The Consultative Meeting was convened by the World Health Organization Division of Emergency and Humanitarian Action (WHO/EHA), as part of the Health as a Bridge for Peace project, sponsored by the Department for International Development of the United Kingdom. The main purpose of the project is to develop practical guidance on peace building skills for health professionals. The Consultative Meeting is part of the scope of work for the project. The meeting built upon earlier work undertaken by the World Health Organization's Task Force on Health in Development Policies, several international symposia, and regional initiatives most notably in Southern Africa, Central America, and Eastern Europe. (See Agenda in Appendix A).
The two-day meeting brought together 25 representatives of the World Health Organization, international organizations, academic institutions, NGOs, and bilateral agencies (see Appendix B). Facilitators included Dr. Louisa Chan of WHO/EHA, Dr. Rosalia Rodriguez-Garcia of the George Washington University Center for International Health (GWCIH), Dr. Judith Large of the University of Kent, and Dr. Tom Weiss of Brown University. The Foundation Merieux graciously offered its facilities for the meeting and lodging of participants.
2. A preliminary classification of types of Health as a Bridge for Peace activities and illustrative case studies
In order to provide a context for discussions on particular instances of health serving as a bridge for peace, the GWCIH presented a framework applying an epidemiological approach to the analysis of conflict and health as a bridge for peace actions. For purposes of discussion, three stages of conflict were considered: latent phase, violent conflict, and post conflict. Consequently three major types of health as a bridge for peace actions were also identified: promotion of health and peace, prevention/mitigation of violence, addressing inequities during conflicts and post conflict rehabilitation and peacebuilding.
Documented experiences suggest the following courses of action:
Strategic and creative ways of collecting, analyzing and using epidemiological data is seen as an important common thread throughout the different stages of conflict. This public health tool offers a powerful approach to influence policies which have an impact on violent conflicts.
One of the strategies of the ICRC campaign for banning landmines was to use health data to demonstrate that certain weapons have unacceptable and inhumane effects. The ICRC chose to focus not on the weapons technology itself (i.e. certain weapons are simply unethical) but rather to concentrate on the health effects of weapons technology (i.e. any weapon that purposefully leaves severe permanent disability by design is unacceptable). As the ICRC landmine campaign shows, in order to effect changes, it is necessary to activate data-to-policy link. In addition to good epidemiological data, it is also essential to have images to convince, to be credible vis-a-vis policy-makers, and to create a public constituency.
This presentation demonstrated means by which health professionals can influence and change policy through creative and strategic use of health data.
Finally, it was mentioned that health professionals must also be aware of the possibility of their work being manipulated. By simply reporting the health effects of certain weapons, we may inadvertently contribute to the research of new ways for weapons to injure or kill. Thus, just as in conflict situations, there is the potential for being manipulated. It is important to understand these risks in order to minimize and, if possible, to counteract them.
"Health as a Bridge for Peace" was coined in the early 1980s by the Pan American Health Organization (WHO/AMRO/PAHO) while developing a multi-country, multi-agency programme supported by the Ministers of Health of the Central American nations. The initiative was based on the principle that "shared health concerns can transcend political, economic, social and ethnic divisions among people and between nations."
The strategy utilized in Central America truly tested the thesis that health could serve as a bridge to understanding, cooperation, solidarity and peace within a reality marked by ideological differences and conflict. The initiative reinforced the technical cooperation among countries in that region as well as created a framework for external mobilization of resources and development of priority projects.
The details of the methodology developed during more than 10 years of regional experience and cooperation are essential as the basis for development and adaptation to practical programmes in other geographic areas.
The goal of the WHO health-to-peace initiative in the Eastern Slavonia region of Croatia is to facilitate the reintegration of the health sector of Eastern Slavonia into Croatia, according to the principles of the Erdut Agreement. Beginning in January 1996, WHO played the role of the principal mediator in health by chairing the Joint Implementation Committee (JIC) in health. Activities undertaken included bringing together Croat and Serb health workers for confidence building, joint technical analysis of the health situation, joint planning and implementation of health activities, and the administrative reintegration of the health sector. Specific activities included developing commissions on administrative reintegration, technical activities in mental health, physical rehabilitation and epidemiology, health research, organizing a sub-national immunization day against polio, and provision of essential drugs.
