War and Health: Title and subTitle BreakFrom Solferino to Kosovo—The Evolving Role of Physicians

In the past century, the world has witnessed ongoing epidemics of armed conflicts and violations of international human rights, epidemics that have devastated and continue to devastate the health and well-being of humanity. Armed conflicts have claimed the lives of more than 100 million people in the 20th century, and increasingly, civilians have become the victims of war and internal conflicts.¹ Today, 90% of war-related deaths are civilians.¹ Torture, forced disappearance, and political killings are systematically practiced in dozens of countries,² and more than 100 million land mines threaten the lives and limbs of ordinary people.¹ In 1995, 1 in every 200 people in the world was displaced as a result of war or political repression.¹

Conceptualization of health and human suffering is often reflected in physicians' health practices and research.³ Since the concept of disease as the cause of human suffering has preoccupied the medical profession for most of the 20th century, it is not surprising that physicians' first organized responses to the consequences of war focused on restoring the physical integrity of the body. In 1859, after witnessing soldiers dying on an Italian battlefield from lack of medical attention at the Battle of Solferino, a Swiss citizen named Henri Dunant organized medical services for the wounded. Several years later, he helped initiate an international conference in Geneva, Switzerland, that led to the founding of the International Committee of the Red Cross and to the adoption of what later became the first of the 4 Geneva Conventions of 1949.⁴ The conventions, among other concerns, provide for the humane treatment of the sick and wounded in times of war.

During the past 30 years, physicians have remained in the forefront of humanitarian relief activities. The Biafra War of Secession in Nigeria (1967-1970) gave rise to the Doctors Without Borders movement, which has continued to grow. Subsequently, physicians and public health professionals have had the unfortunate opportunity to apply their skills and knowledge in a large number of increasingly complex emergency settings. In emergency situations as diverse as Cambodian refugees fleeing to Thailand to escape the murderous Pol Pot regime, Ethiopians fleeing to Sudan and Somalia to escape drought and crop failure compounded by oppressive land reform schemes, survivors of genocide in Rwanda seeking refuge in Zaire and Tanzania, and Bosnians and Kosovars expelled by Serbian forces, concerns for the health and well-being of refugees and the displaced have always been at the forefront. At first entirely curative in nature, health interventions have slowly evolved to include preventive measures. Public health nutrition in the form of therapeutic and supplementary feeding and increased attention to the quantity and quality of general rations of food-dependent populations has become an important discipline.⁵ Vaccination programs, targeted especially at the prevention of measles, have become reflexive activities of humanitarian interventions.⁵ This year, the InterAgency Working Group for Reproductive Health in Refugee Situations developed a field manual to promote key interventions to protect and improve the reproductive health of men, women, and adolescents in emergency and stable relief settings.⁶

In this issue of THE JOURNAL, 2 articles^{7 - 8} address another emerging public health problem—the mental health effects of war. During the last quarter of this century, researchers have begun to address this aspect of the health consequences of war. The evolution of curative humanitarian intervention to include individual and community mental health concerns reflects a parallel evolution in the conceptualization of health to include "physical, mental, and social well-being, and not merely the absence of disease or infirmity."⁹

The article by Mollica et al⁷ on mental health and disability demonstrates the importance of timely and culturally appropriate assessments of mental health in refugee settings and the impact that these conditions may have on individuals and their communities. That the comorbidity of depression and posttraumatic stress disorder is associated with higher levels of disability than in asymptomatic refugees or those with a single diagnosis emphasizes the need for effective individual and community interventions to alleviate these psychological conditions. Furthermore, such timely field research is more likely to contribute to subsequent in-country strategies to improve mental health than research conducted years later in countries of asylum.

The research by Neugebauer and colleagues⁸ on prenatal nutritional deficiency and the development of antisocial personality disorder suggests that the effects of war, in this case prenatal nutritional deficiency caused by wartime famine, may have long-term pernicious effects on the behavior of the subsequent generation. As the authors state, "the strength of the reported associations, the security of the temporal order, specificity of first and/or second trimester effect, and the coherence with findings in collateral research supports the view that early biological insults to the developing brain are implicated in antisocial behavior." Although the limitations acknowledged in the article preclude a causal relationship, the findings warrant further examination of questions such as the following: Does this association exist in other situations of maternal starvation, such as in developing countries and among refugee populations fleeing natural disasters as well as conflict and war? What factors are associated with the development of antisocial personality disorder in populations in which maternal starvation is not present?

