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Peace Through Health

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Medical Education
Peace Through Health
Andrew D. Pinto, B.Sc. (0T6)
Abstract
Peace through health (PTH) is an emerging philosophy in
medicine, giving health professionals means by which they
can work towards peace. Conflict can be seen as a public
health threat and approached as a disease at multiple levels.
Several examples of effective PTH initiatives exist, such as
arranging cease-fires for vaccinations or increasing aware-
ness of the health implications of new weapons systems.
Canadian health professionals have an opportunity to make
a significant difference in preventing war around the world
and create a more peaceful and healthy society.
“Medicine is a social science, and politics is nothing more than med-
icine on a large scale.”
– Dr. Rudolph Virchow (1821-1902)
This statement forgoes the traditional separation of politics
and the practice of medicine, and broadens the scope of
health and its determinants, challenging health professionals to
address new problems. War is a very real phenomenon to
every human on Earth, and is recognized as an immense
threat to health. By 2020, the World Health Organization
(WHO) predicts it will be one of the top ten causes of loss
of disability-adjusted life years.1 Its immediate impact is seen
in terms of lives lost or those wounded directly in conflict.
However, war indirectly causes suffering through its long-term
negative effect on social, cultural and economic factors, result-
ing in poorer health for the entire population.2,3,4 The creation
of peace in a conflict area would greatly improve the health
of many in several ways. A simple example is by observing
an increase in health care spending, due to a decrease in mil-
itary expenditure. If peace can be seen as a solution to this
great public health problem, then it should be a viable goal
and a priority for physicians. This is the premise of the peace
through health (PTH) movement. PTH is the use of health
interventions that support structures and processes for peace,
while undermining the mechanisms of violence. These inter-
ventions foster the development of political, economic and
social arenas in which local groups and individuals actors can
build a just and peaceful society.5,6
158 University of Toronto Medical Journal
This movement has its origins in the International Physicians
for the Prevention of Nuclear War (IPPNW), a group active
during the Cold War nuclear crisis. Founded in 1980 by
American and Soviet physicians, it has worked to raise aware-
ness of the lack of a meaningful medical response to nuclear
war. Using this fact, IPPNW has been dedicated to the abo-
lition of all nuclear weapons.7 During the Vietnam war, doc-
tors and nurses, such as Dr. Benjamin Spock and Claire
Culhane, were vocal advocates of the cessation of conflict.
They, and others, played an important role in revealing how
the conflict impacted health.6 In the past twenty years there
has been a global increase in interest in PTH, and some recent
projects are outlined below. Several PTH groups, many of
which are affiliates of IPPNW, have been formed, including
the Canadian Physicians for Global Survival (PGS). This
organization is not only dedicated to the abolition of nuclear
weapons, but also the prevention of war, the promotion of
non-violent means of conflict resolution and social justice in
a sustainable world. The PTH movement has culminated in
the recent McMaster-Lancet Peace Through Health
Conference, an international gathering to address a need for
increased understanding of peace-building through health,8
and its implications for medical education.9
The practice of nonviolence is at the core of all PTH initia-
tives. By approaching war as a disease, which must be elim-
inated by several preventative measures, rather than further
conflict, successful projects are able to build a sustainable
peace. Each of the preventative steps below mimic regular
health care practices while treating various stages of an illness,
as seen in Figure 1.10 Tertiary prevention works to heal or
rehabilitate a population after a war. This can include indi-
vidual and social rehabilitation, improved access to equal
health care and creating a culture of care in the area.11
Secondary prevention acts to develop peace in a situation
where war is ongoing, such as by arranging a ceasefire for the
delivery of medical aid. Primary prevention is aimed at pre-
venting war from breaking out, and can focus on bringing to
light the effects that war will have on both factions. Finally,
primordial prevention works on the risk factors for war
including working to develop international agreements and
supporting international health initiatives and collaborative
research.10,12 This theoretical medical approach allows health
workers to grasp what is at the root of the conflict, and how
one can “cure the disease”.
