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COLLECTIVE VIOLENCE: HEALTH IMPACT AND PREVENTION

Victor W. Sidel, MD1

Barry S. Levy, MD, MPH2

Introduction

Collective violence, especially in the form of armed conflict, accounts for more death and disability than many major diseases worldwide. Collective violence destroys families, communities, and sometimes entire cultures. It diverts scarce resources away from the promotion and protection of health, medical care, and other health and social services. It destroys that health-supporting infrastructure of society. It limits human rights and contributes to social injustice. It leads individuals and nations to believe that violence is the only way to resolve conflicts. And it contributes to the destruction of the physical environment and the overuse of nonrenewable resources. In sum, collective violence threatens much of the fabric of our civilization.

Definition of “Collective Violence”

In 1996 the World Health Assembly, the governing body of the World Health Organisation (WHO), adopted Resolution WHA49.25, which declared violence “a major and growing public health problem across the world” (World Health Assembly, 1996). The Assembly asked the WHO

1

Distinguished University Professor of Social Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York; Adjunct Professor of Public Health, Weill Medical College of Cornell University, New York, New York.

2

Adjunct Professor of Public Health, Tufts University School of Medicine, Boston, Massachusetts.



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7 APPENDIX C COLLECTIVE VIOLENCE: HEALTH IMPACT AND PREVENTION Victor W. Sidel, MD1 Barry S. Levy, MD, MPH2 Introduction Collective violence, especially in the form of armed conflict, accounts for more death and disability than many major diseases worldwide. Collective violence destroys families, communities, and sometimes entire cultures. It diverts scarce resources away from the promotion and protection of health, medical care, and other health and social services. It destroys that health- supporting infrastructure of society. It limits human rights and contributes to social injustice. It leads individuals and nations to believe that violence is the only way to resolve conflicts. And it contributes to the destruction of the physical environment and the overuse of nonrenewable resources. In sum, collective violence threatens much of the fabric of our civilization. Definition of “Collective Violence” In 1996 the World Health Assembly, the governing body of the World Health Organisation (WHO), adopted Resolution WHA49.25, which declared violence “a major and growing public health problem across the world” (World Health Assembly, 1996). The Assembly asked the WHO 1Distinguished University Professor of Social Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York; Adjunct Professor of Public Health, Weill Medical College of Cornell University, New York, New York. 2Adjunct Professor of Public Health, Tufts University School of Medicine, Boston, Massachusetts.

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72 APPENDIX C Director-General to develop public health activities to deal with the prob- lem. The resulting World Report on Violence and Health, published by WHO in 2002, was the first comprehensive report by WHO on violence as a public health problem (Krug et al., 2002). The WHO report presents a typology of “violence” that defines three broad categories based on char- acteristics of those committing the violent acts: self-directed violence, inter- personal violence, and collective violence. This paper deals with elements of the third category, collective violence, with a primary focus on collective violence that involves “armed conflict.” The three forms of violence in some ways overlap. Those engaged in collective violence may engage in self-directed violence as a symptom of posttraumatic stress syndrome or as a result of self-hatred because of acts committed in war. Collective violence may also be associated with inter- personal violence. For example, individuals and groups engaged in armed conflict may commit interpersonal violence, sometimes fueled by ethnic tensions or in the military by conflict with superior officers or with fellow servicemembers in the midst of war. Soldiers may return from war with a battlefield mindset in which they commit interpersonal violence to address interpersonal conflicts that might have been addressed in nonviolent ways. And children raised in the midst of war may come to believe that violence is an appropriate way to settle interpersonal conflicts. Collective violence has been characterized as “the instrumental use of violence by people who identify themselves as members of a group— whether this group is transitory or has a more permanent identity—against another group or set of individuals, in order to achieve political, economic, ideological, or social objectives” (Zwi et al., 2002). The WHO report gives, as examples of collective violence, “violent conflicts between nations and groups, state and group terrorism, rape as a weapon of war, the movement of large numbers of people displaced from their homes and gang warfare.” As noted in the report, “all of these occur on a daily basis in many parts if the world” and “the effects of these different types of events on health in terms of deaths, physical illness, disabilities and mental anguish, are vast.” This paper includes extensive discussion of war and other military activi- ties and brief discussion of “terrorism” and the “war on terror” (Levy and Sidel, 2008a). Definition of “Armed Conflict” Conflict is a common characteristic of most societies but rarely escalates into the use of physical force and even more rarely into the use of weapons. When weapons are used in “collective violence,” they are usually termed “arms.” This paper concentrates on collective violence in which weapons are used, for which we use the term “armed conflict.” These weapons range

