Education And Debate

Commentary: Life in the real world is more complicated

BMJ 1995; 311 doi: (Published 14 October 1995) Cite this as: BMJ 1995;311:1001
  1. Anthony B Zwi, senior lecturer in health policy and epidemiologya
  1. aHealth Policy Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT

    These past months have been filled with the wars in former Yugoslavia: the fall of Srebrenica and Zepa to the Bosnian Serbs, the flight of tens of thousands of Bosnian Muslims, the retaking of Krajina by the Croatians and evidence of Croatian atrocities, the flight of Croatian Serbs, wanton violence and war crimes, rape, and ethnic cleansing. The historically hesitant and inconsistent response of the West and the United Nations, enabling the Bosnian Serbs to continue with their genocidal project, has at last been placed at the top of the political agenda. Hopefully the current negotiations will lead to a lasting peace, but doubt somehow lingers.

    Gellert's important article1 is timely, relevant, and deserves to be debated widely. It raises many crucial issues which should be recognised, endorsed, and acted on by us all. Below, I focus on a few areas where further debate is merited: the role of data, improving the international response, and assessing vulnerability in order to intervene and prevent violence at an earlier stage. Hopefully, many of the other complex issues raised by Gellert will be addressed by others: through further debate we clarify the way forward.

    Data alone are not enough

    Gellert hopes for a more humane and rational world: “the introduction of a standardised protocol for decision making in humanitarian intervention, based on quantifiable thresholds which invoke specific international actions, will ensure that consistency, regularity, and predictability prevail in the international response to mass violence.” Life in the real world is, however, more complicated than this. What is happening now in Bosnia highlights the need for consistency, rationality and humanism: the responses in Washington, London, Paris, Bonn, and Moscow demonstrate how difficult these are to achieve when economic and political objectives vary.

    Gellert asserts that thresholds for concerted action would reduce the indecisiveness that characterises decisions over whether the international community should intervene in civil conflicts. In both former Yugoslavia and Rwanda, however, atrocities were being perpetrated in real time in front of our eyes. There was no question about what was going on: genocide. The threshold for action was surely exceeded. Yet little was done.

    Data on the public health burden of organised violence are necessary but may be insufficient to lead to action. Data are not by themselves objective: what is collected, how and by whom, and how it is analysed and presented all influence our interpretation. Data which tell a different story are often dismissed or ignored by politicians and media alike. Improving the quality of data on the impact of atrocities and violent conflict is desirable; but alone, it will not stimulate a response. Instituting “data driven” interventions could even be used to delay, rather than speed up, international responses, particularly if such data have to be rigorously collected in situations where this is hardly feasible.

    Policy responses to humanitarian crises are heavily influenced by political and economic considerations. We need a better appreciation of the economic and development costs of conflict if more appropriate interventions are to be promoted. Decades of development efforts, international “assistance,” and health gains have gone down the drain in the presence of humanitarian crises and costly post hoc emergency and rehabilitation interventions of limited effectiveness.

    Better international mechanisms for action

    Gellert raises issues of national sovereignty, arguing that “states may have a primary responsibility for human rights within their territory, but when they fail to meet this responsibility the international community has a duty to intervene and provide humanitarian assistance.” Reviewing the concept of sovereignty and how the international community can provide support to populations at risk within countries is appropriate. But such debate also raises important questions. Who will make decisions about whether or not to intervene? How will such decisions be made? In arguing for uniform action in response to organised violence and war crimes, we need to recognise that the structures established for such decision making and action have not been up to the task. Liberia, Rwanda, Somalia, Bosnia are all testimony to that uncomfortable truth. The limitations of the United Nations system must be recognised and rectified if it is to play a more appropriate role in the next millennium. For a start, the large amount of control exercised by a few powerful states needs to be replaced by a system which draws in a greater range of the world's nations in deciding on action by the “international community.”

    Gellert's call for more transparency and accountability in responding to complex emergencies should be supported. We need urgently to understand why responses to complex political disasters have been so cumbersome, inconsistent, and, in many senses and most settings, ineffective. Appreciating how national economic and political interest influence the nature and form of response is also imperative, especially if we seek to influence policymakers at local and national level as well as within bilateral and multilateral aid organisations.

    Public health has a part to play beyond providing emergency assistance. It can also help in identifying vulnerabilities to abuse and in sustaining health services and policymaking during periods of conflict and in redefining and re-establishing health systems after the conflict is over.2 We should be asking governments, aid agencies, and multilateral organisations what they are doing in response to these needs and whether they are facilitating the development of conceptual and practical tools for operating in these complex environments.


    Primary prevention is key: action should be taken early to prevent bloodbaths rather than in response to their aftermath. Perhaps even more important is “primordial prevention”: avoiding creating the conditions that may lead to internal conflict, violence, and genocide, such as inequitable distribution of resources, repression of segments of the population, and massive international debt.3 4 We need to promote those forms of social policy and development which increase the chances of economic, social, and political benefits accruing to all sections of society and that reduce rather than increase inequities in access to resources.5 6 As Gellert argues, assessing vulnerability to conflict and violence should receive priority. This would be a sensible investment in promoting peace, stability, and the conditions necessary for economic growth.

    Promoting rational policy responses is desirable, and we should continue to strive for this. But we do need to recognise that this is not how most decisions get made in the real world. In defining more rational pathways we may nevertheless help empower concerned communities, including the public health community, to ask governments to account for what they do, and do not do, in foreign lands. That may stimulate public debate, pressure, and change that will ultimately bear fruit in the form of greater health for all.

    Gellert argues cogently that we should actively take up the challenge of responding to conflict in today's world: we cannot afford not to.


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