Response to 2009 Question of the Year
Dr. Hagopian is senior workforce advisor, Health Alliance International, and faculty member, University of Washington School of Public Health, Seattle, Washington.
Mr. Ratevosian is U.S. field coordinator, Physicians for Human Rights, Boston, Massachusetts, and chair, Policy/Advocacy Committee, American Public Health Association's International Health Section, Washington, DC.
Ms. deRiel is communications and policy manager, Health Alliance International, Seattle, Washington.
Correspondence should be addressed to Dr. Hagopian, Health Alliance International, 4534 11th Ave NE, Seattle, WA 98105; telephone: (206) 543-8382; fax: (206) 685-4184; e-mail: (firstname.lastname@example.org).
Academics, more than most humans, are bent on gathering in groups to chatter about the events and discoveries in their disciplines and enjoy debating policy issues pertaining to their academic concerns. This inclination toward building academic civil society explains the proliferation of associations and our memberships in more than one of these groups. For example, any community pediatrician might belong to the American Medical Association, a state medical association, the American Academy of Pediatrics, and perhaps even the state or national public health association. The responsible academic physician, then, is paying dues, reading relevant journals, and attending conferences.
While academic medical and public health associations are excellent spaces to discuss new medical or public health discoveries or advance proven practices, they are also important places to launch courageous conversations that stretch our thinking about the roles of our professions in advancing human health in the context of a global world order.
War is arguably the largest threat to human health, although health professional associations rarely acknowledge it as such. Perhaps because war and the conditions that create it are considered “too political” or “beyond the scope of our mission,” our associations traditionally duck when it comes to challenging the decision to enter into a war. And yet, as a Lancet editorial pointed out earlier this year, the Hippocratic Oath and care for human life should make advocacy for the health needs of civilians during war more than just a humanitarian concern: “It is what being a member of the medical profession should be all about.”1 The editorial suggests that all doctors should call on their governments, “perhaps through their national medical organizations,” to ensure civilian access to medical attention.
While the direct mortality and morbidity rates resulting from armed conflict are the most visible assault on health created by war, remarkably, they may be the least important. More substantial are deaths and injury secondary to the displacement and the destruction of infrastructure important to the determinants of health, such as sanitation, education, transportation, environment, and health care facilities. The recent Global Burden of Armed Violence Report estimated that between 3 and 15 times as many people die “indirectly” for every person who dies violently in conflict.2 The most consequential effect of war, however, is the diversion of the immense treasuries of nations and their soldiers toward conflict and away from peace and social institutions.
Our associations set the standards for normal behavior and our professional values, and so what they do is important. Medical, nursing, and public health associations can and should do more than just advocate for health interventions once conflict has begun—they must take a stand for peace. Several sections and groups within the American Public Health Association (APHA), including the International Health Section, the Peace Caucus, the Environmental Health section, and others, proposed an extensive policy resolution for consideration by the governing council at its fall 2009 meeting.3 The intent was to change the dominant framework so that failing to act against war would be the more peculiar act of health professionals, rather than the opposite. The resolution also proposed that public health professionals engage in primary, secondary, and tertiary prevention of war—primary prevention before the commencement of armed conflict, secondary prevention to mitigate morbidity and mortality after the onset of armed conflict, and tertiary prevention to provide health services to the victims of conflicts and rebuild infrastructure.
The resolution also called on schools of public health to infuse their curricula with training on the public health consequences of war and on methods to prevent war. Practitioners were encouraged to conduct research on the effects of war and to develop new conflict prevention strategies. As the APHA is charged with demonstrating leadership on and advancing solutions for all threats to public health, the resolution called on the APHA policy team to engage its membership and policy makers on legislation related to the arms trade, ratifications of treaties and protocols related to war, military expenditures, financial and political engagement in multilateral peace operations, and in international development programs that address structural causes of war.
In answer to the question, “How should academic medicine contribute to peace-building efforts around the world?” we call on associations in each of the health professions to take stands similar to that of the APHA, aiming the considerable strength and influence of their associations to take on war and armed conflict—the greatest modern threats to human health—and, if we believe in the power of humans to control our own destinies, the most preventable of all the threats we face.
1 Violent conflict: Protecting the health of civilians. Lancet. 2009;373:95.