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7 APPENDIX C from knives, bayonets, and machetes to nuclear weapons. In this paper, we are primarily concerned with “small arms and light weapons,” since these are the weapons most often used in armed conflict in low- and middle- income countries, but we will also include discussion of bombs (both air- borne and land-based, such as “improvised explosive devices”), landmines, and artillery shells, which are also commonly used. Nuclear, chemical, and biologic weapons, sometimes termed WMD (weapons of mass destruction), , are also discussed since these are weapons that pose the risk of indiscrimi- nate and widespread devastation, injury, and death. Definition of “Low- and Middle-Income Countries” The World Bank classifies countries into economic groupings based mainly on the country’s gross national income (GNI) per capita (World Bank, 2007). Based on its GNI per capita, every economy is classified as low income, middle income (subdivided into lower middle and upper middle), or high income. The World Bank’s tables classify all 185 member countries, and all other economies with populations of more than 30,000 (208 total). Low-income and middle-income economies, the Bank com- ments, are sometimes referred to as “developing countries,” a term we use in this background paper. The use of the term is convenient; it is not intended to imply that all countries in the group are experiencing similar development or that other economies have reached a preferred or final stage of development. Classification by income does not necessarily reflect devel- opment status. The World Bank currently classifies economies according to 2006 GNI per capita, calculated using the World Bank Atlas method. The groups are as follows: low income, $905 or less; lower-middle income, $906 to $3,595; upper-middle income, $3,596 to $11,115; and high income, $11,116 or more. The countries in the low-income, lower-middle-income, and upper-middle-income groups can be found on the World Bank web- site. Examples of low-income economies include those of the Democratic Republic of Congo (DRC), Haiti, India, Nigeria, Pakistan, Vietnam, and Zimbabwe. Examples of lower-middle-income economies include those of China, Cuba, Egypt, Iran, Iraq, the Philippines, Thailand, and Ukraine. Examples of upper-middle-income economies include those of Argentina, Brazil, Hungary, Mexico, Poland, South Africa, and Turkey. World Bank data demonstrate a striking relationship between the wealth of a nation and its chances of having a civil war. For example, a country with a gross domestic product (GDP) per capita of US$250 has a 15 percent probability of war onset in the next 5 years, and this prob- ability reduces by approximately half for a country with a GDP of $600 per person. In contrast, countries with per capita income of more than US$5,000 have less than a 1 percent probability of having a civil conflict,

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7 APPENDIX C all else being equal. In addition to poverty, risk factors for armed conflict may be associated with poor health and poor access to quality medical care, low status of women, large gaps between the rich and the poor, weak development of a civil society within a country, people not having the right to vote or otherwise participate in decisions that affect their lives, limited education and employment opportunities, increased access to small arms and light weapons, and the basic needs of civilians not being met (deSoysa and Neumayer, 2005). The Health Impacts of Collective Violence There are profound direct and indirect health consequences of armed conflict (Levy and Sidel, 2008a,b,c). These are described below. Direct Consequences of War and Military Operations Armed conflicts in the 21st century largely consist of the civil wars (conflicts within countries, to which other countries sometimes contribute military troops) that continue to rage in many parts of the world. For example, at the beginning of 2007 it was reported that there were 15 sig- nificant armed conflicts (1,000 or more reported deaths) and another 21 “hot spots” that could slide into or revert to war (Smith, 2007). During the post–Cold War period of 1990-2001, there were 57 major armed conflicts in 45 locations—all but three of which were civil wars (Stockholm Interna- tional Peace Research Institute, 2002). Some of the impacts of war on public health are obvious, while others are not. The direct impact of war on mortality and morbidity is apparent. Many people, including an increasing percentage of civilians, are killed or injured during war. An estimated 191 million people died directly or indirectly as a result of conflict during the 20th century, more than half of whom were civilians (Rummel, 1994). The exact figures are unknowable because of generally poor recordkeeping in many countries and its disrup- tion in time of conflict. War has direct, immediate, and deadly impact on human life and health. The “body counts” and the data on those with war-caused injuries and disabilities, both physical and psychological, while woefully incom- plete, document the many people tragically killed and wounded as a direct result of military activities. Through the early 20th century, up to the start of World War II, the vast preponderance of the direct casualties of war were uniformed combatants, usually members of national armed forces. Although noncombatants suffered social, economic, and environmental consequences of war and may have been the victims of what is now termed “collateral damage” of military operations, “civilians” were generally not

