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vi Archives of Iranian Medicine, Volume 23, Number 4 (Suppl 1) April 2020 Table of Contents

• Original Articles Secular Trends of Global Burden of Violence, 1990–2015: In Spite of Successes, Women and Children S1 Are Highly Affected in Low- and the Middle-Income Countries Alireza Salehi, Hossein Molavi Vardanjani

The Past Victim, the Future Abuser S6 Ali Firoozabadi

Health Care Utilization and Expenditure in War Survivors S9 Batool Mousavi, Farzaneh Maftoon, Mohammadreza Soroush, Kazem Mohammad, Reza Majdzadeh

• Review Article

Impact of War on Fertility and Infertility S16 Ayeh Bolouki, Fatemeh Zal

Peace, Health, and Sustainable Development in the Middle East S23 Amirhossein Takian, Golnaz Rajaeieh

Peace through Health and Medical Education: First Steps in Inclination of Healthcare Workers S27 Toward Conflict-Preventive Activities Erfan Taherifard, Hossein Molavi Vardanjani, Neil Arya, Alireza Salehi

• Mini Review

Human Casualties and War: Results of a National Epidemiologic Survey in Iran S33 Mohammadreza Soroush, Zohreh Ganjparvar, Batool Mousavi

• Opinion

“War Epidemiology” Versus “Peace Epidemiology”: A Personal View S38 Mohsen Rezaeian

Provision of Peace and Right to Health through Sanctions: Threats and Opportunities S43 Reihaneh Dastafkan, Hadi Salehi, Mohammad Mehdi Hooshmand

Rights of Citizens and the Classification of People into Believer (Mu’min) and Non-Believer (Kafir) S49 Seyyed Mostafa Mohaghegh Damad

The Health Consequences of Economic Sanctions: Call for Health Diplomacy and International S51 Collaboration Vahid Yazdi-Feyzabadi, Mostafa Amini-Rarani, Sajad Delavari

Archives of Iranian Medicine, Volume 23, Number 4 (Suppl 1) April 2020 vii Table of Contents

• Report Conception of “Peace through Health” in the “Middle East” Region: Report of the International S54 Congress on Health for Peace, Shiraz, Iran Hossein Molavi Vardanjani, Alireza Salehi, Faramarz Aminlari

• Meeting Report Educating Health Science Students About Peace through Health Topic; A Panel Discussion S60 Mitra Amini, Mesbah Shams, Mohammad Bagher Khosravi, Anneli Milen, Neil Arya

viii Archives of Iranian Medicine, Volume 23, Number 4 (Suppl 1) April 2020 ARCHIVES OF Arch Iran Med. April 2020;23(4 Suppl 1):S1-S5 IRANIAN doi 10.34172/aim.2020.s1 http://www.aimjournal.ir MEDICINE

Open Original Article Access Secular Trends of Global Burden of Violence, 1990–2015: In Spite of Successes, Women and Children Are Highly Affected in Low- and the Middle-Income Countries

Alireza Salehi, MD, MPH, PhD1; Hossein Molavi Vardanjani, PhD2*

1Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran 2MD/MPH Program, Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, Iran

Abstract Background: Violence is a challenging modern epidemic worldwide. Less evidence is available on the populations most affected by violence in recent decades. The aim of the study was to ecologically investigate temporal trends of the global burden of violence according to gender, age group, and socio-demographic development. Methods: Data on the age- and gender-specific rates of country-level disability adjusted life years (DALYs) attributable to different types of violence i.e. interpersonal violence (IV), and collective violence (CV) and legal interventions were retrieved from online database provided by the global burden of diseases project. Countries were categorized according to their socio-demographic index (SDI). Incidence rate ratio (IRR) per one year was estimated according to age groups, genders and SDI categories applying Poisson regression modeling. Results: The highest decrease of the DALYs attributable to IV was observed for the under-five-years age group and then for 5–14-years in both genders, globally. Considering the CV, estimated IRRs were significant only for the under-five-years age group, which was at 1.30 (95% CI: 1.20, 1.40, per 10 years) for girls and 1.29 (95% CI: 1.21, 1.39, per 10 years) for boys. Conclusion: The rate of DALYs due to IV has been more decreasing among women and children during the recent decades. By the next 10 years, the attributed DALYs to CV would increase up to 120%. Children, adolescents and women are highly affected by CV in countries with middle-low and middle social development in the recent decades. Keywords: Child, Interrupted time series analysis, Violence, Women Cite this article as: Salehi A, Molavi Vardanjani H. Secular trends of global burden of violence, 1990–2015: in spite of successes, women and children are highly affected in low- and the middle-income countries. Arch Iran Med. 2020;23(4 suppl 1):S1–S5. doi: 10.34172/aim.2020.s1.

Received: February 25, 2019, Accepted: October 12, 2019, ePublished: April 1, 2020

Introduction the most affected or high risk groups is scarce, mainly due Violence is a challenging modern epidemic and one of to lack of qualified primary data.2,9,10 the most important causes of disability adjusted life years The global burden of diseases (GBD) project provides (DALYs).1,2 The relative burden of violence would be the best of available data on the burden of some major types expected to significantly increase in the future years.3 of violence for almost all countries for recent decades.1 Various preventive programs have been introduced Therefore, there is now a possibility to ecologically during recent decades to address various types of investigate the temporal trends of the burden of violence in violence.3-6 In addition to national prevention and control terms of DALYs attributed to the major types of violence programs, several global collaborations and programs have in different subpopulations. It would provide evidence on been designed and implemented to prevent and control the most affected subpopulations and high risk groups, to violence.3 be considered as target populations of the future violence Despite the national and international efforts, the preventive programs. burden of some types of violence have been increasing This study aims to investigate the temporal trends of during recent decades.1,2,7 Consequently, promotion of the global burden of violence in different subpopulations current violence preventive and interventional public according to gender, age group, and socio-demographic health programs is highly appreciated.3 However, effective development. We reanalyzed the data provided by the promotion of any public health program has to be founded GBD project. on a robust knowledge of the current situation.8 The most recent situation analysis of the epidemic of Materials and Methods violence is “the global status report on violence prevention This study was a secondary data analysis of available data 2014”, which mainly focuses on the availability of data, from the official online database of the GBD project preventive services and programs.3 However, evidence on (Supplementary file 1).11 Temporal trends of burden of

*Corresponding Author: Hossein Molavi Vardanjani, PhD; Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, Iran. Email: [email protected] Salehi and Molavi Vardanjani violence were analyzed. Results Age- and gender-specific rates of DALYs (per 100 000 Interpersonal Violence populations) attributed to each type of violence, including The overall estimated IRR for calendar year was at 0.989 interpersonal violence (IV including dating, domestic, (95% CI: 0.988, 0.991). The IRR was estimated at 0.968 and sexual violence and stalking), and violence due to (95% CI: 0.946, 0.991) for SDI (High SDI was defined as collective and legal interventions (CV) were retrieved reference category) and at 3.21 (95% CI: 2.99, 3.46) for by country. The definition of IV was based according to gender (Female was defined as reference gender). Effect the WHO as violence between individuals but not large of the SDI was different between males and females (P = groups.12 Collective and legal interventions, hereafter 0.001). As a result of the effect of SDI on the burden of IV, collective violence (CV), was also defined according to the the rate of DALYs was decreasing across different levels of WHO as violence committed by large groups or violence socio-demographic development. due to armed war.12,13 Almost all estimated IRRs for age groups to predict the As social development of countries is a major determinant rate of DALYs were statistically significant and ranged from of violence, stratified analyses were done according to 0.4 (95% CI: 0.39, 0.42) for 5–14 years to 3.22 (95% CI: different levels of social development. In this study, socio- 3.15, 3.28) for 20–24 years compared to under 5 years. demographic index (SDI) was considered as a measure of Estimated IRR were increasing up to 25 years and then social development. Data on SDI were also retrieved from started to decline with increasing age. It was estimated at the GBD project database. SDI is a combination measure 0.46 (95% CI: 0.45, 0.48) for the 70+ year population. of the per capita income, the highest degree of education Considering these results, the trends of age- and gender- which has been completed by the population and the specific DALYs rates were separately analyzed according total fertility rate in a region. It is a measure of socio- to the level of socio-demographic development (Table 1). demographic development of a geographic region which According to the trend analyses, the crude rate of DALYs varies from zero to one, representing the lowest and highest rate was decreasing across different SDI categories as well as socio-demographic development, respectively.14 SDI most of age groups. From a global perspective, the highest values were categorized according to the recommended decrease was observed for the under-five-years age group categorization by the GBD collaboration. and then for 5–14-years in both genders. Considering Retrieved data were reorganized in a long shape dataset socio-demographic development, the highest decreases which consisted of six variables including “type of violence” were estimated for countries with middle and high-middle (i.e. interpersonal violence, and CV), “age group” (under socio-demographic development for the under-five-years 5 years, 5-14 years, 15–19, 20–24, 25–29, 30–34, 35–39, age group. The lowest decrease was estimated for countries 40–44, 45–49, 50–69, and older than 70 years), gender, with low SDI. “calendar year” (1990, 1995, 2000, 2005, 2010, and 2015), “socio-demographic category” (categorized as high, Collective Violence and Legal Interventions high-middle, middle, middle-low, and low), “crude rate The overall estimated IRR for calendar year was at 1.02 of DALYs per 100 000 population” and “age-standardized (95% CI: 1.01, 1.03). The IRR was estimated at 3.20 rate of DALYs per 100 000 population”. (95% CI: 3.18, 3.22) for SDI (High SDI was defined Considering two different types of violence, two Poisson as reference category) and at 3.53 (95% CI: 3.49, 3.58) regressions were fitted, as violence type-specific cured for gender (Female was defined as reference gender). The rate was considered as dependent variable, and calendar effect of the SDI was different between males and females year, SDI, gender, age group and their interaction terms (P = 0.019). As a result of the effect of SDI on the burden were entered into the model as independent variables. of this type of violence, rate of DALYs was rising across Considering the significance of interaction term in the different levels of socio-demographic development except abovementioned models, stratified analysis was applied. for high and high-middle SDI categories. Stratification was done according to the age groups, Almost all estimated IRRs for age groups to predict rate gender and SDI categories. Consequently, stratum- of DALYs were statistically significant and ranged from specific Poisson regressions were fitted considering types 0.53 (95% CI: 0.51, 0.55) for both 70+ and 5–14 years, of violence. To estimate the overall slope of each of the to 2.68 (95% CI: 2.63, 2.73) for 20–24 years compared stratum-specific trend lines, “calendar year” was defined to the under 5-years group. Estimated IRR were increasing as the only predictor variable in each model. Estimated up to 25 years and then started to decline with increasing incidence rate ratios (IRRs) and 95% confidence intervals age. It was estimated at 0.91 (95% CI: 0.88, 0.93) for the (CIs) were estimated. Annual percent change (APC) 45–49 year population. Again, considering the significant was calculated using APC = (1-IRR)*100. Statistically interactions of age, gender and SDI, the trends of age- significant APCs and their 95% CI were reported. Data and gender-specific DALYs rates were separately analyzed analysis was done using Stata software (StataCorp LP. according to socio-demographic development (Table 2). USA, version 11.2). The only significant percent changes at the global level

S2 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 Trends of the Global Burden of Violence

Table 1. Percent Change (Per 10 Years)* of DALYs Rate Attributed to Interpersonal Violence, 1990–2015, According to the SDI and Gender

Age (y) Gender L-SDI LM-SDI M-SDI HM-SDI H-SDI Global M -0.15 (0.21, 0.09) -0.32 (0.39, 0.26) -0.47 (0.53, 0.4) -0.43 (0.49, 0.38) -0.15 (0.22, 0.08) -0.34 (0.41, 0.38) <5 F -0.15 (0.21, 0.09) -0.26 (0.34, 0.21) -0.50 (0.60, 0.47) -0.48 (0.54, 0.42) -0.19 (0.25, 0.11) -0.38 (0.44, 0.31) M NS NS -0.20 (0.28, 0.12) -0.30 (0.37, 0.22) -0.23 (0.34, 0.12) -0.20 (0.29, 0.18) 5–14 F NS -0.15 (0.28, 0.02) -0.24 (0.34, 0.14) -0.30 (0.40, 0.20) -0.24 (0.36, 0.11) -0.24 (0.34, 0.13) M NS NS 0.08 (0.04, 0.1)$ -0.10 (0.13, 0.08) -0.27 (0.31, 0.23) -0.06 (0.09, 0.02) 15–19 F -0.09 (0.18, 0.02) -0.09 (0.17, 0.02) NS -0.15 (0.22, 0. 09) -0.26 (0.34, 0.20) -0.13 (0.20, 0.06) M NS 0.05 (0.01, 0.08) 0.05 (0.01, 0.08) -0.13 (0.15, 0.11) -0.21 (0.24, 0.18) -0.07 (0.09, 0.03) 20–24 F -0.12 (0.19, 0.06) -0.08 (0.14, 0.01) -0.13 (0.20, 0.05) -0.20 (0.25, 0.14) -0.21 (0.26, 0.15) -0.14 (0.20, 0.08) M NS NS NS -0.14 (0.16, 0.12) -0.19 (0.22, 0.16) -0.07 (0.09, 0.05) 25–29 F -0.11 (0.18, 0.05) -0.08 (0.15, 0.02) -0.09 (0.16, 0.02) -0.20 (0.25, 0.13) -0.20 (0.25, 0.13) -0.14 (0.20, 0.08) M NS NS NS -0.15 (0.17, 0.12) -0.21 (0.23, 0.17) -0.08 (0.11, 0.05) 30–34 F -0.11 (0.17, 0.03) -0.09 (0.17, 0.02) -0.13 (0.21, 0.05) -0.23 (0.30, 0.17) -0.20 (0.26, 0.14) -0.18 (0.24, 0.11) M NS NS NS -0.17 (0.20, 0.14) -0.23 (0.27, 0.20) -0.10 (0.14, 0.07) 35–39 F NS -0.09 (0.17, 0.03) -0.12 (0.20, 0.05) -0.24 (0.31, 0.18) -0.22 (0.28, 0.16) -0.18 (0.25, 0.11) M NS NS NS -0.20 (0.23, 0.17) -0.22 (0.26, 0.19) -0.13 (0.17, 0.10) 40–44 F NS -0.11 (0.18, 0.03) -0.13 (0.22, 0.05) -0.24 (0.31, 0.16) -0.22 (0.28, 0.16) -0.20 (0.27, 0.12) M NS -0.07 (0.11, 0.02) -0.08 (0.12, 0.04) -0.22 (0.26, 0.18) -0.16 (0.20, 0.12) -0.13 (0.17, 0.09) 45–49 F NS -0.12 (0.19, 0.04) -0.12 (0.21, 0.02) -0.23 (0.31, 0.15) -0.16 (0.22, 0.09) -0.17 (0.24, 0.08) M 0.07 (0.02, 0.12) NS NS -0.15 (0.22, 0.08) -0.13 (0.18, 0.07) -0.10 (0.15, 0.05) 50–69 F NS NS NS -0.17 (0.21, 0.12) -0.17 (0.25, 0.08) NS M 0.15 (0.04, 0.22) NS NS -0.24 (0.34, 0.14) NS NS +70 F NS NS NS -0.47 (0.52, 0.41) NS NS M, Male; F, Female; NS, Not significant at 0.05 alpha level; SDI, socio-demographic index; L, low; LM, middle-low; M, middle; MH, middle-high; H, high. * Percent change per 10 years was reported. In cases of decreasing trends, percent change was reported as a negative number (i.e., -percent change). $ Bolded fonts depict an increasing trend.

