This project was made possible through Cooperative Agreement Number HRN-A-00-96-9006 between the US Agency for International Development and Tulane University

           On May 15, 1998, the WHO “Consultation on Health as a Bridge for Peace” in Geneva sought to insert Health as a Bridge for Peace into the WHO mission and defined a specific agenda for analyzing and utilizing HBP. The GW Center for International Health (GWCIH) developed the background paper for the event (GWCIH, 1997).  Participants at the WHO Consultative Meeting voiced concerns that the original definition of Health as a Bridge for Peace, stipulating that shared concerns around fundamental health issues can provide an entry point in the process of negotiation because health issues may transcend political, economic, social, and ethnic divisions among peoples, does not accurately reflect the reality of conflict in the post cold war era (WHO, 1997).  Participants questioned whether concern for delivering health care should excuse health workers and organizations from the need to be more aware of the political realities in which they operate.  Proponents of the HBP approach contend that health workers should do more than endeavoring to “do no harm,” and that they have a responsibility to seek out creative opportunities to promote peace.  Participants endorsed this more strategic orientation to HBP, which is summarized in Box 4, below.

Box 4: Revised  WHO Definition of HBP

The WHO Consultative Meeting also focussed on a number of other important questions, which are briefly discussed below:

1. What is the role of health professionals in promoting peace? Participants found the role of the health professional to be unique due to the strength of the health profession and feelings of solidarity among its members worldwide. In addition, there is a perceived impartiality of health professionals.  They have an intimate relation with individuals and communities, and can have opportunities that may open doors for other sectors.  Other strengths of health professionals in working for peace include the personal attributes of health providers, professional skills and know-how in rebuilding the health sector, and the potential ability to act as brokers for peace.

            At the same time the idea of the sanctity of the health and medical professions was questioned.  For if health professionals are supposed to hold the sanctity of human life above all else, how do we explain the actions of some who incite ethnic rivalry, who condone ethnic cleansing and participate in genocide?  While the cases reviewed at the meeting illustrated the potential of health professionals to contribute in a unique way to promoting peace, participants also recognized that the assumption that health is always an overriding ethical imperative for all health professionals or within all societies is questionable.  Participants identified critical activities for health professionals in fulfilling their responsibilities towards peace promotion, which are detailed in Box 5, below. 

2. The role of international organizations, especially WHO, within a war or conflict situation.  Participants acknowledged that any organization working within a war or conflict situation is working within a political context.  Consequently it can have an impact on the political dynamics of that conflict, and runs a potential risk when trying to promote peace.

            Participants also identified a number of potential roles that international agencies such as WHO could play in the peace process.  They include:

·           The potential to act as a facilitator, or a catalyst to bring all sides together;

·           The potential to contribute to the development of health and peace infrastructure; and

·           The potential to take the lead in coordinating civil society through public health and medical associations, institutes of higher learning, and other sectors (WHO, 1997).

They concluded that conflict analysis skills and best practices should be documented and diseminated to enable health professionals to take into account such risks in the design and implementation of HBP interventions.

            3. The importance of health data.  At all stages of conflict, data, especially health data, have the potential to move public opinion and can instigate political change.  Some examples include the success of the international campaign to ban land mines, and the contribution of the International Physicians to Prevent Nuclear War in the ratification of the atmospheric test ban treaty.  Health professionals can influence policy by activating the data-to-policy link.  This includes conducting studies of "strategic epidemiology," making cases for policy change based on health data, and developing constituencies both from the grassroots to the level of decision-makers (WHO, 1997).   Box 6 describes the Demographic and Health Surveys (DHS), which is a particularly relevant data collection vehicle in post-conflict environments (Mock, 2000).

Box 6:  The Demographic and Health Surveys Program (DHS) 

                  4. Is health itself really neutral?  .4.5.Is health itself really neutral?  Participants questioned the assumption that health is by its very nature neutral.  Cases presented suggested that health and health actions, especially in situations of conflict, are not always viewed as neutral or value-free.  Health assets can be manipulated by political leaders to further their own interests.  Nevertheless, health providers and organizations can try to be impartial.  At the very least, they should not contribute to or exacerbate conflict. Experiences also show that even though health may be as politically charged as other sectors or concerns, the act of technical cooperation in health and among health professionals has the potential to facilitate certain aspects of the peace process.  In some instances, health can bring together conflicting sides and serve as a bridge for peace (WHO, 1997).           

            5. Stakeholders. Three basic categories of stakeholders emerged from the analysis: Top-level leadership consisting of political decision-makers, business leaders, the diplomatic community, member states, and donors; middle range leaders, including ethnic or religious leaders, prominent members of the health professions, and academic community, and staff of international organizations; and grassroots organizations (WHO, 1997).

Participants described different types of actions corresponding to the different categories of stakeholders.  To influence top-level leaders, international agreements, accords, and visible leadership are necessary.  At times, a grassroots movement may also trigger high-level leaders to recognize an issue (such as land mines). Three other elements seem to be essential in mobilizing the power of health as a bridge for peace: resources, political will, and the media.  One strategy for mobilizing support for HBP initiatives is to strengthen the data-to-policy link through the use of the media, which may be especially important in influencing public opinion especially (WHO, 1997).

