Deaths rates in war reached unprecedented levels in the 20th century, with the increase in deaths far out of proportion to increases in population. There were twice as many civilian deaths (34 million) as military deaths (17 million) in World War II (Holdstock, 2002). A large proportion of these deaths were due to indirect causes related to conflict, including insufficient and unsafe water supplies, non-functional sewerage and restricted electricity supplies, deteriorating health services with insecure access, and the flight of health professionals. In absolute terms, the major causes of mortality during complex emergencies such as war are diarrhoeal diseases, acute respiratory infections, neonatal causes and malaria (Burnham et al., 2006, Burnham and Roberts, 2006, Black et al., 2003). Yet typically it is Ministries of Defence and not Ministries of Health that make assessments (necessarily inadequate) of the likely social and population-health outcomes of war.
Defence ministries document the physical causes of morbidity and mortality in wars, but little or no research or public policy debate is oriented toward reducing the impact of war on civilian populations. Analyses of war and defence policy are typically applied from a national security perspective. In contrast, a human security perspective on war and defence policy is less commonly articulated. Recent attention has been focussed on the concept of "human security" as a distinct but complementary concept to that of national security. Human security can be defined either as the absence of conflict, or more broadly as encompassing human rights, good governance and access to health and education (Human Security Centre, 2005). Human security thus distinguishes the concerns of individuals and communities from the broader concerns of the state.
The objective of this paper is to identify the role of public health in the analysis of pre-event scenarios of conflict. We argue that one of the main reasons for the marginalization of public health in war planning and national security assessments has been the failure to develop effective methods of pre-event analysis which focus on human security. This results in the inability to adequately forecast the long term impacts of conflict on the health of populations, and therefore acts as a constraint on public health participation in the analysis of war and defence policy and decision making.
The concept of "human security" was first elucidated in the United Nations Development Programme (UNDP) World Development Reports of 1993 and 1994. Security was analysed in terms of environment, community, food security, politics, personal security and finally "health security." The concept of human security acts to stimulate "forward looking contingency planning" (Gutlove and Thompson, 2003, p. 1734). Human security facilitates contingency planning through the capacity of the concept to grasp the interdependency of social sectors in securing survival. For example, the functioning of public health referral systems is contingent upon ensuring the political and personal security of health professionals and communities. In the absence of this security, free movement and access of the population and health workforce between primary and secondary levels of the health care system cannot be assured.
Public health is therefore a central pillar of any concept of human security. In recognition of this, the Special Rapporteur on human rights at the United Nations recently developed an agenda for "right to health." The Special Rapporteur articulates accessibility to quality functioning public health care services as a fundamental social right of individuals and communities. In recognition of the multi-dimensional nature of human security, the Special Rapporteur observes that public health systems are core social institutions, in much the same way as is a fair justice system or democratic political system (Hunt and Human Rights Council, 2008).
The Changing Nature of War and Its Impact on Population Health and Development
Historians have highlighted the role of modern technology in reshaping the character of warfare, particularly its changing impact on military personnel and civilians. The increasingly destructive capacity of war-making technology is extending the reach of traditional warfare and the level of destruction caused to the economic and social infrastructure of societies in conflict is increasing. In terms of scope and impact, wars are becoming both more intra-state and more civilian. Between 1946 and 1991, there was a twelve fold increase in the number of civil wars (Human Security Centre, 2005). As societies become more urbanised, distinctions between military targets and civilians have been blurred, leading to the modern phenomenon of the so called "infrastructure war" where urban power and water systems, as well as civilian populations, are strategic military targets (Nokkala, 2002).
As a result the rate of civilian deaths in war increased dramatically throughout the twentieth century. In the First World War, 14% of war deaths were civilians. This increased to 67% in the Second World War (Sidel, 1995). The first Gulf War and its aftermath provide an illustration of the size of the effect of conflict on civilian mortality rates. A comprehensive assessment of the impact of the January-February 1991 Gulf War on mortality rates estimated that there were 111,000 civilian deaths from "post-war adverse health effects", the largest number of casualties caused by the war (Daponte, 1993). Of these deaths, 70,000 were children under the age of 15. A more recent assessment has indicated that in Iraq, pre-invasion mortality rates were 5.5 per 100 people per year, compared with 13.3 per 1000 people per year in the 40 months postinvasion. It has been estimated that 654,965 people (or 2.5% of the Iraqi population) died as a consequence of the war (Burnham et al., 2006). Similarly, a national survey conducted in 2004 following conflict in the Democratic Republic of Congo found that the crude mortality rate of the population was 67% higher than pre-conflict measurements (Coghlan et al., 2006).
This changing nature of war has recently generated a literature that investigates and analyses the impact of conflict on population health and development. This collective, preventable violence practiced under the banner of national security produces health effects long after the war has ceased. Mortality rates remain high for many years after conflict has ended. The World Health Organisation (WHO) Global Burden of Disease Study indicates that 15% of global disease burden is attributable to injury (Murray, 2008).
UNICEF statistical tables clearly document the impact of...