160421middletonj bcu course

Armed organised conflict
and public health
Professor John Middleton
Honorary Professor Public Health
Wolverhampton University,
President Elect, UK Faculty of Public
Health

Medical Peace Work
Online Course 1
Health professionals, conflicts and peace

Definition of Public
Health
What we, as a society, do
collectively to ensure the
conditions in which people
can be healthy.
The Future of Public Health
Institute of Medicine, 1988

Public health:
‘promoting health, preventing disease, prolonging life through the
organised efforts of society’
Sustainable development:
‘protecting resources from one generation to the next’
Environmental justice:
‘the pursuit of equal justice and equal protection under the law for all
environmental statutes and regulations without discrimination based on
race, ethnicity, and /or socioeconomic status.’
Security:
freedom from danger, social, military, environmental

War
War has an enormous and tragic impact -- both
directly and indirectly -- on public health. War causes
death and disability, destroys families, communities,
and the environment, diverts resources and destroys
infrastructure needed for human and health services,
limits human rights, and often begets further violence.
(War and Public
Health, 2000)

What is violence?
Definition by World Health Organization:
Violence is the intentional use of physical force or
power, threatened or actual, against oneself, another
person, or against a group or community, that either
results in or has a high likelihood of resulting in injury,
death, psychological harm, mal-development or
deprivation.
(WHO, 2002:5)

What is “Terrorism”?
In Terrorism and Public Health, 109
definitions of “terrorism” were analyzed;
the most common definitional elements
were violence, force, political and
fear.
“Politically motivated violence or the
threat of violence, especially against
civilians, with the intent to instill fear.”

Meaning of “Terrorism”
Use of the term “terrorism” is political.
U.S. Government definition of terrorism is
limited to acts by individuals or non-
governmental groups. Acts of violence or
the threat of violence against civilians
with the intent to instill fear by nation-
states are considered by the United States
to be “acts of war” rather than “terror.”

Armed organised violence
,
In what ways might Public
Health England consider
terrorism to be a public health
issue?

Public health effects of war
Public Health: concerned with the health of the community as a whole
immediate effects of violent conflict are increase in death and injury
fires in refugee or displaced persons camps
epidemics and communicable diseases
displacement, disruption and debilitation
lack of food security and malnutrition
mental health problems
lack of drugs for treatment of disease

Timing of peace work
 Primary prevention
 Risk factors ↓
 Protective factors ↑
 Secondary prevention
 Early warning
 De-escalation
 Conflict handling
 Tertiary prevention
 Reconstruction
 Resolution
 Reconciliation

Primary prevention of public
health damage due to
terrorism

Terrorism and public health; John Middleton
Article 1
APHA
Address poverty, social injustice, and health disparities that may contribute to the development
of terrorism.
Article 2.
Provide humanitarian assistance to, and protect the human rights of, the civilian populations
that are directly or indirectly affected by terrorism
Article 3.
Advocate the speedy end of armed conflicts and promote non-violent means of conflict
resolution. [ to prevent circumstances in which terrorism may arise and be seen as the only
way out viz Iraq,Chechnya]
Article 10.
Prevent hate crimes and ethnic, racial, and religious discrimination; promote cultural
competence and diversity training, and dialogue among people and protect human rights and
civil liberties;
Article 11. Advocate the immediate control and ultimate elimination of biological, chemical and nuclear
weapons;
Authors’
addition 1
Promote sustainable development to ensure the appropriate and fair use of resources and the
protection of the environment minimising conditions of injustice to which terrorism may be a
response
Authors’
addition 2
Strengthen international laws and respect for international law amongst politicians. Strengthen
the resources available to the United Nations for peacekeeping purposes and strengthen the
mandate of the United Nations, to create binding and enforced international laws.
American Public Health Association Guiding principles of the public health response to terrorism October
Primary prevention 2001

Policies and Practices Adversely
Affecting Societal Health Conditions
War / Violence
Global warming / Environmental damage
Failure to provide health services
Corruption of government or culture
Erosion of civil liberties and freedoms
Restriction of education, research, discourse

