Preventing War
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j 5 T the timeof writing,endof MarchI99I, one month ^ aftertheendof hostilitiesin theGulfwar,an accurate inventoryof allcasualtiesc,ivilianandmilitaryi,ncludingtheperiodsincetheinvasionof Kuwaitby Iraqon ' Augustz, I990, is stillnotpossible;moreoverc,ivilwar has ensuedwithin Iraq, as well as mass repression againsttheKurdpopulationt,herebyaddingto thevictimtoll.Justduring thefirst,essentiallyaerial,phaseof thewar,fromJanuaryI 7 to February 23, I99I, some go,ooo sortiesweremadeby the alliedairforces(i). Takingthis as a crudeoverallmarkerof war activitiesandspeculating that,unlessthe bombsweresentto desertedareas,one majorcasualty, i.e.,a deathorsevereinjuryc,ouldresultfromanythingbetweenoneand tensorties,thecasualtytollforthefirstphasealonemightruninthetens of thousandsT.hisfitswiththelikelyspanof figuresquotedfortheIraqi deathsduringthe 43 daysof the Gulfwar, rangingfrom ioo,ooo (z) down to theentirelyunspecified"nota greatnumber"(3). Itshouldbe kept in mind that some 30,000 deathswould approximatelyamount to thedoubling- duringthewarperiod-of thecrudedeathrateoftheIraqi population. The casualtytoll demonstrateosnce morethat, irrespectiveof how mucha war can be seen,fromone's own viewpoint,as ethicallyand legallyjustorpoliticallyandeconomicallyjustifiable(orevennecessary), a majorresultis loss of humanlivesandpermanenotr transientinjury, physicalorpsychologicalt,o thelivesofothers.Healthdamageinvariably accompaniewsars.Fromapublichealthperspectivwearcanberegarded as an epidemicdisease-or, as for somechroniccivilwars,an endemic one-that onceit escapespreventioncannotbe fullycontrolledat later stages:at the bestthe numberandseverityof casualtiescanbe limited. Casualtiesof whichfightingside?Economiccalculationsandeconomy-
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JOURNAL OF PUBLIC HEALTH POLICY * AUTUMN 1991
basedchoicesin thehealthdomainencounterseveraldifficultiess,ome
of themostfundamentasltemmingfromtheneedto
translateintoquantitativeestimatesthe valueof humanliveswhencomparingcostsand
expectedbenefitsof intrinsicallyheterogeneouisntervention(s4): for
instance,when havingto allocatelimitedresourceseitherto establishing
a hearttransplantservicefor adultsor a screeningfacilityfora congenital
defectin newborns.Yet,withinthe frameof referenceof peace,open and
extensive discussionsby a varietyof involvedpartiescan take place to
settleby socialconsensuswhat mayappearat firstas irreconcilableissues
of values.
In war no consensussolutionsexist. Evenwithin each of the battling
sidesopen analysesof therelativevaluesof thelivesatstakeareeschewed,
lest too muchlightis focusedon the kindof choicesimplicitand actually
made in war, often in an expeditious,oversimplifiedway, with little, if
any, room for consultation:choices between,say, the riskof sacrificing
some of the enemy civilians, including children, through bombing a
militarypositioninstalledin a village,andtheriskof exposingadvancing
soldiersto the position's fire.Alternativesand decisionsof this nature,
often involvingsizablenumbersof lives,areinevitablefor
anyone,however humaneand rational,exercisinghis rationalitywithin the frameof
referenceof war, irrationalin its very foundation,as it brutallyequates
what is right with what is gained by violence. Moreover, human
behaviour, especiallywhen faced with life and man-inflicteddeath, can
hardly be simplifiedto "rational"acting of the kind assumed,for
instance,in abstracteconomic models.
It may be arguedthat in von Clausewitz'sdictum (
5
) that "war is a
simplecontinuationof politicsbyothermeans,"the keyword is "other"
as the meansof war arenot merelypassiveinstrumentsto an end. To be
activatedthey first requirea change in the value system prevailingin
peace, and to turn out effectivethey usuallyincludeamong the results
the loss of humanlives, an outcome aliento peace.
Preventingthe loss of humanlives fromwar is a pertinentconcernfor
publichealthprofessionals,as is preventionof otherviolent deaths.The
escalatingnumberof war deathsin thiscentury-sixty millionandmore
deathsin the two world wars alone (
6
) -and the catastrophicscenarios
for health and the environmentwhich could derivefrom nuclearwar
have prompted,particularlyover the last decade,some incisiveactions
againstnuclearwar, recognizedby the Nobel Prizefor Peaceconferred
in I 9 85 on "InternationaPlhysiciansforthePreventionof NuclearWar."
SARACCI * PREVENTING
Theinjuriesto lifeandhealth,directandindirect(forexample,through
environmentadleteriorationo)f theGulfwardemandrenewedinitiatives
to preventall formsof war, includingthose startedas international
"policeoperations"withtheexecutiveassentof theUnitedNations.This
label,anymorethanthe label"inthe nameof God,"doesnot exempt
them from scrutinyof theirreasons,ends, meansand actualresults,
amongwhichhumanlossesfromallsidesstandprominentT.hosemost
directlyinvolvedin preventions,uchas publichealthprofessionalasnd
epidemiologistsc,antakethelead,alongat leasttwo lines:
i. P (...truncated)