 In 1999 the GWCIH established the Health Diplomacy Institute to serve as a think tank for putting into practice health as a bridge for peace as a key to conflict resolution and development.

Table 1: Major Symposia on Health as a Bridge for Peace

Source: Adapted from GWCIH, 1997.

C. The Link Between Health as a Bridge for Peace and CERTI Approaches

The Complex Emergency Response and Transition Initiative (CERTI) is an international and interagency program initiated in 1996 by the USAID Bureau for Africa in support of one of its Strategic Objective, known as Programs for Preventing, Mitigating and Transitioning out of Crisis.  The purpose of this initiative is to form a link between relief and development strategies. CERTI has two major objectives:

·         To establish broad-based international consensus on best practices before, during, and following complex emergencies (CEs); and

·         To strengthen the capacity of various implementing organizations which provide public health interventions in crisis and post-crisis contexts.

The CERTI approach is congruent with the HBP approach in several areas, which are discussed below:

1. Stages of Conflict

The CERTI framework identifies phases of conflict that call for different programming approaches.  Four principal strategies have been developed to enhance the transition from conflict to sustainable development: 1) investment of development resources to address the causes of conflict such as inequity (gaps and disparities) and the lack of a foundation for civil society; 2) development of early warning and conflict resolution/management strategies; 3) strengthening relief response to ensure professionalism and interventions that are supportive to rather than competitive with long term development goals; and 4) design and support of effective programs that facilitate the peace process while addressing the special developmental needs of populations emerging from the trauma and devastation of war (CERTI, 1999).

The HBP approach is compatible with the CERTI conception of conflict analysis. Figure 2 shows the main stages of conflict as conceptualized by the CERTI approach: conflict, crisis, chaos, complex emergency and recovery. These stages are indicated by the text boxes. Each CERTI stage corresponds with the HBP stage depicted inside the circle: Impending crisis, outbreak of violence, war, post-crisis, and stable peace.  Furthermore, like the CERTI approach, HBP suggests that different actions are appropriate at different stages of conflict. The case studies analyzed in Section V. provide a critical assessment of the types of HBP actions that have been initiated at different stages of the conflict.  

Figure 2: Congruence of CERTI and HBP Stages of Conflict and Action

Source: adapted from Macinko, et al., 1998.

It is important to note, however, that one of the key issues in analyzing a conflict is to determine when exactly the conflict is over.  For relief agencies, the end of a crisis means an end to much of their work and a transition to development work.  Macrae (1995) suggests several indicators that may signal the end of a conflict: 1) signing of a formal peace agreement; 2) a political transition such as elections or negotiated power transfer; 3) increased levels of security; 4) perception among national and international actors that there is an opportunity for peace and recovery.   However, As Van der Heijden (1997) points out, single characteristics may be misleading.  He points to Ethiopia and Uganda as cases where peace developed without formal peace accords, and to Angola where the first UN-brokered peace accord and election were the start of the next phase of war.  Moreover, different actors in a conflict may feel they are at different stages. For this reason, the stages of conflict approach can be used as a heuristic device, but must be analyzed within the context of each conflict. 

2. Multiple Units of Analysis and Action

The CERTI approach recognizes that crises have both sub-regional and highly location-specific manifestations.  For this reason, the nation-state may no longer be the most effective analytical unit for programming purposes.  Rather strategic actions that can be implemented through cross-border programs affecting subregions may be most appropriate.  Within a country, programs that are flexible and decentralized enough to permit the delivery of interventions across the relief/development spectrum may be more likely to succeed (CERTI, 1999).

The HBP approach has been applied within countries (e.g. Angola), across borders (e.g. Croatia), and within regions (e.g. Central America) and is congruent with the CERTI approach.  HBP recognizes the concerted efforts of individual health providers and organizations and attempts to link them through networks to each other and to higher levels of authority (GWCIH, 1997).  HBP has been practiced in one form or another by the United Nations system, as well as by bilateral agencies, international NGOs, civil society organizations, and local communities. 

One approach, known as decentralized cooperation (DC), engages actors at multiple levels and has been utilized in the former Yugoslavia.  Decentralized cooperation may be relevant to the CERTI environment and is described in greater depth in subsequent sections of this document.  Box 6 provides a summary of the DC approach.

Box 7: Decentralized Cooperation

3. A multidisciplinary approach to understanding the causes of and possible solutions to conflict.

The CERTI framework for intervention acknowledges the strategic role of development investments, improved early warning and preparedness, professional development and training, improved policies and programming, and networking and coordination (CERTI, 1999). The framework incorporates the actions of donors; international NGOs; PVOs; the military; and indigenous, regional, and local institutions, and underscores the relationship between poor investments in human development and the development or perpetuation of conflict.  It recognizes the critical role of public health in preventing as well as responding to complex emergencies worldwide and in leveraging the developmental potential of African countries (CERTI, 1999).

The GW Center for International Health, in collaboration with WHO, has developed a conceptual framework for guiding research and action in the area of Health as a Bridge for Peace.  The conceptual framework (see Figure 3) seeks to contribute to a better understanding of specific conflict situations and their health impacts.  It represents a holistic view of the health to peace concept, including its environmental, health, political, economic, social, gender, and human development dimensions.  These dimensions are described in more detail below.