Secondary prevention of public
terrorism

American Public Health Association Guiding principles of the public health response to terrorism October 2001
Secondary prevention
Article 2. Provide humanitarian assistance to, and protect the human rights of, the civilian populations
that are directly or indirectly affected by terrorism
Article 4. Strengthen the public health infrastructure (which includes workforce, laboratory and
information systems) and other components of the public health system (including
education, research, and the faith community) to increase the ability to identify, respond to,
and prevent problems of public health importance, including the health aspects of terrorist
attacks.
Article 6. Educate and inform health professionals and the public to better identify, respond to, and
prevent the health consequences of terrorism, and promote the visibility and availability of
health professionals in the communities that they serve.
Article 7. Address mental health needs of populations that are directly or indirectly affected by
terrorism
Article 9 Assure clarification of the roles, relationships and responsibilities among public health
agencies, law enforcement and first responders;

Preparedness planning/
‘resilience’
Resilience has come to mean the overall ability of public
services and communities to respond to and deal with
‘all risks’ of civil, environmental, communicable disease
disasters and breaches of security.

Tertiary prevention of public
terrorism

American Public Health Association Guiding principles of the public health response to terrorism
October 2001
Tertiary prevention
Article 5. Ensure availability of, and accessibility to, health care, including medications and vaccines, for
individuals exposed, infected, made ill, or injured in terrorist attacks;
Article 7. Address mental health needs of populations that are directly or indirectly affected by terrorism
Article 8. Assure the protection of the environment, the food and water supply, and the health and safety of
rescue and recovery professionals;
Article 12 Build and sustain the public health capacity to develop systems to collect data about the health
and mental health consequences of terrorism and other disasters on victims, responders, and
communities, and develop uniform definitions and standardised data-classification systems of
death and injury resulting from terrorism and other disasters.
Authors’
addition 3
Promote sustainable development in order to enhance resilience in the light of a terrorist action

The Role of Health Workers
in the Prevention of War
-- Addressing the Underlying Causes
of War and Terrorism
-- Controlling the Weapons
-- Promoting a Culture of Peace
-- Promoting Peace Through Health

‘Armed organised violence’
‘Armed organised violence’ vs ‘terrorism’ ?
What wider examples might this encompass?

Commonly-Accepted
Examples of “Terrorism”
Small arms and light weapons: Munich
Olympics; Basque separatists;
Explosives: Irish Republican Army; Middle East;
Oklahoma City; Embassy Bombings; USS Cole;
Attacks on WTC and Pentagon
Chemical weapons: Sarin in Tokyo subway
Biologic weapons: Salmonella in Oregon;
Anthrax dissemination in the U.S.

Less-Accepted Examples
of “Terrorism”
Assaults on abortion services in the U.S.
Bombing of Guernica, Warsaw, Rotterdam, Coventry,
London, Dresden, Hamburg, Tokyo, Hiroshima,
Nagasaki
Sanctions against Iraq
Bombings or invasions to destroy “terrorists” and their
infrastructure or to kill or topple national leaders

Bombs dropped by a
U.S. B-17 Flying
Fortress in northern
Germany, January,
1945
Photograph from
BIPPA
New York Times
Magazine, 3/20/03
Bombs dropped by a
U.S. B-17 Flying
Fortress in northern
Germany, January,
1945
Photograph from
BIPPA
New York Times
Magazine, 3/20/03

 US detonated a second
bomb over Nagasaki,
Japan, on August 9, 1945
 73,884 immediate deaths
 74,909 injuries
 6.7 million square metres
(2.6 miles) leveled
Deaths/Injuries in Nagasaki — 21-kt BombDeaths/Injuries in Nagasaki — 21-kt Bomb

Collapse of the Communist bloc/
end of the Cold War
 Did it deliver a peace dividend?
 Imbalance of terror?
 Redistribution of small arms
 Disseminated potential for chemical, biological, radiological and
nuclear weaponary
 Environmental terror
 Cyber terror ?
 New world insecurity
 Reduced civil liberties?


Association of Schools of Public
Health delegation to Gaza June
2015
Middleton J. Cement: Gaza’s
forgotten public health need.
BMJ Blog, July 8th
2015.
http://blogs.bmj.com/bmj/2015/07
Middleton J. Vimeo slideshow
ASPHER delegation to Gaza.
https://vimeo.com/133947395
Wafa rehabilation
hospital , destroyed
2014

Other lessons (less optimistic)

RSM Health in Gaza: Prof John Middleton. Partnership working for better health in
Gaza
Other lessons (less optimistic)
The West Bank is more exposed …..

‘Armed organised violence’
Taking a salutogenic perspective:
What might be a positive alternative to ‘preventing
violence’?

