COMMENTARY

February 2003: In the Face of War

Ursula Snyder, PhD

Disclosures

February 06, 2003

Introduction

You can't treat war any differently from other risks to health. We are ... developing a much wider debate in the health community about the serious implications of war on public health.

Richard Horton, Editor, The Lancet

"Overall a total of 72 million people are believed to have lost their lives during the 20th century due to conflict, with an additional 52 million lives lost through genocides."

First World Report on Violence and Health World Health Organization

"More than 85% of the major conflicts since the second world war have been in poor countries... During the 1990s the poorest countries of the world became saturated with arms, with brokers often supplying both sides of a conflict... Between 1986 and 1996, a major proportion of those dying as a result of armed conflicts were civilians, particularly women and children... Huge differences in the health of mothers and children exist between the poor countries undergoing conflict and the predominantly rich countries exporting arms to them."

Empty Arms: The Effect of the Arms
Trade on Mothers and Children
David P. Southall, Professor of Pediatrics,
Bernadette A M O'Hare, Consultant
Pediatrician, Child Advocacy International,
Newcastle under Lyme, Staffordshire, UK

"Only a small percentage of the populations that find themselves in a situation of danger gain the attention of the media."

Médecins Sans Frontières
(Doctors Without Borders)

"An estimated 110,000 Iraqi civilians died in 1991 from the health effects of the war, bring the total number of Iraqis who died as a direct consequence of the Gulf war to around 205,000... A Harvard-based international study team estimated that child and infant mortality increased more than threefold from January to August 1991 compared to the previous six years, corresponding to an excess of about 47,000 deaths among children under five. Thousands of other children were handicapped by landmines and other war-related incidents. Many war widows became sole wage earners, often going hungry to feed their children; possibly 60% suffered from psychological problems, with physical manifestations such as weight loss and difficulty breast-feeding.

Collateral Damage: The Health and
Environmental Costs of War on Iraq

Medact, UK affiliate of International
Physicians for the Prevention of Nuclear War

"Women, especially those bringing up children alone or lacking family support, and children already living in poor circumstances, disabled, or lacking strong family support, are most vulnerable to emotional disturbance. The experience of another war is likely to magnify psychological disturbance already present in adults and children."

Collateral Damage: The Health and
Environmental Costs of War on Iraq

Medact

"Officially there were fewer than 500 dead and 500 hundred injured combatants from the Coalition countries but the figures are strongly contested...The longer term impact of veterans of exposure to depleted uranium and other toxins is difficult to quantify, as is the extent of Gulf War Syndrome, said to affect 25,000 US and UK veterans. A third of Gulf War veterans experienced post-traumatic stress disorder."

Collateral Damage: The Health and
Environmental Costs of War on Iraq

Medact

"In the U.S. war plan for Iraq, more than 3,000 guided bombs and missiles would rip military and leadership targets in the first 48 hours..."

Reuters, February 2, 2003

"The challenge of avoiding collateral deaths in Iraq is likely to be much greater than in Afghanistan, given the number of military targets in densely populated Baghdad and the Iraqi regime's apparent decision to embed military troops and installations within civilian neighborhoods... A significant source of civilian casualties in the Afghan theater that is likely to be a bigger concern in Iraq is the use by allied forces of cluster bombs..." [Cluster bombs have a wide scatter radius and "dud" bomb-lets if picked up by civilians may detonate on contact].

Holly Burkhalter, US Policy Director,
Physicians for Human Rights

"Estimates of the total possible deaths on all sides during the conflict and the following three months range from 48,000 to over 260,000. Civil war within Iraq could add another 20,000 deaths. Additional later deaths from post-war adverse health effects could reach 200,000. If nuclear weapons were used the death toll could reach 3,900,000. In all scenarios the majority of casualties will be civilians."

Collateral Damage: The Health and
Environmental Costs of War on Iraq

Medact, UK

"The LD50/60, the median lethal dose of radiation that will kill 50% of the exposed persons within 60 days, is 3.5 Gy when medical care is not instituted. Acute radiation syndrome has variable symptoms depending on the radiation dose, type, and individual sensitivity. The prodromal phase is marked by rapid onset of nausea, vomiting, and malaise. The latent phase follows and is relatively symptom free... Individuals exposed to 0.7 to 4 Gy will suffer bone marrow effects, with changes in the peripheral blood smear seen as early as 24 hours postexposure. Bone marrow suppression causes an increased risk of infection and anemia from 10 to 60 days postirradiation... Exposure to 6 to 8 Gy of radiation results in a GI syndrome. Hemorrhage, fluid loss, and diarrhea are common manifestations of the GI syndrome as the mucosa is denuded of functional cells after villi radiation damage. With concomitant injury to the microvasculature, shock can occur within 1 to 2 weeks... A neurovascular syndrome occurs in victims exposed to acute high-dose radiation of 20 to 40 Gy. In these cases the latent phase lasts only hours before the onset of symptoms. Clinically, these patients deteriorate into a coma resulting in death. Convulsions may or may not occur with few signs or symptoms to suggest an increased intracranial pressure. Exposure to this amount of radiation in a nuclear explosion would cause 100% lethality due to blast and thermal effects. With this level of exposure, survival is not likely."

