Prevention of War

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Prevention of War
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Prevention of PTSD

• Chemical prophylaxis
• Stress innoculation training
• Debriefing and decompression
• Education and early recognition
• Eliminate humiliation and degradation as
  motivational techniques
• AVOID WAR

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Prophylaxis with Propranolol

• Selectively blocks consolidation of traumatic
  memory
• Case series trauma patients given propranolol on
  presentation in ER Roger Pitman
• Small differences found in
• PTSD symptoms at 1 month Clinician Administered
  PTSD Scale (CAPS)
• Neurophysiological parameters at 3 months - heart
  rate, skin conductance, EMG
• Ethical questions

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Pitman et al., Biol Psychiatry 2002
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Pitman et al., Biol Psychiatry 2002
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Prevention of War

• Public Health Approach
• Define the problem
• Design, implement, monitor interventions
• Phases of Conflict
• Preconflict
• During Conflict
• Postconflict

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Role of Health Professionals in Mitigating the
Health Effects of War

• Existing efforts
• Assessment of health impact
• Designing prevention and treatment strategies
• Programs to prevent infectious disease and
  malnutrition
• Possible efforts
• Preventing armed conflict from happening
• Addressing problems that have received little
  attention, including mental health problems

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Preconflict Interventions

• Popular interventions require extensive public
  health research
• Economic sanctions
• Terrorism preparedness
• Surveillance for risk and protective factors
• Research to identify these factors
• Early warning system

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Ethnic Conflict in India

• Conflict between Hindus and Muslims in India is
  common in some cities and rare in others
• Strong associational forms of civic engagement
  protect against violence (Varshney, 2002)
• Integrated business organizations
• Trade unions
• Political parties
• Professional associations
• Creating integrated community associations may
  prevent violence

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Health Professionals During Conflict

• Direct aid
• Witnessing and documentation of human rights
  violations and atrocities
• Research, education, and advocacy
• Speak truth to power
• Citizen diplomacy

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Postconflict Interventions

• United Nations peacekeeping
• Malnutrition and infectious disease prevention
• Landmine/unexploded ordnance injury prevention
• Resettlement and vocational training
• Research needed on risk factors for recurrence of
  conflict - 40 of countries in relapse into war
  within 5 years

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Postconflict Interventions Mental Health

• Strengthen and rebuild family and village
  structures
• Traditional practices and ceremonies
• Education about psychological trauma
• Training grassroots mental health works
• Research needed on evidence-based mental health
  interventions
• Population-wide psychological first aid
• Identifying and triaging to psychiatric treatment
  those with severe mental health problems

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Evidence-Based Approaches to Mental Health

• Comprehensive Mental Health Program in
  Bosnia-Herzegovina (Mooren et al., J Clin Psychol
  2003)
• Systematic assessment of efficacy
• Multicenter outcome studies of counseling
  interventions
• Mental Health Action Plan (Mollica et al., Lancet
  2004)
• Evidence-based plan for addressing mental health
  in complex emergencies
• Utilizes primary care providers, traditional
  healers, and relief workers
• Research agenda

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Recurrence of Armed Conflict

• Mental illness caused by psychological trauma is
  associated with feelings of hatred and desire for
  revenge
• Kosovo (Lopes Cardozo et al., J Traumatic Stress
  2003)
• Afghanistan (Lopes Cardozo et al., JAMA 2004)
• Openness to reconciliation and feelings of
  revenge correlated with presence of PTSD
• Ugandan Congolese Child soldiers (Bayer et al.,
  JAMA 2007)
• Effective treatment of psychological trauma may
  help prevent recurrence of violence

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Relationship Between Cognitive and Psychological
Effects of War

• Cross-sectional, population-based study in former
  Yugoslavia (Basoglu et al., JAMA 2005)
• Association with PTSD and depression
• NO sense of injustice arising from perceived
  lack of redress for trauma
• YES fear of threat to safety and loss of
  control over ones life
• Implications for reconciliation efforts

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Health Consequences of War

• More death and disability than many major
  diseases combined
• Destroys families and communities
• Diverts resources from health services
• Destroys infrastructure that supports health
• Destroys environment

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Source www.childinfo.org
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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.World Health Assembly Resolution
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Teaching War and Health

• War can and should be addressed as a public
  health problem
• Design and implement interventions, monitor
  outcomes
• Primary, secondary, tertiary prevention
• Preconflict, during conflict, postconflict
• Preventing war and its consequences should be
  part of any Global Health curriculum

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Multitrack Peacework

• Challenges narrow view that dominates media
• Track two diplomacy nongovernmental efforts
• Multitrack diplomacy (Diamond and McDonald) 9
  tracks including business, education, religion
• Peacework more comprehensive term

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The Health Track

• Values
• Altruism
• Scientific Procedure
• Peace-Health Overlap
• Social Characteristics
• Social Legitimacy, Funding Support
• Access to War Zones
• Strongly Integrated Community

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• Guided by the values and expertise of medicine
  and public health, Physicians for Social
  Responsibility works to protect human life from
  the gravest threats to health and survival.
• www.psr.org

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Medicine is a social science, and politics
nothing but medicine on a grand scale.
- R. Virchow, Die Medicinische Reform, 1848
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After all, few professions are as international
in character, share age old traditions, have a
common pool of knowledge, search a single
scientific data base, and are guided by similar
methods, terminology and objectives. This
ancient tradition and enduring global association
of medical practitioners, enables doctors to
engage in effective citizen diplomacy.
Bernard Lown
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Mechanisms of Peace through Health

• 1. Redefinition of the situation
• 2. Superordinate goals
• 3. Mediation and conflict transformation
• 4. Dissent and noncooperation
• 5. Discovery and dissemination of knowledge

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Mechanisms of Peace through Health

• 6. Rebuilding the fabric of society
• 7. Solidarity and support
• 8. Social healing
• 9. Evocation and extension of altruism
• 10. Limiting the destructiveness of war

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Tools of Peace through Health

• Analysis health needs, peace deficits, types of
  violence, stage of conflict
• Peace and Conflict Impact Assessment
• Do No Harm Project
• Peacebuilding Filter
• Respect for Culture
• Epidemiology

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Case Studies

• Primary prevention
• Weapons limitation
• Peace education
• Secondary prevention
• Humanitarian ceasefires
• Medical peacebuilding
• Tertiary prevention
• Psychosocial healing
• Community-based rehabilitation

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The world cannot continue to wage war like
physical giants and to seek peace like
intellectual pygmies.
Basil OConnor