Book
Review:
A Portrait of War as Destroyer of HealthWar
and Public HealthBarry S. Levy, Victor W. Sidel (eds.)
Oxford University Press (1997)
412 pp., US$55
Reviewed by Jennifer Leaning,
MD, SMH 
The latest edition of the classic text on public health (Public Health &
Preventive Medicine, edited by J.M. Last and R.B. Wallace, published in 1992
[1] has 1,257 pages, of which 17 are devoted to a chapter
on military medicine and 14 devoted to the public health consequences of disasters,
including war. The next edition will have to look quite different. That
necessity is created by the publication of War and Public Health, edited
by Barry Levy and Victor Sidel. This book marks a milestone in our collective
consciousness by placing the subject of war squarely in the mainstream of public
health concerns. An important tradition within military medicine has dealt with
problems of the health of the fighting army. Not until very recently, however,
has the robust and prolific field of public health turned its attention to what
is, once identified, a most obvious topic for all health professionals: the extent
to which preparation for and conduct of war contributes to short and long term
population morbidity and mortality. The distant mentor for many of us working
and writing within the field of public health is Rudolf Virchow, the 19th century
German pathologist who studied the interactions between social forces, including
war, and human health. Yet aside from Virchow, an interest in the health effects
of war on human populations has been singularly lacking among the framers of the
Western public health tradition. Historical demographers, historians, and sociologists
have looked at the social and demographic changes wrought by war, but from the
perspective of their own disciplines. In the last
10 years, however, and particularly now with the publication of War and Public
Health, it is becoming clear that the public health community has determined
that war is a worthy subject for study and comment. This journal, first as The
PSR Quarterly and now as M&GS, has as its mission the explication of
the connections between calamity, including war, and human and ecological health.
A number of influential articles and editorials during this past decade (for instance,
the commentary on mass death by Richard Rhodes [2] have pressed
the point dramatically. In 1994, authorities on famine, drought, and war contributed
to a most thoughtful and troubling book entitled War and Hunger (edited
by Joanna Macrae and Anthony Zwi [3]; in 1996 the International
Committee of the Red Cross published A Handbook on War and Public Health
[4], written by Pierre Perrin, the current ICRC medical director.
Other books in this burgeoning field are underway for publication dates in the
next two years. Several factors undoubtedly contribute to this new willingness
to entertain war as a legitimate subject for public health. We are still in the
midst of anniversary analyses of World War II. Since the end of the Cold War,
the world has seen a marked rise in the number of unchecked and very bloody regional
and civil wars. And emergency medical relief in these wars has increasingly been
sustained by the participation of civilian health professionals from all over
the world, working within the framework of nongovernmental organizations.
Levy and Sidel have done an excellent job in conceiving of this book, choosing
the wide and yet most appropriate range of topics it covers, organizing and mobilizing
the many expert contributors, and maintaining suitable editorial control over
the themes and arguments. They have staked out the ground and delved into the
problems with definitive force. All books that follow this one and attempt to
deal with this subject matter will have to address the issues covered here, or
give a very good explanation as to why not. The book begins with a discussion
of the rationale for looking at war as a public health issue and then proceeds
to sections dealing with the effects of war: the impacts one can perceive (human
morbidity and mortality, effects on human rights, environmental consequences);
the effects of different weapons systems, including weapons of mass destruction;
and the effects of war on social and economic trends and population subgroups
(such as children, women, and displaced peoples). The book then breaks to deal
with three main case studies: Vietnam, the wars in Central America, and the war
in the Gulf. Two final sections address the history and potential of organizational
efforts to eliminate weapons systems, prevent war, and promote conflict resolution
and peace. The book is not everything it might be, in that some topics
are addressed in insufficient depth; a few issues are not explored that in my
view are relevant; and a few sections could reasonably be condensed. These observations
are advanced with little vehemence, however, because there is so much to approve
of and applaud in these pages and because everything that might be improved upon
can easily be addressed in the subsequent editions, of which I hope there will
be many into the next century. The readers of this journal will recognize
the names of the contributors. These are people who have labored for years acquiring
the expertise they now share with us. Many of them have been leaders in the physician-led
movement to reduce the risk of nuclear war, to promote the cause of human rights,
to address the health and psychological needs of desperate people around the world
trapped in extreme circumstances. It is altogether fitting that they have been
brought together to make the case that war, seen broadly in its causes and consequences,
has everything to do with how we live, how we die, and whether as a species we
survive. Among the chapters that can build on the strongest data base
and make the best use of the information that is available are those dealing with
population casualties, biological weapons, the effects of nuclear weapons development,
production, and testing, and with landmines. Also excellent are the chapters on
the effects of military activities on civilian populations (although this topic
should be a book in itself); human rights, displaced persons, nuclear war prevention,
physician ethics in war, and the United Nations. These essays reflect an easy
command of the subject matter and, depending upon the complexity of the topic,
serve either as strong overview or definitive assessment of the field to date.