First, the physical environment and gender are shown as overarching dimensions of the framework.  All health actions take place within a particular physical environment, the characteristics of which may contribute to or hinder efforts to provide humanitarian assistance, reduce conflict, and promote health.  Gender is also important, especially when looking at differences between conflict perpetrators and victims.

Second, the economic situation of a nation, especially in terms of unemployment, economic instability, and inequitable distribution of wealth, may create or exacerbate conflict.  Inequity and poverty can lead to the creation of vulnerable groups unable to participate fully in the development process, thus creating a situation for continued or future conflict situations.  In turn, conflict ultimately affects a nation’s economic development, resulting in lost investment, deterioration of trade, and long-term damage to the economy as a whole.  As the economy deteriorates, funding for public health services also dwindle, leading to breakdowns in disease surveillance and vector control, inadequate primary and preventive health care, deterioration of water and sanitation services, and ultimately a higher level of morbidity and increased economic costs.  Due to a greater burden of disease in a society, lower productivity may be seen, and in many cases extend to post-conflict generations.

Third, social factors such as poverty, poor housing, the breakdown of community structures, and poor educational opportunities place people in survival situations of increasing marginalization and hopelessness.  These factors may promote aggressive behavior and exacerbate conflict, leading to the emergence or strengthening of a culture of violence, which favors force as a means to resolve frustrations and disagreements.

Fourth, lack of political participation and government accountability, coupled with social and economic disparities can lead to increased prevalence of conflict and violence.  Obstacles to the establishment of democratic forms of government occur when, in attempting to contain violence, governments favor one group over another, silence opposition, or allow police and security forces to infringe on basic human rights.

Finally, conflict takes a heavy toll on human development.  Besides the economic, political, and social dimensions mentioned above, violations of human rights and the persistence of unresolved conflict can lead to a devaluation of life and a lessening of mutual respect on the part of both the authorities and civil populations.  Children and youth raised in such hostile environments may come to understand these attitudes as normal.

In summary, the framework does not endorse a particular theory of conflict.  Instead, it allows both researchers and practitioners to address certain key aspects that may lead to conflict.  Health is seen as central as a bridge for peace, utilizing epidemiologically-based public health tools for conflict prevention, surveillance, and evaluation. This approach facilitates comparisons among conflict situations; provides a means to address multiple dimensions of conflict; and allows for a common framework, which may be adapted to examine individual countries or particular conflicts.  By combining political, economic, social, health, and human aspects, the conceptual framework can guide the process of identifying, characterizing, and evaluating past and current HBP initiatives and aid in the design of future activities. (Rodriguez-Garcia, et al., 1998).  The HBP approach as depicted here allows for a multidisciplinary analysis of the causes of conflict, and points to sectors, stakeholders, and institutional features that need to be addressed in the context of post-conflict rehabilitation.

Figure 3: GWCIH Health as a Bridge for Peace Framework

4. Concern with human security

The United Nations 1994 Human Development Report defines human security as "the sense that people are free from worries, not merely from the dread of a cataclysmic world event but primarily about daily life. Human security is people-centered while being tuned to two different aspects: It means, first, safety from such chronic threats of hunger, disease and repression. And second, it means protection from sudden and hurtful disruption in the patterns of daily life – whether in homes, in job or in communities." (UNDP, 1994).

The CERTI project has asserted that "human security" should be an outcome of relief-to- development activities.  Though the HBP approach does not explicitly address human security, it does place human development as the objective of its actions and a measure of its success. Moreover, some measure of human security may be seen as a necessary, but not sufficient, condition for the realization of human development and for sustainable improvements in population health status.  For this reason, the framework depicted in Figure 3 includes elements of human security along with the general concept of human development, which may be viewed as analytical approaches to defining problems as well as outcome measures.

5. Adaptations to the HBP framework

Several adaptations are needed to make the HBP approach more relevant to CERTI.  First, the HBP approach should focus on the stages of conflict most relevant to CERTI – Chaos, complex humanitarian emergency, and most importantly, recovery.  For this reason, the majority of experiences reviewed here will focus less on the prevention side (although several important prevention initiatives will be reviewed) and more on the conflict and post-conflict stages.  Second, the HBP approach has, by and large, focused on the actions of international organizations, most notably, the World Health organization (WHO).  However, in order to be relevant to CERTI it must incorporate the actions of multiple parties including local and international NGOs and civil society, the military, and bilateral and multilateral donors. Third, the focus should be on Africa.  Although several important HBP activities have taken place in Africa (Angola, Uganda, Mozambique) the majority have taken place in other regions.   When reviewing the lessons from other regional experiences in HBP, it will be important to take into account the applicability of the approach and the lessons derived from it within the context of Sub-Saharan Africa.  Finally, the original HBP projects took place in a vastly different international political context- that of the cold war.  In order to be most relevant to CERTI, lessons should be learned from experiences in Rwanda, Democratic Republic of Congo, and the former Yugoslavia, for example, in order to place the HBP approach within the context of contemporary political realities.