The strategy behind the initiative was to provide a safe space for dialogue on technical issues, creating the basis for mutual understanding and cooperation within the health sector. This included emphasizing the respect for both sides' roles as health professionals, and emphasizing their traditional neutrality and impartiality in situations of conflict. The case study presented preliminary evidence that the initiative has increased at least partially reciprocal acceptance of the two groups of health professionals, has partially increased the number of Serb and Croat health employees working together, and has begun to provide for more equal opportunities to the local Serb health workers.
Challenges include the fact that to date only a few Serb health professionals have received their contract to work under the Croatian administration, no Serb professionals have been selected for key positions in the health system, and only about 50 percent of the Serb population are covered by the Croatian National Insurance System.
The case study also highlighted operational issues for WHO, including:
The WHO experience in Angola centred on assistance in the disarmament, quartering, and demobilisation of soldiers from armies on both sides of the conflict. After the signing of the Lusaka protocol in 1994, WHO played an important role in the development and implementation of the health programme during quartering and demobilisation phases. Key activities included designing common protocols between groups, brokering arrangements for joint data collection activities, working with communities to develop public health programmes, training military health personnel, setting up health units in the quartering areas, development of an agreement for a joint medical team to classify disabilities, and supporting a legal basis for institutionalizing benefits to disabled war victims and demobilized soldiers.
Key lessons learned included:
3. Discussion on Concepts
This discussion focused on six thematic areas: the meaning of health as a bridge for peace, the use of data and information in influencing policy, the role of health professionals in situations of conflict, the role of WHO in promoting peace, the concept of health as neutral, and an analysis of stakeholders in Health as a Bridge for Peace. The main ideas of this discussion follows.
The Consultative meeting made an attempt to develop a definition for "Health as a bridge for Peace" to reflect the reality of present conflicts and the possibility of influencing them with health activities.
Further discussions also reflected concern over whether the proper role for health workers and organisations should be the promotion of peace or the promotion of health. In some circumstances it was perhaps not clear if certain types of actions would promote one at the expense of the other. Some even suggested that all health promotion could be interpreted as peace promotion and that all peace promotion could be interpreted as health promotion. Ultimately, participants suggested that as health professionals our priority should be health, but that we should be aware of the political realities we are working in, and should not only endeavour to Ado no harm but that we also have a responsibility to seek out creative opportunities to promote peace. In this sense, Health as a Bridge for Peace was said to reflect a spirit rather than a specific definition.
In all stages of conflict, reliable health data can be a powerful and convincing tool to move public opinion and can instigate policy change. Examples discussed included the lesson of the international campaign to ban land mines. Representatives from International Physicians to Prevent Nuclear War discussed how their organization used data and advocacy to facilitate the ratification of the atmospheric test ban treaty.
Although many of the case study experiences presented involved medical services and physicians, participants acknowledged the need to widen the discussion to consider all health professionals, especially given the potential role for health educators, policy makers and others to contribute to this process. The role of the health professional as the "healer" offers unique opportunities as well as responsibilities. This intimate relation with individuals and communities 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 in solidarity to address common collective concerns. At the same time the idea of the sanctity of the medical profession and the overriding ethical imperative of Adoing no harm@ underline our responsibilities for upholding the values of equity, the right to health, the protection of public health assets, and the promotion of peace.
The specific role WHO can play in promoting peace were identified:
A brainstorming session on networking identified a wide group of possible advocates, stakeholders, and partners. These included:
Participants organized stakeholders into three basic categories: Top-level leadership including political decision-makers, business leaders, diplomatic community, Member States and donors; middle range leaders such as ethnic or religious leaders, academics, highly visible health professionals, and international organizations; and grassroots organizations such as groups of war victims, mothers, youth, NGOs, and other avenues of influencing public opinion.
4. Framework for Action
At each of these different levels, different types of actions are necessary. To influence top-level leaders, international agreements, accords, and credible leadership are necessary. It was also discussed that a grassroots movement may also trigger high-level leaders to recognize an issue (such as landmines). Two other elements were thought to be essential in mobilizing middle and grassroots level participation: information and the media. The data to policy link should be strengthened and targeted to influence public opinion through the use of the media.