(per 10 years) were estimated for the under-five-years age been decreasing, even if the current situation continues, group which was at 0.3 (95% CI: 0.2, 0.4) for girls and we will have to wait for at least 10 years to reduce the 0.29 (95% CI: 0.21, 0.39) for boys. This increasing trend current DALYs down to around 90% as IRR per year was was observed in spite of the decreasing trend in high, estimated at 0.989 (95% CI: 0.988, 0.991). In case of CV, high-middle and low SDI countries. It was mainly due the situation is worsening as estimated IRR per year was to increasing trends in the middle and middle-low SDI at 1.02. It means that DALYs due to this type of violence countries. Although an increasing trend of rate of DALYs would increase up to 120% by the next 10 years. These in countries with middle and middle-low SDI was observed findings may be interpreted as a failure or insufficiency across all age groups, the trends were not statistically of the currently implemented global violence preventive significant at 0.05 in several age groups. Age- and gender- programs.3 However, this interpretation is from a global specific trends were more decreasing in countries with low point of view, not the individual countries. In other words, SDI compared with countries with high and high-middle the concept of ecological fallacy must be kept in mind in SDI (Table 2). order to interpret these results appropriately.14 Our findings show that in most age groups across Discussion different social development strata, the burden of In this study we showed that the rates of DALY attributed interpersonal violence was decreasing more among to IV have been consistently decreasing across different women. It may be evidence of greater effectiveness of social development categories for 1990–2015, except for violence preventive programs which have aimed to reduce some age groups. However, the trend of DALYs due to CV different types of gender-related violence such as intimate has been decreasing in countries with high, high-middle partner violence.15-17 The higher level of public demands and low social development and increasing in countries to reduce gender-related violence may be a probable cause with middle and middle-low development (Such as Iraq of this finding.18,19 A more decreasing trend was observed and Syria). We also showed that the global trends of among children. DALYs rate attributed to IV were more decreasing among According to the study results on the trends of IV, the women and children, while the global trends of DALYs highest decreasing rates were observed among countries attributed to CV were increasing among children. with high and high-middle social development, while Although the trend of DALYs attributed to IV has this rate was the lowest for countries with low social

Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 S3 Salehi and Molavi Vardanjani

Table 2. Relative Change (Per 10 Years)* of DALYs Rate Attributed to Collective Violence and Legal Intervention, 1990–2015, According to the SDI and Gender

Age (y) Gender L-SDI LM-SDI M-SDI HM-SDI H-SDI Global M -0.70 (0.80, 0.60) 10.4 (10.3,10.5)$ 10.5 (10.3, 10.6) -0.51 (0.60, 0.42) -0.40 (0.60, 0.20) 0.29 (0.21, 0.39) <5 F -0.70 (0.80, 0.60) 10.4 (10.3, 10.5) 10.5 (10.4, 10.7) -0.50 (0.60, 0.40) -0.35 (0.60, 0.10) 0.30 (0.20, 0.40) M -0.60 (0.70, 0.50) NS NS -0.73 (0.89, 0.53) NS NS 5–14 F -0.70 (0.80, 0.60) NS 0.80 (0.60, 0.90) -0.74 (0.90, 0.50) NS NS M -0.60 (0.63, 0.58) 0.20 (0.10, 0.30) 10.4 (10.3, 10.5) -0.48 (0.59, 0.41) -0.32 (0.55, 0.25) NS 15–19 F -0.58 (0.62, 0.53) NS NS -0.50 (0.70, 0.40) -0.22 (0.51, 0.10) NS M -0.61 (0.63, 0.59) 0.20 (0.10, 0.30) 10.2 (10.1, 10.3) -0.49 (0.58, 0.38) -0.29 (0.37, 0.19) NS 20–24 F -0.55 (0.60, 0.51) 0.20 (0.02, 0.40) NS -0.40 (0.60, 0.21) -0.25 (0.51, 0.14) NS M -0.63 (0.65, 0.61) 0.16 (0.10, 0.24) NS -0.51 (0.62, 0.40) -0.35 (0.54, 0.16) NS 25–29 F -0.48 (0.53, 0.43) NS NS -0.30 (0.40, 0.11) NS NS M -0.61 (0.63, 0.59) 0.10 (0.05, 0.15) NS -0.53 (0.57, 0.38) -0.30 (0.53, 0.10) NS 30–34 F -0.45 (0.50, 0.40) NS NS -0.20 (0.39, 0.11) NS NS M -0.55 (0.58, 0.53) 0.10 (0.01, 0.20) 0.78 (0.69, 0.91) -0.52 (0.62, 0.43) -0.30 (0.54, 0.13) NS 35–39 F -0.48 (0.53, 0.43) NS NS -0.28 (0.35, 0.13) NS NS M -0.45 (0.48, 0.43) NS 0.62 (0.53, 0.73) -0.40 (0.52, 0.32) -0.22 (0.43, 0.14) NS 40–44 F -0.48 (0.53, 0.43) NS 0.68 (0.54, 0.89) -0.41 (0.52, 0.20) NS NS M -0.30 (0.33, 0.27) 0.13 (0.01, 0.20) 0.62 (0.53, 0.68) -0.30 (0.40, 0.20) NS NS 45–49 F -0.44 (0.49, 0.40) NS 0.71 (0.41, 0.92) -0.40 (0.50, 0.20) NS NS M -0.18 (0.22, 0.15) NS 0.64 (0.44, 0.75) -0.23 (0.33, 0.12) -0.25 (0.40, 0.15) NS 50–69 F -0.44 (0.50, 0.38) 0.20 (0.10, 0.30) 0.60 (0.30, 0.80) -0.29 (0.53, 0.11) NS NS M -0.27 (0.32, 0.22) NS 0.20 (0.11, 0.40) NS NS NS +70 F -0.55 (0.61, 0.49) NS NS NS NS NS M, Male; F, Female; NS, Not significant at 0.05 alpha level; SDI, socio-demographic index; L, low; LM, middle-low; M, middle; MH, middle-high; H, high. * Percent change per 10 years was reported. In cases of decreasing trends, percent change was reported as a negative number (i.e., -percent change). $ Bolded fonts depict an increasing trend. development. There is a crucial point which may be helpful This study had an ecological design, and therefore, its in appropriate interpretation of these results, as quality of results should not be interpreted on the level of individual available data for countries with lower social development countries. Violence control and prevention programs hold may be questionable.3,5,20,21 However, as the prevention different ranks among national priorities according to and control of IV is a public demand in countries with socio-demographic development. It could be considered as higher social development, while it may be a neglected a strong confounder and/or interacting factor. To address issue by population of countries with lower development, this issue, stratified trend analyses were done according violence preventive programs in these counties were to socio-demographic development index. Despite this, superior compared with less developed countries.6,22,23 a residual confounding effect was unavoidable due to the In addition, some forms of violence against women are ecological nature of the study. Although the data provided supported by cultural and religious norms in regions by the GBD project collaboration has some shortages, it with lower social development or conservative and male- may be the best of the available data on the burden of dominated settings.24 Accordingly, more international diseases in a global perspective.29 support is needed for control and prevention of IV in less In conclusion, global burden of interpersonal violence developed countries. has been more decreasing among women and children. Although CV may have been considered as a masculinized By the next 10 years, the global burden of CV and legal issue, according to the study results, children, adolescents interventions would increase up to 120%, if the current and women are highly affected by these types of violence, situation continues. Children, adolescents and women are as the trends of the burden of CV showed the highest highly affected by CV in countries with middle-low and increase for children and adolescents. This finding is in middle social development. line with previous reports,25,26 and may be also a result of institutionalized violence in such settings.27 In addition, Authors’ Contribution in female population, the trends were increasing across HMV designed the study. Data collection and data analysis were performed by HMV; AS collaborated in data analysis. HMV wrote most age groups. Accordingly, there is a need for adopted the first draft of the manuscript. AS and HMV revised the manuscript. violence preventive programs focusing on the prevention and control of violence victimization among children, Conflict of Interest Disclosures adolescents and women.28 None.

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Ethical Statement the social & Behavioral sciences. Vol 6. New York: Elsevier; This study was a secondary data analysis and no ethical issue was 2001:4027-30. applicable. 15. Patrick JM, Ugwu AN. Culture and gender-related violence against women in Ogoni ethnic nationality in Nigeria: Supplementary Materials implications for adult education. Gender and Behaviour. Data are available in Supplementary file 1. 2013;11(2):5804-11. 16. Alldred P, Biglia B. Gender-Related Violence and Young Acknowledgments People: An Overview of Italian, Irish, Spanish, UK and EU We would like to thank the GBD Project team. Legislation. Child Soc. 2015;29(6):662-75. 17. Langhinrichsen-Rohling J. Controversies involving gender References and intimate partner violence in the United States. Sex Roles. 1. Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, 2010;62(3-4):179-93. Mullany EC, et al. The global burden of injury: incidence, 18. Bott S, Morrison A, Ellsberg M. 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Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 S5 ARCHIVES OF Arch Iran Med. April 2020;23(4 Suppl 1):S6-S8 IRANIAN doi 10.34172/aim.2020.s2 http://www.aimjournal.ir MEDICINE

Open Original Article Access The Past Victim, the Future Abuser

Ali Firoozabadi, MD1,2*

1Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran 2Associate Professor of Psychiatry, Hafez Hospital, Department of Psychiatry, Shiraz University of Medical Sciences, Shiraz, Iran

Abstract Background: Childhood trauma exerts a significant effect on psychological life of people. It is a ubiquitous phenomenon. We face a social epidemic with serious consequences that shatter the life of survivors. Victimization in early years of life entraps the individuals in the victim-rescuer-abuser triangle. Many perpetrators and criminals have had history of childhood abuse. The main objective of this study was the assessment of patients with a history of child abuse who behaved in abusive manner in adulthood. Methods: By reviewing the files of 3694 patients referred to my outpatient private clinic, I tried to gather data to answer the questions related to this study including history of abuse, victimization, substance abuse, and the percent of patients who were involved in abusive behaviors in adulthood. Results: In total, 1075 patients reported a history of some abuse during childhood (29.10%). Of them, 19.44% (total = 209, 78 men and 131 women) behaved as an abuser for most of their life. The prevalence of substance abuse in people with history of abuse was 36.6% compared to 28.36% in those without. The prevalence of acting as an abuser and perpetrator in adult life was 27.5%, 19.5%, 18.4% and 11.11% among the divorced, married, single and widowed respectively. Conclusion: This preliminary study showed that a significant number of patients with history of childhood abuse involved in abusive behavior and victimization of others in adulthood. Paying attention to this issue by mental health practitioners and policy makers can prevent the intergenerational transmission of abuse and development of a more peaceful society. Keywords: Child abuse, Iran, Shiraz, Trauma, Victim Cite this article as: Firoozabadi A. The past victim, the future abuser. Arch Iran Med. 2020;23(4 suppl 1):S6–S8. doi: 10.34172/ aim.2020.s2.