D. The Challenges of HBP in Today’s Global Environment

The fall of the Berlin Wall spelled the end of the bi-polar world.  However, rather than having the effect of reducing the number of conflicts worldwide, there has been an acceleration in the number of conflicts, which have affected more people around the world than ever before.  Indeed, from 1990 to 1995, over seventy states were involved in 93 wars, killing at least 5.5 million people, three-quarters of whom were civilians, including nearly one million children (Smith, 1997).  However, mortality data represent only part of the situation.  Mortality estimates should be supplemented with data on injuries and trauma as well as economic, social and political erosion within and among countries as a result of wars and other less overt manifestations of conflict.  Additionally, the majority of impacts are seen within the world’s poorest countries or within the poorest, most neglected populations within countries, exacerbating already critical situations.  An example can be seen in East Timor, which has the lowest development level among all 27 provinces of Indonesia, even 25 years after it was incorporated into the country.  Given the widespread mortality and morbidity resulting from conflict and its obvious impact on health; development programs; and economic, social, and political security, it is not surprising that the health community has found it imperative to understand and explore the relationship between conflict and health.

Health has also been recognized as a security issue.  The Institute of Medicine (1992) underscored the important link between economic and human development needs in developing countries and the risk of newly emerging infectious diseases that could affect the U.S. population while traveling abroad and at home.  Jack Chow (1996) also discusses the potential of infectious diseases, such as AIDS, for disrupting political and economic security in the developing world, and highlighted the fact that even our responses to such humanitarian emergencies may be manipulated for political ends, further exacerbating potential security threats. 

The Center for Strategic and international Studies (CSIS) identified three main areas where health intersects with security, namely failing states and instability, assistance during “humanitarian warfare,” and terrorist use of biological weapons (CSIS, 2000).

1) Failing States and Instability  CSIS identified failing economies and lower levels of humanitarian assistance as leading to reductions in public health services in many developing countries.  As a result, some governments have lost popular support and have been replaced by societal factions competing each other to protect their own well-being.  This competition often turns violent, leading in some instances to the collapse of national health infrastructures.

2.  Humanitarian warfare This term refers to the growing tendency of civil combatants to manipulate food and medical supplies in efforts to gain advantage over adversaries.  This often results in forced displacement or mass expulsions of groups, creating new political factors to be resolved.  The “safe havens” and refugee camps created for meeting the needs of displaced populations can both overwhelm the capability of relief services and create an additional factor to be manipulated by warring factions.

3.  Biological Weapons The use of biological weapons (BW) involves the deliberate spread of disease, either by state entities in the context of a conflict situation, or by non-state entities seeking to inflict a high level of casualties on an unsuspecting population.  CSIS outlined several international findings in this regard, including:

·         the surprising size and scope of Iraq’s BW program;

·         the existence of an offensive BW program in Russia, in violation of the 1972 Biological and Toxic Weapons Convention (BWC), of which Russia was a signatory nation;

·         an attempt by the cult responsible for the 1995 poison gas attack in the Tokyo subway to develop BW;

·         interest in acquiring BW by an increasing number of countries.

Material and technology that can be used to make BW also have legitimate commercial or medical uses.  As developing countries demand more sharing of technology to combat disease, the question of how to manage the global diffusion of “dual-use” material will become a major political issue (CSIS, 2000).

As illustrated in the preceding discussion, the intersections of health and international security are, and will continue to be, important issues for policymakers.  In the future, it will become increasingly important for policymakers to develop an approach to dealing with these questions in the most effective way possible.  To do this, three key questions must be addressed:

Ø      What are the key intersections of health and security at the state and international levels?

Ø      What are the critical dimensions of the health/security interface?

Ø      What policy challenges does the interaction of health and security create and what mult-sectoral approaches will most effectively deal with this relationship? (CSIS, 2000)

These topics are discussed below.

1.  New Approaches to post-conflict mitigation and negotiation tactics

In an attempt to address such questions, the World Bank has advanced the concept of post-conflict development, which represents a new type of development that bridges relief and reconstruction.  Post-conflict development entails detailed analysis of the conflict situation in order to address the structural causes of the conflict, the demands of different interest groups, and concern for human security.  It promotes collaborative efforts among development agencies and relief and emergency organizations and local ownership of post-conflict development initiatives.  Accordingly, some countries have reduced their national military spending, using the funds instead to strengthen social and civil institutions.  However, these funding reallocations have required increased attention by national governments on issues such as demilitarization, demobilization, and the reintegration of ex-combatants into society (World Bank, 1998). 

Scholars at the London School of Hygiene and Tropical Medicine have also written about the concept of “post-conflict rehabilitation.”  They have agreed that opportunities may be gained in garnering political support for negotiated peace settlements by addressing the direct and indirect effects of war on health and health systems.  Like the counterparts at the World Bank, the proponents of the post-conflict rehabilitation concept focus on the transition from relief to rehabilitation to long-term development and argue that cooperation is often necessary among development agencies and relief organizations as well as national political leaders.  However, they also acknowledge that such cooperation may be difficult in situations where there exist serious questions of legitimacy of the government in power.  In such circumstances, international aid is increasingly delivered outside of government structures, by international and non-governmental organizations, allowing donor governments to avoid endorsing political entities that were party to conflict situations (Lanjouw, et al., 1999).

The mission of the Department for International Development (DFID) of the Government of the United Kingdom has expanded on these ideas.  Its policy is to examine the conditions that have led to conflict, assess strategies for reducing violence, and build lasting peace.  The DFID seeks to fulfill this mandate by building political and social infrastructures that enable meaningful representation of different interest groups, promoting human rights, and resolving disputes and grievances without recourse to violence.  In addition, the DFID has begun a process of integrating conflict reduction objectives into its development programs, placing emphasis on fostering economic growth that benefits all sections of society and ethical trade conditions which are fair to all countries.  In so doing, macro-economic policies become key in addressing underlying causes of conflict, namely social inequality and poverty (DFID, 1999) .        