Although both articles address important aspects of the health effects of war, it is essential to recognize that additional concerns must be acted on to effectively restore and promote health in the aftermath of war. For example, fundamental community structures, including families, schools, places of worship, and employment opportunities, must be established so that those affected by war can be reintegrated into a sound, functioning community.¹⁰ Perhaps most important, the goal of alleviating suffering and promoting health depends on preventing acts that undermine the dignity and worth of individuals and their communities.

Physicians' efforts to document the health consequences of war and human rights violations have gained momentum in recent years. Increasingly, physicians and other health care professionals are realizing that promoting conditions for health often requires the protection and promotion of human rights.^{3 ,11 - 13} This perspective has enabled physicians to achieve considerable success in promoting the health of individuals and humanity as a whole, and physicians have been recognized by the international community for their efforts. For example, in 1985 the International Physicians for the Prevention of Nuclear War received the Nobel Peace Prize for spreading authoritative information and creating an awareness of the catastrophic consequences of nuclear warfare.¹⁴ Also, Physicians for Human Rights was one of the corecipients of the 1997 Nobel Peace Prize for its contribution to the International Campaign to Ban Landmines.¹⁵

In the past 10 years, physicians have applied their knowledge and skills to document the health consequences of human rights violations and to advocate, as nonpartisans, for effective remedies.¹⁶ Documenting human rights violations is important to establish responsibility for criminal acts, identify possible reforms, and ultimately prevent future abuses. The work traditionally has involved collecting case testimonies and raising awareness among policy makers and the public. However, such methods are not adequate to establish both the patterns and extent of abuses within specific populations.

For example, in the recent crisis in Kosovo, journalists and human rights researchers investigated, documented, and reported many individual accounts of human rights violations taking place in Kosovo, but these accounts did not describe well the frequency of such violations in the population of Kosovar refugees. Consequently, representatives of Physicians for Human Rights and the Program on Forced Migration and Health of the Columbia School of Public Health conducted a population-based study to establish patterns of human rights violations among Kosovar refugees by Serbian forces.¹⁷

In that study, 1209 Kosovar refugees randomly selected from 31 refugee camps and collective centers in Albania and Macedonia were surveyed between April 19 and May 3, 1999. The survey assessed human rights abuses among 1180 participants representing a total of 11,458 household members that occurred while the respondents were living in Kosovo. The findings demonstrated that Serbian forces engaged in a systematic and brutal campaign to forcibly expel the ethnic Albanians from Kosovo. Ninety-one percent of participants reported that they were forced, directly or indirectly, to leave their homes simply because they were Kosovar Albanians. Only 5 of the 1180 participants (0.4%) cited the Kosovo Liberation Army as the cause of their displacement. Contrary to Serbian media reports, not 1 survey participant cited the NATO (North Atlantic Treaty Organization) bombings as a reason for displacement from his or her home.

In the course of these mass deportations, and during the past year in Kosovo, Serbian forces committed widespread violations of human rights against ethnic Albanians. One in every 3 households (31%) reported at least 1 of the following abuses among their household members: beating, killing, torture, separation and disappearances, threat at gunpoint, shooting, and sexual assault. Participants reported that these abuses occurred in 23 of the 29 municipalities of Kosovo, and that more than half of the abuses (58%) occurred in March and April of 1999. In addition, approximately 1 of 5 respondents had seen medical facilities that had been destroyed or had witnessed Serbian police or soldiers expelling patients and medical personnel from medical facilities or using medical facilities for military purposes.¹⁷

The findings of this study provide crucial information for policy makers, prosecutors of war crimes, and the public. The study illustrates how physicians and other health care professionals can work to address causes of human suffering and promote the health of communities by protecting and promoting human rights.

Throughout history, society has charged physicians with the duty of understanding and alleviating human suffering. As we enter the 21st century, the nature and extent of human suffering has compelled health care professionals to redefine their understanding of health and the scope of their professional interests and responsibilities. Despite a century of technological progress, war and political violence continue to undermine the health and well-being of the world community.

Health care professionals have a responsibility to protect and promote human rights. When the devastating health consequences of human rights violations are considered, promotion of human rights may be the most effective means of providing the conditions for health and well-being in a civil global society. Ultimately, that society must recognize and preserve the inherent dignity and equal and inalienable rights of all members of the human family as the foundation of freedom, justice, and peace in the world.¹⁸