This month, I am not reviewing the state of the pandemic across Europe. You can find great summaries every week of the current state in your country and sub-region on the ASPHER COVID-19 web pages. You will also find in this bulletin the incredible outpouring of papers and conference presentations made by colleagues and myself on behalf of ASPHER over the last month. I commend these to you.

I will instead reflect on the further explosion of violence in Israel-Palestine.

ASPHER is a membership organisation and we greatly value colleagues in schools of public health in Palestine and Israel. We admire your professionalism, your expertise, your knowledge; we enjoy your friendship and comradeship; we admire your courage, fortitude and leadership in these hard times and we respect all your rights to live freely and equally under the law. We know that you have in the past sought to work harmoniously together in the interests of health and peace and ASPHER will support you in all your further efforts.

ASPHER strongly condemns violence against unarmed civilians, irrespective of who the parties are from and from whom the violence originates. ASPHER’s statement in 2016, ‘Is war a man-made public health problem?’ still holds true. It was made in response to rights abuses in Turkey, but it applies equally now in Israel-Palestine.

‘Wars and armed conflicts have devastating consequences for the physical and mental health of all people involved, for the social life within and surrounding the war-affected regions, and for the health of the environment. Wars destroy health infrastructure, undoing years of health advancement, and severely compromise health systems’ capacity to respond to the direct and indirect health consequences of fighting. Millions of people have been internally displaced or forced to flee their countries because of armed conflict. Forced migration creates further physical and mental health problems during transit, in enforced encampment, and because of restricted entitlement to health care in countries hosting refugees. The disastrous effects might last for generations to come. In short, war is a man-made public health problem.’

The indirect negative health effects of this conflict also further compound the effects of the COVID-19 pandemic, and we call for public health communities to continue sharing the responsibility of equitable vaccine distribution across regions. Public health professionals from Israel and from the international community - continue to call on the Israeli government for COVID-19 vaccines to be supplied without condition or reservation to Palestinians. The foundation for this call is moral, humanitarian and for the benefit of the whole region.

President’s personal view

In the depths of the Cold War, my colleague and friend David Josephs, a fervent anti-nuclear war campaigner said “compared to preventing nuclear war, immunisation and preventing smoking are just ‘rearranging the deckchairs on the Titanic’”. Many will feel ASPHER’s calls to the Israeli government to vaccinate Palestinians is in that category – the ‘band aid for a broken leg’. Although I understand that sentiment, it is also the case that failure to vaccinate Palestinians, has been, to quote one Israeli colleague, ‘another opportunity engendering anger and resentment’. This is particularly the case when Israel has been exporting surplus vaccine to other nations, buying influence through vaccine diplomacy. The Israeli government has also failed to heed ASPHER and Israeli Physicians for Human Rights calls for fair and equal treatment of Palestinians during the pandemic.

Pictured: Guerrillas in El Salvador participating in immunisation campaign. From Health as a Bridge for Peace: PAHO's experience, The Lancet

I still hold the view I held in the Cold War era, that ‘Health Promotion is Peace Promotion’. The World Health Organisation describes peace as an essential prerequisite for health. In its landmark reports on global violence and public health, WHO describes every level at which violence damages health, from child abuse, through domestic abuse through racial harassment and inter-community violence, to international conflict. The causes are understandable and therefore preventable; a public health approach to understanding and preventing violence is vital.

Some national public health bodies have put forward statements on the role of public health services in preventing violence – among them the American Public Health Association and the UK Faculty of Public Health. In the UK, there have been calls for a public health approach to knife crime and preventing violent extremism. There are roles for public health professionals in the epidemiology of violence, the life course approach to violence and a public mental health approach. There is a community development role in conflict mediation and resolution.

Figure: Medical Peace work 

We in public health have in many cases, set our priorities in terms of major causes of death – ­heart disease, strokes and cancer have been major preoccupations. Violence is lower down the causes of death globally, but it rises with years of life lost and it rises with the unmeasured impact on generation after generation. The impacts in terms of mental ill-health and spiritual ill-health are measured – surveys exist about human feelings of bitterness, inter-community hatred, distrust, desire for revenge and retribution but they are marginal in their use in public health fields. We should all embrace the growing interdisciplinary science on adverse childhood experiences – there is growing evidence of how these affect physical and mental health throughout life, ruining life chances for millions of children, ‘incubated in terror’. The experience of COVID-19 is one giant adverse childhood experience. Now in the Israel-Palestine conflict it only adds to the brutalised experience of children growing up on both sides of the divide.  

In our ethical codes, we are required to be experts at what we do ­– working as conscientiously and to the best of our knowledge and ability, counting and monitoring the causes of disease and disability in our communities and advocating for effective treatments and public policies to protect and improve health. Our ethical codes also require us to act selflessly, to be courageous in our stand against injustice and in our advocacy for better health. The history of public health is a history of battles against exploitation and injustice, the abuses by the powerful against the rest of the population, be it in the fight against infectious disease, against aggressors in conflict, or against commercial exploitation.

We cannot ignore the political determinants of health. Power may be pursued for its own sake sometimes without the motive of profit or material benefit. It is harder for the public health community to consider ourselves knowledgeable and able to stand up against this – being told it is outside our remit and understanding – but understand we must and we must be prepared to bring people together, to be a bridge for peace. We must forge alliances with international lawyers and political scientists and with organisations skilled in mediation and collaboration. We must try to understand the core motivations of those in power and how they work against the interests of health and fairness. We must call on the body of international learning on conflict resolution and apply all its principles to bringing conflicting parties together.

It is the role of the international health community to promote peace, through its actions to protect and improve health. We must be respectful of all human life, and champions of human rights. We must reject violence and call for others to reject it also. The action of the international health community creates the conditions for better health through which material inequalities and injustices can be reduced. People can re-learn to trust and connect. They can enjoy their full potential to live healthy and rewarding lives and the future of people and planet can be secured.

The final article of the Alma-Ata declaration still holds true and is worth repeating. ‘An acceptable level of health for all the people of the world … can be attained through a fuller and better use of the world's resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, détente, and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share.’

Professor John Middleton
President, ASPHER