The DFID approach complements HBP strategies by utilizing similar values and strategies on a much broader macro-level.  For example, while supporting capacity-building activities of local disaster response entities, the DFID advocates for strengthening international networks such as the United Nations and the Red Cross.  And, while health is not specifically mentioned in its policy document, concepts related to health security, such as human rights and more general “humanitarian needs” are emphasized.  Importance is placed on diminishing barriers imposed by strict adherence to national sovereignty, focusing instead on international collaboration and cooperation among poor and rich nations alike, conflict resolution and peacebuilding, and peacekeeping operations in order to build mutual confidence (DFID, 1999).

This new type of development approach, while still in its infancy, reflects the growing importance of the basic philosophy behind using health as a bridge to peace.  It underscores the importance of brokering peace by rebuilding social and civic structures, among which the health system is especially critical to fostering long-term stability and recovery.  Like the HBP perspective, the emphasis is on viewing a conflict situation from a holistic perspective, including its political, social, economic, and human development dimensions, in the design of appropriate long-range development strategies, while addressing the root causes of conflict.  Health is seen as crucial for peace-building.  Conflict-affected nations are often among the most health deprived, with the poorest and most vulnerable populations least likely to be able to access health services (Lanjouw, et al., 1999).  In the absence of health security, countries risk renewed unrest and a return to conflict or violence.

2.      Relationship Between HBP and Conflict Mitigation and Negotiation Tactics

As discussed above, there is a clear link between approaches such as Health as a Bridge for Peace and post-conflict development. There are also similarities between these approaches and contemporary conflict mitigation/negotiation strategies, which include the use of persuasion, bargaining, arbitration, and threats (Brams, 1990).  Conflict negotiation requires planning and strategic thinking.  In order to plan effectively, a negotiating party must: a) understand the nature of the conflict; b) specify goals and objectives; c) clarify the process for managing the negotiation process, which includes identifying the issues for negotiation, prioritizing issues, developing desirable packages among the important issues, and establishing an agenda; and d) understand the opponent, including the opponent’s current resources and needs and the history of the opponent’s bargaining behavior (Lewicki and Letterer, 1985). 

A bargaining situation may be distributive in nature, whereby the goals of one party and the attainment of those goals are in fundamental and direct conflict with the goals of the other party.  This type of bargaining situation may be characterized as a win-lose situation.  On the other hand, in integrative bargaining, the goals of the parties are not mutually exclusive.  One side attaining its goals does not preclude the other from doing so as well, making possible a win-win situation (Lewicki and Letterer, 1985).

The relationship between Health as a Bridge for Peace approaches and contemporary conflict negotiation strategies may be seen in both the planning elements necessary for successful negotiation and the integrative bargaining approach.  As described in Peters (1996), careful planning of a Health to Peace initiative is crucial to its success.  Further, an integrative bargaining process that involves the identification of common problems and goals and mutually-benefiting strategies for problem resolution, allows the health sector along with all sides of a conflict situation to move towards common ground and to begin to build trust and working relationships.  Such relationships may help lay the groundwork for more permanent peace agreements.

A full understanding of conflict and strategies for negotiation/mitigation by health personnel is critical in identifying appropriate opportunities for negotiations between warring parties.  As noted earlier, health can be a powerful tool in bridging the gap between conflicting parties because health problems often must be addressed in a timely manner to avoid catastrophic situations.  Irrespective of the nature of the conflict, health issues will most likely affect all parties, particularly outbreaks of epidemics such as cholera, malaria, dengue, tuberculosis, and other infectious diseases.  Microbes neither take sides nor identify an adversary. Therefore, health becomes a priority for all parties in conflict and a concerted action will be more effective than isolated and unilateral efforts. 

Despite the role that health can play in resolving conflict, health personnel are not traditionally provided with training in conflict and conflict resolution.  There is a need, then, to train health personnel, in particular those working in conflict areas, in conflict management and negotiation.  Such training programs must include information about basic tenets of conflict and negotiation.  The newly acquired skills can then be used to identify opportunities for bringing parties together to discuss common problems and facilitate appropriate interactions.  By seizing such opportunities, health may be used as a springboard for dealing with issues that go beyond health, towards broader conflict resolution.

IV. Overview of HBP Experiences Worldwide

In order to make sense of the varied HBP experiences undertaken over the past 15 years, a comprehensive literature search was conducted of documents describing, analyzing, and evaluating different HBP initiatives in different countries. Public health and international affairs databases were searched and the bibliographies of retrieved documents were culled for additional references.  Note, this search was very narrow in scope: it sought only relevant experiences where health was used (or misused) to promote peace. In total, 56 documents were retrieved and reviewed.  Results of the literature search are summarized in table 2 below.

