War and health

26 Sep 2011

When I began thinking about this topic and doing my research, I realized that I should be discussing not only about war and health but, more importantly, on the war against the people’s right and access to health.


The two wars against the people’s right and access to health occurred simultaneously during the last decade of the previous century: the war of globalization and the war against “terrorist states,” “rogue states,” “the axis of evil,” and eventually the war on terror. The war on terror did not begin with the World Trade Center attacks in September 11, 2001. If began after the change in the political landscape in Eastern Europe and the USSR and the conception of the Defense Policy Guidelines in 1992 by then Defense Sec. Dick Cheney and Paul Wolfowitz, and the 2000 policy paper “Rebuilding America’s Defenses – Strategy, Forces, and Resources for a New Century” of the conservative think tank Project for a New American Century, which, by the way, is comprised of the very same group of people: Dick Cheney and Paul Wolfowitz, Jeb Bush, I. Lewis Libby, and Donald Rumsfeld, who became the Defense secretary of Bush Jr.


The change in political landscape in the Eastern bloc during the latter part of the 1980s provided both an opportunity and a challenge to the US. The communist bogey no longer exists while at the same time, it provided the US with the opportunity to use its political and military dominance to push for its own economic interests and agenda. Thus, even as there was no longer any serious challenge to its hegemony, it refused to downscale its military spending. It even increased it by creating a hype about a supposed new specter: Islamic fundamentalism. That is why even before the September 2011 attacks, the US, in its defense policy paper “Rebuilding America’s Defense – Strategy, Forces, and Resources for a New Century,” was already able to underline the principles that would shape its global “defense” policy. The 9-11 attacks merely gave the US the perfect excuse to launch its war on terror.


What were these principles guiding US defense policy and global positioning?


  • we need to increase defense spending significantly if we are to carry out our global responsibilities today and modernize our armed forces for the future;
  • we need to strengthen our ties to democratic allies and to challenge regimes hostile to our interests and values;
  • we need to promote the cause of political and economic freedom abroad;
  • we need to accept responsibility for America’s unique role in preserving and extending an international order friendly to our security, our prosperity, and our principles


Those countries that were included in the list of “terrorist,” “rogue,” or “evil,” states are those that “stridently oppose US presence and influence in their regions” and those that oppose “economic freedom” or the “free market ideology” of globalization.


Globalization, as we experienced it during the last two decades is about “downplaying government intervention” in the economy, of controlling budget deficits, and deep cuts in government social spending. It is, according to economist Joseph Stiglitz, about “austerity packages and privatization.” And among the most hit by these measures are the budgets for health and education. And the countries that refuse these measures, as well as US power projections run the risk of being targets of the US war on terror.


How did the war on terror affect the people’s right and access to health?


Let us take the example of Afghanistan. According to the World Health Organization, Afghanistan’s health care system in 2001 was among the poorest in the world because of “23 years of conflict, a collapsed economy, and three years of drought.” “Obtaining the most basic of necessities – food, shelter and clothing – is a constant struggle. Such exposure intensifies an already poor health situation, with acute respiratory illnesses, diarrheal diseases, and malnutrition killing and weakening the children of Afghanistan. There is a critical shortage of health care workers at every level. Healthcare facilities are in urgent need of restoration. There are inadequate supplies of medicines, vaccines, equipment and fuel. An estimated 6 million people have no access, or insufficient access to health care.”


  • Life expectancy rates are among the lowest in the world and 25 percent of children die before their fifth birthday. Lack of basic health care and malnutrition contribute to the high death rates.
  • Afghanistan has the second highest maternal mortality rate in the world. Less than 15 percent of deliveries are attended by trained health workers, mostly traditional birth attendants.
  • About half of children under 5 years of age are stunted due to chronic malnutrition and up to 10 percent have acute malnutrition
  • Mental health is a major health concern. Experts estimate that approximately 30–50 percent of the population undergoing violent conflict develop some level of mental distress. Residual mental health problems that appear normally in any population have been unattended in Afghanistan for decade
  • Diseases that have largely been controlled in most countries in the world continue to cause death and disability in Afghanistan. More than 60% of all childhood deaths and disabilities in Afghanistan are due to respiratory infections, diarrhea, and vaccine preventable deaths, especially measles.


How did Afghanistan fare after eight years of being “liberated” by the US from the rule of the Taliban?


Eight years of US occupation has not resulted in any improvement in the state of health in Afghanistan. According to an article “Afghanistan Faces a Public Health Emergency, which was published by the Epoch Times, in 2009:


  • More than 1.6 million children under the age of five and thousands of women could die in 2009 as a result of the lack of food and medical care
  • Food shortages and inclement weather could leave eight million Afghans—30 percent of the population—on the brink of starvation. People’s access to food is being stymied by low agricultural production, attacks on food convoys, and increases in the prices of food and other basic commodities. In 2005, an average household was reported to be spending 56 percent of its income on food. By 2009, it has risen to 85 percent, according to Susannah Nicol, a spokeswoman for the UN WFP.
  • Citing UNICEF statistics, the Epoch times reported that “Diarrhea and acute respiratory infections account for approximately 41 percent of all child deaths in this desperately poor nation of 26 million people, while vaccine-preventable diseases—such as measles, polio, and diphtheria—account for another 21percent.”
  • “Afghanistan rates low in practically all health indicators. As a result, it has one of the world’s highest infant and maternal mortality rates. Hospitals in most of the country are in deplorable conditions, and lack enough trained doctors or medical equipment for even the most basic surgeries. Life expectancy is 42 years, according to figures from the World Health Organization (WHO)”
  • Mental health persists as a problem that is not being adequately addressed.