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7 APPENDIX C directly targeted and were largely spared direct death and disability result- ing from war (Zwi et al., 1999; Levy and Sidel, 2008a). But since 1937, when Nazi forces bombed the city of Guernica, a non-military target in the Basque region of Spain, military operations have increasingly killed and maimed civilians through purposeful targeting of non-military targets. The use of “carpet bombing” and the collateral dam- age of heavy attacks on military targets have caused many civilian casual- ties. The percentage of civilian deaths as a proportion of all deaths directly caused by war has therefore increased dramatically (Levy and Sidel, 2008a). Many of these civilian deaths may have been indirectly rather than directly caused by war. Indirect Effects of War and Other Military Activities Along with the direct impacts of war and other military activities on health, collective violence may also cause serious health consequences through its impact on the physical, economic, social, and biologic environ- ments in which people live. The environmental damage may affect people not only in nations directly engaged in collective violence but in all nations. Much of the morbidity and mortality during war, especially among civil- ians, has been the result of devastation of societal infrastructure, including destruction of food and water supply systems, health care facilities and public health services, sewage disposal systems, power plants and electrical grids, and transportation and communication systems. Destruction of infra- structure has led to food shortages and resultant malnutrition, contamina- tion of food and of drinking water and resultant foodborne and waterborne illness, and health care and public health deficiencies and resultant disease (Levy and Sidel, 2005). Preparation for war also can adversely affect human health. Some of the impacts are direct, such as injuries and deaths during training exer- cises; others are indirect. As with war itself, preparation for war can divert human, financial, and other resources that otherwise might be used for health and human services. Not only is the actual use of arms a problem, but also the threat to use them. This is especially true of WMD but also applies to spending on other weapons, from small arms and light weapons to warplanes and warships. The resources used for preparation for war are frequently diverted from the resources a country needs for education, hous- ing, and medical and social services. Preparation for war is also destructive to the environment, including the use of nonrenewable resources and the use of bombs and shells in military training and military exercises. Perhaps most important, preparation for war may incite preparation for war by potential enemies and may make war more likely. Damage to the physical environment—water, land, air, and space—and

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7 APPENDIX C use of nonrenewable resources may be the result of preparation for war as well as war itself. Lakes, rivers, streams and aquifers, land masses, and the atmosphere may be polluted through testing and use of weaponry. Outer space could be damaged by placement of weapons. Significant amounts of nonrenewable resources may be used in weapons production, testing, and use (Renner, 2000; Levy and Sidel, 2005; Westing, 2008). The economic environment may also be adversely affected by the diver- sion of resources from education, housing, nutrition, and other human and health services to military activities and through an increase in national debt and/or taxation. These economic impacts affect both developed and developing countries (National Priorities Project, 2007). Governmental and societal preoccupation with preparation for wars— often known as “militarism”—may lead to massive diversion and subver- sion of efforts to promote human welfare. This preoccupation may lead to policies that promote “preemptive war” (when an attack is allegedly immi- nent) and to “preventive war” (when an attack may be feared sometime in the future). Diversion of resources to war is a problem worldwide but is especially important in developing countries. Many developing countries spend substantially more on military expenditures than on health-related expenditures; for example, in 1990, Ethiopia spent $16 per capita for military expenditures and only $1 per capita for health, and Sudan spent $25 per capita for military expenditures and only $1 per capita for health (Foege, 2000). The social environment may be affected by increasing milita- rism, by encouragement of violence as a means of settling disputes, and by infringement on civil rights and civil liberties. In addition, preparation for war, like war itself, can promote violence as a means for settling disputes. Another indirect impact of war is the creation of many refugees and internally displaced persons. Many of the world’s 12 million refugees have left their native countries as a result of war. Refugees often flee to neigh- boring less-developed countries, which often face significant challenges in addressing the public health needs of their own populations. In addition, the vast majority of the 22 to 25 million internally displaced persons world- wide have left their homes to escape war. The vast majority of refugees and internally displaced persons as a result of war are women, children, and elderly people who may be highly vulnerable not only to disease and malnutrition, but also to threats of their security. These internally displaced persons are often worse off than refugees who have left their countries because internally displaced persons often do not have easy access to food, safe water, health care, shelter, and other necessities. Approximately 8 million of these internally displaced persons live in the DRC, Uganda, and Sudan—all in Africa (Roberts and Muganda, 2008). In West Darfur, Sudan, hundreds of thousands of people have been internally displaced and hundreds of thousands have fled to refugee camps in neighboring Chad

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77 APPENDIX C as a result of bitter ethnic conflict (Sirkin, 2008). Refugees and internally displaced persons experience much higher rates of mortality and morbidity, much of it due to malnutrition and infectious diseases (Associated Press, 2007; Toole, 2008). The biological environment may be disrupted: by conventional weap- ons during use in training, in conflict or from their disposal; by ionizing radiation from nuclear weapons production, testing, use, and disposal and from use or testing of radioactive weapons, including depleted uranium; by toxic substances from production, testing, use, and disposal of chemical or toxin weapons and from “conventional” weapons during their use in train- ing or in combat or from their disposal. Spread of infectious diseases may occur as a result of degradation of protective factors, such as safe sewage disposal and water treatment, or possibly by the production, testing, and use of bioweapons. Hazardous wastes from military operations represent potential contam- inants of air, water, and soil. For example, groundwater was contaminated with trichloroethylene, a probable human carcinogen, and other toxins at the Otis Air Force Base in Massachusetts; 125 chemicals were dumped over 30 years at the Rocky Mountain Arsenal in Colorado; and benzene, a definite human carcinogen, was found in extremely high concentrations at the McChord Air Force Base in the state of Washington (Renner, 2000). During both war and the preparation for war, military forces consume huge amounts of fossil fuels and other nonrenewable materials. Energy consumption by military equipment can be substantial. For example, an armored division of 348 battle tanks operating for 1 day consumes more than 2.2 million liters of fuel, and a carrier battle group operating for 1 day consumes more than 1.5 million liters of fuel. In the late 1980s, the U.S. military annually consumed 18.6 million tons of fuel (more than 44 per- cent of the world’s total) and emitted 381,000 tons of carbon monoxide, 157,000 tons of oxides of nitrogen, 78,000 tons of hydrocarbons, and 17,900 tons of sulfur dioxide (Renner, 2000). Specific Wars Civil Wars in Africa According to data from the Stockholm International Peace Research Institute, for the 1990-2005 period, the regions that had the largest number of armed conflicts were Asia and Africa. For example, in 1998, when there were 26 major armed conflicts reported, 11 were in Africa and 8 were in Asia, and in 2005, when there were 16 armed conflicts reported, there were 6 in Asia and 3 in Africa. There has been a progressive decline in armed conflicts in Africa since 1990, with most of these conflicts being civil wars.