Action plans were developed through small group discussions and feedback from facilitators. Each of the three groups was composed of WHO, NGO, and other personnel, representing a variety of geographic and technical affiliations and expertise. Each workgroup developed the action plan according to guidelines developed by the workshop facilitators and based on discussions during the first day of the Consultative Meeting. Action plans were presented to the plenary for discussion and endorsement. Summaries of the action plans appear below.
The action plan for enlarging the knowledge base was charged with identifying current gaps in knowledge, developing criteria for further research on health as a bridge for peace, discussing appropriate methodologies and mechanisms for the collection and analysis of information, and presenting a plan for sharing and disseminating lessons learned.
The main types of study proposed were:
Criteria for selecting which experiences to investigate include:
Finally, sharing and dissemination of experiences should take place within WHO through its consultative process, and through a policy framework looking at managerial, technical, and normative aspects of the lessons learned. The results of research should feed into advocacy, networking, institutional learning and skills development for health professionals, inside and outside of WHO.
Criteria for selecting which experiences to investigate include:
The action plan for institutional learning and individual skills development identified means by which lessons learned from health as a bridge for peace activities could be systematically identified, documented, analyzed and disseminated. It also suggested specific skills, knowledge, and mechanisms necessary to assimilate lessons learned from the field into the daily work of health professionals working in situations of conflict.
The group identified several mechanisms to institutionalize lessons learned. First, placing health as a bridge for peace within the policy framework for WHO, through the Renewal of Health for All process, and through WHO's constitutional review process. In addition, Health as a Bridge for Peace could be incorporated within specific programming areas, as it is within EHA's scope of work. This policy-level institutionalization should be accompanied by documentation explaining the policy and illustrating its applications in the field. Target groups for dissemination of this information include sensitizing and advocating for health as a bridge for peace within WHO headquarters, providing briefing materials, advocacy and other information to WHO country representatives, national health workers, and providing specific training materials to WHO staff, consultants, and health NGOs.
Through an analysis of case studies and discussion with those involved in such initiatives, the group identified specific skills that health professionals may need in order to take advantage of opportunities to promote peace. These include negotiation, problem-solving, situation analysis, fact-finding, coalition building, and conflict handling training. These skills should be presented within the context of lessons learned from the field, both positive and negative. The content of specific training would differ according to the target audience. For example, materials might include a core set of briefing materials for advocacy and sensitization. Other more specific materials for health personnel working in situations of conflict could include in-service training materials on negotiation, conflict resolution and other skills, checklists, and summary information on international human rights and humanitarian law.
Finally, as one mechanism to institutionalize the study and documentation of experiences, field experiences can be collected through the use of a Ablack box@ similar to an airplane flight recorder. This involves the systematic reporting of events related to health as a bridge for peace, allowing for evaluation and appraisal of initiatives, and facilitate dissemination of new tools, techniques, and lessons learned. It was suggested that the black box reside within WHO headquarters in Geneva.
The action plan includes a preliminary mission statement on health as a bridge for peace (see Appendix C). The advocacy message should be shaped according to each of the major target audiences: members of WHO's governing bodies, governments at large, the media, and the public at large. Specific messages should reflect the differing interests of the target audiences. For example, governments will be more interested in their image and the impact of certain actions on their own citizens, while the public at large will be more sensitive to individual suffering and risks. Other target audiences might include military health personnel, and ex-military leaders. The latter will be particularly important in counteracting the messages of the military and weapons manufacturers. Messages should be formulated looking at the data to policy link, focusing on the health impact of violence, weapons and war, and should be both realistic and credible. The plan also indicated that it is unrealistic to expect to compete with other types of lobbying without the use of professional communications specialists to present these messages.
Partners with which to network may range from all those interested to a selective group of targeted partners, which include collaborating centres, NGOs, and other types of groups. Mechanisms for networking and advocacy could include a Health as a Bridge for Peace advocacy task force composed of high-level political and health leaders from around the world. A technical working group might also be established to develop messages and implement recommendations of the task force. Monitoring impact could include surveying the media for mentions of the key messages, conducting polls, looking at international conventions which include health as a bridge for peace, and others.
5. Recommendations for next steps
Participants suggested the following strategy to prioritize actions and ensure follow-up to the Consultative Meeting.