Figure 1. Health professionals can approach armed conflict using different levels
of intervention, similar to those used to treat a disease.10
Although war can be seen as a disease or a public health threat,
the role of health workers in the peace process is not immediate-
ly obvious. However, the unique characteristics of health care
providers allow them to engage in this process.6 First, extended
altruism is at the foundation of medicine, medical education and
health care policy. Globally, people recognize that health workers
strive to improve the quality of life of others. Such goals are
humane and superordinate, and all parties involved applaud such
achievements. International health organizations, such as the
WHO or Médecins Sans Frontières (MSF), have specifically altru-
istic doctrines. These groups have a recognized attitude for the
refusal of hate-based identities and depersonalization, upon which
war is based. Secondly, medicine is rooted in scientific inquiry.
Objectivity and a high regard for proven fact prevents physicians
from being seen as sources of propaganda. Indeed, health work-
ers can use their position to debunk ethnic prejudices, or be cred-
ible sources of information about human rights abuses.11 Third,
health care providers hold a great deal of legitimacy. They are con-
sistently considered members of an honest and ethical profession,
and are more trusted than politicians. This reputation can give a
physician or a nurse power in public discourse and publications.6,13
These special characteristics lend themselves to certain roles that a
health worker can play in a conflict area, and are the basis for PTH
projects.6 They can act to manage conflict or negotiate an end to
hostilities. For example, health workers often have diplomatic
access due to their high credibility. They can point out health care
goals which may be shared by both sides, and so negotiate a
framework for cooperative peace action. Health workers can also
act in solidarity with civilians, providing knowledge, skills and
resources to peace workers. Thus they can be vigilant against
human rights abuses and act as witnesses to deter such acts.
Strengthening the social fabric through proper health care is anoth-
er role for health workers. This action makes an area more resis-
tant to violence and makes hate-based mobilization difficult.
Health workers can also speak and act out against military action.
The position of altruism and high credibility makes them a pow-
erful means to mobilize public sentiment against war. Finally,
health workers can restrict the destructiveness of war by working
to prevent the creation and implementation of weapons that cause
extreme injury, suffering and death.14 Galtung echoes these mech-
anisms, as he indicates that health workers can act as dialogue part-
ners, organizers of dialogue, brokers of agreements, and help with
reconstruction and reconciliation.15
Recognized PTH projects have been ongoing since IPPNW suc-
cessfully raised awareness of the implications of nuclear war.
Khrushchev cited its efforts as a key factor in the reduction of ten-
sions during the Cold War, and the organization was awarded the
Nobel Peace Prize in 1985. IPPNW continues to be an active
group, speaking out against the continual threat that nuclear
weapons pose.7 A similar movement, which won the 1997 Nobel
Peace Prize, is the International Campaign to Ban Landmines. To
encourage governments to ban landmines, the group increases
awareness of the health implications of their use.16 Continued
research into the health effects of different weapons systems will
hopefully dissuade further investment and development into this
industry.14
Another PTH example is the arrangement of cease-fires in areas
of conflict, to allow for the vaccination of children. In El
Salvador, organizations like the Roman Catholic church and
UNICEF, arranged for three days of cease-fire each year from
1985 to 1992, resulting in 300 000 children being vaccinated.17
This initiative was successful in causing a significant decrease in the
incidence of measles, tetanus and polio. Peace-building was also
accomplished by the subsequent decrease in hostility and the sign-
ing of peace accords.18 This strategy has been used in Sri Lanka,
where it helped form channels of communication between the
Singhalese nationalists and the Tamil separatists. In Somalia, roads
were demined to allow for vaccination to occur.5 This strategy is
now recognized globally as successful in conflict mediation. It may
be used to advance the WHO polio eradication program, as war
continues to be the key challenge to vaccination in countries like
Angola, Liberia, Afghanistan and Tajikistan.5
Two PTH projects in the former Yugoslavia have been judged
successful in both health and peace initiatives. The first was the
preparation and implementation of an elementary school curricu-
lum in Croatia. It was designed to teach ethnic tolerance and how
to deal with symptoms of post-traumatic stress disorder (PTSD).