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7 APPENDIX C For example, in 1990, there were 19 conflicts in 17 locations in the region, only one of which was an interstate conflict (between Eritrea and Ethio- pia). The three armed conflicts reported in Africa in 2005 were the lowest number for the region in the period after the end of the Cold War. Like in Africa, most of the recent armed conflicts in Asia have been within states as opposed to between states. In the 1990-2005 period, there were four con- flicts in Africa that were active in all 16 years in this period: those in India (Kashmir), Myanmar (Karen), Sri Lanka (Eelam), and the Philippines. One conflict in the region was fought between states, that between India and Pakistan (Stockholm International Peace Research Institute, 2006). A civil war in the DRC, which began in 1996 and involved forces from other countries between 1998 and 2002, accounted for almost 4 million deaths, primarily of civilians (Roberts and Muganda, 2008). Most of the deaths in this war, in one analysis approximately 98 percent, were not directly due to warfare, but rather due to malnutrition, infectious disease, and other indirect effects due to damage to the health-supporting infrastructure of society (Roberts and Muganda, 2008). The impact of this war on civilians was documented by epidemiologic surveys conducted by the International Rescue Committee, the results of which were widely publicized in the news media and then in peer-reviewed journals. Although foreign armies formally withdrew in 2002, when a peace accord was signed, there have been difficulties in establishing a functional central government, especially in the eastern section of the DRC. Lessons that can be learned from this war include the following: 1. This war resulted from the unwillingness of the international com- munity to arrest and control the perpetrators of the Rwandan genocide who had fled to neighboring countries. 2. The international community did little to respond to Rwanda and Uganda invading the DRC in 1996 to overthrow the government. 3. This war demonstrated the importance of recognizing and pre- venting the public health and human rights consequences that generally accompany armed conflict. 4. Even intrastate conflicts can cross national boundaries and these conflicts can be harder to control since most conflict control machinery is aimed at interstate conflicts. The Iraq War An important current example of the direct and the indirect effects of armed conflict in a lower-middle-income country is the impact on Iraq of war from 1980 to the present. In the Iran-Iraq War from 1980 to 1988, between 500,000 and 1 million people were killed, and another 1 to 2 million people

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7 APPENDIX C were wounded. The Iran-Iraq War uprooted 2.5 million people and destroyed whole cities. It cost over $200 billion (Levy and Sidel, 2008c). In the 1991 Persian Gulf War, tens of thousands of people died, many were injured, and many became chronically ill. But the numbers of deaths and illnesses during the Persian Gulf War were far exceeded by those that occurred in the several years after the war. UNICEF estimated that between 350,000 and 500,000 excessive children’s deaths occurred in Iraq from 1991 to 1998, largely due to postwar sanctions imposed by the United States and other countries (Levy and Sidel, 2008c). These sanctions restricted food and medicine from getting into Iraq for several years until the Oil-for-Food Program began. In March 2003, U.S. and other Coalition forces invaded Iraq. Two months after the invasion, President Bush declared that most hostilities were over. Most of the health consequences of this war, however, have occurred since then. There have been more than 3,200 deaths among U.S. military personnel, and more than 24,000 U.S. military personnel have been wounded (as of July 2007). An additional 30,000 U.S. military personnel have suffered significant injuries or illnesses during the war. There has been a high incidence of mental health disorders among U.S. troops; the Surgeon General of the U.S. Army has estimated that 30 percent of returning troops have stress-related mental health problems. The toll on Iraqis has been many times greater than that on U.S. military personnel. A study in 2006 based on a systematic sample of approximately 2,000 households found that since the start of the war approximately 650,000 Iraqis have died, approximately 600,000 as a result of violence, most commonly gunfire (Roberts et al., 2004; Burnham et al., 2006). The Iraq War has had pro- found effects on health services and the health-supporting infrastructure in Iraq, including water treatment facilities, sewage treatment plants, the food supply, and transportation and communication systems. In addition, there have been many violations of human rights, including cruel punishment and torture of detainees. The war has diverted a huge amount of resources that might otherwise have been spent for health and other human services in Iraq, the United States, and elsewhere. And there have been many adverse impacts of the war on the physical, sociocultural, and economic environ- ments, especially within Iraq (Levy and Sidel, 2008c). Eight million Iraqis—nearly one in three—are now in need of emer- gency aid, states a report, “Rising to the Humanitarian Challenge in Iraq,” by Oxfam International and the NGO Coordination Committee in Iraq (NCCI), a network of aid organizations working in Iraq (Oxfam Interna- tional, 2007). According to the report, • Four million Iraqis—15 percent—regularly cannot buy enough to eat.