Notions of peace
 State of tranquillity or quiet within a community
 Freedom from civil disturbance
 State of security or order provided for by law or custom
 Freedom from disquieting or oppressive thoughts or
emotions
 Harmony in personal relations
 State or period of mutual concord between governments
 Pact or agreement to end hostilities between those who have
been at war or in a state of enmity
(Merriam-Webster Online Dictionary)

A holistic concept of peace
1. Peace as the negation of violence
 Health disease = peace violence↔ ↔
 Peace is relative
 Peace is subjective
 Peace grows as violence diminishes
fredpeace
violence

A holistic concept of violence
Different forms of violence
Direct: use of physical or mental power
Structural: socioeconomic or political system
Cultural: justifying parts in religion, ideology, art, science
and language
Different levels
Collective, interpersonal,
and self-induced (WHO)
Mega, macro, meso, and micro (Galtung)
Direct
violence
Structural
violence
Cultural
violence
Micro level
Macro level

Negative
peace
Positive
peace
• Absence of war
• Absence of terror
• Absence of human rights
violations
• Absence of interpersonal
violence and suicide
• Individual and social harmony
• Development and justice
• Fulfilment of basic needs
• Human security

2. PEACE as a state of complete harmony
HEALTH is not merely the absence of disease or infirmity, but
a state of complete physical,
mental and social well-being. (WHO)
PEACE is not merely the absence of violence, but …

Typology of positive peace
Direct peace
loving, harmonious acts to elicit the good in each other
Structural peace
equitable, horizontal relations
Cultural peace
religion, ideology, science, art, language promoting
direct and structural peace
(adapted form Galtung, 1996:33)

Good health: strong immune system and quick recovery
Peace: capacity to handle conflicts with empathy, creativity
and by non-violent means
(Galtung 2002:8)
3. Peace as the capacity to handle conflict

What is conflict?
 clash of incompatible goals
 neutral, potential to positive change
 always and everywhere
 from micro to macro level
ABC-triangle of conflict
(Galtung 1996)
content
behaviourattitude

Four stages of conflict (Mitchell, in Large 1997:5-6)
Conflict
can move towards escalation or de-escalation

Violence
turns conflicts into “big problems”
does not lead to just and sustainable peace
Peace - the capacity
to handle conflict
attitude
content
behaviour
aggressiveness aggression
win or loose
creativity
empathy non-violence

What is peace work ?
Peaceful interventions
to reduce or abolish direct,
structural or cultural
violence
to build harmonious, mutual
beneficial relations and
structures
to strengthen the peace
capacity of individuals and
societies
Direct
peace
Structural
peace
Cultural
peace
Micro level
Macro level
Direct
violence
Structural
violence
Cultural
violence
Micro level
Macro level

Peaceful means for social change
Non-violent protest and persuasion
 a picket line or a peaceful demonstration
Social non-cooperation
 students on strike
Economic non-cooperation
 disinvestment, sanctions and boycotts
 workers taking strike action
Political non-cooperation
 Gandhi’s call on civil servants in the British administration of India to
stop working
Non-violent intervention
 the Freedom Flotilla that took medical equipment, food, building
material, and other necessities to Gaza

A public health
approach to violence
prevention and conflict
resolution

A public health approach to
violence
From problem identification to
effective response
Define the problem:
Data collection,
surveillance
Identify causes:
Risk factor
identification
Develop and test
interventions:
Evaluation research
Implement
interventions,
measure
effectiveness:
Community
intervention,
training, public
awareness
(Adapted from: Mercy et al. 1993)

Violence – a public health
problem
“Violence is often predictable and
preventable. Like other health
problems, it is not distributed evenly
across population groups or settings.
Many of the factors that increase the
risk of violence are shared across the
different types of violence and are
modifiable.”
Gro Harlem Brundtland
(WHO 2002)

Why do health professionals deal with
peace issues?
1. Violence as a public
health problem
2. Health professionals at
risk of committing
violence
3. Health work can worsen
a conflict situation
Estimated global deaths by
direct violence in year 2000
Homicide 520 000
Suicide 815 000
War-related 310 000
Total 1 659 000
(WHO 2002:10)

FPH Statement on violence prevention and
the role of public health
‘Security’- ‘freedom from danger’
Bio security
Food security
Environmental security
Freedom from fear of violence
Freedom from violence
Military security

Identification of risk factors
Violence as the result of a complex interplay of risk and
protective factors on many levels
An ecological model(WHO 2002)