Weapons of Mass Destruction: Radiation
Chris J. Neal, MD, Leon E. Moores, MD,
Pediatric Neurosurgery, National Capital
Consortium, Walter Reed Army Medical
Center, Washington, DC

"Despite repeated attempts to evaluate the humanitarian needs and set up aid programs in Iraq, MSF [Médecins Sans Frontières] has been unable to establish a presence in the country since the 1991-3 period when we assisted Iraqi Kurds fleeing government repression and provided medical aid in the southern parts of the country following the Gulf War. For MSF, genuine humanitarian aid must reach those most affected by the crisis and be delivered with no political strings attached. Unfortunately, MSF has so far not been successful in obtaining satisfactory guarantees from the Iraqi government that we would be allowed to independently carry out and monitor the delivery of our aid in order to ensure that it benefits those most in need."

Nicolas de Torrente,
Medecins Sans Frontieres

"The entire health sector has been profoundly degraded over this decade: lack of manpower and training, particularly in nursing; breakdown of infrastructure and inability to replace or repair equipment and acquire new technology; intermittent drug shortage; lack of transportation and weak communications. This has contributed to many professionals leaving the country and meant an impoverished and demoralized workforce. Salaries (physicians earn $20/month and nurses similarly) and working conditions discourage entry into the health professions, raising serious questions about the future of health care in Iraq. Private practice has now replaced much of the free medical care prior to 1990 and patients have reduced access to care, incomplete investigations, and more expensive treatment options. Preventable conditions are still common, due to a combination of marginal nutrition and poor water/sanitation. Diarrhea, typhoid fever, hepatitis, influenza and TB are common and chronic conditions such as mental illness, heart disease and cancer are increasing. International organizations, including Red Cross, CARE, and Premiere Urgence have assisted in some refurbishing of infrastructure in institutions, including water systems, but these remain unreliable due to power outages and drops in water pressure. Certain drugs (20% of essential drug lists) and much electronic and imaging technology continue to be blocked from entry by the UN 661 Committee."

Dying for Peace in Iraq: Disaster
Preparedness on the Brink of War

David Swann MD, FRCP; Physicians for
Global Survival, Canada; Amir Khadir MD,
FRCP; Medecins du Monde, Canada

"Collective violence is associated with an increase in homicide and other crimes, both during the phase of violence and thereafter, and has also been shown to lead to increased suicide rates in settings bordering civil wars. Experience of international war has been reported to make the use of violence within states more common. Data from Afghanistan and Cambodia indicate that a substantial proportion of those injured by weapons sustained their injuries for reasons which were unrelated to interfactional fighting and that use of weapons remains high in post-conflict settings where weapons remained generally available. These important interrelations, coupled with the fact that settings with generalised availability of military style weaponry tend to remain violently unstable, has led to increasing concern on the part of the international community around the effects of widespread availability of small arms and light weapons."

First World Report on Violence and Health
World Health Organization

"If, as some suggest, there is a war in Iraq come February, then the war will eclipse every other priority... People living with HIV/AIDS are in a race against time ... What they never imagined was that over and above the virus itself, there would be a new adversity and that adversity would be a war... Wars divert attention, wars consume resources, wars ride roughshod over external calamities..."

Stephen Lewis, Special UN Envoy to Combat
AIDS in Africa

"Physicians for Human Rights (PHR) is gravely concerned about the potential for loss of life on a large scale and serious risk to health and human rights of the Iraqi people and others in the region should a war ensue. We urge continued efforts to avoid war, but if a war is waged, we urge the US Government to take crucial steps to protect the civilian population and captured combatants through scrupulous compliance with international humanitarian law, including the Geneva Conventions, by prohibiting the use of antipersonnel landmines, through protection of Iraqi citizens against reprisals by their own government and care for refugees and displaced persons, and through provisions for the health needs of the people of Iraq and others who may be affected by the conflict."

