to combat and displacement can generate severe emotional disturbances in all age groups, but particularly children. Both the severity and chronicity of these exposures are important. Posttraumatic stress disorder is all too common, particularly when children witness the death of a parent or loved one. The failure to provide normalizing or therapeutic environments, such as access to schools or mental health services, only exacerbates long-term mental health effects. It seems that the impact of conflict in very-low-resource settings such as the Democratic Republic of the Congo may have very different indirect effects than in mid- to high-income locations, such as Bosnia or Kosovo. In this manner, the estimation of indirect effects is coming into line with the estimation of direct effects
Sanctions can represent a special case of warfare in which all the effects on civilians are indirect. Not all sanction regimes may be considered a type of warfare. However, it seems a bias in definition not to recognize state-enforced, crossborder deprivation resulting in mass death in an enemy population as somehow evading the moral logic of just war theory. Ethicist Joy Gordon has documented in great detail the devastating impact of international sanctions against Iraq from 1990–2003. Ineffective and at times corrupt oversight by the United Nations personnel coupled with a blinkered US fixation on weakening the Iraqi regime to create a catastrophic collapse of the Iraqi nutritional and health infrastructure, resulting in what may have been up to hundreds of thousands of excess childhood deaths. Other sanctions regimes, such as that imposed against the Mugabe regime in Zimbabwe, have also generated tragic indirect effects, despite attempts to devise mechanisms to protect the interests of civilian populations.
In general, war generates significant elevations in indirect mortality and disability above prior baselines or trends. One review has suggested that a useful rule of thumb is that indirect deaths will generally total approximately twice that of direct deaths. While this may be helpful in underscoring the importance of indirect effects, this kind of generalization may obscure very real differences in these effects based upon the setting, timing, and nature of combat operations. Nevertheless, I can only imagine the indirect effects occurring in Syria, Iraq, and South Sudan as I write this essay. The key point being that it should not be left up to the imagination; the capabilities to document and address these horrors exist now.
The indirect effects of war are not new. They have likely existed whenever and wherever wars have been fought. The histories of the Mongol invasions, the Thirty Years War, and the Siege of Leningrad all tell dramatic stories of indirect civilian suffering and death. But my argument regarding the importance of indirect effects is based not on its modern origins but rather its modern neglect. Norms regarding the conduct of war have changed and our capabilities to publicly account for the indirect effects of war have advanced substantially. Even if one does not accept arguments regarding changing norms or technical innovation, the continued marginalization of the indirect effects of war is still, nevertheless, unjust.
If just war theory must respond to the reality of war, then just war theory must respond to the indirect effects of war. While just war traditions have long acknowledged the existence of indirect effects, it seems fair to say that the moral and practical implications of these indirect effects have not received the critical scrutiny they deserve. The principles of jus ad bellum speak to the “why” of war and provide an architecture for ensuring that the reasons for going to war are just. Of special interest to those concerned with indirect effects is the requirement that the initiation of war must be based on a reasonable expectation that the aims of the war can be achieved successfully (the principle of success) and that the violence employed is proportional to the established threat (the principle of proportionality). An appreciation of potential indirect effects could prove a particularly important factor in considering the dimensions of proportionality. There seems to be little rational justification for confining the human cost of war to direct effects alone.
When war is justified on the basis of humanitarian intervention, of “saving innocent lives,” some predictive comparison must be made between the human impact of intervention — both direct and indirect — and that likely to occur were the intervention not undertaken. In this manner, a consideration of indirect effects can either create incentives to initiate or refrain from war. Philosopher Steven Lee has suggested that this dual capacity informs the analysis of proportionality as weighing the “created evil” generated by a violent intervention against the “resisted evil” that the intervention intends to avert. Both considerations should involve some prediction of indirect effects. This predictive imperative cannot be dismissed by the mere assertion that the intention of the intervention was inherently well-meaning or just. As Lee states: “Proportionality limits what a state can do in the name of a just cause.”
The principles of jus in bello provide guidance as to “how” wars should be fought. Central to these principles is the distinction between combatants and non-combatants. Although concern for civilians is predominantly expressed as protections against direct exposure to combat, some recognition of the potential for indirect effects is included in Additional Protocol I (1977) of the Geneva Conventions, advocating the “protection of objects indispensable to the survival of the civilian population.”