Shared risk factors for interpersonal violence
 Individual:
Victim of child maltreatment, personality disorder, alcohol/substance abuse, history
of violent behaviour
 Relationship:
Poor parenting, marital discord, low socioeconomic household, violent friends
 Community:
Poverty, high crime levels, high residential mobility, high unemployment, local illicit
drug trade, weak institutional policies, inadequate victim care
 Societal:
Rapid social change, economic inequality, gender inequality, policies that increase
inequalities, poverty, weak economic safety nets, poor rule of law, high firearm
availability, war/ post-war situation, cultural violence

FPH Statement on violence prevention and the
role of public health….
Violence child abuse
Domestic violence
Community violence / hate crime
National and international violence / hate crimes

FPH Statement on violence prevention
and the role of public health
A life course approach
A public mental health approach
An asset based community development approach
An evidence based policy and intervention approach….

Violence prevention interventions with some
evidence of effectiveness
Key:
• Well supported by evidence
(multiple randomized
controlled trials with different
populations)
◦ Emerging evidence
Type of violence:
- CM: Child maltreatment
- IPV: Intimate partner violence
- SV: Sexual violence
- YV: Youth violence
- EA: Elder Abuse
- S: Suicide and other forms of
self-directed violence

FPH Statement on violence prevention
and the role of public health
A real politik approach?
Power may be the only reality-
Political
Economic
Religious

Global Campaign for Violence
Prevention
www.euro.who.int/violenceinjury
www.who.int/violence_injury
www.who.int/gender

Mechanisms of medical peace
work
1. Redefinition of the situation
2. Superordinate goals
3. Mediation and conflict transformation
4. Dissent and non-cooperation
5. Discovery and dissemination of knowledge
6. Rebuilding the fabric of society
7. Solidarity and support
8. Social healing
9. Evocation and extension of altruism
10. Limiting the destructiveness of war
(Santa Barbara and MacQueen 2004)

Addressing structural violence

Fairer and
more sustainable
global health…

The Gini coefficient
- measuring inequality within societies

Poverty, inequality & violence
Local forces – poverty
Global forces – colonialism & globalisation
Ethnicity
Poverty, inequality & economic development
Political factors – social contracts & democracy
The international dimension
The underlying causes of civil war
The underlying causes of structural violence

Priorities for action on health systems
More funding for developing countries
No user charges – public funding
Better pay, working conditions and
prospects for health workers

All based on an
unsustainable
economic model
consumerism
status
trust
social cohesion
Unequal societies are
less sustainable

Income to improve health
– what’s the evidence?
L
I
F
E
E
X
P
E
C
T
A
N
C
Y
INCOME

The world map reflecting production related to climate change. “Climate
Change presents the biggest threat to health in the 21st
Century” The Lancet (373;9697 pp 1659-1734, May 16-22 2009).
Who produces the greenhouse gases?

Who bears the burden?
The world map reflecting mortality related to climate change. “Climate
Change presents the biggest threat to health in the 21st
Century” The Lancet (373;9697 pp 1659-1734, May 16-22 2009).

Climate change and war, conflict over scarce
resources
Conflict over unfair resources
Conflict over destroyed environments

From Alcamo and Heinrichs, 2002. In: Dialogue on Water and Climate, 2003.
Water critical regions
Medium water stress today & future increase in stress plus
HDI>0.8
A2 scenario, ECHAM4, 2020s

COP21 Paris Agreement
‘Climate complacency’

In the decade between 2001 and 2011, global military
spending increased by an estimated 92 percent, according
to
Stockholm International Peace Research, although it fell by 1.9
International Peace Bureau (1), almost 10 gigatons of carbon d
Global Carbon Project, 2014 emissions are set to reach a reco

Opportunity cost
The cost of liberty is less
than the price of
repression
The cause of war is the
preparation for war
WE Burqhart Du Bois

Thank you
John Middleton
Johnmiddleton@phonecoop.coop

APPENDIX1
WEAPONS OF WAR -MASS DESTRUCTION, CBRN, SMALL
ARMS, HAND GUNS, SEXUAL VIOLENCE

Characteristics of nuclear weapons
 Purpose: to threaten to kill massive numbers of
people in order to prevent attack (deterrence)
 Much greater destructive power than
conventional weapons
 Explosion created by
splitting atoms and chain
reaction, releasing massive
amounts of radiation