Received: February 25, 2019, Accepted: October 12, 2019, ePublished: April 1, 2020

Introduction such behaviors is to overcome the stresses of past trauma Trauma is a widespread and ubiquitous phenomenon and rewrite early scenarios with a more tolerable ending. in our world that affects people in different and diverse As a victim, children expect someone to come and help ways. People in some countries have been suffering from them. This rescuer may be a real person or represented by continuous turmoil and exhaustive conflicts. Physical and a fantasy figure in the victim’s mind. Also, he/she cannot sexual abuse are constant parts of life in these areas. Also, express his/her anger at the perpetrator. He/she is too weak trauma has not been rare in times of tranquility at all. A to defend directly. Anger and hate accumulate in their national survey, conducted by phone, of 2000 randomly mind and wait for appropriate time to be expressed. The selected individuals, aged 10–16, found that one half of triangular model introduced by Karpman10 can be applied the boys and one third of the girls had been subjected to to describe the behavior of such individuals who are trying some form of violent victimization.1 Russel found that to gain mastery over past traumatic experiences. However, the prevalence of sexual abuse in girls before the age of without proper insight, such efforts are doomed to fail. 18 was 38% and the prevalence of incest was 16 %.2 As They play the previous roles of victim, abuser (persecutor) Howell mentioned, “… these rates might push expected and rescuer again and again in their life. Such behavior normal personality structure into the realm of what one is expressed in several psychopathological conditions such might call the pathological normal”.3 Re-enactment of as dissociative disorders, borderline personality, substance victimization is a major cause of violence.4 The association abuse disorders, mood disorders, eating disorders and between childhood abuse and subsequent victimization somatic symptom disorders. In search for an environment of others has been found in many studies.5-9 Most child capable of satisfying her/his needs, she/he involves in maltreatment occurs at home. About 80% of abusers blind behaviors hoping to get a different result this time. are parents.9 Some people bear the heavy weight of their Among these three roles, the role of persecutor (abuser) traumatic past on their shoulders. These experiences has a significant effect on reproduction of new abusers influence their behavior unconsciously. It seems that and continuation of victimization of people in the society. they have had no choice other than obeying the forces In this study, through the review of the past history of that channel them towards certain behaviors. The aim of 3694 psychiatric outpatients, I tried to respond to this

*Corresponding Author: Ali Firoozabadi, MD; Hafez Hospital, Department of Psychiatry, Shiraz University of Medical Sciences, Shiraz, Iran. Email: [email protected] The Past Victim, the Future Abuser question: what percent of the patients who were victimized and 11.11%, respectively. In patients with history of abuse, physically, sexually or neglected in the childhood, act as an 17.5% reported loss of one or two parents before the age abuser in adulthood? The triangle is not static and the role of 11, whereas the prevalence of parental loss before the one plays is not fixed. However, I focused on the dominant age of 11 was 6.22% in the patients without history of role in the life history of each patient. abuse.

Patients and Methods Discussion The electronic files of 3694 patients (2296 women and This preliminary study shows that a remarkable number 1398 men) who referred to my private clinic in the last of patients with history of abuse in their childhood tend two years were reviewed. By abuser patient, I mean an to behave as abusers in adulthood. As Miller mentioned, individual who behaves predominantly as abuser in it seems that evil is re-produced in each new generation. interpersonal relationships. Patients who acted periodically She argues that the destructive behavior of people is the in the abuser role were excluded. result of experience of cruelty at the beginning of their own life. She points out the life of a number of tyrants and Results authoritarian leaders such as Adolf Hitler, Milosevic and Among the patients, 1075 reported a history of some abuse Stalin to show us the relationship between maltreatment during childhood (29.10%) (Table 1). Table 2 summarizes in childhood and cruelty in adulthood.11 The concept and shows the different types of abuse in the patients. of “repetition compulsion” was introduced by Freud The history of 19.44% of them (total = 209, 78 men and and other psychoanalysts to describe the reenactment 131 women) indicated that they behaved as an abuser for and persistent activation of early traumatic scenarios most of their life. They were aggressive, bully, controlling, in the individual life. The ones who could not integrate authoritative and superior in their relationships. Some of the trauma repeat the repressed material as a current them had been involved in illegal acts and had history of experience instead of remembering it as something substance abuse. The prevalence of substance abuse in belonging to the past. According to Janet, the traumatic the people with history of abuse was 36.6% compared to memories persist as “fixed ideas” that act as foci for further 28.36% in those without such a history. Table 3 shows the repetition.12 Memories of trauma return as sensations, frequency of abuse among the divorced, married, single images, nightmares and behaviors, “as if their personality and widowed patients, which is 36.36%, 27.6%, 31.2% development has stopped at a certain point and cannot and 22.76%, respectively. The prevalence of acting as an expand anymore by the addition or assimilation of new abuser and perpetrator in adult life among the divorced, elements”.12 Freud believed that the goal of repetition was married, single and widowed was 27.5%, 19.5%, 18.4% to gain mastery over the trauma but as Van der Kolk noted, this rarely happens and repetition causes further suffering.4 Table 1. Comparison of History of Child Abuse between Male and Female A considerable finding in this study was the dominance Patients of female patients among the patients who acted as abusers Abuse History Female Male Total in adult life (62.7% women vs. 37.3% men). Carmen et Yes 726 (31.62%) 349 (24.97%) 1075 (29.10%) al13 indicate that through the mechanism of “identification No 1570(68.37%) 1049 (75.03%) 2619 (70.90%) with aggressor”, boys victimize others whereas abused Total 2296 (100%) 1398 (100%) 3694 (100%) women would be attached to an abusive man. This contemplation is not supported by our study. However,

Table 2. Frequency of Different Types of Abuse we have to wait for more sophisticated studies to obtain a reliable conclusion. Type of abuse No. Percent We found higher rates of victimization and also acting as Physical/sexual 46 4.30 Neglect 345 32.11 abusers in the history of divorced individuals. It can be a Parental conflict 301 28.00 measure indicating the importance of a history of trauma Physical 235 21.87 in marital life and its fate. Sexual 148 13.72 Repetition of the past trauma in the form of abusive Total 1075 100 behavior leads to continuation of victimization. The past

Table 3. Marital Status in Patients with and without History of Abuse

Abuse History Divorced Married Single Widowed Total

Yes 121(63.68%) 1436 (72.93%) 1001 (68.75%) 61 (77.22%) 2619 (70.90%)

No 69 (36.32%) 533 (27.07%) 455 (31.25%) 18 (22.78%) 1075 (29.10%)

Total 190 (100%) 1969 (100%) 1456 (100%) 79 (100%) 3694 (100%)

Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 S7 Firoozabadi victim becomes the future abuser and this pattern repeats all have accomplished by the author. itself in the next generation. The goal of treatment is to Conflict of Interest Disclosures help such patients to gain control over their life rather None. than repeating trauma in action.4 A peaceful society could be established by peaceful and adapted individuals. Ethical Statement People who are in peace with themselves can develop Ethical issue of this study has been approved by ethics committee of Archives of Iranian Medicine. peaceful relationships with others in the external world. The current victim is a potential persecutor in the future. References Appropriate and timely interventions have a significant 1. Boney-McCoy S, Finkenlhor D. Is your victimization related role in preventing such undesirable consequences and to trauma symptoms and depression after controlling for prior symptoms and family relationships? A longitudinal. reappearance of another Hitler. Prospective study. J Consult Clin Psychol. 1996;64:1406-16. This is a preliminary study that shed a dim light on an 2. Russell D. The Secret Trauma: Incest in the Lives of Girls and important subject. Further and more sophisticated studies Women. New York: Basic Books. 1986. should be done to address many unanswered questions 3. Howell EF. The Dissociative Mind. New York: Routledge Taylor & Francis Group; 2005 about the interactions among factors which influence the 4. Van der Kolk BA. The compulsion to repeat the trauma. destiny of children in their life. As Chu mentioned, abuse Psychiatr Clin North Am. 1989;12(2):389-411. is often accompanied by a sense of shame and the children 5. Krystal H. Trauma and affect. Psychoanal Study Child. may be reluctant to reveal what happened. A caring and 1978;33:81-116. doi: 10.1080/00797308.1978.11822973 warm environment could help the children to recruit their 6. Lewis DO, Pincus JH, Bard B, Richardson E, Prichep LS, Feldman M, et al. Neuropsychiatric, psychoeducational and inner resiliency to overcome the consequences of trauma. family characteristics of 14 juveniles condemned to death in the United States. m J Psychiatry. 1988;145(5):584-9. Doi: Limitations 10.1176/ajp.145.5.584 This is a study on patients referring to a single private 7. Lewis DO, Shanok SS, Pincus JH, Glaser GH. Violent juvenile delinquents. Psychiatric, neurological, psychological and clinic which reduces external validity. The method of abuse factors. J Am Acad Child Psychiatry. 1979;18(2):307-19. identification of “abuser” and “abused” has been based on 8. Seghorn TK, Prentky RA, Boucher RJ. Childhood sexual abuse clinical judgment in routine psychiatric interviews. Since in the lives of sexually aggressive offenders. J Am Acad Child the study has been based on secondary data and noting the Adolesc Psychiatry. 1987;26(2):262-7. 9. Chu JA. Rebuilding Shattered Lives: Treating Complex PTSD limited time allocated to examining such a high number and Dissociative Disorders. 2nd ed. Hoboken, NJ: John Wiley of patients without a clear-cut method and instrument, & Sons, Inc. 2011. the possibility of identifying the “abused” is higher than 10. Karpman S. Fairy tales and script drama analysis. Transactional having been an “abuser” with no history of being abused Analysis Bulletin. 1968;7(26):39-43. 11. Miller A. The Truth will Set You Free: Overcoming Emotional and this might have led to a systematic error. This is a Blindness and Finding your True Adult Self. Translated by preliminary study and the author hopes to design more Andrew Jenkins. New York: Basic Books; 2001. elaborated studies in the future to shed light on such an 12. Janet P. The Mental State of Hystericals. Paris: Félix Alcan; important issue. 1911. 13. Carmen EH, Reiker PP, Mills T. Victims of violence and Authors’ Contribution psychiatric illness. Am J Psychiatry. 1984;141(3):378-83. Gathering of data, statistical analysis and the writing of manuscript

© 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

S8 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 ARCHIVES OF Arch Iran Med. April 2020;23(4 Suppl 1):S9-S15 IRANIAN doi 10.34172/aim.2020.s3 http://www.aimjournal.ir MEDICINE

Open Original Article Access Health Care Utilization and Expenditure in War Survivors

Batool Mousavi, MD1*; Farzaneh Maftoon, MD2*; Mohammadreza Soroush, MD3; Kazem Mohammad, MD4; Reza Majdzadeh, MD5

1Prevention Department, Janbazan Medical and Engineering Research Center (JMERC), Tehran, IR Iran 2Population Health Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, IR Iran 3Janbazan Medical and Engineering Research Center (JMERC), Tehran, IR Iran 4Department of Epidemiology and Biostatistics, Health Faculty, Tehran University of Medical Sciences, Tehran, Iran 5Knowledge Utilization Research Center, Community Based Participatory Research Center, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

Abstract Background: To describe the utilization and out-of-pocket (OOP) payments of war survivors receiving health care services and its determinants. Methods: A cross-sectional study was carried out by systematic random sampling at national level (n = 3079) on healthcare utilization in war survivors on their last received services. A validated questionnaire was used to gather the information of inpatient and outpatient healthcare services and OOP payment. The data were analyzed to indicate the determinants of health utilization and expenses. Results: Health care utilization was reported in 91.6% (n = 2822). The majority (82.5%) received one or two services in their last visits, mostly related to physician visits and medications (65.97%). Health care utilization was higher than general population annually, especially in physician visit (6.6 versus 4.89), medication (5.1 versus 3.6), and hospitalization (0.78 versus 0.15). About 20.2% (n = 599) of the study population paid out of their pocket for their last medical care services. The frequency of OOP payment was greater for physician visit and medication. Payment for hospitalization, imaging, and lab tests were more significantly associated with proceeding to reimburse the expenses (P < 0.001). The median OOP payment was US$10.8 (interquartile range US$20.6). Gender (P = 0.003), area of residence (P = 0.01) and being war victims (P = 0.005) were the significant determinants for both OOP payments and reclaiming the expenditure. Higher amount of payments (P < 0.001) and more received health services (P = 0.002) were also important factors in reclaiming the expenditure. Conclusion: Both outpatient services and hospital admission are more frequent among war survivors compared to the general Iranian population. Future studies should attempt to explore the reasons. Keywords: Health care, Health expenditure, Injuries, Utilization, War Cite this article as: Mousavi B, Maftoon F, Soroush M, Mohammad K, Majdzadeh R. Health care utilization and expenditure in war survivors. Arch Iran Med. 2020;23(4 suppl 1):S9–S15. doi: 10.34172/aim.2020.s3.

Received: July 14, 2019, Accepted: October 12, 2019, ePublished: April 1, 2020

Introduction simple medical and laboratory services due to financial During 8 years of the Iran-Iraq war, which was the longest hardship.6 Principally, the use of health services should war in the 20th century, about 200 000 Iranians were not be determined by ability to pay.7 Out-of-pocket killed while half million were injured and suffered from (OOP) payment is when a patient pays money directly chronic complications. Today war survivors are middle- to the provider for provision of services which increases aged, with health issues complicated by comorbidities of the incidence of impoverishment and catastrophic health poly-trauma and aging.1 There are more than one million expenditure.8 OOP payments for outpatient/inpatient families of not only martyrs (who lost their life due to services, mainly among people with chronic conditions, Iran-Iraq war) but also war survivors. Today, 30 years after could be more detrimental over the long period of time the end of the war, survivors are left with many physical, and lead to an unpredictable situation that family member mental, and chemical injuries. There are few articles about may be hard equipped to deal with. Moreover, this might satisfaction of medical services among Iranian survivors of impose additional burden on vulnerable populations.9 the war.2,3 Despite many published papers about injured Since many war survivors survive injuries that would victims, there has been no inclusive study on health care have killed or caused them multiple injuries (amputations; utilization in this population. brain injury; head trauma and/or blindness), they will Almost 44 million households and more than hundred require long-term costly rehabilitation. Doctor/hospital million face tragic health care costs annually.4,5 In addition, visits, use of diagnostic testing and other health care a large number of people may decide not to use even technologies has been growing dramatically. Burdens