Table 2: Results of Literature Search

There are several limitations to this literature search. First, there is a likelihood of some publication bias, as many HBP activities may not have been documented at all.  Moreover, in at least eleven of the twenty-one actions identified, the World Health Organization appears as the principal architect of the HBP activity, which may reflect the fact that, by and large, the WHO has supported the documentation of many of these efforts. It is also important to note the involvement of UN agencies in nearly every experience. Fewer experiences point to the role of NGOs in the design of the HBP activity. Nevertheless, the limited experiences seem to imply a larger role for NGOs in the implementation of the activity.  It is important to highlight the fact that few of the documented experiences were written by or from the perspective of NGOs and other civil society actors so we may not be able to have access to the extent of the NGO experience through a simple literature review.  In order to address this potential bias, NGO experiences will be solicited through key informant interviews in subsequent chapters of this document.

Table 3 presents a catalogue of documented experiences in Health as a Bridge for Peace as identified through the processes discussed above.  The table presents an overview of the country or countries involved, the type and stage of conflict, the actors involved in the HBP activity, the main HBP interventions, and the source and quality of the data.

A total of 21 HBP experiences were identified.  In terms of geographic distribution, six took place in Africa, five in Asia, two in the Americas, five in Europe and three in the Middle/Near East.  Among those in Europe, all but one took place in countries of the former Yugoslavia.  There are several cases ( Bosnia-Herzegovina) where more than one HBP activity was implemented in the same country. These experiences were only listed separately if the HBP projects were independent of each other.

The data quality column is meant to give a crude indication of how well documented the specific HBP activity is.   It is important to note, however, that these categories are meant to be relative only to each other.  In general, very few of the documented HBP experiences appear to have been evaluated.  The few that have been evaluated have been done so in an ex-post design.  This means we can have little confidence of the effects of the program independent of other activities occurring simultaneously.  More rigorous evaluation of HBP experiences (whenever possible) would allow us to be more confident about the real strengths, weaknesses, and ultimate impacts of individual HBP efforts.  Nevertheless, the qualitative descriptions of the different HBP programs provide a wealth of information about the context and the process of the HBP approach.  In order to provide a somewhat crude ranking of evidence, the following classification scheme was used.  E (Excellent) means the case study is well documented, detailed, and supported by other existing documents. In addition, there must be at least one external program evaluation of the HBP component. G (Good) means that there is a well-documented case study of the experience, but that evaluations of the HBP activities have not been located. P (poor) means that no written case study was located, the specific HBP activities were described as mentioned in other published documents. UK (unknown) means that we were unable to find a thorough description of the HBP activity, only an anecdote in another document. It is important to note that this classification system is based on the researcher’s ability to locate and access documents.  For this reason, discovery of new documents may lead to a re-classification of certain experiences.  Nevertheless, for the purposes of this review, the data labels may give the reader an idea of the level of confidence the researchers had when reviewing each individual case.

The most frequently cited experiences are the original activities undertaken in Central America in the 1980s and 1990s.  A variety of documents discuss the original HBP experience in Central America.  The Pan American Health Organization prepared several monographs (see PAHO, 1990; Teruel, 1991) on El Salvador and Nicaragua (PAHO, 1990/1991) and the First and Second Madrid Conferences presented specific plans of action for cooperation in health (PAHO, 1985, 1988). These documents spell out quite clearly the process of utilizing health activities for peace-making. The emphasis in these documents is on government-to-government collaboration as the conflict was recognized as a regional/political civil war.  Although the Central American initiatives appear to be the most frequently cited HBP activities, we are unable to find an adequate description or evaluation of specific interventions on the ground.  Evaluative information comes both from speeches presented to various international fora (Guerra de Macedo, 1994) and reports to donor organizations (PAHO, 1989).

A number of HBP documents recount the various approaches undertaken in countries of the former Yugoslavia.  Activities carried out by the WHO European Office describes in detail the rationale for engaging health professionals in peace-building efforts (WHO-EURO, 1997; ODA, 1997) and related activities have been sponsored by the British (ODA, 1997) and Italian bilaterals (WHO, 1999; Italian Cooperation, 1998).  These documents primarily describe the approach and specific aims of the activities to be undertaken. 

One detailed case study of particular interest presents HBP activities undertaken to integrate the health sector of Eastern Slavonia, Croatia (Balladelli, 1997).  These activities were facilitated by WHO and are unique in that there has been a fairly detailed evaluation of the HBP efforts (WHO, 1999a). This evaluation provides an excellent framework for some of the evaluative questions one would like to answer when assessing most HBP activities.  It assesses the methodology of the HBP approach, its sustainability, the viability of interventions, and the appropriateness of the implementing organization (in this case WHO).  In brief, the evaluation suggests that WHO was instrumental in the reintegration of the heath sector in Eastern Slavonia, and acted as the principal mediator in this capacity.  WHO‘s aim to advocate peace through health initiatives took place at the micro level (social peacebuilding) and at the macro level (structural peacebuilding). Evaluation findings are discussed more thoroughly in the Croatia case study. 

Box 8: Selected Health and Development for Displaced Populations (HEDIP) Activities

Source: Peters, 1996

Another WHO effort, the Health and Development for Displaced Populations (HEDIP) project undertook operational research in areas of conflict (Mozambique, Sri Lanka, and former Yugoslavia) on the use of health and social interventions to promote reconciliation and development (Swartz as presented in Peters, 1996).  Box 3 details some of the activities of the HEDIP project.  Lessons learned from this participatory action and research program informed the approach undertaken by others in the development of the Decentralized Cooperation models.