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0 APPENDIX C • 70 percent are without adequate water supplies, compared to 50 percent in 2003. • 28 percent of children are malnourished, compared to 19 percent before the 2003 invasion. • 92 percent of Iraqi children suffer learning problems, mostly due to the climate of fear. • More than 2 million people—mostly women and children—have been displaced inside Iraq. • A further 2 million Iraqis have become refugees, mainly in Syria and Jordan. Weapons Systems Conventional Weapons Conventional weapons consist of explosives, incendiaries, and weapons of various sizes, ranging from small arms and light weapons (SALWs) to heavy artillery and bombs. SALWs, which include pistols, rifles, machine guns, and other hand-held or easily transportable weapons, are the weapons most often used in wars. While some restrictions have been placed on their use in war, such as the outlawing of the use of “dum-dum bullets,” which cause extensive injuries when striking a human, there has been little effec- tive effort to outlaw their use (Cukier and Sidel, 2006). In the Millennium Report of the UN Secretary-General to the General Assembly, Kofi Annan stated that small arms could be described as WMD because of the fatalities they produce. “The death toll from small arms dwarf that of all other weap- ons systems—and in most years greatly exceeds the toll of the atomic bombs that devastated Hiroshima and Nagasaki. In terms of the carnage they cause, small arms, indeed, could be described as ‘weapons of mass destruction.’ Yet there is still no global non-proliferation regime to limit their spread” (Taljaard, 2003). Conventional weapons have accounted for the overwhelming major- ity of adverse environmental consequences due to war. During World War II, for example, extensive carpet bombing of cities in Europe and Japan accounted not only for many deaths and injuries, but also widespread dev- astation of urban environments. As another example, the more than 600 oil well fires in Kuwait during the Persian Gulf War accounted for wide- spread environmental devastation as well as acute, and possibly chronic, respiratory ailments among people who were exposed to the smoke from these fires. As a further example, bombing of mangrove forests during the Vietnam War led to destruction of these forests, and the resultant bomb craters remain several decades afterward, often filling with stagnant water

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 APPENDIX C that is a breeding ground for mosquitoes that transmit malaria and other mosquito-borne diseases (Allukian and Atwood, 2008; Westing, 2008). Nuclear Weapons Nuclear weapons have been increasingly widespread since their devel- opment in the 1940s. There are now an estimated 27,000 nuclear warheads in at least eight nations—the United States, Russia, the United Kingdom, France, China, Israel, India, and Pakistan—and possibly also North Korea (Sutton and Gould, 2007). The historic high in explosive capacity of the world nuclear weapons stockpiles was reached in 1960 with an explosive capacity equivalent to 20 thousand megatons (20 billion tons or 40 trillion pounds) of TNT, equivalent to that of 1.4 million of the nuclear bombs dropped on Hiroshima (Yokoro and Kamada, 2000). In the United States in 1967, the nuclear stockpile had reached approximately 32,000 nuclear warheads of 30 different types. In 2003, the U.S. stockpile was about 10,400 warheads, totaling about 2,000 megatons—equivalent to 140,000 Hiroshima-size bombs. Five thousand of the nuclear weapons in the United States, Russia, and possibly other countries are on “hair-trigger” alert, ready to fire on a few minutes notice. The detonation of nuclear bombs over Hiroshima and Nagasaki in August 1945 during World War II led to the immediate deaths of approxi- mately 200,000 people, primarily civilians, as well as lasting injury and later death of many others and massive devastation—and widespread radio- active contamination—of the environment in these two cities (Yokoro and Kamada, 2000). Atmospheric testing of nuclear weapons by the United States, the Soviet Union, and other countries has also led to environmental contamination, with increased rates of leukemia and other cancers among populations who were downwind from these tests. The carcinogenic effects on children of exposure to iodine-131, a radioactive isotope of iodine produced by the testing, have been well documented (Institute of Medicine and National Research Council, 1999). In addition to the potential for the use of nuclear weapons by national armed forces, such as that described in the recent U.S. Nuclear Posture Review, which threatened use of nuclear weapons under a wider range of circumstances, there is an increasing threat of their use by individuals and groups (Gordon, 2002; Sutton and Gould, 2008). Radiologic Weapons “Dirty bombs,” consisting of conventional explosive devices mixed with radioactive materials, or attacks on nuclear power plants with explo- sive weapons could widely scatter highly radioactive materials. Another

