Physicians and the Health Consequences of War

Less than 2 weeks after Russia’s invasion of Ukraine on February 24, 2022, following its prior invasion of the Crimean Peninsula in 2014, nearly 2 million Ukrainians had already become refugees fleeing the Russian attack on Ukrainian civilian centers, as bombing continued in and around the largest Ukrainian cities. The war in Ukraine, the first land war of this scale in Europe since World War II, is playing out in public in an unprecedented fashion. Images of conflict, of military and civilian casualties, are available on the internet and through social media allowing the world to witness the war unfolding in real time.

As political commentary swirls about the geopolitical peril and significance of the moment, we, as citizens of the world, watch in near disbelief at the seeming senseless violence unfolding. Those of us who are trained in the health professions watch with an additional engagement, recognizing that the ravages of war are, above all else, about health. This experience pushes us to ask: What is the role of physicians and other health professionals as war unfolds around us? and How best do we live by our responsibility? These notions are well captured by the modern version of the Hippocratic Oath used by many US medical schools “that [we] remain…member[s] of society, with special obligations to all [our] fellow human beings.” Against a backdrop of the war in Ukraine, physicians and other health professionals should thoughtfully consider how they can, and should, engage in the context of war to fulfill our obligations as citizens who are trained and committed to the promotion of health worldwide.

War threatens health in the immediate moment, killing and harming thousands of people—combatants and civilians alike—who are caught in its wake. As injury mounts in areas affected by conflict, it is up to the health professionals in the affected areas to tend to the wounded in the short-term and to help rehabilitate those who are injured in the long-term. Long-established—but often violated¹—principles of medical neutrality and of respect for health professionals and health care institutions are essential to ensure that medicine can help at a time when it is needed most. The World Medical Association statement on medical neutrality, issued the day after Russia invaded Ukraine, affirms this sentiment. Physicians worldwide need to ensure that they speak with one voice about the importance of protecting health care workers who are in war-torn areas, offering both solidarity in word, and—when possible—pragmatic support to ensure that local clinicians have the best conditions to restore those injured to health. We might have expected that much as there has been an outcry against the Russian invasion from a range of private-sector actors, there also would have been an outcry from professional medical and health bodies worldwide. That such an outpouring of public sentiment from these organizations has lagged may betray a feeling of helplessness among physicians and health care organizations worldwide.

Although much of the public conversation about the invasion of Ukraine has been about the political ramifications of the moment, we cannot forget that fundamentally war is about health. The near-term and long-term consequences of war can be catastrophic for health.² Certainly, during war, thousands of people are often killed or injured, resulting in the need for long-term rehabilitation and restoring of those injured back to physical health. Chronic pain, for example, continues to affect about half of military service members in the long-term.³ War also has devastating and long-term consequences on the mental health of veterans and civilians alike.⁴

Less discussed are war’s intergenerational effects on health, as trauma unfolds across time, undermining health for years, even decades, after a conflict ends. For example, research after war in Liberia showed ongoing increased prevalence of posttraumatic stress disorder, consistent with patterns of conflict more than 20 years after the war had ended.⁵ This reflects a core truth about wars: their consequences do not conclude with the cessation of armed hostilities.

Documenting the long-term effects falls to those of us who are entrusted with the public’s health worldwide—the physicians and health scholars who use science to bear witness to the harms of war. Documenting these harms may seem a wan response to an evolving humanitarian crisis, but it is on a scaffolding of documentation that we change the world’s perspective on the harms incurred by actions like war, with the goals of preventing or halting such conflicts in the long-term. This calls for a redoubling of effort to study and write about the harms of war, including the current war in Ukraine, to remind the world that health is at the heart of these conflicts, and that this very threat to health should make war intolerable.

Physicians and health professionals have a particular responsibility to engage with wars, to the end of mitigating their consequences in the short-term and long-term, and, ideally, to end wars as we know them. This also suggests a role for physicians to engage in advocacy, using the platform and public trust afforded them as stewards of the public’s health. Physician organizations have a long tradition of engaging with these issues, often to tremendously positive global social good. The International Physicians for the Prevention of Nuclear War, which was awarded the Nobel Peace Prize in 1995, was at the forefront of helping de-escalate the nuclear threat 30 years ago,⁶ a threat that we now see terrifyingly rear its head once again. Other physician-led organizations worldwide, including Physicians for Human Rights, Physicians for Social Responsibility, and Swedish Physicians against Nuclear Weapons, are part of a global network of civil society organizations that are a critical counterweight to formal governmental bodies, shaping the global consensus within which consequential decisions are made. If the war in Ukraine has taught us anything, it is the imperative for more, not less, involvement of health professionals in civil society, to work toward embedding health as a central universal value, one whose import pushes back against any argument for engagement in war. It is also important to note the good that has long been achieved by global health delivery organizations. They need collective protection as they deliver health services in countries affected by war, and their work can be buttressed by global physician and citizen advocacy.

Although the war in Ukraine has rightly galvanized attention, it is by no means the only war that should have captured our awareness in recent years. Recent wars in Syria⁷ and Yemen,⁸ among others, have been responsible for thousands of deaths and millions of refugees, with an enormous cost to human health. That these wars unfolded with substantially less attention than that being paid to the current Ukrainian conflict should occasion soul-searching about the harms that we respond to and the ones we overlook.

Perhaps one of the elements of the current war that is most jarring is the notion that such land wars were confined to the 20th century, when nearly 200 million people died in such wars. One hopes that physicians and others in the health professions can leverage the moment to galvanize public sentiment to leave such wars behind in the 21st century.

Published: March 17, 2022. doi:10.1001/jamahealthforum.2022.0845

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Galea S. JAMA Health Forum.

Corresponding Author: Sandro Galea, MD, DrPH, School of Public Health, Boston University, 715 Albany St, Boston, MA 02118 (sgalea@bu.edu).

Conflict of Interest Disclosures: Dr Galea reported serving on the board of Sharecare.