Intended for healthcare professionals

Jennifer Leaning on 'Physicians and War'

BMJ, 2002; 324 (9 Feb)

Physicians and War

Jennifer Leaning
Professor of International Health

Harvard School of Public Health, 651Huntington Drive, Boston MA 02115, USA

see Editorial by Smith and Richards

Those who wish to see health professionals stick to the pressing concerns of clinical practice and not comment on major world events like the war in central Asia should have stopped the clock on the eve of World War II. The last 50 years have seen an unparalleled crafting of international norms of war and peace[1] and a robust expansion of our capacity to assess the causes and consequences of calamities on populations.[2] Physicians have figured prominently in both sets of activities, whether as negative agents (the Nuremberg Medical Trials) or as positive contributors (trauma surgeons in the military, analysts of impact of nuclear war on public health). Building on normative definitions, analytic insights, and epidemiologic skills developed over this period, the medical and public health professions are now positioned to make substantive contributions to understanding and policy with regards to the health of populations caught in war, disaster, and civil conflict.

This qualitative leap in understanding can be seen by comparing two articles on nutrition on war. A physician familiar with military medical tradition in the United States wrote one in the midst of World War II. Physicians and health workers who have made careers out of work in conflict and disaster epidemiology wrote the other.

The first, in a review article published in 1943, begins by noting that population food supplies have historically determined who wins and who loses in war. It then surveys what is known about major dietary components, their relative supply among the Allied and Axis powers, and then discusses empirical reports from current war zones. The article cites a report in JAMA—a letter from Greece—that currently nine out of 10 children die before they reach six months of age, and that (also according to this report) conditions elsewhere in occupied Europe are nearly as bad:

"In no country under enemy domination is food sufficient to maintain the children in health; in many it is insufficient to keep them alive. Even in countries normally self-sufficient in basic foodstuffs, such as the Netherlands and Norway, requisition of the country’s produce, by means either over or covert, has debased the standard of living, threatening the young, while in Poland and Yugoslavia one must ask how many children will be left alive after another year of war."

In occupied France, a medical journal is quoted as saying:

"Already children are being born whose weight is far below normal… There is an increase both in quantity and in quality of people who are deformed or weak, women who… run a grave risk of having children deformed from their birth. Tuberculosis is also increasing in the number and gravity of its cases... An enormous number of the children are victims, because their diet, especially from the age of five onward, is deficient, and the number of deaths is increasing as the forms taken by the disease become graver. They are no longer the exception. They are the rule. And what will be the fate tomorrow of those who escape?"

The article concludes by lamenting what will happen after the war is over, noting:

"…every statement I have made relative to the effects of famine in war will apply with equal force after the war. The dislocations... with their accompanying disillusionments, cynicisms, revolutions, and other social evils, will demand a comprehensive and sympathetic study of the intricate problems brought to all of us by the miseries of the war itself... Only by recognising and understanding such problems can we hope to find a way to meet them effectively."

Compare these passages in tone, level of analysis, and perspective with the letter from Afghanistan this past December. The letter begins by summarising the scant known demographics and vital statistics of the country, noting that the human effects of the 20 plus year war have been exacerbated by three past years of severe drought. It then dives into its topic, the impact of the drought on level of malnutrition and resultant health effects in a district in NW Afghanistan (Kohistan). The methods section takes up 20% of the article; the results section is packed with data (morbidity and mortality rates from diarrhoea, respiratory infections, measles predominately), medical and anthropometric evaluation of nutritional status, diet histories, household economic indicators). Crude mortality rate for 3,165 persons was 2.6 (95% C.I. 1.7-3.5); the rate for 763 persons under five was 5.9 (95% C.I. 2.0-8.8). The prevalence of wasting among 708 children aged 6-59 months was 7.0% (95% C.I. 5.9%-9.0%); of stunting for the same group was 63.7% (95% C.I. 58.6% -68.8%). Evidence was found for pre famine coping indicators.

The comment section, laced with caveats regarding limitations, is summarised thus:

"These data indicate that, by April 2001, a humanitarian crisis already existed in Kohistan. Essential humanitarian services, including food aid and public health programs, are urgently required in such regions of Aghanistan and will be crucial if a worsening humanitarian crisis is to be avoided... international community needs to create adequate humanitarian space... to ensure that humanitarian organizations have access to populations within Afghanistan as well as to refugees who flee to surrounding countries."

In the first article the tone is apocalyptically hopeless; the level of analysis general, qualitative, lacking in a disciplinary base or method; and the perspective focused on what might be the situation and the task after the war is over. Those women and children trapped in occupied Europe were assumed to be beyond the reach of anyone, even those with compassion who could claim some professional insight into their needs.

In the second article, the tone is dispassionate. The level of analysis based on proven methods and precisely aimed at elucidating the key data points in framing an assessment of civilian nutrition crisis conditions. The perspective defined by firm knowledge of the norms of war and humanitarian intervention—protection of civilians, humanitarian aid, and international responsibility transcending national boundaries. Not only are these civilians considered salvageable in real time but they are also held up as obligatory charges of the international community.

Here we see what value can infuse the passage of time, when good people labour to do much. At the outbreak of World War II, very few physicians or health workers, apart from those with military careers, saw war as a major concern for those in medicine or public health. No one in civilian medicine or science had made strides past Rudolf Virchow’s 1848 analysis of the crisis fed typhus epidemic in Upper Silesia.

The professional focus in the century after Virchow’s observations was instead on biomedical discovery and the prowess of clinical applications. It took the unprecedented global carnage of World War II, the resultant effort to establish durable international institutions and norms, and the related post-war struggle against colonial regimes to galvanise all realms of society into the recognition that, as Virchow put it:

"...epidemics resemble great warning signs on which the true statesman is able to read that the evolution of his nation... Don’t crowd diseases point everywhere to deficiencies of society? ... Abnormal conditions always produce abnormal situations. War, plague and famine condition each other, and we don’t know any period in world history where they did not appear in more or less large measure either simultaneously or following each other."

So we see here in this issue of the BMJ addressing the first war of the new century, the fruits of the fusion of social concern and scientific discipline. The profession has come of age, hopefully in time to help ensure that the next 100 years are less extreme than these just past.

1. Leaning J. Medicine and international law. BMJ 1999;319:393-4.

2. Centers for Disease Control. Famine-affected refugee and displaced populations: Recommendations for public health issues. MMWR 1992:41(RR-13):1-76.

3. Cannon PR. Food and war. In Taliaferro WH, ed. Medicine and the war. Originally published by University of Chicago Press, Chicago, Il, 1944, reprinted by Books for Libraries Press, Freeport, NY, 1972: 23-39.

4. Assefa F, Jabarkhil MZ, Salama P, Spiegel P. Malnutrition and mortality in Kohistan district, Afghanistan, April 2001. JAMA 2001;286:2723-8.

5. Virchow R. The epidemics of 1848. In Rather LF, ed. Rudolf Virchow: Collected essays on public health and epidemiology. Science History Publications. Watson Publishing International. Canton, MA, 1985.

6. Starr P. The social transformation of American medicine. Basic Books. New York, 1982.

7.Virchow R. The epidemics of 1848. In Rather, LF, ed:115.