And there are also the disabilities caused by landmines and unexploded ordnance, as well as the effects of hazardous waste from military warfare such as depleted uranium.


In Iraq, displacement, lack of income, insufficient diet, poor sanitation and lack of safe water sources, and the trauma of war have been taking its toll on the health of the internally displaced. Provision of much-needed health service is being hampered by security concerns.


“Health care in Iraq deteriorated greatly over the last decades as result of the repeated wars, sanctions and the generalised violence and conflict since 2003. This deterioration in health services also resulted from the exodus of qualified professionals, a severe shortage of medication and equipment, and damage to medical facilities.” (IDP Working Group, 27 June 2008)


What are the responses of the international community to address the health situation and problems confronting Afghanistan and Iraq?


In Afghanistan, the UN World Food programme is calling for more food aid to the war-torn country. In Iraq, on the other hand, the US claims that it has poured assistance for the rehabilitation of hospitals and health centers.


How would these responses impact on the health and well-being of the people of Afghanistan and Iraq? Let us now take Somalia as an example.


In Somalia, a country torn apart by a civil war since the US-backed dictator Siad Barre was toppled in1991, recurrent droughts and the war have caused widespread famine. The response of the international community has been to flood the country with food and other “development” assistance.


Historically, aid agencies have been in the country since the early 1980s. The USAID funded agricultural training projects encouraging the nomadic Somali people to practice semi-permanent agriculture. This destroyed the traditional coping strategy of Somalis during droughts. Consequently, it made them dependent on food aid. And since aid agencies have been flooding Somalia with food supplies from Western countries, food aid became the most traded good in the market. Eventually, food aid destroyed the agricultural economy in Somalia because the traded food is much cheaper than the products being produced by farmers. So the aid which was supposed to solve the hunger problem in the country would, ironically, become the source of famine in the future once the flow of food from Western countries is stopped.


So if food and other “development’ assistance would not, in the long term, help a country being ravaged by war and hunger confront its health and other basic needs, especially if it is being regarded not as a temporary, stop-gap measure but as a policy response, how about the rehabilitation of hospitals and health centers. Surely, the people would benefit from the increase in capacities of hospitals and health centers.


A study with the title “Public spending on health care in Africa: do the poor benefit?” by F. Castro-Leal,J. Dayton, L. Demery, and K. Mehra looked into health spending of the governments of select African countries: Guinea, Madagascar, CoÃte d’Ivoire, Ghana, Tanzania , and South Africa. The study aimed to determine to what extent government health spending has been effective in reaching the poor. All the African countries, which were included in the study, have a three-tiered public health system: there were clinics and dispensaries at the first level, district level hospitals at the secondary level, and referral and specialty hospitals at the tertiary level. Government health spending was biggest at the tertiary level.


What were the results?


The study revealed that since government health spending was focused on curative health care, it benefited the more well-off rather than the poor. This is because the poor rarely access curative health care services unless in dire emergencies. The study attributed this to the attitude of the poor to regard illnesses as a normal feature of life and to a lack in information. It concluded that to target the poor, government health spending should focus more on primary health care and less in hospitals.


This is also true in the Philippines, the poor are wary of going to hospitals because they lack the money to spend on tests and medicines, which are not being provided for free even in government hospitals.




The globalization policies of deregulation, liberalization and privatization have resulted in the decreasing government budget and spending in health. This forced government hospitals, with substantially slashed budgets, to undertake cost recovery schemes by charging for services that used to be subsidized, and reduce the allocations for indigent patients. This also made the deficiencies in supplies, medicines and personnel of health centers even worse.


To address this, health NGOs and advocacy groups have been campaigning for an increase in government budget and spending for health while training and supporting communities in setting up community health programs with focus on primary health care. Health NGOs also support communities in establishing a health referral network for their tertiary health care needs.


Ironically, the Philippine government and its armed forces do not view this favorably. As part of its counterinsurgency program, the government and its military have been targeting health workers servicing far flung communities and accusing them of being enemies of the state who are influencing the people to fight the government. Health workers servicing poor communities have suffered the brunt of the enemy-centric and population-centric approaches of the AFP: being targeted as enemies of the state without regard to the fact that they are unarmed and have merely been providing much-needed health services and being treated as competitors in influencing the people. This has been the experience of the Morong 43. We have also been receiving reports from Chestcore, a health service NGO servicing communities in the Cordillera region, that its staff have been receiving death threats. There were also medical missions that have been blocked by the military.


What should committed health workers do then?


To be able to address the health problems of the people and enable them to improve their quality of lives, should health workers confine themselves to hospitals in the hope that the poor would eventually access their health care services? How could health workers confront the problem of diminishing health budgets that result in understaffing, machines that always break down, insufficient supplies and medicines? How could health workers enable peoples and communities to access and enjoy their right to health?


In situations of armed conflict, how could health workers confront attacks on the people’s right to health, as well as attacks on their safety and well-being? How should health workers address the additional problems of lack of food, displacement and poor living conditions, and trauma injuries, which are prevalent in situations of armed conflict?


Should health workers confine themselves to providing curative and emergency health services, while projecting themselves as neutral providers of humanitarian assistance or perform multiple roles as health service providers, advocates for the people’s right to health as a basic human right, and activists who organize, mobilize, and enable communities to assert their right to health while taking care of their primary health care needs?


This article is a talk given by the author during the 8th Finnish-Philippine U.P Global Health Course, which is an undertaking of the University of the Philippines College of Medicine and the University of Tampere, last August 9, 2011.


Source: Benjie Oliveros/Bulatlat

Benjie Oliveros/Bulatlat