*Corresponding Authors: Farzaneh Maftoon, MD; Population Health Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, IR Iran. Email: [email protected]; Batool Mousavi, MD; Prevention Department, Janbazan Medical and Engineering Research Center (JMERC), Tehran, IR Iran. Email: [email protected] Mousavi et al of health expenditure imposed on all veterans and their seventy-nine cases were studied, and among them, the families can be no longer ignored. The crucial challenges latest information on the type of service received in the are to quantify the impact of health care expenses of a last two months was collected. family and to control health care spending.10-12 Information on the frequency of OOP payment for the Coverage of medical and rehabilitation healthcare received health care services was collected, as well. In cases facilities remains inadequate for the vulnerable parts of where the recipient prepared the expense of health care, community.13 Low- and middle-income families are more the amount of payment was questioned. Reclaiming the affected by the impact of growth in OOP health care expenditure through the reimbursement process was also expenditure while wealthier families are able to pay more inquired. for health.14,15 The World Health Organization (WHO) Using telephone interviews, data was collected on the believes that payments by the recipients of health services variety of health care services in the war survivors and their are the most inaccurate method of payment.13 family members. Information on the latest health service It is anticipated that governments must play a principal that the insurer received was collected via interviews. role in providing healthcare services for the population, Demographic data were collected in terms of age, gender, but only a small part of government revenue is assigned to level of education, marital status, and employment status. this purpose.7 In Iran, the government allocates adequate Additionally, OOP payment data were collected using portion of its budget to healthcare expenditure for war a validated questionnaire. The questionnaire consisted survivors and their families. Providing insurance to the of different health services including outpatient visit, war survivors’ community and covering most health care medication, lab test, imaging, home care, medical trip and expenses is the policy of Veterans and Martyrs Affairs hospital admission. Foundation (VMAF). Insurance coverage includes health services, physician visit, medication, outpatient/inpatient Participants/Sampling surgeries, paraclinical services, nursing, refractive errors The data of war victims suffering from war-related treatment, ambulance transport (in or between the cities), injuries and their families (including parents, spouses, and and home care services.16 children), as well as the families of the martyrs are kept by Despite improvement of health indices, availability the VMAF.16 Their contact information was obtained at the of resources for medical care facilities is still inadequate national level from all 32 provinces using a database of the and economic safety for health expenditures is not well VMAF. Sample size was calculated with 95% confidence distinguished. The amount of paying OOP in war survivors with error not exceeding 0.05% for estimation of each and its associated factors is not clear. Information on the health care utilized services with P = 0.50 and d = 0.05. current levels and distribution of expenditures on health The samples for each health service was calculated at 385 care is needed to plan for better health in this particular (2695 samples totally). In this study, a systematic random group of the community. Today, war survivors are middle- method was used and 4161 telephone calls were made. Of aged, with health issues complicated by comorbidities these, 3308 responded to the calls (response rate to call: of poly-trauma and elderly. The aim of this study was to 79.5%). About 3079 cases were interviewed (response rate: evaluate health care utilization, expenditure and OOP 93.1%). Health care services were reported to have been payment by Iranian war survivors for health care services, received in 2822 of the interviewed population during the and to find the associated factors in the target population. two months before the interview (health care utilization 91.6%). We respected the confidentiality and anonymity Materials and Methods of our research respondents and their participation was Study Design and Setting voluntarily. A cross-sectional study was conducted on war survivors. In this survey, war survivors consisted of war victims, families Data Analysis of the war victims, and families of the martyrs. Information Data were explored using descriptive and inferential on health care utilization and prevalence of OOP payment statistical tests including chi-square, Mann-Whitney U for the received medical services was collected from all test and logistic regression analyses (variables with P value provinces in both urban and rural areas. less than 0.2 were entered to regression). Determinants of Health care utilization indicators were assessed based OOP payment and proceeding to reclaim the expenditure on the information on received health care services during of health services were also examined using R version the months preceding the study in 2015. The studied 3.5.0. population were asked on the frequency of health care services during the two months before the interview. Then, Results the probability of health utilization was calculated in one Among the recipients of health services, 38.6% (1089) day, and this probability was annualized for inpatient and were war victims and 1733 (61.4%) were their families. outpatient medical services, separately. Three thousand The mean age was 52.4 (SD = 17.5) years, and males

S10 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 War Health Care accounted for 53.1% (1497) of the sample. The majority reimbursing the expenditure and OOP are demonstrated of the study sample (86.9%; n = 2453) were living in in Table 2. OOP payment was significantly correlated with urban areas, 369 cases (13.1%) were living in rural areas, the type of health services (P <0.001). Frequency of OOP and 29.1% (822 cases) were unemployed. The study payment was greater for physician visit and medication. population utilized 5127 health care services, a majority Hospitalization, imaging, and laboratory test were more (82.5%) received one or two services (1.82 per individual), significantly associated with proceeding to reclaim the mostly related to physician visits and medications expenses (P < 0.001) (Table 2). As Table 2 shows, the (65.97%; 3387 health services). Physiotherapy was the participants who paid more significantly were more likely least utilized service (0.7%). The average number of health to proceed to reclaim their expenses, especially in the care utilization in war survivors compared to the general outpatient visit, medication, lab tests, imaging, home care, population is presented in Table 1. As the table shows, and hospitalization. total health care utilization, outpatient visit and especially The determinants of OOP and proceeding to reclaim hospital admission in the studied population were higher the expenses of medical services are demonstrated in compared to the general population. Moreover, although Tables 3 and 4. Gender, area of residence and being war war victims received more health services compared to their victim were significantly the most important determinants family members, there was not any significant difference for OOP. The determinants of proceeding to reclaim the between the groups. expenses were greater amount of payment, more health The prevalence of payment for receiving health care care received, being male and war victims. was reported in 37.4% (n = 1054) with median and interquartile range of US$10.8 and US$20.6 and 95% CI: Discussion 35.6, 39.2 (351 000 and 669 500 Rials- Iranian currency, This study was based on a national probability-based respectively); first quartile 0.5 and third quartile US$21.1. sample, which assessed the frequency and pattern of The expenses were between US$0.31 and 4612 (10 000- health care utilization and expenditure for both outpatient 150 000 000 Rials). Less than half of the participants who services and hospital admission among war survivors. We paid for their health care expenses proceeded to reimburse have highlighted the high rate of health care utilization. their expenditure (43.2%; n = 455). The median amount The results of this study showed that most health of payment was US$26.2 (851 500 Rials). Health care services used were related to physician visits and expenditure including details of amount of payment for medications. The annual rate of outpatient health services

Table 1. Health Care Utilization Indicators (Outpatient and Inpatient) in War Survivors (N = 3079)

Annualized Health Care Utilization in Studied Population General Population Annualized Health Care War Victims War Victims’ Family Total Utilization 201517,18 Physician visit 8.9 5.6 6.6 4.9 Medication 6.6 4.3 5.0 3.6 Lab test 1.9 1.6 1.7 0.7 Imaging 0.9 0.9 0.9 0.4 Paraclinic 2.9 2.5 2.6 1.0 Outpatient 22.2 12.1 14.1 9.6 Inpatient/hospitalization 0.79 0.76 0.78 0.1 Total 22.8 12.7 14.8 9.7

Table 2. Distribution of Health Expenditure in War Survivors (US$) by Received Health Care Services

Proceeding to Reimburse Expenditures Out-of-Pocket (OOP) Payment Median Q1 Q3 IQR Median Q1 Q3 IQR No. (%) No. (%) P Value* (US$) (US$) (US$) (US$) (US$) (US$) (US$) (US$) Physician visit n=490 203 (41.4) 7.7 6.1 9.2 3.1 287 (58.6) 6.2 3.4 9.2 5.8 <0.001

Medication n=449 150 (33.4) 13.8 6.1 30.8 24.6 299 (66.6) 9.2 3.6 18.5 14.9 <0.001

Lab test n=110 57 (51.8) 19.5 11.2 30.7 19.6 53 (48.2) 15.4 6.2 30.8 24.6 0.1

Imaging n=151 83 (55.0) 24.6 12.3 55.4 43.1 68 (45.0) 18.5 6.4 38.4 32.0 0.01

Hospital admission n=140 80 (57.1) 161.5 65.4 161.5 596.3 60 (42.9) 58.3 18.5 123.1 104.6 <0.001

Home care n=56 22 (39.3) 38.5 15.4 110.8 106.2 34 (60.7) 2.6 1.2 16.9 15.8 <0.001

Medical trip n=43 12 (27.9) 12.3 8.6 30.8 22.1 31 (72.1) 10.8 6.9 21.5 14.6 0.4

Total n=1439 607 (41.2) 26.2 10.5 81.8 72.4 832 (58.8) 10.8 5.5 26.1 20.6 <0.001 * Mann-Whitney U test.

Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 S11 Mousavi et al

Table 3. Determinant of Out-of-Pocket Payment on Medical Services in the Studied Population (n = 2822) Out-of-Pocket Payment 95% Confidence Interval Adjusted Odds Ratio P Valuea No Yes Lower Upper Gender Female 905 314 1.0 (Ref.) Male 1145 244 1.68 1.19 2.36 0.003* Employment Employed 1507 448 1.0 (Ref.) Unemployed 543 110 1.16 0.88 1.52 0.29 Area of residence Rural 253 87 1.0 (Ref.) Urban 1797 471 1.38 1.10 1.80 0.01* War survivors group Martyrs’ family 759 257 1.0 (Ref.) War victims 893 190 1.47 1.12 1.92 0.005* War victims’ family 398 111 1.34 0.90 2.01 0.14 a Logistic regression.

Table 4. Determinant of Proceeding to Reimburse the Expenses of Health Services (n = 1054)

Proceeding to Reimburse the 95% Confidence Interval Expense Adjusted Odds Ratio P Valuea No Yes Lower Upper Gender Female 314 209 1.0 (Ref.) Male 244 203 0.63 0.41 0.97 0.03* War survivors group: Martyrs’ family 257 154 1.0 (Ref.) War victims 190 156 0.60 0.38 0.87 0.007* War victims’ family 111 102 0.64 0.36 1.11 0.11 Number of paid for health services 558 412 1.41 1.13 1.74 0.002* Amount of payment (national currency) 558 412 1.0 1.0 1.1 <0.001* a Logistic regression. utilization was 14 which is twice higher than that of the population aging which accounts for most of the increase general Iranian population. The annual rate of physician in health utilization. visits and medications/prescription was higher compared Our study revealed that more than 85% of war survivors to the general population. Most of the clients received received medications on their last physician visits which medications on their last physician visits. War survivors was higher than similar studies.16,19 The medication received three time more para-clinical services. Although is known as a supplemental commodity of general the inpatient admission was much higher than the general practitioners’ visits.16,19 A study in Canada showed that one Iranian totally,17,18 the rate was similar in both war victims of the main factors of not using doctors’ visits is high cost and their families. The causes should be addressed in future of the drug.20 Patient participation in drug costs resulted studies. First, the excess health care utilization highlights in a 15% reduction in the number of visits to the doctor.21 the important situation of individual’s health care needs This can also cause resorting to low-price, non-scientific and government health care expenditures. Second, the methods or self-medication.22 Insurance coverage has a higher rate of utilizing health care might be due to the fact key role in providing and utilizing healthcare services and that this population is under the cover of supplemental some factors affecting the correlation among insurances insurance so they have free and better access to health and healthcare coverages.23 People with insurance (basic care services. Future studies should focus on the details or supplementary) need more health services.24-28 An separately, especially regarding hospital admission in the explaining reason might be that people with insurance war survivors. Sociodemographic, diagnosis variables, express their health problems more easily and receive psychosocial and functional status should be studied for more medical care.26 The findings highlight the need to better understanding of the use of inpatient-outpatient, plan and assess new interventions that increase health- home physician visits or nursing. Increasing the load of care accessibility. These could be programs such as rehabilitation and health planning to decrease disability in home-based evaluation, electronic medical/personal the population will help for amending this burden. Going records and devices, as well as innovative health facility forwards, health systems need to expand to accommodate platforms including smartphones or telemedicine. These

S12 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 War Health Care performance measures help to identify war survivors who expensive health services. Facilitating reimbursement is live in rural areas or those who have less access to care. needed, particularly processing of claims, with monitoring One-fifth of the study population had paid for the and evaluating the process. Disability increased expense of their last incoming health service including government-reimbursed expenditures for health care, both outpatient and inpatient health services with an which will place a huge burden on government finances. average US$33. This finding is lower than similar surveys The correlation between disability and medical expenses, (35%–50%),29,30 and the study by Moses et al. In that that modifies disability itself and its effect on health care study, the unit costs for outpatient and inpatient services use, is expected to be multifaceted.36 Increase in OOP for the funds needed to meet a united health care standard payment creates greater incentive to seek insurance and were estimated at US$67 and US$7217 respectively.24 War affect the household economy. However, it must be survivors paid less OOP for receiving health care services emphasized that the current information is insufficient for which might be related to the their supplemental and make-or-buy decisions. complementary health insurance. The results also indicated that the amount of expenditure OOP financing is the main mechanism in most Asian is significant for the families of martyrs and war victims and developing countries.31 In a study on health-related with insurance coverage. Moreover, a higher rate of OOP socio-economic indicators, do Rosário estimated the share payment was observed in men and urban communities. of drug costs in household income as one of the highest This can be related to two main factors: first, most of the Gini coefficients (extreme inequality).32 Studies in Asian population of war survivors who need more medical care countries showed that at least 30% of the health care are men, and second, the distribution of medical services financing costs were provided by OOP payments.33,34 Our varies widely in rural and urban. Living in a rural area is expense was based on the population in 2015 but future associated with greater disparity in access to health care estimates should include the additional expense associated compares to urban areas.37 Rural areas are less developed with population aging. Remarkably, expenditure (OOP than urban areas in Iran, resulting in poorer access to payment) and proceeding to reimburse the expenditure medical resources. This inconvenience probably ends in were significantly correlated with hospitalization, imaging poor health condition and more medical expenses. To and lab tests. These services are usually expensive, and reduce medical financial inequality, accessibility of medical a large number of the health centers are private and not care should improve. Furthermore, medical recompense under the contract of health insurance. motivations such as higher reimbursed insurance fees, Except for travel health services, higher amount of increased payment for circuit medical services, or payment was accompanied with proceeding to reimburse subsidizing transportation costs should be implemented the expenditure. Travel health issues accounted for the to cover medical services. The findings indicate that health highest amounts of expenditure, while the least in terms providers need to promote better equity of treatment for of proceeding to reimburse the expenditure. Although health recepients.38 participants were under the cover of insurance, they did not use their insurance to get medical care during trips. Limitations They paid for their medical expenses and did not proceed The first limitation is that we estimated the health care to reclaim their expenses. In fact, bureaucracy, lack of time utilization and expenditure based on self-reported health and distance from health centers covered by the insurance, services received by the studied population. Another compels patients not to use their insurance during traveling limitation is the recall bias which may have resulted in in these cases. The health system can help the insured by underestimation or overestimation of both health care facilitating the rules on insurance repayment.35 utilization and expenditure. This bias could have an The higher the expense, the more likely it was to be ignorable impact on determinant factors. About 20% did reclaimed. This was more observed for hospital admission not respond to the phone calls; thus, the possibility of and medication as shown in Table 2. The median selection bias due to non-response should be considered difference between OOP and Proceed to Reimburse as another limitation. Moreover, the outcomes were expenditures was US$1.3–1.5. Based on the contract, the measured at a single period of time, making it difficult to insurance company is pledged to repay the money within establish causation. These statistics are limited in that we a month. Our study showed wherever the health recipient did not explore any extra data, especially the differences in spent more than average on receiving a health care service, hospital admission, physician visits, types of medication they would more probably proceed to reimburse it. This and para-clinical care use, total health expenditures and was more obvious for hospital admission, imaging and socioeconomic status in the studied population. medication. In some cases, the amounts were catastrophic In conclusion, outpatient and especially inpatient services (US$4000). As shown in Table 3, the studied population are more frequent among war survivors compared to the more frequently paid out of their own pocket for the general Iranian population. Future studies should attempt

Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 S13 Mousavi et al to explore the reasons. Interventions must be tailored to Research Center (JMERC), Tehran, Iran approved the project through the health essentials of war survivors. Evaluating provider protocol no. 93EP101, 2015. All subjects gave consent. attitudes concerning these interventions is important Funding Sources for future health planning. The rate of OOP payment JMERC and VMAF funded the study. was higher for hospitalization, imaging and lab tests, mostly without proceeding to reimburse the expenditure. Acknowledgements The authors would like to thanks the JMERC and VMAF, Tehran- Implementation of supplemental insurance is one of the Iran. The authors would also like to thank Marziye Asgari and Shirin most essential medical policies for war survivors in Iran. Abdolkarimi for their helpful and support during the study. Supplemental insurance improved access to medical and health services, resulting in a remarkable shift to reducing References 1. Taebi G, Soroush MR, Modirian E, Khateri SH, Mousavi OOP payments. However, improvements are required to B, Ganjparvar Z, et al. Human costs of Iraq’s chemical war moderate the economic burden imposed on in-need war against Iran; an epidemiological study. Iran J War Public survivors (rural residents). Last but not least, future studies Health.2015;7(2):115-21. must ascertain whether health is improved, unchanged, or 2. Soroush MR, Mousavi B, Maftoon F, Mohammad K, Ganjparvar Z. Satisfaction of supplementary insurance and medical even adversely affected through medical care. services during trips in war survivors and their families. Int J Travel Med Glob Health. 2016;4(2):65-8. Strengths and Limitations 3. Mousavi B, Maftoon F, Soroush MR, Mohammad K, • This is the first study to examine the frequency and Rahimpoor D, Khoubyarian A. Satisfaction with outpatient pattern of health care utilization and expenditure visits in veterans covered by supplementary health insurance. Payesh.2017;16(2):142-49. for both outpatient services and hospital admissions 4. Ilunga-Ilunga F, Levêque A, Laokri S, Dramaix M. Incidence of among war survivors, using samples from a catastrophic health expenditures for households: An example representative cross-sectional survey. of medical attention for the treatment of severe childhood • This survey contributes to better understanding of the malaria in Kinshasa reference hospitals, Democratic Republic of Congo. J Infect Public Health. 2015;8(2):136-44. doi: epidemiological distribution of health care utilization 10.1016/j.jiph.2014.08.008. and OOP payment and its associated factors in war 5. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, survivors. Ameh EA, et al. Global Surgery 2030: evidence and solutions • Limitations of cross-sectional study are present; thus, for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624. doi: 10.1016/S0140- it is not possible to establish causality. 6736(15)60160-X. 6. aFlores G, Krishnakumar J, O’Donnell O, Van Doorslaer Key Findings E. Coping with health-care costs: implications for the • The annual rate of hospital admission was five times measurement of catastrophic expenditures and poverty. Health Econ. 2008;17(12):1393-412. doi: 10.1002/hec.1338. higher than the general Iranian population. 7. Adebayo E, Uthman O, Wiysonge CH, Stern E, Lamont K, • The annual rate of outpatient health services Ataguba J. A systematic review of factors that affect uptake utilization in war survivors was 14 which is 1.5 times of community-based health insurance in low-income and higher than the general Iranian population. middle-income countries. BMC Health Serv Res. 2015;15:543. • doi: 10.1186/s12913-015-1179-3. 85% of clients received medications on their last 8. Pace LE, Dusetzina SB, Fendrick AM, Keating NL, Dalton VK. physician visits. The impact of out-of-pocket costs on the use of intrauterine • While all participants were under the cover of contraception among women with employer-sponsored insurance, 21% paid for their medical expenses out of insurance. Med Care. 2013;51(11):959-63. doi: 10.1097/ their own pocket. MLR.0b013e3182a97b5d. 9. Leive A, Xu K. Coping with out-of-pocket health payments: empirical evidence from 15 African countries. Bull World Authors’ Contribution Health Organ. 2008;86(11):849-856. BM was the principal investigator, designed the study, analyzed the 10. Auerbach DI, Kellermann AL. A decade of health care cost data, and wrote the first draft. FM and KM actively contributed to growth has wiped out real income gains for an average US study design and data analysis. FM, MS and BM collected the data. family. Health Aff (Millwood). 2011;30(9):1630-6. doi: FM, MS, KM and BM actively contributed to elements of the study. 10.1377/hlthaff.2011.0585. RM interpreted the results, revised the manuscript and approved the 11. Yu H, Dick AW. Impacts of rising health care costs on families final draft. All authors agreed to be responsible for this work. with employment-based private insurance: a national analysis with state fixed effects. Health Serv Res. 2012;47(5):2012-30. Availability of Data and Material doi: 10.1111/j.1475-6773.2012.01397.x. The generated and/or analyzed data during the current study are 12. Razavi SM, Ghanei M, Salamati P, Safiabadi M. Long-term available from the first author on reasonable request. effects of mustard gas on respiratory system of Iranian veterans after Iraq-Iran war: a review. Chin J Traumatol. 2013;16(3):163- Conflict of Interest Disclosures 8. The authors declare that they have no competing interests. 13. World Health Organization. World Health Report, 2010: health systems financing the path to universal coverage. Ethical Statement Geneva: WHO; 2010. The Ethics Committee of the Janbazan Medical and Engineering 14. Polsky D, Grande D. The burden of health care costs for

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Abolhallaje M, Ansari M, et al . Total Health Expenditures and 17. Saba R. Safakish M, Rezaei-Gharoodi Z. Iran’ Health Care Proportion of Out-Of-Pocket Payments in Iranian Provinces [in Utilization Survey 2015. Tehran; Joint publication of the Iran Persian]. Iran J Epidemiol. 2017;12(5):20-31. National Institute of Health Research and Iran’s Statistics 30. Mirabedini SA, Esmaeil Fazl Hashemi SM, Sarabi Asiabar A, Center. 2016. Rezapour A, Azami-Aghdash S, Hosseini Amnab H. Out-of- 18. Kameli ME, Behtaj F, Parvan, M, Lotfi- Golmishe F, Vahedi- pocket and informal payments in Iran’s health care system: a Bozorgi A. Curative Affairs Statistics 2017. Deputy of Curative systematic review and meta-analysis. Med J Islam Repub Iran. Affairs at Ministry of Health and Medical Education; June 2017;31:70. doi: 10.14196/mjiri.31.70. 2018. 31. Van Doorslaer E, O’Donnell O, Rannan-Eliya RP, Somanathan 19. Shamliyan TA, Duval S, Du J, Kane R. Just what the doctor A, Adhikari SR, Garg CC, et al. Effect of payments for health ordered. Review of the evidence of the impact of computerized care on poverty estimates in 11 countries in Asia: an analysis of physician order entry system on medication errors. Health household survey data. Med J Islam Repub Iran. 2017;31:70. Serv Res. 2008;43(1 Pt 1):32-53. doi: 10.1111/j.1475- doi: 10.14196/mjiri.31.70. 6773.2007.00751.x. 32. do Rosário GM. Equity in socioeconomic areas with impact 20. Allan GM, Lexchin J, Wiebe N. Physician awareness of drug on health in countries of European Union [in Portuguese]. Cad cost: a systematic review. PLoS Med. 2007;4(9):e283. Saude Publica. 2001;17(3):533-44. 21. Winkelmann R. Co-payments for prescription drugs and the 33. O’donnell O, Van Doorslaer E, Rannan-Eliya RP, Somanathan demand for doctor visits–Evidence from a natural experiment. A, Adhikari SR, Akkazieva B, et al. Who pays for health care Health Econ. 2004;13(11):1081-9. doi: 10.1002/hec.868 in Asia? J Health Econ. 2008;27(2):460-75. doi: 10.1016/j. 22. Sharma P. Health care access in a developing country: jhealeco.2007.08.005. significance of medical pluralism. Institute of Development 34. Van Doorslaer E, O’Donnell O, Rannan-Eliya RP, Somanathan Management. 2014;1(3):284. A, Adhikari SR, Garg CC, et al. Catastrophic payments for 23. Chu TB, Liu TC, Chen CS, Tsai YW, Chiu WT. Household out- health care in Asia. Health Econ. 2007;16(11):1159-84.doi: of-pocket medical expenditures and national health insurance 10.1002/hec.1209 in Taiwan: income and regional inequality. BMC Health Serv 35. Soroush MR, Mousavi B, Maftoon F, Mohammad K, Ganjparvar Res. 2005;5:60. Z. Satisfaction of supplementary insurance and medical 24. Moses M, Pedroza P, Baral R, Bloom S, Brown J, Chapin services during trips in war survivors and their families. Int J A, et al. Funding and services needed to achieve universal Travel Med Glob Health. 2016;4(2):65-8. health coverage: applications of global, regional, and national 36. Fried TR, Bradley EH, Williams CS, Tinetti ME. Functional estimates of utilisation of outpatient visits and inpatient Disability and Health Care Expenditures for Older Persons. admissions from 1990 to 2016, and unit costs from 1995 to Arch Intern Med. 2001;161(21):2602-7. doi: 10.1001/ 2016. Lancet Public Health. 2019;4(1):e49-e73. doi: 10.1016/ archinte.161.21.2602 S2468-2667(18)30213-5. 37. Caldwell JT, Ford CL, Wallace SP, Wang MC, Takahashi LM. 25. Mohammadbeigi A, Hassanzadeh J, Eshrati B, Rezaianzadeh Intersection of living in a rural versus urban area and race/ A. Socioeconomic inequity in health care utilization, Iran. J ethnicity in explaining access to health care in the United Epidemiol Glob Health. 2013;3(3):139-46. doi: 10.1016/j. States. Am J Public Health. 2016;106(8):1463-9. doi: 10.2105/ jegh.2013.03.006. 19. AJPH.2016.303212. 26. Abouie A, Majdzadeh R, Khabiri R, Hamedi-Shahraki 38. Araujo M, Silva M, Galvao T, Pereira M. Prevalence of health S, Emami Razavi SH, Yekaninejad MS. Socioeconomic services usage and associated factors in the Amazon region of inequities in health services’ utilization following the Health Brazil: a population-based cross-sectional study. BMJ Open. Transformation Plan initiative in Iran. Health Policy Plan. 2017;7(11):e017966. doi: 10.1136/bmjopen-2017-017966. 2018;33(10):1065-1072. doi: 10.1093/heapol/czy096.

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Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 S15 ARCHIVES OF Arch Iran Med. April 2020;23(4 Suppl 1):S16-S22 IRANIAN doi 10.34172/aim.2020.s4 http://www.aimjournal.ir MEDICINE

Open Review Article Access Impact of War on Fertility and Infertility

Ayeh Bolouki, MS1; Fatemeh Zal, PhD1,2*

1Biochemistry Department, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran 2Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran

Abstract Background: War causes more death and disability than many major diseases. There are few studies in the context of the deleterious impact of war on fertility potential; therefore, in this study, we tried to review articles about the adverse effects of war on male/ female fertility potential Methods: In this study, a total of 183 articles related to the effects of war on fertility potential were examined by a systematic search using known international medical databases. Results: Among these studies, there were limited studies on the effects of war on female infertility and most studies examined the effects of war on sperm parameters and male infertility. The physical and psychological trauma of war can increase the risk of infertility in men and women. Presence of reproductive system toxins in weapons, stressful periods of war and direct damage to the reproductive system can impair the fertility of men and women. The way war affects male fertility is not clear, but the higher degree of stress during wartime seems to play an important role. Using reproductive toxicants during the war also increases the risk of impairment in reproductive function in men. Some studies have shown the harmful effects of Sulfur mustard as a war chemical toxin especially on sperm quality and male infertility. Oxidative stress induced by free radicals is a major mechanism for the direct effects of Sulfur mustard on male infertility. Conclusion: The study of past research suggests that exposure to war may be an independent risk factor for reproductive disorders and infertility in men. For female infertility, war leads to menstrual dysfunction. Keywords: Chemical warfare, Free radicals, Infertility, Mustard gas, War-Related injuries Cite this article as: Bolouki A, Zal F. Impact of war on fertility and infertility. Arch Iran Med. 2020;23(4 suppl 1):S16–S22. doi: 10.34172/aim.2020.s4.