Nuclear weapons –
effects on health and environment
Flash  retinal injury, blindness
Fireball  Heat wave  vaporizes everything within
certain distance  third-degree burns
Blast  destroys buildings  mechanical injuries,
lacerations, ruptures organs, eardrums
Firestorms  hurrican-like winds, infernos  people are
incinerated  climate change
Fallout  acute radiation sickness  cancer, genetic
damage, weakening

Nuclear weapons - use scenarios and effects
1. Accidental nuclear war
2. Large-scale nuclear attack
3. ‘Limited’ nuclear exchange
4. Attack on hardened,
underground target
5. ‘Unauthorised’ use

Nuclear weapons - other medical, environmental
and social effects
Climate change
Nuclear tests
Production of
nuclear weapons
Nuclear fuel cycle
Costs of maintaining
arsenals

Biological weapons
Characteristics
Uses living (micro) organisms to cause disease or
death in large numbers of people, plants or animals
Organisms should multiply in target
Infection should take hold and infect others
Also toxins made by organisms or plants
Can be lethal or ‚non-lethal‘
Best known examples:
anthrax bacteria and small-pox virus

Biological weapons - health effects
Anthrax: bacterial agent, not contagious, lethal if
inhaled
Smallpox: highly contagious viral agent, very
high death rate, travels easily through air
Plague: highly contagious bacterial agent,
incubation period of 1-5 days, causes potentially
lethal pneumonia
Ebola: fever caused by viral agent, no cure or
treatment, extremely lethal, leads to bleeding from
all orifices
Botulinum: toxin, causes lethal muscular paralysis

Biological weapons - legal status
Outlawed by treaty: Biological and Toxins
Weapons Convention (BTWC)
all development or production of biological
weapons outlawed
Problems: advances in bioscience, and lack of a
verification system

Chemical weapons
 Nerve agent: highly lethal, kills in very small
dosages (e.g. sarin, soman, VX)
 Blistering agent: causes burns and blisters on
the body, damages eyes; If inhaled severely
damages lungs, often leading to death (e.g.
mustard sulphurous gas, lewisite)
 Asphyxiating agent: causes damage to
lungs (e.g. phosgene, mustard gas)
 Psychotomimetic agent: causes a
hallucinatory effect similar to LSD (e.g. BZ)
 Incapacitating agent: relies on irritants and
toxic effects to incapacitate a person
temporarily (e.g. tear gas, CS gas)

Chemical weapons - control regime
Chemical Weapons Convention (CWC) came into effect in
1997
188 parties to treaty, but Egypt, Israel, North Korea and
Syria not yet signed
Problems:
- pace of destruction of stockpiles
- verification not taken seriously
- no challenge inspections
Definitions of banned
weapons problematic,
many not prohibited

Radiological weapons
Radiological dispersal weapons: „Dirty
Bombs“ disperse radioactivity by detonating
explosives surrounded by nuclear material.
Nuclear facilities: Nuclear reactors,
nuclear transports and waste storage can be
turned into weapons through deliberate
attack.
Uranium weapons: containing depleted
uranium for use against tanks

Radiological weapons
- measures to deal with threat
Best measure is prevention, i.e. guard against theft
Transfer and export control regime: multilateral
Convention on the Physical Protection of Nuclear
Material (1980)
IAEA Code of Conduct on the Safety and Security of
Radioactive Sources
Protect nuclear reactors against
sabotage including
attack with planes
Ban uranium weapons

Landmines and cluster
munitions
90% of landmine victims are civilians
destroy infrastructure, make fields useless, and
prevent refugee return
cause disability, demoralization, unemployment,
social stigmatization and economic hardship for
families and communities
women victims suffer more,
higher death rate
disproportionate number of
victims are children

Small arms and light weapons
(SALW)
SALW include handguns, assault rifles, machine guns,
grenades and landmines
cause the majority of deaths in violent conflict globally
639 million small arms globally, or approximately one for
every ten people on earth
direct death toll due to SALW range from 80 000 to 500
000 per year, most in developing world
3-4 times this number of people are injured

’Non-lethal’ weapons (NLWs)
designed to incapacitate people or disable equipment,
minimal collateral damage
intended to be discriminate and not cause unnecessary
suffering
effect on people should be temporary and reversible
should provide alternatives to/ raise the threshold for use
of lethal force
actual use of NLWs shows that none
of the above are guaranteed, having
exactly the opposite effect to that
intended