The insistence is that the expected damage to civilians or civilian infrastructure not be intentional but rather occur as a side effect, even if such an effect were clearly foreseen. This logical framing, known generally as the doctrine of the “double effect,” has roots in Catholic moral theology and underscores the moral pivot on intentionality, rather than the foreseen consequences of any given act of war that had been deemed militarily useful. The practical utility of this doctrine can be questioned on the grounds that it is too easy to justify high civilian casualties because they were not intended. Michael Walzer has argued for a more stringent set of criteria that includes not only that a combatant not intend to harm non-combatants but that the combatant take positive steps to actually minimize civilian casualties. This “double intention” framework endorses a “positive commitment to save civilian lives” even if it requires combatants to assume a greater risk of harm to themselves.
The protection of civilian populations has become an important instrumental concern — about winning the war — in some armed conflicts. Both direct and indirect effects can translate into deeply felt grievance. Standard counterinsurgency doctrine has made the protection of civilian populations an explicit strategic objective. Moreover, the direct provision of public goods, such as health care, has also been embraced as a means of generating tactical support and political legitimacy for combatant forces. While the emphasis and precise tactical expression of this concern for civilian casualties has differed over time and setting, the explicit goal of minimizing both direct and indirect civilian effects has remained a core principle of counterinsurgency doctrine. This has perhaps been most apparent in Afghanistan, where the US forces have routinely accepted greater risk to themselves in order to avoid civilian casualties, basically embracing Walzer’s double intention framework.
Theorists from Augustine (“the aim of a just war is a just peace”) to Walzer (“implicit in the theory of just war is a theory of just peace”) have recognized the essential relationship between ad bellum justification and post bellum performance. However, the prevention of indirect effects as a necessary element of a just peace has not been explicitly addressed, or at least not been emphasized sufficiently. This requirement seems especially vital when the initiation of hostilities is justified on humanitarian grounds. As was noted for the in bello conduct of a war rooted in humanitarian rescue, the prescription for the post bellum peace of such a war must also ensure that the health and well-being of civilian populations are a central priority.
In this context, great care should be taken when humanitarian justifications demand regime change but, in reality, also imply the destruction of the state. This is because even a murderous or potentially murderous regime may sit atop a functioning state apparatus that ensures the maintenance of daily life for much of the civilian population. The human toll resulting from the neglect of these just peace requirements can vary, particularly in response to the prewar level of health and essential services. While the wars in Iraq and Libya have resulted in catastrophic indirect suffering, the war in Afghanistan since 2001, despite its bitter and protracted nature, may have been associated with generally improved health outcomes, particularly for women and children. This may reflect skewed reporting or the extremely poor health status of the Afghan people prior to the US invasion, but it may also be a testament to the efforts of Afghan, US, and coalition partners, as well as a number of nongovernmental organizations, to enhance health, education, and related services.
If a regime must be destroyed, there must be a concurrent obligation to protect or replace those functions of the state that assure the essentials of daily life. This is most apparent when victors become occupiers. Under this condition, just war theory most clearly shares provisions with what has come to be known as “human security,” including the availability of adequate food, shelter, and access to health care. In some sense, just war traditions respond to the “freedom from fear” while human security principles include the additional element of the “freedom from want.” Here, indirect effects blend into issues of development and good governance, provinces that one might suggest extend beyond the dimensions of just war.
The primary basis of estimating the indirect effects of war has been to measure those health outcomes that would not have occurred if war were not present. As one report stated, “measuring war related deaths involves comparing the number of deaths that occurred due to a conflict against the counterfactual scenario of peace.” The indirect component comprises those deaths not due to direct combat-related injury. This approach often means that indirect effects are expressed in some form as “excess” outcomes defined by some comparative simulation. These excess outcomes are calculated as the difference between, for example, an expected number of deaths based on peacetime mortality rates and the actual observed numbers of deaths during the war-defined study period, be it in bello or post bellum in nature. Again, indirect effects relate those excess outcomes not due to direct, traumatic causes. One should note, however, that this calculation of excess adverse outcomes does not compare the predicted effects of intervention with the counterfactual of not intervening, a comparison essential to proportionality considerations.
