Public Health, War, and Militarism

Public Health, War, and Militarism
Martin Donohoe

Am I Stoned? A 1999 Utah anti-drug pamphlet warns: “Danger signs that your child may be smoking marijuana include excessive preoccupation with social causes, race relations, and environmental issues”

Perspective The earth spins at 1,038 mph at the equator, between 700 mph and 900 mph at mid-latitudes The earth rotates around sun at 18.5 miles/sec The solar system orbits the center of the Milky Way Galaxy at 137 miles/sec One rotation per 225 million years

Perspective The sun is one of hundreds of billions of stars in the Milky Way Galaxy The Milky Way is one of over one hundred billion galaxies in the known universe The universe may be one of an infinite number of universes

The Planets

Our Solar System

Jupiter = one pixel, Earth = invisible

Sun = one pixel, Jupiter = invisible

History of war 10,000 yrs ago – agriculture
Stable populations, division of labor, warrior class 3500 yrs ago – bronze weapons and armor 2200 yrs ago – iron 1900 yrs ago – widespread use of horses

History of war Ninth Century China - bombs
Thirteenth Century China – rockets Forgotten until the 19th Century 1783 – Balloon (Montgolfier brothers)

History of War (Napoleonic Wars): English General Henry Shrapnel fills cannonballs with bullets and exploding charges to increase killing capacity 1903 – airplane (Wright Brothers) 20th Century – nuclear weapons, increasingly sophisticated chemical and biological weapons

Atomic Weapons - History
Hiroshima, August 6, 1945 15 kiloton bomb, 140,000 deaths Nagasaki, August 9, 1945 22 kiloton bomb, 70,000 casualties

Atomic Weapons Today Approximately 17,300 nuclear weapons in at least 9 countries Down from over 71,000 at height of Cold War 4,300 active U.S./Russian warheads today 1,800 on hair-trigger alert Several thousand megatons (100,000 Hiroshimas)

History of War Violent conflict ubiquitous in the animal kingdom:
Interspecies conflict – food, territory Intraspecies conflict – food, territory, mates (usually not directly fatal) Violence among non-human primates Gorilla infanticide Chimps vs. Bonobos

Origins of War Foragers vs. Agriculturalists Agriculture
Hierarchical society Private property Money Subjugation of women Infectious/chronic diseases

Origins of War Violence Today
Link with poverty, oppression, fueled by desire for wealth/power Familial vs. Societal Gun culture Media Violence Glorification of militarism

Militarism The deliberate extension of military objectives and rationale into shaping the culture, politics and economics of civilian life so that war and the prepapration for war is normalized, and the development and maintenance of strong military institutions is prioritized An excessive reliance on military power and the threat of force in pursuing policy goals in international relations

Militarism Positively correlated with: Conservatism Nationalism
Religiosity Patriotism Authoritarianism

Militarism Negatively correlated with:
Respect for civil liberties Tolerance of dissent Democratic principles Sympathy and welfare toward the troubled and poor Foreign aid for poorer nations Subverts other societal interests (health, environment, education, social programs)

History of War 20th Century: Small arms
90% of the 300,000 yearly deaths from violent conflict Land mines 110 million planted since 1960 in 70 countries 24,000 deaths/yr (est.), tens of thousands more disabled

American Weapons Gone AWOL
Iraq – U.S. supplied Saddam Hussein, arms ultimately used against U.S. in Iraq Wars; 30% of weapons given to Iraqi forces between 2004 and 2007 never accounted for; more recently, U.S.-supplied weaons finding their way to ISIS and Iranian-backed Shiite militias

Afghanistan – U.S. armed anti-Soviet soldiers, weapons ultimately ended up with Taliban; 40% of those recently given to Afghan army and police can’t be traced Libya – guns sent from Qatar as part of U.S.-approved deal (2011) now with Islamic militants

Somalia – almost ½ of arms supplied to Uganda and Burundi to fight al-Shabaab sold off by underpaid troops, ended up with Somali militants Yemen – U.S. lost track of $500 million worth of small arms and other gear it sent to Yemeni government before 2015 collapse