Received: February 26, 2019, Accepted: October 12, 2019, ePublished: April 1, 2020

Introduction female fertility problems. Warfare can lead to death and disability more than any The precise mechanism of how warfare affects other malignant disease in societies. War destroys family the fertility and reproductive systems is not entirely and community frames and sometimes even destroys the understood. Evidence suggests that war-related exposure, intact cultural and identity foundations of a society. The trauma and extremely toxic pollutants in weapons can socio-economic problems in war-torn countries are rising severely affect men/women’s fertility.3-5 Therefore, given sharply, even sometimes affecting the economic affairs of the devastating effects of war on the fertility of men and other countries. Medical support and other human services women and future generations, in this study, we attempted are profoundly influenced by war, which undermines to review important studies published to date in this field. public health in the country.1,2 In recent years, several studies have examined the Materials and Methods destructive effects of war on various aspects of reproductive In this study, we examined 183 articles related to the disorders. One of the negative effects of war on the effects of war on male and female fertility. Systematic reproductive system has been its effects on fertility. However, search was performed on international medical databases there are restrictions on studying the consequences of such as Medline, ISI, PubMed, and Scopus as well as war on fertility in war-torn countries. One of the biggest Iranian medical databases such as SID, Irandoc and obstacles is collecting accurate epidemiological data about Iranmedex. Only articles published from 1960 to 2018 the pregnancy history of soldiers and inhabitants of war- were reviewed in this study. The keyword used in the torn zones. Besides, poor economic conditions and lack search was ‘war’ and the search terms used were ‘infertility’, of funding in the war-torn countries are other problems ‘female infertility’, ‘male infertility’, ‘menstrual cycle’, for such studies. For this reason, most studies in this field ‘menstrual period’, ‘menstrual irregularity’, ‘menstrual are based on self-reported information and infertility aberration’, ‘amenorrhea’, ‘semen parameters’ and ‘sperm registrations. Furthermore, most studies have focused on quality’, ‘sex hormones’ and ‘reproductive systems’. Since male fertility problems and few have been conducted on fertility is mainly dependent on sperm quality in men

*Corresponding Author: Fatemeh Zal, PhD; Biochemistry Department, School of Medicine, Shiraz University of Medical Sciences, Shiraz. Email: [email protected] Impact of War on Fertility and Infertility and menstrual health in women, we also reviewed studies war on environmental degradation as a factor associated that investigated the effects of war on sperm parameters with reproductive health and infertility, effect of SM on and menstrual health. Our main focus was to study the fertility, and the oxidative stress induced by SM. effects of war on the fertility of men and women. People who have been unsuccessful in pregnancy for more than Deleterious Effects of War on the Menstruation Cycle one year are considered infertile. We reviewed studies and Fertility in Woman involving indigenous populations and soldiers in war Evidence has indicated that menstrual dysfunction is zones. Studies that included other severe reproductive very prevalent in the periods of long warfare. One study disorders such as congenital malformation, miscarriage, evaluated the effect of imprisonment of women in German fetal malformation, ectopic pregnancies, spontaneous camps during World War II on the health of menstruation abortion, and modification in sex ratio were excluded. and fertility. The study reported that women prisoners had severe short-term disorders in the menstrual system.6 Results In another study, the acute and long-term effects of In this systematic study, a total of 183 articles were Hiroshima and Nagasaki atomic bombs on pregnancy and investigated. Some of the studies on female and male infertility in Japan were investigated. Yamazaki et al31 found infertility are presented in Table 1 and Table 2, respectively. excessive fetal loss and infant mortality, but no change was In this study, we investigated the effects of sulfur mustard shown in the fertility potential. Seigel evaluated the effect (SM), as one of the most common chemical warfare of war on fertility over a 16-year period from 1945 to agents, on the male reproductive system, some of which 1961 among Japanese official family registration records, are presented in Table 3. Our study is in accordance and no significant differences were found in the number with the rules of the ethical review board of Shiraz of live births.7 A more detailed study was published in University of medical sciences. This assessment covers 1972 confirming the results of prior studies. In this study, the following key areas: deleterious effects of war on the fertility was evaluated over 18 years, and it also included a menstruation cycle and fertility, stress and menstruation calculation of radiation dose.7 cycle irregularity, impact of war on men fertility, effect of Studies of the Desert Storm operation in Iraq in 1996

Table 1. Summary of Some Published Papers on the Effects of War on Women’s Fertility

Reference Population Under Study Study Design Results Interview survey of Amenorrhea increased significantly in the imprisoned women. Pasternak and World War II: Imprisoned women in Menstrual and reproductive After liberation, 8.9% of the women resumed menstruation. Brooks6 German concentrations camp histories of the women Surviving women exposed to the atomic Female fertility potential has not changed in surviving women Blot and Sawada7 Interview survey bombs of Hiroshima and Nagasaki exposed to high doses of atomic radiation. Women who remained in conflict zones showed 35% Lebanese war: Women exposed to war Interview survey of Hannoun et al8 menstrual disorders and women who fled war zones showed a in 1996 Menstrual history lower percentage of menstrual disorders. US: Male and Female veterans of Lifetime history of infertility was 15.8% in women and 13.8% Katon et al9 operation enduring freedom/operation Self-reported infertility in men. Iraqi freedom

Table 2. Summary of Some Published Papers on the Effects of War on Men’s Fertility

Reference Population Under Study Study Design Results Vietnam war: American soldiers who There were no significant differences in conception Stellman et al10 Male fertility questionnaire served during the Vietnam War problems in American Legionnaires. No changes in sex hormones and fertility were Ishoy et al11 Danish veterans of the Gulf War Interview survey with blood samples observed among Danish veterans. Australia: male and female veterans in Postal survey with clinic visit for a Risk of conception difficulties was increased among Sim12 the Gulf War general health examination of infertility male veterans. Postal survey with clinical validation of Reported infertility was higher among UK male Maconochie et al13 UK: male veterans of the Gulf War reported infertility problems veterans. Australia: male veterans of the Gulf Australian male veterans showed an increased rate Kelsall et al14 Self-administered postal questionnaire War of fertility problems. Lebanon: males exposed to war Retrospective review of patient records Sperm concentration was markedly reduced during Abu-Musa et al15 (1985–1989) and clinical semen analysis war in comparison to post-war period. Clinic-based, case-control study, using Lebanon: males exposed to the long- Kobeissi et al16 reproductive history and laboratory- This long-term civil war impacted the male fertility. term civil war (15 years) based semen analysis

Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 S17 Boluki and Zal

Table 3. Toxic Effects of SM on Male Reproductive System

Study Model Duration Effects References

↓ Infertility (23.3%); ↓ Sperm quality (38.7%); ↑ Abortion (13.6%); Pour-Jafari and Moushtaghi17; SM victims Several years ↑ Sexual dysfunction (9%); ↓ Libido (30%); ↑ Premature ejaculation Ketabchi18 (23.6%); ↑ FSH (57.6%); ↑ LH (66.3%)

SM victims 1st week after exposure ↓ Free serum testosterone; ↓ Dehydroepiandrosterone (DHES) Azizi et al19

SM victims 5th week after exposure ↓ Free serum testosterone; ↓ Dehydroepiandrosterone (DHES) Azizi et al20

SM victims 3rd and 5th week after exposure ↑ Serum FSH; ↑ Serum LH Azizi et al20 Y Free serum Testosterone; ↑ Testicular atrophy; Y Spermatogenesis; Azizi et al20; Safarinejad21; Amini SM victims 3 years after exposure ↑ Sertoli cell only pattern and Hosseinpour22 SM victims 20 years after exposure Normal LH, FSH and Testosterone Amirzargar et al23

SM victims 3 months after exposure ↑ Oligozoospermia (33.3%) Azizi et al20

SM victims 4 years after exposure ↑ Sperm counts (172 × 106) Amirzargar et al23

↑ Abnormal sperm (38%); ↑ Abnormal morphology of sperm (54%); SM victims 10 years after exposure Shakeri et al24 ↓ Sperm motility (48%) SM victims 15 years after exposure ↑ Oligozoospermia (10%) Ghanei et al25 ↓ Semen volume; ↓ Sperm counts; ↓ Sperm motility; ↓ Normal Amirzargar et al23; Pour-Jafari and SM victims 20 years after exposure morphology of sperm Moushtaghi26; Safarinejad27

SM victims 20 years after exposure ↑ Sperm DNA damages Safarinejad27 ↓ Libido (33.3%); ↑ Erectile dysfunction (9%); ↑ Premature SM victims 8 years after exposure Ketabchi18 ejaculation (23.6%)

SM victims Few hours or few days after exposure ↑ Genital lesions; ↑ Hypopigmentation Balali‐Mood and Hefazi28

Male rats 10 days ↑ Abnormal sperm; Y Sperm counts; Y Sperm motility Sasser et al29

↑ Abnormal sperm; Y Sperm counts; Y Sperm motility; ↓ Free serum Male rats 10 days Kooshesh et al30 testosterone; ↓ Testis weight

indicated that menstrual irregularities during the war were problems.8 very prevalent among American women soldiers. Indeed, Women comprised approximately 7% of the US military these women soldiers had abnormal uterine bleeding,32 in the Gulf War. Some results indicated high rates of such as long periods of menstruation and missed periods women’s problems such as abnormal Papanicolaou (Pap) of menstruation.33 smears, vaginal yeast infections, infections of bladder and Using the data from a nationally representative survey breast and uterus cysts among female Gulf War veterans. conducted in 1996, Agadjanian and Prata examined the One of the major studies investigating the reproductive adverse effects of war on the timing of deliveries and health of female Gulf War veterans was the National war-related disorders in fertility potential in Angola.34 Health Survey/Longitudinal Health Study. In this study, a They found that fertility was considerably reduced in sample of 30 000 veterans participated in 1995 and again the wartime period and subsequently increased in the in 2005 and 2012. Ectopic pregnancy and spontaneous postwar period, and these significant changes in fertility abortion were increased among the women participating potential depended on the period of exposure to war in this study.9 and women’s socioeconomic aspects. In another study, Unfortunately, to the best of our knowledge, there is researchers indicated that Angolan women’s fertility no study examining the impact of the Iran-Iraq war on potential significantly decreased during the conflict peak menstruation function and infertility rate among woman and increased in the relatively peaceful period. These living in war-torn cities and villages in southern Iran. notable changes in women’s fertility potential in the Angola conflict were stronger in regions more affected by Stress and Menstruation Cycle Irregularity war than those less affected.35 Many organs and hormones in the female body regulate The Lebanon war is one of the wars considerably menstrual cycles. The hypothalamic-pituitary-ovarian affecting women’s menstruation and reproductive health. axis plays a vital role in regular menstruation in women.4 A study was conducted on menstruation health of women Furthermore, regular menstrual cycles are very important living in small towns and villages in southern Lebanon in having a functional reproductive system. Studies show that were bombed in the date of April 11–27, 1996.8 that factors such as stress, smoking, and malnutrition The results showed that short-term warfare can act as an are associated with irregular menstruation and early extremely stressful condition and lead to severe menstrual menopause. Physiological stress has been shown to cause

S18 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 Impact of War on Fertility and Infertility menstrual perturbations.36-38 In a study by Yao et al, the observed sex ratio at birth. effects of occupational stress on menstruation and female The Lebanese civil war was one of the most destructive sex hormones were examined. The authors showed that wars lasting for 15 years (1975–1990) with adverse effects a higher stress degree significantly increases FSH and on fertility potential in men. Many studies have shown estrogen levels and reduces testosterone levels. They that the Lebanese war has severely weakened the socio- concluded that stress could lead to menses disorders. economic and public health conditions in the country. The In addition, previous studies indicated that increased prolonged Lebanese war destroyed Lebanese infrastructure childhood adversity might result in adult fertility and severely damaged the environment, social services and disorder; however, the accurate mechanism is unclear.36 medical care.15 Besides, the inappropriate disposal of toxic In another study, Jacobs et al examined how childhood waste and the toxic waste imported from Europe during adverse experiences can affect menstrual cycle indices and wartime is very common.15 In one study, Abu-Musa et fertility problems. They concluded that the deleterious al examined the effects of the Lebanese war on sperm effects of childhood stress on fertility are the result of parameters. In this study, semen samples obtained during the impaired hypothalamic-pituitary-ovarian axis that the war were compared with post-war semen samples. suppresses fertility in response to less optimal reproductive The results indicated that the Lebanese civil war caused conditions.37 It can be concluded that stress has negative significant reduction of sperm concentration during effects on menstrual cycle indices and menstrual disorders wartimes. Besides, the percentage of normal morphology can eventually lead to fertility problems. It can be very of sperm was reduced in the postwar period. Furthermore, clearly stated that wartimes is the most stressful period that volume and motility of sperm remained unchanged. The people may encounter in any society. Therefore, it can be authors concluded that higher stress degree during the war suggested that a high degree of physiological stress in the played a pivotal role in these findings. wartime period can cause menstrual cycle abnormalities Concerning the Gulf War, three epidemiological studies and subsequently, reproductive problems and reduction of have specifically examined infertility among veterans.12-14 fertility among women. The UK male veterans of the first Gulf War showed high rates of infertility in comparison to non-deployed Impact of War on Men’s Fertility veterans. Moreover, trying to conception was also greater Studies show that exposure to war increases the risk of among UK male veterans of the first Gulf War. The same fertility in men. Various reproductive toxicants are among results were observed among Australian veterans of the the risk factors that increase the risk of infertility in men first Gulf War. However, Ishoy et al did not find any during war. War stresses, as well as direct damage to the significant change in reproductive hormones and fertility reproductive system, are other important risk factors that potential among Danish veterans of the Gulf War.11 Only increase infertility rates in men. Previous studies reported one epidemiological study especially evaluated infertility that stress has deleterious impacts on various parameters of in relation to the Iran-Iraq war. However, Ladier-Fouladi semen quality such as semen concentration, morphology, did not find any effects for the Iran-Iraq war on Iranian and motility.39-41 fertility potential, and further studies are needed to better The Joint Commission for the Investigation of the characterize the influence of psychological stress on semen Atomic Bomb reported (1956) that sperm counts are quality parameters in the Iran-Iraq war.44 reduced in those proximally exposed to atomic bombs. Besides, histological gonadal changes have markedly seen Effect of War on Environmental Degradation as a Factor in fetal cases.42 Associated with Reproductive Health and Infertility In one study, DeStefano et al investigated semen The prolonged war in Lebanon caused widespread characteristics among Vietnam War veterans.They found environmental damage. Considerable toxic waste was lower sperm concentration among Vietnam veterans, illegally imported from abroad and dumped on Lebanon’s and rate of abnormalities in sperm morphology was also soil. Heavy metals are known to be highly damaging significantly increased among Vietnam War veterans.41 agents to the reproductive system. Many Studies indicated In 1991, a short war occurred in Slovenia, Zorn et that environmental contamination by heavy metals such as al examined the effects of the stress associated with Cd, Zn, Pb, Mn, Se, and As could damage the production, this war on men’s fertility potential and sperm quality maturation, motility, and fertilizing capacity of human indicators.43 The authors identified that sperm motility spermatozoa.45 Men living in urban areas have a greater was significantly decreased, while sperm concentration reduction in ejaculation volume and sperm concentration and morphology remained unchanged. Moreover, in this in comparison to those living in rural districts. Thus, it study, a significant reduction of sex ratio at birth was can be suggested that chronic and low-level exposure to observed. They concluded that acute psychological stress environmental contamination in war-torn countries can caused by a short war in Slovenia could lead to adverse be associated with reproductive problems.46 changes in sperm motility and ultimately reduction in the

