The population health argument against war
Authors: Sandro Galea, Katy Wortman
Journal: World Psychiatry (2006)

There is ample evidence of a high prevalence of psychopathology among those persons unlucky enough to have lived through war, either as combatants, or, and even more so, as civilians caught in the middle of larger conflicts (1-3). Murthy and Lakshminarayana's article summarizes this evidence cogently and also shows that persons who are socially or economically vulnerable, including children, the elderly, and in many cases women, are more susceptible to the mental health consequences of war, and that ongoing displacement, stressors, or traumas may prolong the course of psychopathology and delay recovery. Although this review focuses on psychopathology, we should not forget that war is also accompanied by substantial mortality and physical morbidity, and, importantly, that there is a strong interrelationship between physical and psychological morbidity: persons who are physically injured are more likely to have prolonged psychopathology (4,5), and conversely, mental illness or injury increases the likelihood of poor physical health (6).

War is a display of force intended to subjugate one group to the will of another. It is perhaps then one of the primary goals of war to inflict harm (physical and psychological) as a means of forcing surrender and a cessation of activities undesirable to the warring party. Although war has long been part of human history and experience, a recent resurgence in between-nation conflict has resulted in substantial political discussion about  wars, or wars that are acceptable (7-9). These arguments suggest that war, while potentially having adverse consequences for those involved, is justifiable based on the alternatives. We suggest, however, that the burgeoning evidence documenting the mental and physical health consequences of war, among combatant and noncombatant populations alike, is seldom considered in the calculus leading up to decisions being made about war and its acceptability. Further, consideration of the full scope of the population health consequences of war raises the bar substantially about the conditions under which war is truly justifiable and as such provides a powerful argument against the initiation or perpetration of large-scale conflict.

One of the myths of modern warmaking is that wars can be conducted in a targeted smart way, focusing hostilities on armed combatants or political leaders without injuring the population. However, the evidence suggests that it is virtually impossible to conduct war in a way that targets only those who might be fighting back or those responsible for political and military decisions (10,11). The consequences of war inevitably include the deterioration of existing social structures, expose populations to stress and trauma, limit population access to preventive and curative health, and result in elevated rates of psychopathology and physical morbidity in persons who may well not be the intended targets of the conflict. In the vast majority of circumstances, poor population health is an inevitable consequence of war. We would suggest that arguments for just wars need to balance the adverse consequences an intended war will likely have on population health with the ongoing damage to population health in the absence of war. 

Although we focus here on population health as an end in and of itself, it is the centrality of health to the achievement of other ends throughout life that in many ways cements the population health argument against war. Health is the underlying precondition for persons to achieve their personal goals and, by extension, achievement of societal goals is predicated on population health. Therefore, through limiting the health of populations, war is effectively limiting the achievement of these populations on all other conceivable fronts. This argues for an appreciation of the fact that the impact of war on societies lingers far after the war itself. Psychological and physical pathology persist for many years after war may have ended and so does the impact of any given war. Unfortunately, our appreciation of a time frame beyond a few years is limited, a limitation that is reinforced by the ever-more-pervasive news media that quickly moves on to the next story once a war is over. However, war is seldom over within any given generation. The health consequences of war persist, and as a result, so do the social and economic consequences that shape all other experiences for a generation that has lived through a war. Perhaps even more alarming, recent studies suggest the inter-generational transmission of psychological trauma (12,13), further reinforcing the pervasive and long-term impact of war.

There is an abundance of accumulating empiric evidence about the social and economic consequences of adverse health. Most obviously adverse health burdens health care systems with a greater volume of need and with the attendant economic costs of providing care to those with psychological or physical morbidity. However, the indirect costs of adverse health are just as important and frequently overlooked. Adverse health is associated with limited productivity, decreased engagement in societal activities, and the imposition of a burden of care-giving on informal, as well as formal, social networks and services (14). The sum total of these costs is difficult to estimate, and is seldom considered, but these costs clearly go far beyond the costs of healthcare or of public health services. Therefore, the economic burden to societies, compounded by the impact of war on population health, must be considered as one of the consequences of war in any calculus about the justness or acceptability of any war.

Both overt inter-nation armed conflict as well as more limited wars such as long-term low-intensity conflict are associated with poor mental and physical health in the short and in the long term. The effect of this increased pathology is pervasive and persistent in the population and has far-reaching social and economic implications for societies at war. Those responsible for public health need to insist that the population health consequences of war are clearly articulated and considered as part of any calculus or public debate about the initiation of war.