Rape as a military strategy
Sexualized violence: „a sexual expression of aggression“
includes rape, sexual degradation, humiliation and violence to
breasts and genitals, forced prostitution and trafficking
abuses used in war to attack the body in order to break the spirit,
gender-specific
Trauma: attack on victim’s innermost
self and personality, often lead to
PTBS, psychosomatic disorders,
phobias, suicide
Physical consequences: injury,
pregnancy, infection, HIV, hormonal
dysfunction

References
 Arya N, Cukier W (2004). The international small arms situation: a public health approach. In
Mahoney P et al. (eds). Ballistic trauma: a practical guide. New York, Springer-Verlag.
 Barnaby W (1997). Biological weapons: an increasing threat. Medicine, Conflict and Survival 14:301-
313.
 Davey B (2004). Public health response to biological and chemical weapons. World Health
Organization.
 International Physicians for the Prevention of Nuclear War (2010). Zero is the only option.
 Jenssen C et al. (2002). Medicine Against War. In Taipale I et al. (eds.) War or Health? A reader. Zed
Books, London: 8–29.
 Joachim I (2004a). Sexualized violence in war and its consequences. In Violence against woman in
war: handbook for professionals working with traumatised women. Cologne, medica mondiale.
 Leaning J (2000). Environment and health: 5. impact of war. Canadian Medical Association Journal
163(9):1157-61.
 Lewer N (2002). New technology: non-lethal weapons. In Taipale I (ed.) War or health? A reader.
London, Zed Books.
© medicalpeacework.org 2012
Author Xanthe Hall, editors Mike Rowson and Klaus Melf, graphic design Philipp Bornschlegl

Appendix 2
Adverse consequences of the war on terror

Injurious and/or Ineffective
Responses
Actions intended for infection control may
be injurious and/or ineffective. Examples
include anthrax immunization, which
causes adverse reactions and is considered
experimental when used to prevent
inhalation anthrax; and smallpox
vaccination, which causes adverse
reactions and and is likely to be unneeded.

Direct Adverse Effects of
Response
Consequences of inappropriate nature of
warnings
Consequences of hazardous immunization
Consequences of inappropriate use of
antibiotics
Consequences of isolation and quarantine

The Power of Fear
Early and provident fear is the mother of safety.
Edmund Burke
Speech in the House of Commons
May 11, 1792
Let me assert my firm belief that the only thing we
have fear is fear itself -- nameless, unreasoning,
unjustified terror which paralyses needed efforts to
convert retreat into advance.
President Franklin D. Roosevelt
Inaugural Address, March 4, 1933

Constraints on Civil Rights
Model State Emergency Health Powers Act
USA Patriot Act
Homeland Security Act

Diversion of Resources -- U.S.
Protection From Chemical Accidents and Infectious
Diseases
Each year in the United States:
– 60,000 chemical spills, leaks, explosions, 8000
“serious,” with over 300 deaths
– 76 million episodes of food-borne illness,
325,000 hospitalizations and 5000 deaths
– 110,000 hospitalizations and 20,000 deaths
from influenza
– 40,000 new cases and 10,000 deaths from
HIV/AIDS

“Smallpox Planning Detracts from Core
Public Health, Officials Say” AP, 4/5/03
“The Homeland Security push to make local health districts
the first defense against bioterrorism, together with
shrinking health budgets, have contributed to Seattle’s
worst tuberculosis outbreak in 30 years,” said Dr. Alonzo
Plough, public health director for Seattle-King County. “It
has forced tradeoffs in everything we do.”

Diversion of Resources -- International
Investment in international public health can help
provide protection against diseases rooted in poverty, in
ignorance, and in absence of services.
In India in 1999 there were two million new cases of
tuberculosis, causing about 450,000 deaths. Effective
treatment of tuberculosis in India costs about 15 US
dollars per person treated
The United Nations has estimated that about 10 billion
US dollars invested in safe water supplies could reduce
by a third the current 4 billion annual cases of diarrhea
that result in 2.2 million deaths.