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0 APPENDIX C minerals, metals, gemstones, drug crops, and timber, have fueled many wars in developing countries. Globalization is similarly a two-edged sword. Insofar as globalization leads to good relations among nation-states and reductions in poverty and disparities within and among nations, it may play a powerful role in preven- tion of collective violence. Conversely, if globalization leads to exploitation of people, of the environment, and of other resources, it may be among the causes of war. The Carnegie Commission on Preventing Deadly Conflict has identified the following factors that put nations at risk of violent conflict, including the following: • Lack of democratic processes and unequal access to power, particu- larly in situations where power arises from religious or ethnic identity, and leaders are repressive or abusive of human rights • Social inequality characterized by markedly unequal distribution of resources and access to these resources, especially where the economy is in decline and there is, as a result, more social inequality and more competi- tion for resources • Control by one group of valuable natural resources, such as oil, timber, drugs, or gems • Demographic changes that are so rapid that they outstrip the capa- bility of the nation to provide basic necessary services and opportunities for employment (Carnegie Commission, 2007) Wealthy nations can play an important role in preventing collective violence by increasing funding for humanitarian and sustainable develop- ment programs that address the root causes of collective violence, such as hunger, illiteracy, and unemployment. Promoting Multilateralism Since its founding in 1946, the United Nations has attempted to live up to the goal stated in its charter: “to save succeeding generations from the scourge of war.” Its mandate, along with preventing war, includes protect- ing human rights, promoting international justice, and helping the people of the world to achieve a sustainable standard of living. Its affiliated programs and specialized agencies include, among many others, the United Nations Children’s Fund (UNICEF), WHO, the Food and Agriculture Organization, the International Labor Organization (ILO), the United Nations Develop- ment Program, and the Office of the UN High Commissioner for Refugees. These UN-related organizations, and the UN itself, have made an enormous difference in the lives of people over the past half-century.

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 APPENDIX C The resources allocated to the UN by its member states are grossly inadequate. The annual budget for the core functions—the Secretariat oper- ations in New York, Geneva, Nairobi, Vienna, and five Regional Commis- sions—is $1.25 billion. This is about 4 percent of New York City’s annual budget—and nearly a billion dollars less than the yearly cost of Tokyo’s Fire Department. The entire UN system (excluding the World Bank and International Monetary Fund) spends $12 billion a year. By comparison, annual world military expenditures—$1 trillion—would pay for the entire UN system for more than 65 years. The UN has no army and no police. It relies on the voluntary contri- bution of troops and other personnel to halt conflicts that threaten peace and security. The United States and other Member States on the Security Council decide when and where to deploy peacekeeping troops. Long-term conflicts, such as those in the Sudan and Kashmir, and the Israeli-Palestinian conflict, fester while conflicting national priorities deadlock the UN’s abil- ity to act. In fact, if stymied by the veto, the organization has little power beyond the bully pulpit. The United States and the United Kingdom have severely weakened the UN’s ability to prevent collective violence by their unauthorized and illegal invasion of Iraq in 2003. The United States also failed to support the International War Crimes Tribunal through signature and ratification of the Statute of the International Criminal Court (Sewall and Kaysen, 2000). Ending Poverty and Social Injustice Poverty and other manifestations of social injustice contribute to con- ditions that lead to collective violence. Growing socioeconomic and other disparities between the rich and the poor within countries, and between rich and poor nations, also contribute to the likelihood of armed conflict. By addressing these underlying conditions through policies and programs that redistribute wealth within nations and among nations, and by provid- ing financial and technical assistance to less-developed nations, countries like the United States can minimize poverty and other forms of social injustice that lead to collective violence. The Commission on Social Deter- minants of Health was established in 2005 to spearhead action on the social causes that underlie ill health and will recommend the best ways to address health’s social determinants and safeguard to help the poor and marginalize the population (Commission, 2007; Marmot and Bell, 2006). Creating a Culture of Peace People in the health and environment sectors can do much to promote a culture of peace, in which nonviolent means are utilized to settle conflicts.

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2 APPENDIX C A culture of peace is based on the values, attitudes, and behaviors that form the deep roots of peace. They are in some ways the opposite of the values, attitudes, and behaviors that reflect and inspire collective violence, but should not be equated with just the absence of war. A culture of peace can exist at the level of the family, workplace, school, and community as well as at the level of the state and in international relations. Health and environ- ment professionals and others can play important roles in encouraging the development of a culture of peace at all these levels. The Hague Appeal for Peace Civil Society Conference was held in 1999 on the 100th anniversary of the 1899 Hague Peace Conference. The 1899 conference, attended by governmental representatives, was devoted to find- ing methods for making war more humane. The 1999 conference, attended by 1,000 individuals and representatives of civil-society organizations, was devoted to finding methods to prevent war and to establish a “culture of peace.” The document adopted at the 1999 conference, The Hague Appeal for Peace and Justice for the 2st Century, has been translated by the UN into all its official languages and distributed widely around the world. Its 10-point action agenda addressed education for peace, human rights, and democracy; the adverse effects of globalization; sustainable and equitable use of environmental resources; elimination of racial, ethnic, religious, and gender intolerance; protection of children; reduction of violence; and other issues (Hague Appeal, 2007). Primary Prevention Primary prevention includes preventing specific elements of collective violence and sharply reducing preparation for war. This includes not only wars between nations but wars within nations as well. Strengthening of Nuclear Weapons Treaties Unlike the implementation of treaties banning chemical weapons and biological weapons, there is no comprehensive treaty banning the use or mandating the destruction of nuclear weapons. Instead a series of over- lapping incomplete treaties have been negotiated. The Partial Test Ban Treaty (PTBT) of 1963, promoted in part by concerns about radioactive environmental contamination, banned nuclear tests in the atmosphere, underwater, and in outer space. The expansion of the PTBT, the Compre- hensive Nuclear-Test-Ban Treaty (CTBT), a key step toward nuclear dis- armament and preventing proliferation, was opened for signature in 1996 but has not yet received sufficient signatures or ratifications to enter into force. It bans nuclear explosions, for either military or civilian purposes,