History of War 20th Century: Predator drones
Potential for drone use by terrorists Weaponization of Arctic/space Nanotech weapons Cyberwar

History of War Belief that each new invention would eliminate warfare
Instead - increased casualties, killing at a distance

Epidemiology of Warfare
Deaths in war: 17th Century = 19/million population 18th Century = 19/million population 19th Century = 11/million population 20th Century = 183/million population Increasing casualties to civilians 85-90% in 20th Century (vs. 10% late 19th Century)

Contemporary Wars 250 wars in the 20th Century
72 million lives lost in 20th Century wars, another 52 million through genocides 190 million deaths in 20th Century directly or indirectly related to war Incidence of war rising since 1950

War Deaths,

Contemporary War Deaths

Worldwide Violence (2013) 526,000 killed by armed violence/yr
396,000 intentional homicides 55,000 direct conflict deaths 54,000 unintentional homicides 21,000 killed during legal interventions 7.9 violent deaths/100,000 persons/yr

Gun Violence U.S. death toll for all wars from the Revolutionary War to Afghanistan: 1.2 million (Congressional Research Service) Number killed by firearms since (suicides, homicides, and accidental shootings): 1.4 million (CDC)

Gun Violence Americans own million guns (#1 in world in privately owned firearms) Almost ½ of world’s civilian-owned firearms Nearly ½ stored improperly in homes with children Average gun-owning household has 8.2 guns (doubled over last 20 yrs) ½ owned by only 3% of population (avg 17 guns each)

Gun Violence 33,000 deaths/yr due to firearm-related violence, suicides, and accidents (highest among industrialized countries) Mass shootings becoming commonplace (Columbine, Sandy Hook, Orlando, Las Vegas) Every day in U.S.: 31 homicides, 55 suicides, 2 unintentional shootings involving guns 84,000 injuries annually

Gun Violence US firearm homicide rate 25X higher/suicide rate 8X higher than in other industrialized countries Direct + indirect societal costs = $230 billion/yr

Gun Violence 276 active militias (2016)
40 states prohibit or limit paramilitary training and unofficial military forces, yet no known cases of laws ever being enforced against private militias Stand your ground laws: 2017 Study of Florida’s 2005 law showed both justifiable and unlawful homicides increased substantially after law took effect, but unlawful homicides accounted for most of the increase

Gun Violence FL, MI, and MT have passed laws limiting doctors’ speech/prohibiting counseling re firearms (FL law overturned by Appeals Court [2017], others tied up in courts) CDC prohibited from studying gun violence using federal funds since 1990s

Gun Violence Access to firearms increases the risk of being a victim of homicide Women are especially at risk of homicide when a firearm is present Access to firearms greatly increases the risk of suicide Firearms are not very effective (if at all effective) at deterring crime

Gun Violence Regulation, polemics, court decisions based on fundamental misunderstanding of Second Amendment and the concept of the subordinate clause: "A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed."

War Deaths Revolutionary War: 25,000 Civil War: 625,000
World War I: 17 million World War II: 60 million Korean War: 2.9 million Vietnam War: 3.8 million

War Deaths Iran-Iraq War: 700,000
Soviet War in Afghanistan: 1.5 million Second Congo War: 3.8 million Second Sudanese Civil War: 1.9 million

Gulf War I 105,000 military and 110,000 civilian deaths (almost all Iraqis) Over 2.25 million refugees 2/3 of US casualties from “friendly fire” Cost $61 billion ($82 billion in 2003 dollars) Environmental devastation

War Deaths (as of 7/15) Second Iraq War: 4,497 U.S. soldiers
Approximately 18,000 Iraqi military Estimates of civilian deaths range from 150,000 violent deaths to 1 million deaths U.S. Afghan War: Over 2,000 U.S. soldiers; 1,200 coalition forces Over 20,000 civilians