Addressing structural violence
APPENDIX 3

Poverty & structural violence
The factors underlying poverty:
Lack of income & assets
Powerlessness
Vulnerability
“Poverty is pain; it feels like a
disease. It attacks a person not
only materially but also morally.
It eats away one’s dignity and
drives one into total despair”
(Narayan et al 1999)

Poverty, inequality
& economic development
Possible links between underdevelopment, poverty
& violent conflict:
- Collective grievance & a desire for change
- Long term deprivation & lack of growth
- Extraction economies & the natural
resource curse

Political factors & the causes of civil
war
 State strength
 The social contract
and democracy??
”The most reliable path to stable domestic peace
in the long-term is to democratize as much as possible”
(Hegre 2001:44)

The international dimension
Effects of colonialism
The Cold War
The ’war on terror’
International economic factors
Foreign investment & trade
International aid

Responding to structural violence at
the national level
Increasing people’s incomes & capabilities:
 Investing in public administration, human capital &
key infrastructure
by
 cutting waste, redistribution, stimulating growth
but
richer countries need to provide more
resources

Improving the health sector - one of the key actions
to improve life expectancy
 Comprehensive primary health
services, publicly funded through
increased allocations
 An emphasis on mother and
child health, and immunisation
 Well trained health workers,
adequately paid and rewarded
particularly for unpopular work
Regulation of the private sector
Other key measures include education, ensuring minimum
nutritional levels are met, water & sanitation and reducing
inequities.

Interventions reducing structural violence
Negative effects Possible Remedies
Trade-poverty trap More pressure on WTO
Barriers to medicines Campaign on TRIPS+ & for
new R&D regime
Arms trade Stop profiting from arms trade
Trade directly supports war Regulation
Vulnerability to international
financial flows & debt
Financial regulation
Cancel and restructure debt
Aid given for donor interests Better managed aid

violence through healthviolence through health
systemssystems
Health systems: ‘all activities whose primary purpose is to

References
 Hegre H et al. (2001). Toward a democratic civil peace? Democracy, political
change and civil war, 1816-1992. American Political Science Review 95(1): 33-
54.
 Narayan D et al. (1999). Voices of the poor: can anyone hear us? Washington
DC, World Bank.
 WHO (2000). The world health report 2000 - Health systems: improving
performance. Available at www.who.int/whr/2000/en/, accessed 10 October 2011.
 WHO (2007). Healthy life expectancy (HALE) at birth (years). Available at
www.who.int/whosis/indicators/2007HALE0/en/, accessed 30 September 2011.
© medicalpeacework.org 2012
Author Marion Birch, editors Mike Rowson and Klaus Melf, graphic design Philipp
Bornschlegl

Appendix 4
Climate chaos, planetary
health and COP21

CARBON EMISSIONS PER CAPITA, 1999
Tons of carbon
per year
<1
9 - 15
1-3 3-9
>15 No data
Source. WRI, 2002

Band of historical
climatic variability
20
15
1900 21002000
14
16
17
18
13
19
Average Global
Temperature (O
C)
Year
205019501860
Low
High
Central estimate = 2.5 o
C
(+ increased variability)
IPCC (2001) estimates
a 1.4-5.8 o
C increase
This presents a rate-of-change
problem for many natural
systems/processes

SUMMARY
[1] There is strong evidence that greenhouse gas
emissions from the burning of fossil fuels are changing
the global climate
[2] The projected rate and magnitude of change will have
adverse impacts on ecological systems and populations
in many regions, especially in low income countries
where the capacity to adapt is limited
[3] The challenge is to ensure more equitable but
sustainable development that enables human societies
to live within the Earth’s regenerative capacity

Rockefeller Lancet
Planetary Health
commission

Climate Change occurring faster
than expected?
 IPCC’s 5th
Assessment Report
 Increasing rates of:
Global Greenhouse Gas emissions
Ice melting (Arctic sea ice, Greenland/Antarctic ice-sheets,
alpine glaciers)
Sea level rise
Carbon stored in permafrost = x2 atmospheric carbon

The UK government has even imposed a
legal obligation upon itself, under the
Infrastructure Act 2015, to
“maximise economic recovery” of the UK’s oil and gas

Conclusions
Policies that address both public health and climate change
are more attractive than focusing on either in isolation.
The health gains associated with climate change mitigation
policies should feature in Climate Change negotiations
A ‘low carbon’ world could be a healthier world and a more
secure world

Action now…
1. SDC Good Corporate Citizenship
toolkit
 www.corporatecitizen.nhs.uk/
1. NHS Carbon Trust Management
Programme
 http://www.carbontrust.co.uk/carbon/publicsector/nhs/
1. Sustaining a Healthy Future
 www.fph.org.uk
1. NHS Confederation briefings
 http://www.nhsconfed.org/Publications/briefings/Pages/Briefings.aspx
1. NHS Carbon Reduction Strategy
and 2030 health care scenarios
 www.sdu.nhs.ukSee notes of this slides for some of the most important specific actions

