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Last Updated

24 Jan 2003

Source: The Lancet 9354(361), January 25, 2003


Open letter to the Right Honourable Tony Blair, Prime Minister of the UK: public health and humanitarian effects of war on Iraq

Sir--Three important reports have been published in the past month on the humanitarian effects of international violence and conflict. All provide evidence of the short-term and long-term adverse health effects of the use of force internationally. WHO's Global Report on Violence [1] is a detailed assessment compiled over 3 years by international health scientists; Collateral damage: the health and environmental costs of war on Iraq [2] reports a study by Medact, a UK charity of nurses, doctors, and other health professionals; and the latest report, released by the Campaign Against Sanctions on Iraq (CASI) based at Cambridge University, UK, is a United Nations report on likely humanitarian scenarios of war on Iraq.[3]

Medact estimate that if the threatened war on Iraq ensues, "total possible deaths on all sides during conflict and in the following three months range from 48,000 to over 260,000. Civil war within Iraq could add another 20,000 deaths. Additional later deaths from post-war adverse health effects could reach 200,000. In all scenarios the majority of casualties will be civilians". The report calculates that "the aftermath of a 'conventional' war could include civil war, famine and epidemics, refugees and displaced people, and catastrophic effects on children's health and development". Knock-on effects could include exacerbation of international conflicts, inequalities, and divisions.

The most recent UN report also estimates substantial and wide-reaching humanitarian effects: "as many as 500,000 people could require treatment to a greater or lesser degree as a result of direct or indirect injuries", based on WHO estimates of 100 000 direct and 400 000 indirect casualties. It indicates existing shortages of some medical items, "rendering the existing stocks inadequate" for war-increased demand, and exacerbated by the "likely absence of a functioning primary health care system in a post-conflict situation". The report also "estimated that the nutritional status of some 3.03 m people countrywide will be dire and that they will require therapeutic feeding [according to UNICEF estimates]". Finally, "it is estimated that there will eventually be some 900,000 Iraqi refugees requiring assistance, of which 100,000 will be in need of immediate assistance [according to UNHCR]. . . An estimated 2 million people will require some assistance with shelter". For 130,000 existing refugees in Iraq "it is probable that UNHCR will initially be unable to provide the support required".

But the most worrying effect of the use of force in Iraq and internationally is in its role as an escalator of collective violence. WHO defines collective violence -- by states or non-governmental groups -- as "The instrumental use of violence by people who identify themselves as members of a group -- whether this group is transitory or has a more permanent identity -- against another group or set of individuals, in order to achieve political, economic or social objectives". WHO reports that such collective use of force has long-term negative effects on stability and social wellbeing. International violence has been steadily increasing and "overall a total of 72 million people are believed to have lost their lives during the 20th century due to conflict, with an additional 52 million lives lost through genocides". Conflict escalates after use of collective force, as violence becomes a more common and legitimated form of political or social action.

Health professionals worldwide care for the casualties of war. We accept this responsibility. However, it is also our responsibility to argue for prevention of violence and peaceful resolution of conflict. Staff and students of the London School of Hygiene and Tropical Medicine come from and work in over 120 countries, many in conflict. Our experience and evidence corroborate the views of WHO, the United Nations, and Medact.

We believe that a war would have disastrous short-term, medium-term, and long-term social and public-health consequences -- not just for Iraq, but internationally. Conflict is rooted in inequality and unjust governance. Military intervention in Iraq, when there remain so many peaceful routes to disarmament, risks escalating collective violence. WHO argues that conflict can be averted only by more equitable forms of development, and by accountable, ethical governance internationally. We strongly support this perspective and believe that further acts of violence can be prevented by international and local governance that shows itself to be peaceful and ethical.

For the reasons above, we oppose the use of military intervention in Iraq. We hope this letter contributes to informed discussion among members of the Government and the public. We also intend this statement to support all those who are opposed to military action on ethical and humanitarian grounds, not originating from any political or religious viewpoint.

Carolyn Stephens, on behalf of 500 signatories of the London School of Hygiene and Tropical Medicine (listed at 03cor1048webappendix.pdf)

Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK (

1 World Health Organization. World report on violence and health, 2002. http://www5. (accessed Jan 15, 2003).

2 Medact. Collateral damage: the health and environmental costs of war on Iraq. http:// (accessed Jan 15, 2003).

3 Campaign Against Sanctions on Iraq (CASI) Internal UN report (2002). Likely humanitarian scenarios. undocs/war0212 (accessed Jan 15, 2003).