Ratio of military contractors to US soldiers Source: Department of Defense
Afghanistan – 1.20 Iraq – 1.10 Balkans – 1.0 Gulf War – 0.01 Vietnam – 0.17 Korea – 0.40 WWII – 0.14 WWI – 0.08 Civil War – 0.20 American Revolution – 0.17

Costs of Iraq/Afghanistan Wars
Financial cost of these two wars: $1.5-5 trillion (est.) Higher estimate includes fighting, rebuilding, veterans’ health care, economic losses, etc. Massive amounts of fraud Taliban still active in Afghanistan, opium trade increasing ISIL, militias, Kurds, Sunnis and Shiites all still fighting for Iraqi territory

Casualties Among Soldiers and Civilians Continue
More US soldiers have committed suicide than have died in Afghan War Veteran health care needs massive (TBI, psychiatric disorders, etc.) 26% of Iraq and Afghanistan veterans are uninsured and not part of the VA health care system VA access limited for those who are insured Providers being pressured not to diagnose PTSD Young veterans: ½ believe war in Afghanistan was not worth fighting; 60% for Iraq War

Josef Stalin “The death of one man is a tragedy. The death of millions is a statistic.”

Colonial Exploitation
Christopher Columbus’ log entry upon meeting the Arawaks of the Bahamas: “They…brought us…many…things…They willingly traded everything they owned…They do not bear arms…They would make fine servants…With fifty men we could subjugate them all and make them do whatever we want.”

Colonial Exploitation
Cecil Rhodes (Rhodesia, Rhodes Scholarship, DeBeers Mining Company): “We must find new lands from which we can easily obtain raw materials and at the same time exploit the cheap slave labour that is available from the natives of the colonies. The colonies would also provide a dumping ground for the surplus goods produced in our factories.”

Exploitation leads to:
Maldistribution of wealth and resources Environmental degradation Wars

Consequences of War Deaths, injuries, physical and psychological sequelae Collapse of health care system (affecting those with acute and chronic illnesses) Famine

Consequences of War 65 million forcibly displaced persons worldwide
21 million refugees (50% are children under 18) 28 million internally displaced persons Over 1 million asylum seekers Approximately ¾ of world’s refugees are hosted by developing countries

Consequences of War Environmental degradation
Increasing poverty and debt All lead to recurrent cycles of violence

Environmental Consequences of Militarization
World’s single largest polluter 8% of global air pollution 2-11% of raw material use Almost all high and low level radioactive waste

Violence Against Women
Common among U.S. servicewomen A deployed female soldier is more likely to be raped by a fellow soldier than killed by enemy fire Rape in war widespread, often genocidal Some refugee camps unsafe

“Comfort Women” Japanese soldiers forced between 100,000 and 200,000 women into sexual slavery (“comfort women”) Some underwent forced hysterectomies to prevent menstruation, make them constantly “available” More than half died due to mistreatment

“Comfort Women” 3-5 year detention 5-20 rapes per day
For 3 yrs of enslavement, low estimate is 7500 rapes per woman Japan has not compensated any victims Historical blindness to atrocities

Violence and Rape in War
Occurs against backdrop of ongoing societal forms of violence against women Legal, educational, social, and political marginalization

Economic Disparities Women 79 cents/$1 Men
Median income of black U.S. families as a percent of white U.S. families 62% 60% in 1968 63% for Hispanic families 64

Women do 67% of the world’s work Receive 10% of global income
Status of Women Women do 67% of the world’s work Receive 10% of global income Own 1% of all property

Worldwide, every minute
380 women become pregnant (190 unplanned or unwanted) 110 women experience pregnancy-related complications 40 women have unsafe abortions 1 woman dies from childbirth or unsafe abortion Reason: Lack of access to reproductive health services

“Mother’s Day Proclamation, 1870” Julia Ward Howe
Arise then...women of this day! Arise, all women who have hearts! … Say firmly: "We will not have questions answered by irrelevant agencies, Our husbands will not come to us, reeking with carnage, For caresses and applause.

Our sons shall not be taken from us to unlearn All that we have been able to teach them of charity, mercy and patience.” … From the bosom of a devastated Earth a voice goes up with Our own. It says: "Disarm! Disarm!