In turning to individual country experiences, we have classified conflicts using the terminology suggested by Large (1997), as adapted from Cottey (1994). Types of conflicts include:

1.      Genocide/large scale loss of human life: situations where central state authorities attempt to exterminate a particular ethnic group (e.g. Rwandan massacres of Tutsis in 1994);

2.      Collapse of state authority: situations where conflict has resulted in collapse of central state authority and armed conflict continues (e.g. Somalia);

3.      Ethic civil war: conflict between (among) ethnic groups within a state where ethnic groups are not regionally divided and secession is not a central issues (e.g. Rwanda, Afghanistan)

4.      Secessionist civil war: conflict within states fought over the issue of whether a particular ethnic group has a right to secede (e.g. Croatia, Eritrea, Bosnia);

5.      Political civil war: conflict between states fought for political control of the state and/or over the political values the state is based on;

6.      Armed challenge to legitimate state authority: use of armed force by nongovernmental groups to challenge the authority of a government within a state (e.g. Khmer Rouge in Cambodia, UNITA in Angola);

7.      Low-level cross-border conflict: conflict across state borders, but falling short of full-scale war, involving either more limited forms of armed action (e.g. Lebanon-Israel; Sudan-Uganda-Zaire);

8.      Inter-state war: classical conflict between national states, involving government controlled armed forces and challenge to state’s territorial integrity (e.g. Iraqi invasion of Kuwait; Korean war 1950-53).

In attempting to classify each conflict, our intent was not to make any statement about the conflict, but rather to help determine if there may be some relation between a given type of conflict and the HBP activities implemented.  It should also be noted that the categories presented above are not mutually exclusive and the nature of the conflict may actually change over time.  Given these limitations, the analysis of the cases presented in Table 3 shows that nearly every type of conflict (with the exception of inter-state war) is represented. Case studies in further sections will analyze the relationship between the type of conflict and the kind of HBP actions implemented.

The literature reveals that a wide variety of HBP measures were implemented.  About half of the HBP interventions included immunization cease-fires or cease-fires intended to permit the delivery of humanitarian aid.  Documented experiences of immunization or humanitarian cease-fires include those of Afghanistan in 1994 and 1996 (WHO, 1995; Peters, 1996); Cambodia (WHO, 1994); El Salvador every year from 1985 to 1991 (PAHO, 1990; Guerra de Macedo, 1994); Lebanon in 1987 (Hammad, 1998), Uganda in 1985 (Peters, 1996), Sudan in 1989, 1994, 1995 and 1996 (CDC, 1995; Peters, 1996;  WHO, 1994); and the Philippines from 1993 to 1995 (Peters, 1996).

In Hay’s analysis, (Hay, 1990) of humanitarian cease-fires including immunization cease-fires, “corridors of tranquility” and other approaches he concludes that, by and large, these activities are ad-hoc measures proposed when humanitarian needs in a war zone become acute.  He further states that the process of negotiating such a cease-fire can have spill-over effects in terms of building trust among conflicting parties and that the “spirit of conciliation fostered by such cease-fires can permeate the final settlement of a conflict.”  His analysis also points to the important role that an interested third party could play (often the UN or concerned donor countries) in helping to broker the agreements often with the threat of economic or political sanction or financial incentives such as increased humanitarian aid.

Other HBP activities range from brief descriptions of preventive diplomacy actions in Bulgaria and Turkey (WHO, 1996), to peace-making activities such as joint training and cross-border surveillance in Central America (Guerra de Macedo, 1994).  Peacekeeping operations such as assisting in the demobilization, quartering and disarmament of troops were utilized in Angola (Zagaria and Arcadu, 1997) and several cases discuss rehabilitation of public health infrastructure in Mozambique (Mocumbi, 1996), Croatia (Balladelli, 1997) and El Salvador (Brentlinger et al, 1999).  Coordination of humanitarian efforts features prominently in the case of Haiti (WHO, 2000a) and Cambodia (Lanjouw et al, 1999). Peacebuilding efforts include decentralized cooperation efforts in the former Yugoslavia (WHO, 1999) and reintegration of health workers in Cambodia (WHO, 1994; Peters, 1996) and Croatia (Baladelli, 1997).  Efforts directed at promoting community-level reconciliation include experiences in Liberia with workshops and community development activities designed to promote mental health and ethnic tolerance (Peters, 1996) and the War and Health program’s experiences in Sri Lanka designed to assess mental health needs through a participatory, multiethnic approach (Peters, 1996).

Although the majority of HBP literature is descriptive in nature, two training manuals were located that are designed to prepare health workers for undertaking a HBP project. 

