Health Impact Assessment: a case study to assess the potential health consequences of military action against Iran Some issues encountered in the process

Why Health Impact Assessment? A lot of work in recent decades to increase the accuracy of health information and data collected during and after conflict This information does not have sufficient influence on decision makers considering military action Health Impact Assessment methodology provides a strong and widely accepted framework and has the potential to influence decision makers. HIAs are increasingly a requirement for planning in other areas.

What information? Information on the health consequences of similar violent conflicts, in countries with broadly similar levels of economic status, population density and infrastructure. Inevitable country specific influences on information and data, and in-country variations, need to be taken into account. The countries most frequently referenced are Iraq, Syria, the Occupied Palestinian Territories, Lebanon, Libya and Kosovo, and Iran in relation to previous conflicts.

Information on… The immediate, medium and long term effects on:  mortality and morbidity  patterns of disease  public health infrastructure  nutrition and food security  psychosocial and mental health  health systems and access to health care  the environment  economic and social costs  displacement

We want significance!

The expectation of quantitative predictions two layers of potential uncertainty: the estimation made by the original sources and its application to a different scenario multiple reasons why information – even from an expert and trusted source - may be contested e.g. the debates around mortality following the invasion of Iraq establishing a ‘normal’ baseline. In Iran in 2013 sanctions were negatively effecting health, particularly of those with chronic diseases and the consequences of the Iran–Iraq war were still being felt

Influences on the baseline Behrouzan, O “Prozàk Diaries: Post-rupture Subjectivities and Psychiatric Futures”. PhD diss., Massachusetts Institute of Technology, Cambridge, MA. Mohammadi, M. R., H. Davidian, A. Noorbala, H. Malekafzali, H. Naghavi, H. Pouretemad, S. Yazdi, et al An Epidemiological Survey of Psychiatric Disorders in Iran. Clinical Practice and Epidemiology in Mental Health 16. doi: / Accessed December 11, pdfhttp:// pdf Borger, J., and S. K. Dehghan “Iran Unable to Get Life-saving Drugs due to International Sanctions.” The Guardian. January 14. Accessed June 14, drugs-international-sanctionshttp:// drugs-international-sanctions Falahati, F et al Late Psychological Impacts of Wartime Low Level Exposure to Sulfur Mustard on Civilian Population of Direh (17 years after exposure). Global Journal of Medical Research. Vol 1 Issue 1 (Ver1.0) June 2010.

Using mortality figures from Palestine and Iraq it is possible to: calculate the average number of deaths per year (direct and/or excess) averaging across different sources from each country calculate how many direct/excess deaths there were per 10,000 population calculate how many deaths are indicated given the size of the Iranian population.

Resulting in….. between 17,354 and 34,782 direct/excess deaths in one year in Iran using the conservative estimate of deaths from Iraq between 17,354 and 190,740 deaths in one year in Iran using other numbers from Iraq does this open the way for the lower figure to be in some way ‘acceptable’?

Going the same way for different reasons

Underestimation and different interpretations most likely initial military scenario; longer term and possible land war not assessed possible erring on the side of caution so that predictions are less likely to be questioned / too great an influence of target group perceptions: are sanctions a peaceful or aggressive / conflict measure?

Alternative and unintended consequences UK military guidelines recommend that a plan to minimize the health effects of military action, including providing assistance to those affected, should be part of an intervention strategy Such plans could make a military intervention appear more acceptable, and information provided by an HIA could be useful in this process. In this case those undertaking military action are highly unlikely to be in a position to provide direct assistance, and given the coverage and sophistication of Iran’s health system the best course of action to assist those affected would be to provide the Iranian Ministry of Health with resources

Recommendations Find a negotiated non-military solution to differences Take the full health consequences into account when contemplating military action Build up expertise in the use of HIA methodology in relation to conflict ?a database that can provide rated information in real time.

Thank you