Let women … …promote the alliance of the different nationalities, The amicable settlement of international questions, The great and general interests of peace.

Critical Public Health Issues

Poverty and Hunger US: 15% of residents and 22% of children live in poverty Rates of poverty in Blacks and Hispanics = 2X Whites Poverty associated with worse physical and mental health

Jacob Riis

Dorothea Lange

Worldwide Poverty 1 billion people lack access to clean drinking water
3 billion lack adequate sanitation services Hunger-related causes kill as many people in 8 days as the atomic bomb killed at Hiroshima

James Nachtwey

Maldistribution of Wealth
Top 85 billionaires worldwide worth $1.7 trillion, the combined income of bottom 3.5 billion people (1/2 of world’s population) U.S: Richest 1% of the population owns 50% of the country’s wealth -poorest 80% own 7% -widest gap of any industrialized nation

Overconsumption (“Affluenza”)
U.S. = 6.3% of world’s population Owns 50% of the world’s wealth U.S. responsible for: 25% of world’s energy consumption 33% of paper use 72% of hazardous waste production

Income Inequality Kills
Higher income inequality is associated with increased morbidity and mortality at all per capita income levels 80

Maldistribution of Wealth is Deadly
880,000 deaths/yr in U.S. would be averted if the country had an income gap like Western European nations, with their stronger social safety nets BMJ 2009;339:b4471

Voltaire “The comfort of the rich rests upon an abundance of the poor”

Hudson River, 2009

Primo Levi “A country is considered the more civilized the more the wisdom and efficiency of its laws hinder a weak man from becoming too weak or a powerful one too powerful.”

The State of U.S. Health Care
29 million uninsured patients Millions more underinsured Remain in dead-end jobs Go without needed prescriptions due to skyrocketing drug prices

Headline from The Onion
Uninsured Man Hopes His Symptoms Diagnosed This Week On House

The State of U.S. Health Care
US ranks near the bottom among westernized nations in life expectancy and infant mortality Est. 51,000 deaths/year due to lack of health insurance Racial disparities in coverage, processes, and outcomes of care

Racial Disparities in Health Care: African-Americans
Equalizing the mortality rates of whites and African-Americans would have averted 686,202 deaths between 1991 and 2000 Whereas medical advances averted 176,633 deaths AJPH 2004;94:

Environmental Degradation and Social Injustice (Causes)
Overpopulation Pollution Deforestation Global Warming Unsustainable Agricultural/Fishing Practices Pesticides, indoor cooking with biomass

Overconsumption / Affluenza Militarization Maldistribution of Wealth National and Global Political and Economic Institutions Exploitation Corporate Profiteering

Poor education Media manipulation and inaccurate reporting Money in politics Citizen apathy

Environmental Degradation and Social Injustice (Consequences)
Increased poverty and overcrowding Famine Global Warming Weather extremes Species loss Human morbidity and mortality 40% of world’s yearly deaths linked to water, air, and soil pollution War Malthusian chaos and disaster

Consequences of Global Warming
400,000 deaths and 5.5 million disability-adjusted life years lost per year WHO, UN Environment Program Expected to double by 2020 Pentagon calls global warming an immediate national security threat

Costs of Wars (2010 dollars, inflation-adjusted)
American Revolution: $2.4 billion War of 1812: $1.6 billion Mexican War: $2.4 billion Civil War (both sides): $79.8 billion Spanish American War: $9 billion

Costs of Wars (2010 dollars, inflation-adjusted)
World War I: $334 billion World War II: $4.1 trillion Korean War: $341 billion Vietnam War: $738 billion Gulf War I: $102 billion Iraq/Afghanistan Wars likely to cost $4-5 trillion

Economic Cost of War, U.S.

