A not so distant mirror

BMJ 1999; 319 doi: (Published 14 August 1999) Cite this as: BMJ 1999;319:a

In Barbara Tuchman's powerful history of the 14th century, A Distant Mirror— a story of plague, war, brigandage, bad government, insurrection, and schism—she quotes the Swiss historian J C L S de Sismondi, who summarised the century as, simply, “a bad time for humanity.” Although life for many BMJ readers is comfortable, historians looking back on this century will probably say the same, and some reasons why are found in this week's issue. It makes sombre reading.

As Jennifer Leaning outlines in her editorial, international humanitarian law—designed to limit warfare and protect civilians—was born out of traditional wars between nation states (p 393) Increasingly, it has to deal with non-conventional wars. Frederick Burkle points out that each of the over 38 major conflicts that have occurred since the end of the cold war share characteristics that lead to public health disasters: extreme violence, lack of protection normally afforded by international law, political collapse, and thousands of displaced people (p 422).

Several papers from the International Committee of the Red Cross document the effects of the weapons that flood into such conflicts—and remain afterwards (pp 410-7). Meddings and O'Connor, for example, show that in Cambodia 51% of the people treated in Red Cross hospitals for injuries were civilians and 30% were injured outside active fighting (p 412)

The point of this theme issue, however, is to show not just how badly people can treat each other—but also how the law can keep up and how doctors can respond. For example, Robin Coupland argues from an analysis of bullet wounds that existing legislation banning bullets of a certain construction (such as dumdum bullets) should be supplemented by legislation based on the damage they actually cause (p 413) Claude Bruderlein and Jennifer Leaning explain how human rights law, traditionally applied in peace, is being asserted during conflict—to help, for example, refugees, child soldiers, and women (p 430). At a more immediate level Pierre Perrin of the Red Cross and Hanna Nolan of Médecins Sans Frontières describe how their organisations deal with challenges to their own ethics—in this case judicial amputations (p 445).

More immediate too for most readers—thankfully not caught up in wars—are the articles by Tessa Tan Torres Edejer and Ruth Chadwick on, respectively, the ethical issues raised by North-South research (p 438) and by the Icelandic database of health records (p 441). These raise classic issues of human rights—individual dignity and freedom from state imposed harm—and, as Leaning argues (p 393), “familiar territory” for doctors.


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