“A hospital alone shows what war is” — Erich Maria Remarque
While the possibility of a full-blown war between India and Pakistan seems to have been abated after the nations consented to a mutual ceasefire, it might be an important chance to think about health systems preparedness — and how public health physicians should be better trained to handle such uncertain situations.
Consequences of war on human health
A series of protracted wars around the world have highlighted the far-reaching consequences of wars on human health. A statement by WHO about ethnic conflict in Sudanreveals that the majority (>67%) of hospitals were out of service, > 4 million women were at risk of gender-based violence, and sharp increase in the probability of vector-borne and infectious diseases.
More than the violence itself, it is the absence of daily amenities such as food, shelter, water, clothing, and sanitation that takes the maximum toll on health. If there is an accompanying cocktail of reduced immunity, poor nutrition, and increased exposure to risk factors predisposes war victims to various infections, which are often worsened by disrupted healthcare delivery, communication blackouts, transport shutdowns, short medical supplies, and a dwindling workforce, thereby, creating a vicious loop.
Prolonged wars, particularly in low- and middle-income countries (LMICs), can have profoundly detrimental effects. They lead to an increase in the number of refugees whose overwhelming need for care puts an enormous strain on an already fractured healthcare system.
The vulnerable populations—children, women of reproductive age, and the elderly—often take the brunt. Non-communicable diseases, mental health, vaccination services, and MCH (maternal and child health ) facilities often fall through the cracks of the healthcare system which has been reoriented towards handling war wounds.
The medium- and long-term consequences of such health disparities are alarming. Wars do lead to regression of a country’s development and negate any strides made in health equity. They also exacerbate environmental degradation, rapid deforestation, habitat destruction, greenhouse emissions (the third year of the Ukraine war caused the CO₂ emissions to rise by 230 metric tons), and contamination of natural resources with munition residues disrupt the natural food cycles.
All of us are well aware of environmental impacts of chemical warfare (such as Agent Orange in the America-Vietnam War) or the genetic mutations observed in multiple generations after the Hiroshima-Nagasaki bombing. But while there are studied effects of environmental degradation, sometimes off-the-page impacts can even take epidemiologists by surprise. The destruction of mangroves in Vietnam during the war led to the creation of craters, which became breeding sites for mosquitoes and a reason for the steep rise in vector-borne diseases in the region.
Public health as a discipline that looks at the intersection of health with social, psychological, physical, and economic impacts of war, acts as a bridge to the community. Experts suggest that decentralising healthcare alone can ensure optimal care in a crisis. A WHO handbook on disaster focuses on community participation. The community is often the first responder and should be endowed with practical knowledge to provide first aid care. Take, for example, the unlicensed midwives of Mosul(Iraq) with limited formal training who operated from bombed houses to provide care to pregnant women.
Disaster management and preparedness
The disaster cycle involves mitigation and preparedness even before the disaster strikes. Detailed protocols for disaster management integrated with armed conflicts should be available at all healthcare facilities. At regular intervals, these protocols must be reiterated through knowledge dissemination and mock drills. Contingency protocols for fuel, power, water, and communications should be in place. The functioning 700-bed Al-Shifa hospital in the recent Israel-Palestine conflict was crippled, due to, among other factors, the lack of generator fuel. A mere 300 liters of fuel was sent by Israel as aid to the hospital, which requires at least 8000-12000 litres every day.
A safe, strategic reserve of essential medicines, lifesaving drugs, blood bags, and vaccinations is essential to building resilient healthcare systems. Deployment of mobile health units and investment in healthcare innovation is another way of improving disaster preparedness. Healthcare systems that had preexisting digital infrastructure showed resilience, operating through telemedicine, and remote prescriptions in Ukraine. In Gaza,solar-powered dialysis machines were used to help patients with kidney failure.
Ensuring availability of emergency health facilities
Continued surveillance and documentation to check the existing as well as future needs of the community are paramount. Collaborative efforts with international organisations such as ICRC, MSF, and the WHO should be strengthened. Diplomatic efforts between the warring countries should ensure that civilian health is not impacted, and this can be done through the creation of neutral health corridors and the availability of aid and emergency facilities. In Afghanistan, UNICEF, WHO, and Afghan health authorities negotiated for temporary ceasefires called ‘Days of Tranquility,’ which were used for vaccinating children and continuing the country’s fight against polio.
In the 2008 edition of War and Public Health, Levy and Sidel emphasised the tragic impacts of war: “War accounts for more death and disability combined.” They also harp on primary, secondary, and tertiary prevention strategies that can be employed by public health professionals to address war. However, it is unfortunate that, worldwide, topics such as refugee health and the impacts of war remain out of the ambit of the public health courses.
Most countries invest in their military capacity; however, they forget to make proper preparations for healthcare. A 2000 report showed that Ethiopia spent $16 on military while only $1 on health in 1990. On the opposite, the Assad regime of Syria was more hostile to its doctors, who were prevented from performing their duties due to fear of persecution.
Until John Lennon’s dream of “all people living’ in peace’ when “there’s no countries, nothing to kill or die for,’ is realised, it is important for doctors to be aware of their rights and responsibilities so that they can not only protect themselves but also the people suffering during a war.
(Dr. Kinshuk Gupta is a public health physician and writer of Yeh Dil Hai Ki Chor Darwaja
Prof. Suneela Garg is ex-dean of Maulana Azad Medical College and Chair, Programme Advisory Committee , NIHFW
Prof. Mongjam Meghachandra Singh is director and head, Department of Community Medicine, MAMC and Chairperson of Centre for Occupational and Environmental Health, Delhi)
Published – May 11, 2025 07:12 pm IST