(Using “constant dollars”; excludes VA, CIA, Homeland Security, Energy, Justice, and State Departments and interest payments on past military spending)

Military Spending The U.S. spent over $1 trillion on national security in 2015 (more than 50% of its average through the Cold War and the Vietnam War) Does not include > $80 billion/yr for interest on military-related share of national debt

War and Peace World military budget
230X what the UN spends on peacekeeping US: Largest arms supplier Profits at top 5 defense firms up 450% since 2002 Greatest debtor to U.N. (including U.N. peacekeeping fund)

Military Spending and Jobs
$1 billion in military spending generates 11,200 jobs 15,1000 in consumer goods production 16,800 in green energy development 17,200 in health care 26,700 in education

Skewed Priorities The world spends $1.8 trillion/year on military goods and services For 25% of this, we could: Eliminate starvation and malnutrition Provide shelter for all Eliminate illiteracy Provide clean and safe water Prevent soil erosion

Skewed Priorities Prevent global warming Stop deforestation
Aid all refugees Retire developing nations’ debt Provide clean, safe energy (through efficiency and renewables)

Skewed Priorities Prevent acid rain Fix the ozone hole
Stabilize world population Provide basic universal health care and AIDS control Eliminate nuclear weapons and land mines

DOD Announcement (September, 2011)
“Pentagon Lacks Funding to Fix Public Schools on Military Bases”

Dwight Eisenhower “Every gun that is made, every rocket fired, signifies in the final sense a theft from those who hunger and are not fed, those who are cold and not clothed”

Martin Luther King “A nation that continues year after year to spend more money on military defense than on programs of social uplift is approaching spiritual death.”

Worldwide Economic Impact of Violence
$10 trillion/yr 1% of global GDP $1,350/U.S. citizen

Health Costs of Militarization
3 hours of world arms spending = annual WHO budget ½ day of world arms spending = immunization for all the world’s children 3 days of US arms spending = amount spent on health, education and welfare programs for US children in one year

Health Costs of Militarization
3 weeks of world arms spending = primary health care for all in poor countries, including safe drinking water and full immunizations Brain drain: 2/3 of US scientists work in military-industrial complex (although much work has widespread applicability)

Foreign Aid In total dollars: U.S. #1
As a % of GDP, U.S. ranks 21st among the world’s wealthiest nations U.S. Aid: Over 1/3 military, 1/4 economic, 1/3 for food and development Most U.S. aid benefits U.S. corporations 116 116

Foreign Aid Americans think that 24% of the federal budget goes toward foreign aid 0.19% of the total federal budget, vs. UN target of 0.7% 117 117

U.S. Charitable Giving 2.5% of income
2.9% at height of Great Depression 118 118

The US: Rogue Nation History: Native Americans, slavery, current excesses, disparities and injustices Co-opting Nazi and Japanese WWII scientists Minimum 277 troop deployments by the US in its 240 year history

The US: Rogue Nation Over 1,000 bases worldwide today (737 in 69 other countries) All other countries combined occupy only 30 foreign bases 54 countries helped facilitate CIA’s secret detention, rendition, and interrogation program

The US: Rogue Nation Conservative estimate = 8 million killed
US invasions/bombings often largely at behest of corporate interests Drone strikes on allied/other nations and on U.S. citizens ¼ killed are non-combatants 10X more likely than conventional airstrikes to kill civilians AI, HRW condemn as extrajudicial executions/war crimes Militarization of police departments

The US: Rogue Nation American Weapons Gone AWOL:
US military has lost track of over 700,000 of the 1.45 million assault weapons, machine guns, and other firearms it provided to allied security forces, militias, and police during Iraq and Afghanistan Wars

The US: Rogue Nation Continued funding of the Western Hemisphere Institute for Security Cooperation Formerly the School of the Americas Over 60,000 graduates, including many of the worst human rights abusers in Latin America (e.g., Manuel Noriega, Omar Torrijos, and the assassins of Archbishop Oscar Romero)

The US: Rogue Nation “Which country is the greatest threat to peace?”
Pakistan - 8% China - 6% Afghanistan - 5% 2014 Gallup poll, 66,000 worldwide participants

Hermann Goering (at the Nuremberg Trials, shortly before being sentenced to death)
“Of course the people don't want war. But…it is the leaders of the country who determine the policy, and it is always a simple matter to drag the people along, whether it is a democracy, or a fascist dictatorship, or a parliament, or a communist dictatorship . . .