References
 Climate and Health Council (www.climateandhealth.org)
Global health, global warming, personal and professional
responsibility, Cambridge Medicine, Pencheon D, Vol 2, No 22,
2008
 Stott R, Healthy response to climate change, BMJ
2006;332;1385-1387
 Gill M, Why should doctors be interested in climate change?
BMJ Jun 2008; 336: 1506
 Griffiths J, Alison Hill, Jackie Spiby and Mike Gill, Robin Stott Ten
practical actions for doctors to combat climate change, BMJ
2008;336;1507
 Sustaining a healthy future: www.fph.org.uk
 Griffiths J et al, The Health Practitioner's Guide to Climate
Change, Earthscan 2009
 Pencheon D, Health services and climate change: what can be
done? J Health Serv Res Policy. Editorial Jan 2009
 UCL Health Commission/Lancet: Managing the Health effects of

Appendix 5
Medical Peace Work- Non violent change

Conflict analysis - a learning
process
constructing a detailed picture of the situation
identifying the factors that can contribute to
peace
Many approaches
and tools:
conflict timeline
conflict mapping
ABC triangle
etc.

Nonviolent social change
Most social movements use nonviolent means.
Removing pillars
of power through:
•blockades
•boycotts
•protests, strikes
•demonstrations
•civil disobedience
•street theatre, etc.

Nonviolent Communication
(NVC)
- a philosophical and educational tool for human
connection
Putting empathy at the centre of thinking and
communicating
Four elements for
honestly expressing
and empathically
listening:
(Model adapted from the Centre
for Nonviolent Communication)

Medical Peace Work-training materials
Appendix 6

MPW training material
• Web-based teaching resource centre
• Seven MPW online courses
- textbook lessons
- test questions
- problem-based e-learning cases
 www.medicalpeacework.org

Goals of MPW training material
Prevent war, terror, human rights violations, and
other abuses of power.
Promote compassion, caring relationships, fair
structures, and a culture of peace.
Improve health outcomes for patients
and communities in violent settings.
Strengthen the health professionals’
competencies in peace and conflict
work.

Characteristics of MPW-framework
• Holistic peace concept
─ Peace work NOT only at the top level
─ Peace work NOT only in war zones
─ Peace work NOT only for peace activists
• Public health approach to violence and peace
• Explicit peace work – for the sake of HEALTH

Educating the public
Know your target audience
Know yourself
What is the message?
Who is delivering the message?
What methods can be used?

History of health professional activism for peace
 First tried to „humanize“ war
 1905: International Medical Association Against War
 1918: Jeanne van Lanschot-Hubrecht questioned giving
medical aid in WW1
 1930: Committee for War Prevention in Holland
 1936: Medical Peace Campaign in UK
 1961: Physicians for Social Responsibility (PSR) in USA
 1980: International Physicians for the Prevention of
Nuclear War (IPPNW)

Data-to-policy work
Evidence for advocacy need credibility (actual and
perceived)
Reliable data has to be collected using recognised
methods
Less influence on policy if disputable
Less credibility if party has strong interest in a certain
result
Lack of transparency damages findings
Predicting future using past data for advocacy

Alliances with larger movements
Examples:
International Campaign to Ban Landmines (ICBL)
International Action Network on Small Arms
(IANSA)
The Red Cross
International Campaign to Abolish Nuclear
weapons (ICAN)

References
 Centre for Nonviolent Communication www.cnvc.org
 Galtung J (1996). Peace by peaceful means: peace and conflict, development and
civilisation. London, Prio/Sage.
 Galtung J (2002). What is peace studies? In Johansen J, Vambheim V (eds). Three
papers by Johan Galtung. Tromsø, Centre for Peace Studies, University of Tromsø,
Norway
 Large J (1997). Considering conflict. First consultative meeting on Health as a Bridge
for Peace. Les Pensières, Annecy, WHO.
 Mercy J et al. (1993). Public health policy for preventing violence. Health
Affairs. Winter:7-29.
 Merriam-Webster Online Dictionary www.m-w.com
 Rosenberg M (2003). Nonviolent communication: a language of life. Encinitas, CA,
Puddle Dancer Press.
 Santa Barbara J, MacQueen G (2004). Peace through health: key concepts. The
Lancet 364:384-5.

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