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 APPENDIX C but does not ban computer simulations and subcritical tests, which some nations rely on to maintain the option of developing new nuclear weapons. The CTBT has been signed and ratified by 140 nations. Entry into force requires ratification by the 44 nuclear-capable nations, which has not yet been achieved. The United States has not yet ratified the CTBT. The Treaty on the Non-Proliferation of Nuclear Weapons (the “Nuclear Non-Proliferation Treaty,” or NPT) was opened for signature in 1968 and entered into force in 1970. A total of 189 states parties (nations) have rati- fied the treaty. The five nuclear-weapon states recognized under the NPT— China, France, Russia, the United Kingdom, and the United States—are parties to the treaty. The NPT attempts to prevent the spread of nuclear weapons by restricting transfer of certain technologies. It relies on a control system carried out by the International Atomic Energy Agency, which also promotes nuclear energy. In exchange for the non-nuclear-weapons states’ commitment not to develop or otherwise acquire nuclear weapons, the NPT commits the nuclear-weapon states to good-faith negotiations on nuclear disarmament. Every 5 years since 1970 the states parties have held a review conference to assess implementation of the treaty. The review conference in 2000 identified and approved practical steps toward the total elimination of nuclear arsenals. The International Court of Justice (the World Court) in 2006 in an advisory opinion urged that the nations possessing nuclear weapons move expeditiously toward nuclear disarmament, as is required by Article VI of the NPT (Weapons of Mass Destruction Commission, 2006). The Anti-Ballistic Missile (ABM) Treaty between the United States and the Soviet Union was signed and entered into force in 1972. The ABM Treaty, by limiting defensive systems that would otherwise spur an offensive arms race, has been seen as the foundation for the strategic nuclear arms reduction treaties. In late 2001, President Bush announced that the United States would withdraw from the ABM Treaty within 6 months and gave formal notice, stating that it “hinders our government’s ability to develop ways to protect our people from future terrorist or rogue-state missile attacks.” The United States in 2007 announced plans to establish a ballistic missile defense system in Eastern Europe, which led Russia to threaten to increase its armory of nuclear weapons. Nuclear-weapons states should help stop the spread of nuclear weap- ons by actively supporting and adhering to these treaties and by setting an example for the rest of the world by renouncing the first use of nuclear weapons and the development of new nuclear weapons. It should work with Russia to dismantle nuclear warheads and increase funding for pro- grams to secure nuclear materials so they will not fall into the hands of individuals and groups.

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 APPENDIX C Strengthening the Chemical Weapons Convention The CWC is the strongest of the arms control treaties outlawing a single class of weapons. Inspection and verification of compliance with its provisions lies in the hands of the OPCW in The Hague, established by the CWC (Spanjaard and Khabib, 2007). The CWC has been signed and ratified by 182 nations. Controversies about safety and protection of the environment during the disposal of chemical weapons required by the CWC has delayed completion of the disposal, and large stockpiles still remain in a number of the world’s nations that pose a continuing threat to health and to the environment. The United States and other nations have failed to fully support the OPCW in its difficult tasks of inspection and in urging nations to comply with CWC (Lee and Kales, 2008). Strengthening the Biological and Toxin Weapons Convention While the development, production, transfer, or use of biological weap- ons was prohibited by the 1975 Biological and Toxin Weapons Conven- tion (BWC), which has been signed and ratified by 158 nations, several nations are believed to retain stockpiles of such weapons. The verification measures included in the BWC are weak and attempts to strengthen them have been unsuccessful. During 2002, the United States blocked attempts to strengthen the verification measures of the BWC, announcing that such measures might lead to exposure of U.S. industrial or military secrets. The United States and other nations must be urged to agree to support the inter- national community’s attempts to develop strong inspection and verification protocols for the BWC. Efforts must be made to convince all nations to support strengthening of the BWC and all nations must refrain from secret activities, often termed “defensive,” that may fuel a biological arms race. Perhaps even more important, global public health capacity to deal with all infectious disease must be strengthened. The best individual and collective efforts at diagnosing and treating disease outbreaks can be over- whelmed by any natural or intentionally induced epidemic. Consequently, support for strong global preventive public health capabilities provides the best ultimate defense against ever-evolving threats. The significant vulner- abilities to persistent global reservoirs of endemic illness in impoverished and underserved populations can provide the source of future pandemics. For example, in India during 1999 there were 2 million new cases of tuberculosis, causing about 450,000 deaths. An investment of $30 million annually over a few years, compared to the current U.S. contribution to India of $1 million for this purpose, could virtually wipe out the disease. In addition, the UN has estimated that $10 billion invested in safe water supplies could cut by up to one-third the current 4 billion cases of diarrhea