Two hundred and fifty Croatian school children were divided into
control and intervention groups. The intervention group showed
a small but significant reduction in ethnic bias and a reduction in
PTSD symptoms. These benefits were long lasting and the cur-
riculum has been applied to a larger student population.19 The sec-
ond project, organized by the WHO and the UN Department of
International Development (DFID), aimed to bring together health
workers of the Federation of Bosnia and Herzegovina (FBIH) and
the Republika Srpska (RS). These two groups had been divided
volume 80, number 2, March 2003 159
 by war, and a great deal of mutual hatred existed. Project activi-
ties included communication and collaboration between public
health directors, the organization of joint national health confer-
ences and the issuing of joint health statements. This project has
been judged successful in terms of reconciliation between the two
sides and an improvement in the health of both populations,20 and
continued progress is seen in this area of the world.21
All of these projects have been evaluated on the basis of whether
they improve health and build peace, in the short and long term.
However, there are also two evaluating tools that measure the
deeper impact of PTH projects. The first is Howarth's "Do-No-
Harm Approach", which is applicable to humanitarian aid projects.
It first examines the reasoning behind the aid and the method by
which it is distributed. After answering these questions, the impact
of the aid on the conflict is assessed.22 A second method to eval-
uate a PTH project is Bush's "Peace and Conflict Impact
Assessment (PCIA)" tool. The PCIA evaluates projects based on
their ability to impact processes that can increase the prospect for
peace and processes that can increase the likelihood of violence.
It examines areas such as political and economic structures (e.g.
Will the project cause political ethnicization?), social reconstruction
and empowerment (e.g. Will the project improve constructive
social communication?) and military and human security (e.g. Will
the project lead to a rise in organized crime and black markets?).23
While the above successes certainly hold promise for the future,
the peace through health philosophy also contains shortcomings.
There tends to be limited opportunity for non-health profession-
als to initiate and develop initiatives that depend on a medical
background. Another deficiency is adequately evaluating the suc-
cess or failure of projects.12 The two evaluation tools described
above are relatively new, and have not been applied to many pro-
jects. Poor evaluation is a major critique of the PTH movement,
and have even lead some to question whether the movement is
driven by actual practice or mere ideology.11,24 An important con-
sideration is the loss of neutrality and impartiality that can result
from involvement in a political movement. Even if health work-
ers could identify goals common to both sides (e.g. vaccination of
children), in many conflict areas, one or more parties would favor
continued violence. This is especially true of those groups that
benefit from an unstable environment. Thus, involvement in a
PTH project may limit the access a health worker has to patients
on one side or the other of a conflict. PTH workers may even
come to be regarded as military targets, and their lives may be in
danger. Finally, there is the opportunity for misinterpretation of
what PTH groups are working towards.25 It is a new field with a
new conception of public health and preventative medicine, and it
will take time for change to occur.
PTH, or bringing together the goals of health and peace, is a grow-
ing movement, and reveals an effective role for physicians to play.
The importance of PTH is illustrated by the World Health
Assembly statement, “The role of physicians and other health
workers in the preservation and promotion of peace is the most
significant factor for the attainment of health for all.”26 Several
PTH projects have occurred throughout the past twenty years and
160 University of Toronto Medical Journal
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many seem to be highly successful. Canada has a role to play in
this movement, as the Canadian Public Health Association
resolved that health professionals "contribute to prevention of
conflict by creating the conditions that enable individuals, com-
munities and societies to achieve their goals without resorting to
violence".27 Further, the recent Romanow Report highlighted the
connection between health and peace, and urged the federal gov-
ernment to assist developing nations.28 PTH, born from the ideals
of medicine, is a means for health professionals to work to
improve the health of people in a new and effective way.
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