Sunday, November 22, 2009

Health Workers and Our Wars

This guest column is by Seiji Yamada, MD, a family physician, Associate Professor of Complementary and Alternative Medicine at the University of Hawai’i John A. Burns School of Medicine, and one of my mentors. This essay is an expansion of the one that was published in the AAMC journal Academic Medicine, chosen as one of the five best responses to the question put forth by editor Steven Kanter “How can academic medicine respond to peace-building efforts worldwide?”. Dr. Yamada’s original essay, “Academic medicine should start at home”, is at

Health Workers and Our Wars

What is the responsibility of American health workers with regard to our nation’s wars in Iraq, Afghanistan, and Pakistan? As Americans, our primary responsibility should be to influence the actions of our own government. As health workers, our expertise is in the realm of morbidity and mortality, encompassing the direct effects of violence as well as the indirect effects arising from the collapse of health services, poor access to water and food, and damage to infrastructure, economies, and societies. Thus, we should monitor our government’s actions, apply the scientific methods at our disposal, apply the moral and ethical principles to which we subscribe, formulate and recommend policy, and disseminate our findings to the people. In a democracy, the citizenry would then determine the course of action.

During this decade, our nation has been responsible for invading and occupying two countries halfway around the globe—Afghanistan since 2001 and Iraq since 2003. In the case of Iraq, the invasion of 2003 was preceded by comprehensive economic sanctions, which hampered the rebuilding of its infrastructure after the Gulf War of 1991. The consequences included childhood deaths, mental illness, juvenile delinquency, begging and prostitution, as well as cultural and scientific impoverishment.[1]

In 2002-03, the American people were not convinced by the Bush administration that war on Iraq was justified. However, despite massive demonstrations against the war prior to its launch, the intellectual classes, the corporate media, and our elected representatives went along with the administration. Democracy failed us in this respect. Prior to the war, we health workers should have been recounting the health toll of the First Gulf War and the sanctions regime. With its onset, we should have been disseminating the images and recounting the narratives of casualties of the war.[2] As it progressed, we should have been acutely interested in the number of casualties caused by the war. The best estimates for deaths among Iraqis are those of the July 2006 epidemiological survey that reported 655,000 deaths as a consequence of war.[3] This study did not distinguish among civilians, military, and irregular combatants. While its authors have been criticized for breaches in the non-identification of participants, the study is nevertheless considered the most accurate estimate.[4]

Insofar as we have failed to pay attention to such findings, American health workers have failed its constituents.

At the mention of history or political economy, many health workers groan. We are not interested in politics, they say. But unreflective citizens repeat the blather that they are fed by the corporate media. We need advocate for the cause of health—in particular for the health of those whose voices are otherwise unheard, whose deaths are otherwise uncounted, unmourned, unopposed, and unorganized against. In order to do so, our analysis must be geographically broad and historically deep, as Paul Farmer urges us.

As the United States pulls its troops out of Iraq and sends them to Afghanistan, as our military wields drones called Predator and Reaper in Pakistan, we should concern ourselves with whether the cause of peace is thereby served by such acts. Our commander-in-chief is apparently now reflecting upon whether to double down (again) in Afghanistan and pursue counterinsurgency, as urged upon him by his general in the theater.[5]

Apparently, “counterinsurgency” no longer connotes Vietnam or Central America.[6] But the “clear and hold” strategy utilized late in the Vietnam War was characterized by indiscriminate shelling and bombing of villages[7] and ran concurrently with the Phoenix program of torture and assassination.[8] Extrajudicial killings in the Federally Administered Tribal Areas of Pakistan are now being carried out by the CIA by missile attacks by drones, with the deaths of many innocents.[9] Of 701 people killed in 60 attacks in FATA between January 2008 and April 2009, fourteen were suspected militants.[10]

The British and the Soviets failed in their attempts to militarily control Afghanistan, while inflicting untold casualties on the populace. The Soviet Union’s invasion of Afghanistan proved to be its Vietnam. One would think that our own country would not repeat its mistakes in Vietnam, but our wars in Iraq and Afghanistan’s go on. As American health workers, we must concern ourselves with the morbidity and mortality caused by our own government’s actions. Let us get to work.


[1] Save the Children UK. Iraq sanctions: humanitarian implications and options for the future. Available at: ( Accessed July 21, 2009
[2] Yamada S, Fawzi MC, Maskarinec GG, Farmer PE. Casualties: narrative and images of the war on Iraq. Int J Health Serv. 2006; 36(2):401-15
[3] Burnham G, Lafta R, Doocey S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet 2006; 368: 1421–28.

[4] Tapp C, Burkle FM, Wilson K, et al. Iraq War mortality estimates. Conflict & Health 2008;2:1-13.

[5] Filkins D. Stanley McChrystal’s long war. New York Times Magazine, Oct 18, 2009.

[6] Parry R. Bush’s death squads. In These Times, Jan 17, 2005. Available at ( Accessed Jan 23, 2005.

[7] Steinglass M. Vietnam and victory. Boston Globe, Dec 18, 2005. Available at ( Accessed Sep 27, 2009.

[8] Chomsky N, Herman ES. The Washington connection and third world fascism. Boston, MA: South End Press, 1979.

[9] Mayer J. The predator war. New Yorker, Oct 26, 2009. Available at ( Accessed Nov 15, 2009.

[10] Ahmad MI. Pakistan creates its own enemy. Le Monde Diplomatique. Nov 2009. Available at ( Accessed Nov 5, 2009.

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