The first manual is the Health-to-Peace Handbook, developed by McMaster University and edited by Mary Anne Peters (1996).  The handbook provides a brief overview of the concept of HBP and the rationale for how health workers and health programs can serve as conduits for peace-building.  It also includes several important cautions about potential risks inherent in providing assistance in areas of conflict.  These precautions include that such humanitarian cease-fires may have a limited impact if they are not rooted in a larger peace process.  Risks include the possibility that one or both sides will use the cease-fires as propaganda for their moral superiority at the expense of the potential solidarity that could be gained from the cease-fire and further delay any eventual lasting peace process.  Finally, monitoring is essential to assure that one or more sides do not use the cease-fire as an opportunity to re-arm, reposition forces or smuggle in weapons or other supplies.  The bulk of the manual presents anecdotes about six different HBP initiatives (humanitarian cease-fires in Afghanistan and the Philippines); mental health initiatives in Liberia and Sri Lanka; the WHO HEDIP program; lessons learned by Medecins sans Frontieres; and a description of ways health professionals can influence public opinion and international laws affecting weapons of mass destruction (Peters, 1996). The authors present the results of the 1991 Centre for Days of Peace conference on cease-fires as well as necessary ingredients of a successful humanitarian cease-fire.  These ingredients include:

§         The need for finding common ground among combatants

§         The need for impartiality and transparency, meaning that the benefits of the humanitarian aid should be delivered equally to all and all transactions should be impartial and agreed to beforehand

§         Understanding and respect for indigenous cultures should be the modus operandi in the delivery of humanitarian aid

§         Trust and communication are necessary to ensure the success of the operation

§         Combatants must have confidence in the trustworthiness and impartiality of the implementing organizations.  This may be the reason why WHO and UNICEF have so often been involved in such initiatives

§         International pressure in terms of public opinion (and perhaps threat of legal or economic sanctions) may be essential in convincing parties to agree to the cease-fire

§         A clear legal framework spelling out references to international laws and agreements

§         Community participation including local leadership, women and children, and the military is necessary in order to realize the true peacebuilding potential of the cease-fire.

§         Education and communication including media campaigns can help maximize the confidence-building impact of the cease-fire.

§         Standards and monitoring are crucial in order to maintain compliance with the agreements and to ensure that sides do not use the opportunity to re-arm.

The Handbook ends with a brief discussion on conflict analysis, peacebuilding, project planning and a brief list of resources in peacebuilding, human rights, reconstruction of health systems, and other HBP project descriptions.

The information presented in the Handbook is a step in the right direction in terms of practical guidance.  However, it is not clear in the majority of cases (with the possible exception of Central America) to what extent the announcement of a cease-fire for immunization or delivery of humanitarian assistance actually served to further promote the official peace process.

Paula Gutlove’s (2000) Health as a Bridge for Peace training manual is an excellent complement to the Health-to-Peach Handbook.  The examples presented in the manual are much less varied and detailed, but the framework for how HBP can function (in terms of conflict theory) is more developed than in the Handbook. It provides concrete information on combining initiatives such as peacekeeping, famine relief, public health, and other humanitarian programs with conflict management.  The Briefing Manual describes such “integrated action” as a way of bringing people together through concrete incentives for cooperation.  Conflict management is emphasized as an effective strategy for brokering peace and community reconciliation.  A basic framework for conflict management is outlined, and examples of its practice are provided in two contexts:  the former Yugoslavia and the north Caucasus region.  A large section is dedicated to tools for developing a health bridge strategic approach.  In addition, skill-building exercises are provided in the areas of developing dialogue, active listening, mapping of the status of public health, generating options, strategic planning, and goal setting.  The Training Manual is meant to be a generic guide and should be adapted to specific circumstances.

Based on our assessment of the two training documents, it is clear that both can serve important functions within the limitations of their scope and content.  The Health-to-Peace Handbook by McMaster University provides a range of detailed examples of how health has been and may be used to broker peace in various country contexts and aid individuals and communities in the post-conflict recovery process, with the aim of rebuilding societal health and preventing future violence.  Lessons learned are also discussed.  However, unlike Gutlove’s manual, the Handbook provides only limited information on concrete tools for building or employing health-to-peace strategies, while training and skills development issues are not addressed.  In addition, while a major focus of the Handbook is on providing examples of health-to-peace initiatives, little evaluative information is included.  The authors acknowledge a dearth of evaluative research in this area, and dedicate a short section on conducting evaluation of health-to-peace initiatives and on indicators that may be important.

Two other important literature streams emerged from the literature review. First, documents on actions by international groups such as International Physicians for the Prevention of Nuclear War, the International Campaign to Ban Landmines, and others working to influence the international policy dialogue regarding weapons and the conduct of warfare (See WHO, 1997; IPPNW, 1997; Kaplan, 1999).  Second, a large body of literature has developed on the health, social, and psychological impact of warfare, complex humanitarian emergencies, and population displacements (Summerfield, 2000; Ugalde, et al, 2000; Toole and Waldman, 1997; Zwi et al, 1989 and 1996; Fitzsimmons and Whiteside, 1995).  Each of these sources has in some way enriched the HBP perspective and approach.  However, given the focus of this review on linkages between health and peace actions, particularly within the context of complex humanitarian emergencies in developing countries, these literature streams were not examined in depth as part of this review.

Finally, the literature review also revealed criticism of health to peace ideology (Macrae 1995, 1997, 1998 and Lanjouw, et al., 1999).  Critics of HBP ideology argue that mixing development and conflict resolution objectives with humanitarian objectives is likely to diminish the ethical basis of humanitarian interventions, which is derived from principles of neutrality and impartiality.  In this vein, relief aid is seen as becoming a form of political action, putting pressure on relief actors to take sides and make decisions about preferred outcomes.  Relief actions, then, may be looked upon as being partial to a particular side or warring party, and may be identified as a legitimate target for attack.