Conflict management

Doctors are able, at times, to gain access to the highest political offices in a nation (International Physicians for the Prevention of Nuclear War members spoke directly with Reagan and Gorbachev during the Cold War) while maintaining high credibility with the general public. They also have, through shared medical research and professional organisations, wide international contacts with colleagues. They may be well placed to undertake diplomatic activities such as mediation, facilitation of dialogue, and high level advocacy, although they would require appropriate training to perform such tasks effectively.¹⁹

Superordinate goals transcend the interests of contending parties and are shared by both (or all) of them. Certain goals in population health may make it desirable to seek cooperation between contending parties in a region affected by war. This may create an opportunity to build a negotiating framework, to counter dehumanisation of the enemy, and sometimes to demonstrate the possibility of stopping the violence. Where the warring parties are, or aspire to be, the government, they may willingly espouse public health goals. Funding bodies may make grants conditional on the contending parties finding ways to work together.

In the mid-1980s, Unicef, the Roman Catholic church, and other organisations negotiated “days of tranquility” in El Salvador. Fighting was suspended for the immunisation of children for three days each year from 1985 until the peace accords in 1992. Major gains in the health goals of the campaign were ostensibly achieved, with a total of 300 000 children immunised at several thousand sites each year. The incidence of measles, tetanus, and polio dropped dramatically, that of polio to zero. A negotiating framework between government, the army, and rebel forces, mediated by the church, was created at the national level and multiple local levels. This ostensibly contributed favourably to the achievement of the peace accords.²⁰

Solidarity

Individuals and groups in threatening situations may be struggling to survive, attempting to restrain an existing war or to prevent a possible war, or resisting abuses of state or rebel groups' power. Linkages with health sector groups outside the conflict area may provide much-needed resources, including knowledge. The vigilance intrinsic to such linkages, as operated by organisations like Amnesty International and Physicians for Human Rights, may provide protection against the persecution, disappearance, or death of workers. Solidarity linkages may also offer alternative, non-violent strategies for resolving disputes.

The Medical Action Group in the Philippines comprises physicians, dentists, community development workers, nurses, and medical students. They travel in small teams to remote areas to treat people in communities displaced by war that would otherwise have no health services. They promote the peace and security of these communities by reporting on human rights abuses by the army, and they work for longer term peace and justice by advocating on behalf of affected communities. The army units in each area are always visited by the entering team. Human rights violations are thought to have diminished as a result of the teams' capacity to report and advocate.

Strengthening the social fabric

Health care is one of the chief means by which members of a society express their commitment to each other's wellbeing. An adequate healthcare system accessible to all members of society can promote feelings of security and of belonging to a broad, inclusive group that respects people and meets their common needs. This civic identity makes hate-based mobilisation of ethnic or other identity groups more difficult. In Uganda, for instance, renewed health structures have encouraged displaced people to return home, and it has become clear that rehabilitation of the healthcare system is linked to the wider process of social recovery from war.²¹

In many areas, ethnic and religious divisions may have been manipulated to foment war, and violence may have been propagated as a desirable solution to conflict. Social healing of these divisions is necessary to re-establish conditions for public health. This activity is sometimes combined with the tasks of physical and psychological rehabilitation.²² In Croatia a school based curriculum has been devised for children aged about 11 in areas seriously affected by war. It combines the opportunity to discuss sadness, anger, and stress symptoms with a cautious approach to reducing prejudice, learning about non-violent conflict resolution, developing a vision of reconciliation, and “peace living.” Evaluation of this programme has shown small positive changes in some relevant dimensions in both mental health and ethnic tolerance.^23,24

Working with the idea, the World Health Organization and the UK Department for International Development mounted in Bosnia-Herzegovina “a concerted and intensive attempt to address the fundamental obstacles to peace through health sector development.”²⁵ They show that their programme broke through ethnic barriers and enabled other non-governmental organisations to implement inter-ethnic programmes.

Dissent

Dissent from the policies of the governing or dominant group may take the form of protest, persuasion, non-cooperation, or intervention.²⁶ Dissent by healthcare workers may draw on their legitimacy, experience, or expertise.

Opposition to the Vietnam war by medical professionals included a variety of means and bases of dissent. Benjamin Spock, well known for his writings on the care of infants, drew on his formidable credibility with the American public to speak out against the US war effort.²⁷ Claire Culhane, a Canadian nurse who had worked in a clinic in south Vietnam, protested Canada's involvement in the war through civil disobedience, speaking, and writing.^28,29 Her actions were based less on high legitimacy than on personal experience of the health effects of military policies. Doctors who participated in the international war crimes tribunal held in Stockholm in 1967 under the auspices of the Bertrand Russell Peace Foundation, giving testimony against both weapons and actions taken by the US government in its pursuit of the Vietnam war, spoke primarily as scientific experts.²⁷

Such dissent may be furthered by “redefinition of the situation” by dissenting parties. By redefining the situation, parties attempt to gain control over issues that have been defined by those with formal political power as “none of their business” or “outside their field of expertise.” Healthcare workers have at times been successful in redefining war as a public health problem rather than a strictly political problem, thereby creating a space for the exercise of their knowledge and opinion. Given their generally high legitimacy with the public, they have in this way been able to exercise considerable influence. The strategies used by International Physicians for the Prevention of Nuclear War to redefine nuclear war as a public health issue are a classic example; another is the efforts of the International Study Team to raise doubts about claims that advanced technology was being used to fight a humane war in Iraq.^30,31

For further information, contact the Medical Action Group at 51-H Mother Ignacia Avenue, Quezon City 1103, Philippines. Competing interests: None declared.