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Chemical Warfare Agents is also very prevalent among SM victims, as in one study Effect of Sulfur Mustard on Fertility on Iranian men exposed to SM, 35% of them reported Sulfur mustard (SM or agent HD) is a lipophilic alkylating decreased libido.27 Erectile dysfunction and premature agent that has been widely used as a chemical warfare agent ejaculation were also significantly increased among SM- in several wars. Only few studies have so far examined the exposed men.25 Reduction of serum testosterone level can deleterious effects of SM on the fertility and reproductive lead to these complications.48 system. These studies have shown that SM has negative effects on sperm quality and male fertility potential. Sulfur Mustard Induces Oxidative Stress Studies in animal models have shown that exposure to SM Reactive oxygen species (ROS) are naturally produced can damage the reproductive system in men and impair the by aerobic cells. The cells have a defense line called production of sex hormones, eventually leading to sexual antioxidants that can neutralize ROS. Oxidative stress impotence. SM exposure can also affect sperm quality occurs when ROS are produced excessively. Oxidative and quantity. Patients who have been exposed to SM have stress can damage cells.49 developed azoospermia and severe oligospermia.23 Besides, One of the important factors in poor sperm quality, abnormal morphology of sperm, reduction of sperm sperm dysfunction, and male infertility is the increase in motility, reduced sperm count, abnormal viscosity of oxidative stress. A high percentage of infertile men show semen and reduction of semen volume have been reported a high rate of seminal ROS which can damage the sperm in these patients.19-21 In one study on patients who were DNA.50-52 Spermatozoa are one of the most susceptible exposed to SM during the Iran-Iraq war, semen analysis cell types to ROS.50 Immature spermatozoa and leukocyte indicated that sperm abnormalities were observed in 38% cells originating from the prostate and seminal vesicles can of SM victims.20 Studies on long-term SM exposure two produce excessive ROS.48 It has been clearly determined decades after the exposure indicate that male infertility that by damaging the membrane lipids, DNA and proteins increased among exposed patients compared to non- of sperm and altering the activity of enzymes and inducing exposed individuals.23 Furthermore, severe adverse effects cell death, ROS disrupt sperm quality, ultimately resulting on the semen characteristics have been observed in the in male infertility.49 SM exposed men. Exposure to sulfur mustard analogues SM exposure in the human body induces oxidative also causes changes in the levels of sex hormones such stress, which results in reduction in sperm quality and as gonadotropins and testosterone. Gonadotropins male infertility. It has been shown that SM can result (FSH, LH) and testosterone are the major hormones in in excessive production of ROS in the testicular tissue, the spermatogenesis process.19-23 Thus, changes in the adversely disturbing the structure and function of levels of these hormones can eventually cause abnormal sperm.53-55 It has been also reported that SM exposure can spermatogenesis. For example, the production of FSH in increase inflammatory reactions.56,57 patients with a history of SM exposure was increased.20 Moreover, SM can increase the accumulation of Besides, a long-term study by Azizi et al demonstrated inflammatory cells, including macrophages and deficiencies in androgen hormones and responsiveness neutrophils, thereby increasing the levels of inflammation to GnRH in these patients.19,20 There was also a chemical mediators such as interleukins and cytokines. significant decrease in the levels of free testosterone19 and The elevated levels of inflammation chemical mediators dehydroepiandrosterone20 in these patients. Testosterone can increase the recruitment and activation of other plays a crucial role in spermatogenesis. The reduction in leukocytes in the reproductive system. A high leukocyte intra-testicular testosterone concentrations causes germ number in the reproductive system can increase the level cell apoptosis in the seminiferous epithelium.22 Due to of ROS, which may exceed the potency of the antioxidant the reduced testosterone levels caused by SM exposure, system and ultimately, result in oxidative stress in seminal spermatogenesis is disrupted and apoptosis is induced plasma. ROS produced by SM-induced phagocyte cells in the germ cells, ultimately reducing sperm quality. cause induce inflammations, impaired spermatogenesis as Furthermore, low sperm counts and percentage of sperm well as apoptosis and low quality of sperm.58 SM, in the abnormality are demonstrated to be significantly associated reproductive tract, induces excessive production of ROS, with a high FSH level. An elevated FSH level leads to disrupts the mitochondria function, increases the activity abnormal spermatogenesis and may indicate primary of enzymes producing ROS, and reduces seminal plasma testicular failure.47 Several studies on testicular biopsies antioxidants, including GSH and several antioxidant in SM-exposed patients revealed that spermatogenesis enzymes. Ultimately, SM causes an imbalance in stress was arrested completely or relatively. Furthermore, oxidative level and antioxidant defense.56 atrophy of the germinal epithelium, intact Sertoli cells, and normal-appearing Leydig cells are increased.47 Conclusion Therefore, spermatogenesis seems to be the main target In this study, we conclude that exposure to war can of the gonadal injury caused by SM. Sexual dysfunction increase the risk of male infertility. In women, war leads to

S20 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 Impact of War on Fertility and Infertility menstrual dysfunction. It is not clear how war affects male 2007;109(4):929-32. and female infertility is not clear, but it seems that the 9. Eber S, Barth S, Kang H, Mahan C, Schneiderman A, Dursa E. The National Health Study for a New Generation of United increasing degree of stress during war can compromise the States Veterans: Methods for a large-scale study on the health fertility potential. Physiological stress can affect fertility in of recent Veterans. Mil Med. 2013;178(9):966-99. doi: direct and indirect ways. 10.7205/MILMED-D-13-00175. Physiological stress can directly impair the function of the 10. Stellman SD, Stellman JM, Sommer JF Jr. Health and reproductive outcomes among American Legionnaires in autonomic nervous, the neuroendocrine and the immune relation to combat and herbicide exposure in Vietnam. systems, whereas indirectly, it can cause change behaviors, Environ Res. 1988;47(2):150-74. for instance, smoking. Stress can also cause an abrupt 11. Ishoy T, Andersson A-M, Suadicani P, Guldager B, Appleyard M, change in the hormonal component of spermatogenesis. Gyntelberg F, et al. Major reproductive health characteristics in male Gulf War Veterans. The Danish Gulf War Study. Dan Physiological stress in women also disrupts menstrual Med Bull. 2001;48(1):29-32. cycles and ultimately disrupts women’s fertility potential. 12. Sim M, Abramson M, Forbes A, Glass D, Ikin J, Ittak P. So, psychological stress seems to induce female infertility Australian Gulf Veterans’ Health Study. vol. 2: Commonwealth during and/or after the war. The use of chemical agents Department of Veterans’ Affairs; 2003. 13. Maconochie N, Doyle P, Carson C. Infertility among male UK during war also damages the male reproductive system. veterans of the 1990-1 Gulf war: reproductive cohort study. Recent studies show that SM can severely damage the BMJ. 2004;329(7459):196-201. reproductive function. SM has deleterious effects on sperm 14. Kelsall HL, Sim MR, Ikin JF, Forbes AB, McKenzie DP, Glass quality and male infertility. Oxidative stress-induced DC, et al. Reproductive health of male Australian veterans of by SM exposure is one of the major mechanisms of the 1991 Gulf War. BMC Public Health. 2007;7(1):79. 15. Abu-Musa AA, Nassar AH, Hannoun AB, Usta IM. Effect of impairment of reproduction potential in men. Oxidative the Lebanese civil war on sperm parameters. Fertil Steril. stress can result in lower quality of sperm and ultimately, 2007;88(6):1579-82. higher male infertility rates among SM-exposed patients. 16. Kobeissi L, Inhorn MC, Hannoun AB, Hammoud N, Awwad J, Abu-Musa AA. Civil war and male infertility in Lebanon. Fertil Steril. 2008;90(2):340-5. Authors’ Contribution 17. Pour-Jafari H, Moushtaghi A. Alterations of libido in gased All authors contributed to the study conception and design. AB and Iranian men. Vet Hum Toxicol. 1992;34(6):547-. FZ performed material preparation data collection. The first draft of 18. Ketabchi A. Urogenital and fertility complications in victims the manuscript was written by AB and all authors commented on of chemical war residing in Kerman province. J Kerman Univ previous versions of the manuscript. All authors read and approved Med Sci. 1998;5(2):72-7. the final manuscript. 19. Azizi F, Jalali N, Nafarabadi M. The effect of chemical weapons on serum concentrations of various hormones. Iran J Med Sci. Conflict of Interest Disclosures 1989;7(1): 46-50. None. 20. Azizi F, Keshavarz A, Roshanzamir F, Nafarabadi M. Reproductive function in men following exposure to chemical Ethical Statement warfare with sulphur mustard. Med War. 1995;11(1):34-44. Not applicable. 21. Safarinejad M. Testicular effect of mustard gas. Urology. 2001;58(1):90-4 References 22. Amini M, Hosseinpour M. Late complications of chemical 1. Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on warfare gases on pituitary-gonadal axis. J Faculty Med Shahid violence and health. Lancet. 2002;360(9339):1083-8. Beheshti Univ Med Sci. 1998;21:27-31. 2. Katon J, Cypel Y, Raza M, Zephyrin L, Reiber G, Yano EM, et 23. Amirzargar MA, Yavangi M, Rahnavardi M, Jafari M, Mohseni al. Self-reported infertility among male and female veterans M. Chronic mustard toxicity on the testis: a historical cohort serving during Operation Enduring Freedom/Operation Iraqi study two decades after exposure. J Androl. 2009;32(4):411-6. Freedom. J Womens Health (Larchmt). 2014;23(2):175-83. 24. Shakeri S, Yazdani M, Kheradpazhouh E. Long-term effect of doi: 10.1089/jwh.2013.4468. exposure to mustard gas on male infertility. Iran Red Crescent 3. Welch LS, Schrader SM, Turner TW, Cullen MR. Effects of Med J. 2007;9(2):59-62 exposure to ethylene glycol ethers on shipyard painters: II. 25. Ghanei M, Rajaee M, Khateri S, Alaeddini F, Haines D. Male reproduction. Am J Ind Med. 1988;14(5):509-26. doi: Assessment of fertility among mustard-exposed residents 10.1002/ajim.4700140503. of Sardasht, Iran: a historical cohort study. Reprod Toxicol. 4. Savitz DA, Sonnenfeld NL, Olshan AF. Review of epidemiologic 2004;18(5):635-9. studies of paternal occupational exposure and spontaneous 26. Pour-Jafari H, Moushtaghi A. Alterations of libido in gased abortion. Am J Ind Med. 1994;25(3):361-83. doi: 10.1002/ Iranian men. Vet Hum Toxicol. 1992;34(6):547-. ajim.4700250306 27. Safarinejad MR. Sperm chromatin structure assay analysis of 5. Olshan AF, Faustman EM. Male-mediated developmental Iranian mustard gas casualties: a long-term outlook. Curr Urol. toxicity. Annu Rev Public Health. 1993;14:159-81. doi: 2010;4(2):71–80. 10.1146/annurev.pu.14.050193.001111 28. Balali-Mood M, Hefazi M. Comparison of early and late 6. Pasternak A, Brooks PG. The long-term effects of the Holocaust toxic effects of sulfur mustard in Iranian veterans. Basic Clin on the reproductive function of female survivors. J Minim Pharmacol. 2006;99(4):273-82. Invasive Gynecol. 2007;14(2):211-7. 29. Sasser L, Cushing J, Dacre J. Dominant lethal study of 7. Seigel D. Frequency of live births among survivors of the sulfur mustard in male and female rats. J Appl Toxicol. atomic boms hiroshima. Am J Hum Genet. 1972;24:613-22. 1993;13(5):359-68. 8. Hannoun AB, Nassar AH, Usta IM, Zreik TG, Musa AAA. 30. Kooshesh L, Dashtnavard H, Bahadoran H, Karimi A, Jafari Effect of war on the menstrual cycle. Obstet. Gynecol. M, Asadi M. Evaluation of sulfur mustard effect on the