Advances in epidemiology and the technological means of collecting health data have generated a range of new opportunities to assess the immediate and protracted effects of war. The delineation of baseline prewar rates can be problematic, particularly when prewar periods are characterized by substantial instability, as in the Democratic Republic of the Congo, or the imposition of sanctions, as in Iraq. However, enhanced sampling frameworks and statistical adjustment procedures have provided new quantitative insights into patterns of mortality, injury, illness, and displacement. Mobile technology has been used creatively to enhance both the accuracy and reach of survey protocols. The utility of these new analytic methodologies should not be obscured by the political controversies they may generate when high civilian mortality is associated with specific, and particularly US, interventions.
More striking than the growth in our ability to measure indirect effects has been dramatic advances in our technical capacity to prevent them. Simply put, in most areas plagued by war and chronic conflict, the causes of death associated with the indirect effects of war look almost identical to those associated with peace. What changes, and what generates the excess mortality, are the absolute rates of these causes. For example, during the periods of intense conflict in the Democratic Republic of the Congo and Darfur, direct trauma-related mortality accounted for less than 20 percent of all excess deaths among children under five years of age. The leading causes of excess death were fever/malaria, neonatal (newborn) illnesses, measles, diarrhoea, and acute respiratory infection: precisely the same spectrum of mortality that usually kills children in this age group in low-resource areas of the world. However, what is critical to remember is that modern medicine and public health have developed highly efficacious interventions that can prevent either the occurrence or the severity of these causes of illness and death. Malaria can be prevented through the use of bed nets and mosquito control and mortality largely prevented by early diagnosis and treatment. Measles can be prevented by a safe and highly effective vaccine. Death from diarrhoea and acute respiratory infections can be prevented through vaccines and treatment. Neonatal conditions present a more complex challenge, but effective interventions exist for reducing mortality from complicated births, early infections, and prematurity. A major evidence-based assessment of the technical capacity to prevent mortality among young children suggested that more than two-thirds of this under-five mortality is preventable with extant interventions.
The death of any child is always a tragedy; the death of any child from preventable causes is always unjust. This is, of course, as true in peacetime as it is in war. My argument is that the dramatic growth in our ability to prevent death and disability from the indirect effects of war generates not only humanitarian impulses but also just war demands for the provision of this capability to populations affected by war. The scale of these demands is currently at the highest levels since the end of World War II. There are, of course, global mechanisms to provide succour and health services to war-ravaged communities. The United Nations High Commissioner for Refugees and a variety of nongovernmental organizations have as their central mandate the provision of food, shelter, and health care to such populations. However, the support they receive — both financial and logistical — is woefully inadequate, in part contributing to the mass migration from conflict zones currently underway. Worse still is the archaic global architecture for humanitarian response to war, which has remained relatively unchanged since World War II. The average length of stay in an UNHCR camp is now approaching 20 years and the funding mechanisms used to support displaced and war-ravaged populations are both intermittent and haphazard. Just war considerations seem largely disconnected from these funding mechanisms even though virtually all these humanitarian needs have been generated by the indirect effects of war. A new architecture is needed urgently and, as this discussion argues, the application of just war logic and accountability could help create the necessary moral imperatives and applied financial mechanisms for a new global commitment to address the human cost of war.
The mitigation of indirect effects has moral meaning. If innocence has any meaning, the epidemiology reveals that the victims are those with the most striking moral claims. If the scale of suffering has any meaning, epidemiology demands that indirect effects not be ignored. If the failure to act when capability exists has any meaning, the science of indirect effects testifies to a damning global complacency. There remain both conceptual and technical challenges in crafting a full embrace of the indirect effects of war. But these tasks do not seem the critical obstacles. Rather, the obstacles lie in the apparent utility of diminishing war’s true human cost and the maddening acquiescence of our moral frameworks that gives license to this evasion. The essential challenge lies in renegotiating the tension between the exercise of power and the claims of the vulnerable, a tension from which, not coincidently, both epidemiology and just war theory were born.
(Figures taken from Joy Gordon’s book Invisible War: The United States and the Iraq Sanctions and David Walzer’s Oration on Just Wars delivered in Chicago, 18th November 2015)
by Dr Ashoka Jahnavi Prasad
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