The Health as a Bridge for Peace effort should be housed within WHO
It was agreed that WHO is the appropriate Organization to ground and consolidate this effort. Within WHO, EHA should serve as a focal point for the process of investigation and institutionalization of health as a bridge for peace. It was also acknowledged that in order to do this, WHO would need to undertake a process of learning and growing. This might entail confronting risks, and institutional barriers. Therefore the endeavor should be approached with both healthy skepticism and humility.
The Health as a Bridge for Peace initiative should bring together WHO with other partners
It was agreed that the initiative should not operate in a vacuum. WHO cannot implement this initiative alone, and should draw on its partners and collaborators. Participation and shared responsibilities will also be important to the fulfillment of the Plan of Action.
Leadership and coordination mechanisms may include a task force and/or working group
Suggestions for future leadership mechanisms include establishment of a working group that might include participants of this Consultative Meeting. In addition the idea of a Task Force created of higher-level policy, technical and political figures would be discussed in order to move forward the agenda of Health as a Bridge for Peace at the highest political levels.
Identification of knowledge gaps - documenting field experiences
Group consensus was reached on the importance of the meeting and its excellent organization which allowed participants to share ideas and debate issues in a spirit of collegiality. Follow-up actions include a conference report to be completed within one month of the Consultative Meeting and distributed to all participants. A second consultative meeting was agreed to be scheduled after six months in order to review the implementation of the action plans.
Chair Dr F. Bassani Facilitators Dr J. Large, Dr R. Rodriguez-Garcia, Dr T. Weiss, Dr L. Chan Rapporteurs Dr J. Large and Dr L. Chan
Thursday, 30 October
0900 Introduction: Objectives of HBP Consultative Meeting, Dr F. Bassani
0930 Presentation and Discussion: HBP Working Definitions, Facilitators: Dr J. Large; Dr R. Rodriguez-Garcia
1030 Coffee Break 1045 Presentation and Discussion: Dynamics and Cycle of Conflict, Facilitators: Dr J. Large; Dr L. Chan
1400 Discussion on Health Interventions at Different Phases of the Conflict Cycle, Presenter: Mr J. Macinko
1530 Coffee Break
1545 Case Presentations: Lessons Learned: Limitations and Possibilities of Peacebuilding through Health, Presenters: Dr R. Coupland; Dr P. Balladelli; Dr N. Zagaria
Friday, 31 October
0900 Discussion: Stakeholders, Sensitization and Advocacy, Facilitator: Dr J. Large
1030 Coffee Break
1045 Plan of Action: Group sessions (A. Further Research and Case Studies,Facilitator: Dr R. Rodriguez-Garcia B. Active Skills Training, Facilitator: Dr J. Large C. Networking and Advocacy, Facilitator: Dr H. Siem)
1400 Presentation and Discussion of Action Plans
1600 Closure, Dr F. Bassani
B. List of Participants
C. Health as a Bridge for Peace Mission Statement
The Constitution of WHO states: AThe health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States. Thus underlining the inextricable link between health and peace, clearly such a link is mutually interdependent health being essential for peace and peace being essential for attainment of health for all.
The 20th century has been the most violent in human history. In addition to two major world wars, 250 armed conflicts have taken place in all parts of the world with over 109 million casualties, more than half being civilians. The trends in more recent conflicts are a higher toll of civilian deaths.
A culture of violence driven by insecurity, intolerance, inequity and poverty, coupled with easy access to lethal arms seems to be spreading and has profound adverse effects on health in the affected countries. In addition to huge loss of human life and suffering, there is a major drain on the already scarce resources of the health sector, leading to serious deterioration in the quality of outreach of health services.
The ravages of mass violence have claimed children and women among their victims, leaving long-lasting scars on the society, retarding their recovery. There have been other adverse social implications on this culture, too. In many countries, violence and insecurity have spurred an arms race, and inordinate increase in military expenditures at the cost of the social sector investment affecting health, education of human resource, poverty and economic decline have often led to high indebtedness which further enhances poverty and dependency, setting up a vicious cycle leading to social unrest and political instability, further conducing to conflict and ultimate health consequences.
The Health as a Bridge for Peace initiative calls upon WHO and its partners to recognise responsibility to create opportunities for peace. To this end, we need: