Prevention of War: Can we learn from healthcare?
Published on June 16th, 2022
Professor Paolo Vineis
Imperial College, London
War has often been used as a metaphor for health and disease, as in the “war on cancer”. However, to my knowledge, the prevention of poor health and premature death has never been used as a metaphor for prevention of war. In this short article, I propose that the principles behind public health models can be useful for preventing and “treating” war.[1] I will start with a strong statement: war is intrinsically immoral. Massive investments have been made to develop and produce extremely powerful weapons that cause many civilian casualties. Weapons should be treated as toxic entities—the same way that chemotherapy, which is necessary under certain circumstances, is intrinsically toxic. Refusing chemotherapy when it would be beneficial is irrational; similarly, there are circumstances in which weapons are unavoidable, but their intrinsic toxicity should never be forgotten. Moreover, war can be considered a planetary health issue: in addition to endangering human and animal health, war further stresses the planet’s resources by, for example, exacerbating the problems of the energy market.
Commentary
Professor Paolo Vineis
Prevention of War: Can We Learn from Healthcare?
War has often been used as a metaphor for health and disease, as in the “war on cancer”. However, to my knowledge, the prevention of poor health and premature death has never been used as a metaphor for prevention of war. In this short article, I propose that the principles behind public health models can be useful for preventing and “treating” war.[1] I will start with a strong statement: war is intrinsically immoral. Massive investments have been made to develop and produce extremely powerful weapons that cause many civilian casualties. Weapons should be treated as toxic entities—the same way that chemotherapy, which is necessary under certain circumstances, is intrinsically toxic. Refusing chemotherapy when it would be beneficial is irrational; similarly, there are circumstances in which weapons are unavoidable, but their intrinsic toxicity should never be forgotten. Moreover, war can be considered a planetary health issue: in addition to endangering human and animal health, war further stresses the planet’s resources by, for example, exacerbating the problems of the energy market.
Disease prevention is usually subdivided into three stages: primary, secondary, and tertiary. Let’s start with tertiary prevention, since it reflects the current situation in Ukraine. Attempts to prevent war were unsuccessful, so the world finds itself limiting damage. Tertiary prevention of diseases consists of all interventions aiming to prevent sequelae of a diagnosed disease, including relapses, metastases, or disability. While tertiary prevention strives for cure and rehabilitation, it is often too late to achieve these outcomes. Earlier forms of prevention are preferable because they are often more effective and have fewer side effects. Tertiary treatments also tend to be disease-specific (even personalized), while earlier forms of prevention have a broader spectrum, as discussed below. Tertiary prevention of war is also the least effective: it amounts to preventing as much civilian harm as possible, but there are severe collateral effects, including retaliation, even when this “treatment” is as limited and specific it can be (i.e., neutralizing terrorists).
What about secondary prevention? In health, this includes early diagnosis and screening for latent diseases or their precursors. The assumption of secondary prevention, while not always met, is that earlier treatment is more effective. But there are drawbacks to secondary prevention, including the false positives and false negatives that plague all screening tests. False negatives mean false reassurance, while false positives mean anxiety and unnecessary treatment. In the case of war, all nations and supranational entities (i.e., NATO) have extensive, powerful intelligence networks to detect early signs of potential conflict. The invasion of Ukraine was preceded by numerous early warnings, despite Putin’s insistence that Russia was only playing war games. However, in war, the decision of whether an early sign should be considered a true positive or a false positive is extremely delicate, since the repercussions of an incorrect decision could be immense in today’s nuclear world. While secondary prevention is still better than tertiary prevention, its efficacy must be demonstrated on a case-by-case basis. For example, while screening is successful for cervical, breast, or colorectal cancer, it is a disaster for thyroid cancer, resulting in many diagnoses of benign conditions that would not progress to clinically overt malignancy. Another shortcoming of secondary disease prevention is “medicalization”, which describes the multiplicity of tests and exams that often result for patients. Many of these tests have their own false positives which, in the case of prevention of war, may lead to extensive societal control measures, such as government monitoring of social media, which is often feared in the fight against terrorism.
Primary prevention is better than both secondary and tertiary prevention, for several very good reasons. First, primary prevention has a broad spectrum. For example, the risk factors for cancer are largely shared with cardiovascular diseases, diabetes, and neurological diseases; thus, single preventive initiatives like anti-smoking campaigns can prevent multiple diseases. Second, the effects of prevention endure, while therapies must be renewed with every new generation of patients (with the related costs and side effects), contrasting smoking or bad dietary habits is followed by a long-lasting effect. The downside of the broad, long-lasting impact of prevention is that it is less visible, exactly because it prevents the occurrence of diseases. Thus, prevention is not very appealing to politicians—voters might prefer the building of a new hospital over a campaign that lowers the incidence of a disease, despite the greater success of the latter from a health perspective. With war, however, the situation may be different: people definitely love peace, and a politician who assures a lasting peace without militarization of society might be successful—even more so if it involves reducing the defense budget and investing into other supported activities.
What does primary prevention of war look like? It involves the field of diplomacy, on which I am no expert. However, diplomacy could probably learn from primary prevention of disease, as a key aspect of primary prevention lies in the collection of scientific evidence before implementation, particularly on the effectiveness of various approaches (health education, taxation, incentives, nudges, etc.). Similarly, diplomacy could be more systematic in its investigation of the most impactful ways to prevent war, perhaps by employing field studies and small experiments.
Primary prevention based on health education and nudges is largely ineffective when people are exposed to strong consumeristic pressures, and when their behaviors are strongly influenced by social class. In the case of obesity, for example, there are clear relationships between the cost of food, food quality, the social class of consumers, and their propensity for obesity. Primary prevention is ineffective without eradicating the risk factors, including poverty, social inequalities, and market pressure. In the case of war, the real conundrum is whether and to what extent we can stop weapons proliferation. As Pope Francis has repeatedly reminded us, the level of weapons proliferation is unsustainable and puts humanity in constant danger. The question is whether humankind and its leaders are wise enough to perceive that substantially limiting weapons stockpiles is a win-win choice: less danger for all, less secondary prevention of war needed, and more funds available for alternative investments.
The Covid-19 emergency has helped many people to understand the importance of primary prevention, which is especially important because climate change will increase the numbers and types of viruses to which humans are exposed (1). In this case, primordial prevention—which is a form of prevention that occurs even earlier than primary prevention—must involve stopping deforestation and extensive animal breeding, because these practices create large reservoirs of pathogens and increase animal-human contact. Might the invasion of Ukraine open our eyes to the need to rapidly institute primary and primordial war-prevention practices? The Roman motto “si vis pacem para bellum” (“if you want peace, prepare for war”) has been misleading people for centuries, since it ultimately proposes a lose-lose solution. Primordial prevention should be implemented in peace time. In war time, choices become dramatic and there are few alternatives (2) [2]. Longstanding peace is feasible, as demonstrated by the 70 years since WWII. The European Union has contributed to this long period of peace by inducing nations to work together. Effective disease prevention also requires strong cooperation across disciplines, sectors of society, and nations.
Finally, we must remember that primordial and primary prevention include education. Schools must work harder to counteract the culture of violence endemic in certain areas of the world. Hatred against internal minorities and adjacent nations should be fought with effective educational programs. Resurgence of nationalism and ethnic prejudice is particularly concerning in certain areas, such as former Yugoslavia. Preventing violence and war is not only the responsibility of single nations, but of the entire international community.
[1] I am aware of the limitations of this (and all) metaphors and am not suggesting that disease and war arise from similar dynamics.
[2] A quotation that is worth reporting from this interview with Jeffery Sachs:
“Remember that the Soviet economy had crashed and entered into an intense downward spiral in the late 1980s. In those years, I referred often to John Maynard Keynes’ remarkable 1919 book The Economic Consequences of the Peace. That book was probably the most important book for my professional career, as it made one essential point in my view: in order to end an intense and destabilizing financial crisis in a country, the rest of the world should pitch in, before the situation gets out of hand. That was true in the aftermath of World War I. Instead of putting harsh reparations payments on the German people, Europe and the US should have engaged in cooperation for a recovery for all of Europe, which would have helped to prevent the rise of Nazism”.
(1) Colin J. Carlson, Gregory F. Albery, Cory Merow, Christopher H. Trisos, Casey M. Zipfel, Evan A. Eskew, Kevin J. Olival, Noam Ross & Shweta Bansal. Climate change increases cross-species viral transmission risk. Nature (2022). https://doi.org/10.1038/s41586-022-04788-w
Acknowledgements: I am grateful to Jean-Claude Burgelman, Stefano Orlando, Luca Carra, and Lorenzo Mangone for thoughtful comments.