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 APPENDIX C worldwide that result in 2.2 million annual deaths. Strengthening the BWC and preventing suspicion of human-cost infection will help to eliminate the fear that at times prevents action to prevent naturally cost infection. Promoting the Support of the Anti-Personnel Landmines Convention (Ottawa Mine Ban Treaty) A total of 157 nations have signed or ratified the 1997 Ottawa Mine Ban Treaty, also known as the Anti-personnel Landmines Convention. Regrettably, over 30 nations have not signed, including China, India, Iran, Iraq, Israel, Russia, and the United States. Resources are desperately needed to clear the landmines currently deployed. All the nations of the world must be urged to contribute more resources to this task (Hindi et al., 2005; Bertell, 2006; Sirkin, 2008). Secondary Prevention The consequences of collective violence can also be prevented or dimin- ished by secondary prevention: if war occurs, by preventing casualties among military personnel and civilians and preventing environmental destruction and by seeking an end to the war. Secondary prevention methods include strengthening adherence to the Geneva Conventions and other treaties that lessen the effects of war; reducing military activities, including preparation for war; and negotiating effective treaties to lessen environmental damage. Tertiary Prevention Efforts after the end of an armed conflict to reconstruct the damage and to prevent new conflicts and new collective violence are extremely impor- tant. The initiation of World War II was in part caused by the failure by the Allies to deal with the problems of defeated Germany after World War I. Tertiary prevention methods include providing appropriate aid to countries damaged by war, such as the Marshall Plan after World War II; requiring environmental reconstruction after the war has ended; and demanding appropriate reparations for physical and environmental damage. The Role of Nongovernmental Organizations Important roles for public health workers in prevention and alleviation of the consequences of collective violence lie in work with nongovernmental organizations (NGOs) (Loretz, 2008). These organizations are increasingly being called “civil society organizations” and focus on war from a medical and public health perspective in a variety of ways:

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 APPENDIX C • Intervening to mitigate the consequences of armed conflict • Researching the effects of war • Educating the public and decision makers about its impact on health and the environment • Advocating for changes in global attitudes and policies toward war and the most dangerous weapons and practices of war • Changing the social, economic, and political determinants of col- lective violence Other NGOs provide direct humanitarian assistance to the victims of collective violence. These organizations generally participate in secondary and tertiary prevention but some, such as the Red Cross, have also in recent years begun to play a role in primary prevention. Humanitarian assistance organizations may also play a role in primary prevention of specific acts of violence and atrocities. They may be strong advocates on behalf of civilian populations among whom they live and for whom they provide humanitar- ian assistance (Waldman, 2008). As the Preamble to the Constitution of the United Nations Educational, Scientific, and Cultural Organization (UNESCO) states, “Since wars begin in the minds of men, it is in the minds of men that the defenses of peace must be constructed” (UNESCO, 2007). Acknowledgments The authors are grateful to Mark Rosenberg and James Mercy for their perceptive comments on the draft of this paper and their cogent suggestions for its improvement. References Allukian, M. Jr., and P. L. Atwood. 2008. The Vietnam War. In War and public health. 2nd ed., edited by B. S. Levy and V. W. Sidel. New York: Oxford University Press. Pp. 313-336. Annas, G.J., and H.J. Geiger. 2008 war and human rights. In War and public health. 2nd ed., edited by B.S. Levy and V. W. Sidel. New York: Oxford University Press. Pp. 37-50. Associated Press. 2007. U.N.: Malnutrition on the rise in Darfur. http://enews.earthlink.net/ channel/news/print?guid=20070831/36d8e3c0_3ca6_1552620070 (accessed September 2, 2007). Bertell, R. 2006. Depleted uranium: All the questions about DU and Gulf War syndrome are not yet answered. International Journal of Health Services 36(3):503-520. Burnham, G., R. Lafta, S. Doocy, and L. Roberts. 2006. Mortality after the 2003 invasion of Iraq: A cross-sectional cluster sample survey. Lancet 368:1421-1428. Carnegie Commission. 2007. Carnegie Commission on preventing deadly conflict. http://www. wilsoncenter.org/subsites/ccpdc/index.htm (accessed September 3, 2007). CDC (Centers for Disease Control and Prevention). 2007. http://www.bt.cdc.gov (accessed June 4, 2007).

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