Hermann Goering Voice or no voice, the people can always be brought to the bidding of the leaders…All you have to do is to tell them they are being attacked, and denounce the pacifists for lack of patriotism and exposing the country to danger.”

Horace Odes (III.2.13) Dulce et decorum est pro patria mori It is sweet and fitting to die for one’s country

"Dulce Et Decorum Est" Wilfred Owen, 1917-18
… In all my dreams, before my helpless sight, He plunges at me, guttering, choking, drowning. If in some smothering dreams you too could pace Behind the wagon that we flung him in, And watch the white eyes writhing in his face, His hanging face, like a devil's sick of sin;

"Dulce Et Decorum Est" Wilfred Owen
If you could hear, at every jolt, the blood Come gargling from the froth-corrupted lungs, Obscene as cancer, bitter as the cud Of vile, incurable sores on innocent tongues,- My friend, you would not tell with such high zest To children ardent for some desperate glory, The old Lie: Dulce et decorum est Pro patria mori.

International Non-Cooperation/Isolationism
Failure to sign or approve: Kyoto Protocol on Climate Change Convention on the Prohibition of Anti-Personnel Land Mines Convention on Cluster Munitions Comprehensive Nuclear Test Ban Treaty

Failure to sign or approve: Convention on the Rights of the Child Convention on the Elimination of Discrimination Against Women Convention on Economic, Social and Cultural Rights

Failure to sign or approve: Convention for the Suppression of Traffic in Persons UN Convention on the Rights of Disabled Persons UN Declaration of the Rights of Indigenous Peoples

Failure to sign or approve: Protocol 1, Article 55 of the Geneva Conventions, which bans methods of warfare which can cause severe environmental damage The Basel Convention on the Control of Transboundary Movements of Hazardous Wastes

The US: Rogue Nation Marshall Islands: failure to clean up, safeguard nuclear waste, or adequately compensate dislocated Marshallese Domestic Spying (e.g., NSA) Torture (involving health care professionals) Death Penalty: US executes more of its citizens than any other country except China, Iraq, Saudi Arabia, and Iran Until recently, the US was the only country to execute both juveniles and the mentally ill

The US: Rogue Nation Failure to follow World Court Decisions
Failure to recognize International Criminal Court

International WIN/Gallup Poll, 2014
Which country is the greatest threat to peace? U.S. – 24% Pakistan – 8% China – 6% Afghanistan – 5% 66,000 surveyed worldwide

Solutions Activism (PSR, IPPNW, etc.)
Education (APHA Militarism Education Group) Tolerance and appreciation of diversity Redirect money towards social justice and environmental preservation Eliminate WMDs Restrict guns

Solutions Eliminate military recruiting in public schools
APHA supports Increase foreign aid Create Dept. of Peace Assist victims of war (PHR, MSF, etc.) Treaties

The role of the doctor in society
World Health Organization: “The role of physicians and other health professionals in the preservation and promotion of peace is the most significant factor for the attainment of health for all.”

Speak Up for the Disenfranchised
“The first job of a citizen is to keep your mouth open.” - Günter Grass

“First they came for the Jews” by Pastor Niemoller
“First they came for the Jews, and I did not speak up, for I was not a Jew. Then they came for the communists, and I did not speak up for I was not a communist. Then they came for the trade unionists, and I did not speak up, for I was not a trade unionist. Then they came for me, and there was no one left to speak up for me.” 141

Have Faith in Your Ability to Affect Change
"If you think you are too small to have an impact, try going to bed with a mosquito in your tent“ - African Proverb

Act Out of Love People Environment Earth

Our Home

Earth/Moon Seen by Voyager Spacecraft through Saturn’s Rings

Reference The Role of Public Health in the Prevention of War: Rationale and Competencies Am J Public Health 2014;104:e34–e47. Available at

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