This issue of timing is very important. Some of the chapters address extremely
important questions but are hampered by the very uneven quality of the work that
they must refer to or rely upon. This point is particularly evident in the chapters
relating to the impact of war upon women and children and to the chapter on enivironmental
consequences. The range of material is vast, the studies have been few, small,
and often anecdotal, and thus it is impossible to review and summarize the issues
with the declarative force one can apply to other, more examined topics. As well
reasoned, informative, and intellectually stimulating introductions to major problem
areas, however, these discussions are very worthwhile. The three case studies
contribute great interest and vigor to the book. Read in sequence, they contain
all the themes explored in the preceding chapters, and drive them home with the
integrity and force that only concrete example can provide. All three chapters
move briskly and competently. The chapter on Vietnam ably exploits the fact that
this, of the three wars examined, can turn to the most developed body of historical
and analytical material. Gathered in one relatively small place, this essay is
the best I have seen on the health and social aspects of that terrible war. Again
the question of timing plays its important role. War is not easy to talk about.
Information is hidden, suppressed, lost; and those who managed to live through
those times usually wish to turn away from what happened and move on. It takes
decades for scholars and participants to begin to tease out and commit to public
testimony the facts, connections, and ramifications. The literature on Vietnam
is just now in full flower. When it comes to Central America and the Gulf war,
both the people and the data are not yet ready for full disclosure. The
last two sections of the book explore a number of organizational, political, and
philosophical issues relating to war: the role and ethics of health professionals,
roles of NGOs, humanitarian aid, education for peace, preventing nuclear war,
the role of the UN, conflict resolution. These discussions take up a fourth of
the bookÍs pages and as good as each individual essay is, in sum their import
could have been, in my view, presented more tautly and concisely. This
suggestion is raised in part because two important issues are not given the standing
they are due: 1) the ways in which military medicine, in both its public health
and its trauma modes, has contributed to our understanding of the impact of war
and of the treatment of disease and injury; and 2) the ways in which interventions
to mitigate the consequences of wars (rather than prevent them) might prove beneficial
to affected populations. These are very large topics in themselves and were they
to be addressed in subsequent editions of this book, as well as the inclusion
of updated and expanded discussions of landmines, the Gulf war, and chemical weapons
(all topics that have moved rapidly since this book went to print) the editors
would be forced to make choices relating to space. As it hefts now, it is a perfect
size. At this point in the review, it almost goes without saying that this
book belongs on the shelf of every public health practitioner and everyone engaged
in virtually all fronts of public policy. I would urge further, however, that
of the many books one hears about, buys, and shelves, this one should really be
read from cover to cover. References
1. Last JM, Wallace RB, eds. Public health and preventive medicine.
Appleton & Lange. Norwalk, CT, 1992. [Return to text]
2. Rhodes R. Man-made death: A neglected mortality. JAMA 1988;260:686-87.
[Return to text]
3. Macrae J, Zwi
A. War and hunger. Zed Press. London, 1994. [Return to text]
4. Perrin P. A handbook on war and public health. International
Committee of the Red Cross. Geneva, 1996. [Return to text]
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