Physicians for Human Rights, USA

"Health professionals worldwide care for the casualties of war. We accept this responsibility. However, it is also our responsibility to argue for prevention of violence and peaceful resolution of conflict. Staff and students of the London School of Hygiene and Tropical Medicine come from and work in over 120 countries, many in conflict. Our experience and evidence corroborate the views of the WHO, United Nations, and Medact. We believe that a war would have disastrous short, medium, and long term social and public health consequencesnot just for Iraq, but internationally. Conflict is rooted in inequality and unjust governance. Military intervention in Iraq, when there remain so many peaceful routes to disarmament, risks escalating collective violence. The WHO argues that conflict can be averted only by more equitable forms of development and by accountable, ethical governance internationally. We strongly support this perspective and believe that further acts of violence can be prevented by international and local governance that shows itself to be peaceful and ethical. For the reasons above, we oppose the use of military intervention in Iraq."

Carloyn Stephens, Senior Lecturer in
Environment and Health Policy, London
School of Hygiene and Tropical Medicine, UK

"On behalf of tens of thousands of American doctors, nurses, health professionals and scientists working together with concerned citizens, Physicians for Social Responsibility (PSR) calls upon all members of the United States Congress to vote against taking our great nation into war against Iraq."

Physicians for Social Responsibility, USA

"Tariq Aziz [Iraq's deputy prime minister] has just authorised Emergency to fly to Baghdad with a surgical and logistics team. We'll be there in a few weeks, with a small international staff of less than a dozen people. We don't need to build anything there. I expect we'll be given a hospital unit to run on our own... The situation here [in Kabul] is now relatively quiet. In the last 48 hours we have hospitalised eight people, mainly children and mostly injured by land mines. I'm not sure, though, that the last child we operated on will make it."

Gino Strada, MD, Founder, Emergency (by cell
phone from Kabul, Afghanistan, February 1, 2003)

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https://www.phrusa.org/ research/iraq/123102.html.

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https://bmj.com/cgi/ content/full/326/7382/230.

de Torrente N. Humanitarian concerns about a possible war on Iraq. Available at:
https://www.doctorswithoutborders.org/ publications/other/ opinion_detorrente_iraq.shtml.

Medact. Collateral damage: the health and environmental costs of war on Iraq. Available at:
www.medact.org/tbx/pages/sub.cfm?id=556

Neal CJ, Moores LE. Weapons of mass destruction: radiation. Neurosurgical Focus. Available at:
https://www.medscape.com/viewarticle/431313.

Physicians for Human Rights Policy Statement on War in Iraq. Available at:
https://www.phrusa.org/research/iraq/122302.html

Preparing for the worst [news]. BMJ. 2003;326:244. Available at:
https://bmj.com/cgi/content/full/326/7383/244.

PSR says vote no on preemptive war! Available at:
https://www.psr.org/RollCall_full.pdf.

Southall DP, O'Hare BAM. Empty arms: the effect of the arms trade on mothers and children. BMJ. 2002;325:1457-1461. Available at:
https://bmj.com/cgi/content/full/325/7378/1457.

Stephens C. Open letter to the Right Honourable Tony Blair, Prime Minister of the UK: public health and humanitarian effects of war on Iraq. Lancet. 2003;361:345. Abstract.

Stephens C. Open letter to Tony Blair: Call to prevent escalating violence. Available at:
https://bmj.com/cgi/content/full/326/7382/220

Swann D, Khadir A. Dying for peace in Iraq: disaster preparedness on the brink of war. Available at:
https://swann.activist.ca/view.php?id=0-4886

3,000 U.S. bombs, missiles would quickly hit Iraq. Reuters, February 2, 2003. Available at:
https://www.nytimes.com/reuters/politics/politics-iraq-usa-plan.html.

World Health Organization. First World Report on Violence and Health. Available at
https://www.who.int/violence_injury_prevention/main.cfm?p=0000000682

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https://www.medscape.com/viewarticle/446671

ANA Has Concerns About Smallpox Vaccination: A Newsmaker Interview With Cheryl Peterson, RN, MSN
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Notes From Afghanistan: Nursing in a War Zone
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On the Front Lines in the War on Terrorism: Clinicians Answer the Call https://www.medscape.com/viewarticle/438812

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Doctors of the World https://www.doctorsoftheworld.org/

Doctors Without Borders https://www.doctorswithoutborders.org/index.shtml

International Physicians for the Prevention of Nuclear War https://www.ippnw.org/

Medact https://www.medact.org/tbx/pages/

Médecins Sans Frontières https://www.msf.org/

Medical Association for Prevention of War https://www.mapw.org.au

Physicians for Global Survival https://www.pgs.ca/

Physicians for Human Rights https://www.phrusa.org/

Physicians for Peace https://www.physiciansforpeace.org/

Physicians for Social Responsibility https://www.psr.org/

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