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spermatogenesis process of mature male rats. J Iran Anat Sci. reprotox.2007.10.011 2007;5:27-36. 46. Telisman S, Cvitković P, Jurasović J, Pizent A, Gavella M, 31. Yamazaki JN, Wright SW, Wright PM. Outcome of pregnancy Rocić B. Semen quality and reproductive endocrine function in women exposed to the atomic bomb in Nagasaki. AMA Am in relation to biomarkers of lead, cadmium, zinc, and copper J Dis Child. 1954;87(4):448-63. in men. Environ Health Perspect. 2000;108(1):45-53. doi: 32. Petit N. Dysfunctional uterine bleeding in active-duty women: 10.1289/ehp.0010845. scope of the problem and management options. J Womens 47. do Nascimento A, de Lima E, Boëchat G, Meyrelles S, Bissoli N, Health. 1996;6(6):358-61. Lenz D, et al. Testosterone induces apoptosis in cardiomyocytes 33. Wardell DW, Czerwinski B. A military challenge to by increasing proapoptotic signaling involving tumor necrosis managing feminine and personal hygiene. J Am Acad Nurse factor-α and renin angiotensin system. 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Pohanka M. Antioxidants countermeasures against sulfur 39. Hjollund NHI, Bonde JPE, Henriksen TB, Giwercman A, Olsen mustard. Mini Rev Med Chem. 2012;12(8):742-8. doi: J, Danish First Pregnancy Planner Study Team. Job strain and 10.2174/138955712801264783. male fertility. Epidemiology. 2004;15(1):114-7. 54. Tewari-Singh N, Jain AK, Inturi S, Agarwal C, White CW, 40. Gerhard I, Lenhard K, Eggert-Kruse Wae, Runnebaum Agarwal R. Silibinin attenuates sulfur mustard analog-induced B. Clinical data which influence semen parameters in skin injury by targeting multiple pathways connecting oxidative infertile men. Hum Reprod. 1992;7(6):830-7. doi: 10.1093/ stress and inflammation. PLoS One. 2012;7(9):e46149. doi: oxfordjournals.humrep.a137745 10.1371/journal.pone.0046149. 41. DeStefano F, Annest JL, Kresnow MJ, Schrader SM, Katz DF. 55. Safarinejad MR. Sperm chromatin structure assay analysis of Semen characteristics of Vietnam veterans. Reprod Toxicol. Iranian mustard gas casualties: a long-term outlook. Curr Urol. 1989;3(3):165-73. 2012;6(2):112. doi: 10.1159/000343522 42. Oughterson AW, Warren S. Medical Effects of the Atomic 56. Jafari M, Ghanei M. Evaluation of plasma, erythrocytes, Bomb in Japan. New York: McGraw-Hill; 1956. and brochoalveolar lavage fluid antioxidant defense system 43. Zorn B, Virant-Klun I, Verdenik I, Meden-Vrtovec H. in sulfur mustard-injured patients. Clin Toxicol (Phila). Semenquality changes among Slovenian healthy men 2010;48(3):184-92. doi: 10.3109/15563651003623297. included in the IVF-ET programme during 1983–1996. Int J 57. hohrati M, Aslani J, Eshraghi M, Alaedini F, Ghanei M. Androl. 1999;22:178–83. Therapeutics effect of N-acetyl cysteine on mustard gas exposed 44. Ladier-Fouladi, M. Population et politique en Iran: de la patients: evaluating clinical aspect in patients with impaired monarchie à la République islamique. Presses Universitaires pulmonary function test. 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S22 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 ARCHIVES OF Arch Iran Med. April 2020;23(4 Suppl 1):S23-S26 IRANIAN doi 10.34172/aim.2020.s5 http://www.aimjournal.ir MEDICINE

Open Review Article Access Peace, Health, and Sustainable Development in the Middle East

Amirhossein Takian, PhD1,2,3*; Golnaz Rajaeieh, MSc4

1Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran 2Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran 3Health Equity Research Centre (HERC), Tehran University of Medical Sciences, Tehran, Iran 4Department of Community Nutrition, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Abstract Background: As two essential human rights, as well as pillars of sustainable development, health and peace are closely interrelated. Further, health and well-being are the focus of Sustainable Development Goal (SDG) 3, while peace lies at the heart of SDG 16. This paper investigates the relationship between the three concepts of health, peace and sustainable development in the relevant literature. Methods: This is a qualitative study. Following the establishment of the construct of peace and health through consultation with three key informants (one health sociologists, one high-ranking diplomat, and one health policy maker), we conducted a scoping review of the literature, followed by purposefully obtained grey literature, i.e. UN and country reports. As a result, 30 documents, including journal articles, were identified. We used content analysis to extract themes and categorize them in line with the relevant SDGs. Results: Lack of peace has direct and indirect impact on health, as well as health workers, the civil society, and the whole community who have in turn a critical role in creating peace. Strong and resilient health systems are essential in reaching out to citizens during war, while achieving SDGs would be impossible if SDG 16 is compromised. Health and peace are interchangeable, and achieving either is impossible without the other. Conclusion: Physicians and other human resources for health are the key actors in peaceful environment to attain health for all. In the absence of peace, the resilience of health system will be threatened and the hope for sustainable development may fade. Keywords: Health, Middle East, Peace, Sustainable development Cite this article as: Takian A, Rajaeieh G. Peace, health, and sustainable development in the Middle East. Arch Iran Med. 2020;23(4 suppl 1):S23–S26. doi:10.34172/aim.2020.s5.

Received: February 25, 2019, Accepted: October 12, 2019, ePublished: April 1, 2020

Introduction other goals that are closely related to the aim of sustainable The World Health Organization (WHO) constitution peace,4 which is an embedded prerequisite of “sustainable (1946) considers the utmost degree of achievable health development”,5 which in turn focuses on root causes to standard as an essential right of all humankind.1 Approaches build societal resilience.6 to health that are based on human-right require more Peace is not simply the absence of violence. There are emphasis by policy makers on the needs of vulnerable and various types of peace, which reflect a broader spectrum those left behind, so-called “equity”. Such an approach of the quality of peace. A ceasefire can create peace even has been also endorsed by the United Nations’ (UN) if it is temporary, as happened with the Syrian ceasefire Sustainable Development Goals (SDGs), particularly in December 2016.7 Peace can be defined as freedom SDG 3.8 on universal health coverage (UHC).2,3 SDGs from civil disturbance, a state of security, or order within explicitly recognize the fundamental mutual relationship a community provided by law or customs, harmony in between peace and SDGs, none of which can be attained personal relations, or a state or period of reciprocal accord without the other. between governments.8 Theoretically, there are two aspects SDG 16 is to “promote peaceful and inclusive societies to peace: ‘positive peace’ and ‘negative peace’.9 While for sustainable development, provide access to justice negative peace is the absence of visible and direct violence, for all and build effective, accountable and inclusive which may refer to quality of peace,6 positive peace is self- institutions at all levels”.4 While this goal mentions peace sustaining and is therefore emancipatory in nature.6 more explicitly, peace is essential to achieving the SDGs As two dimensions of essential human right, which have as a whole. There are many targets and indicators under been endorsed by the constitution of many countries,

*Corresponding Author: Amirhossein Takian, PhD; Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, 2nd Floor, New Building, Poursina Ave., Tehran, Iran. Tel: +98-021-42933225, Email: [email protected] Takian and Rajaeieh health and peace are intrinsically interconnected.8 institutions, to prepare and assist people for effective Currently, and in the era of SDGs, peace is considered response. as a prerequisite of quality public health and a resilient As described in Table 1, the relationship between peace health system.10 Considering the definition of health by and health is intrinsically mutual. The role of doctors the WHO as complete state of mental, physical, social and and other healthcare practitioners is crucial in protecting spiritual health, health is not attainable without peace. population health. Indeed, peace is the most significant Countries in conflict need to prioritize building resilient factor to achieve health for all. In addition, health is innocent health systems for delivering productive healthcare.11,12 enough to play a brokerage role by bringing the conflicting The relationship between health, sustainable parties to discuss mutually beneficial interventions for all development and peace has not been substantially studied. parties involved.13 Moreover, healthcare staff have a great This study investigates this relationship and brings some responsibility to maintain humanitarian interventions and examples from conflicting countries in the Middle East. public health during and after armed conflicts, within We aim to draw practical lessons to show how peace can the context of resilient health systems.21 This requires to contribute to a resilient health and a healthier society. keep channels of humanitarian assistance open, including cross-border assistance, and balancing the control between Materials and Methods the government and other parties in action.22 In the area Our initial search identified a total of 1351 articles. We of health, many humanitarian agencies are responsible to removed 189 duplicates; as a result, 1162 articles plus grey protect and help the victims of war, either through direct literature remained. We screened the titles and abstracts actions on behalf of the victims, or providing them with for relevancy and further duplication. Finally, 30 articles food, shelter, water, vaccinations and medico-surgical care. were included for more detailed analysis. We included studies that mentioned resilient health Discussion system during war, the interaction between heath and Peace, health and sustainable development are interlinked. peace, health system implication during war and the Health is at the heart of SDGs, while achieving sustainable relationship between peace, health and sustainable development would be impossible if peace were to be development. compromised. Peace is not simply the absence of violence. We reviewed all remaining articles and summarized Nonetheless, war, as one of the most prominent examples of their information. Both authors held regular meetings lack of peace, has direct and indirect health consequences,23 over a period of two months to discuss findings and reach i.e. disrupted power supply and water sanitation, reduced consensus about the categorization of findings. immunizations, maternal and child health difficulties, psychosocial consequences, and physical deprivations.24 Results Health is a right for all.25 Hence, hospitals, medical The impact of war on health is fundamental, and it can units and health care personnel require special protection ultimately influence the achievement of SDGs.8 Health during crisis to maintain health promotion, disease control often means survival from war and its consequences, and prevention, treatment of acute illnesses and chronic which is in turn associated with access to essential life care, and appropriate responses to emerging public health needs, i.e. water, food, healthcare, and many public health threats.26 When peace is compromised, health system outcomes.8 As an example, armed conflict is recognized as strengthening is crucial in enhancing health security. one of the biggest threats to human societies, which affects Resilient health systems are able to absorb disturbance and health in both direct and indirect ways.13 As a major cause adapt and respond to crisis, through integrated approaches of disease epidemics, such conflicts, e.g. war, are associated for provision of needed services before or during a with death and injury, reduced or abolished access to disaster.27 Indeed, a resilient health system should be able healthcare services, increasing incidence of communicable to regulate itself. diseases, reduced access to sanitary water, psychosocial Reciprocally, health can also affect peace. For instance, effects, and malnutrition.13 Similar to its direct impact, healthcare personnel are trained to utilize primary, indirect consequences of war can be serious in terms of secondary and tertiary prevention strategies to reduce increased mortality and endangering public health. the adverse effects of war on health.20 Even when severe We found nine mechanisms, through which the lack conflict is in place, healthcare staff are expected to resume of peace may affect health and achieving sustainable their duties in development and implementation of development (Table 1). relevant interventions to promote public health, to ensure Health system strengthening towards building a resilient that the essential healthcare services are available and health system is crucial in reducing the impact of conflict healthy and safe physical environments are maintained. on health and withstanding shocks.18 During any crisis, These require effective advocacy for human, financial, and resilient health systems must have robust tailored plans other resources that are needed to implement essential and to enhance the capacity of health actors, e.g. relevant emergency healthcare programs,8 which may nevertheless

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Table 1. Consequences of Lack of Peace on Health and Sustainable Development

Direct or Consequences of Lack of Peace Indirect Impact Example on Health

During the period of March 2003-July 2006, 654 965 people were killed in Iraq war, most of them because of gunfire.11 1. Injury, illness, disability, and death Direct From late 2001 until 2014, more than 26,270 citizens were killed in Afghanistan.13

2. Long-term physical or psychological effects on the The current situation in Afghanistan may be related to an additional 200 000 Indirect individuals injured during war indirect deaths.13

3. Conflict damages the social construction of the society Extensive increase in the number of casualties during the post-war era in Indirect and disrupts all activities of normal life Afghanistan due to military and police injuries. 14

4. Destruction of healthcare infrastructure, e.g. clinics and Severe decrease in pharmaceutical production in Syria, which was 90% hospitals, most of which will not be completely restored for Indirect before the war in Syria and reduced to 10%, resulting in a significant shortage months or years to come. of drugs and essential medicines across the country.15

Every minute, nearly 20 people are displaced as a result of war and conflict. 5. Displacing people as refugees in other countries, or In 2016, the total number of displaced people reached 65.6 million globally, Indirect internally displaced people within their own countries. plus over 10 million stateless people around the globe who are denied a nationality.16 In our region, wars and other conflicts in our neighboring countries, e.g. Iraq and Afghanistan, have drastically affected natural resources in Iran. 6. Harming the environment through reduction of non- High consumption of petroleum-based fuels, military vehicles that produce renewable natural resources and contaminating the Indirect hundreds of thousands of tons of CO , carbon monoxide, nitrogen oxides, environment with harmful materials. 2 hydrocarbons, and sulfur dioxide at an extremely high rate within the war areas.17 In 2005, worldwide military budget passed US$1.1 trillion, which is equal 7. Draining financial, human, and other resources away to 2.5% of global GDP, or an average spending of $173 per capita. Only in from more productive operations, such as healthcare Indirect the United States, the Center for Disease Control and Prevention on terrorism provision. preparedness spent $1.6 billion in 2006, which was 19% of the CDC’s total yearly budget.18 8. Expansion of violence culture and habits across the Many cultural heritage and art pieces were stolen during the war and society, where most conflicts are sought to be resolved occupation in Iraq, i.e. the national library and the national museum, as well Indirect through brutal means.2 as a number of important cultural monuments that were massively damaged and looted during the period of the occupation.19

9. Risk for the spread of infectious diseases, while the In Yemen, war has had devastating impact on mother and child health. private sector that is mostly concentrated in urban settings Vaccination rates have decreased, the incidence of diarrheal diseases has Indirect is not capable of tackling the problem even by the use of increased among children, malnutrition has increased among mothers and advanced care services.10 children, while both maternal and U5MR have increased.20

face several constraints, i.e. poor security, both for the impossible to achieve without meaningful and widespread victims and staff that in turn could slow down the relief peace. As such, peace and justice, i.e. strong institutions operations and very often limit their effectiveness.28 The are defined as SDG16, without which other SDGs are role of civil society is fundamental in bringing health unattainable. Strengthening health systems towards concerns to the center of foreign policy, so that effective building a resilient health system, especially in countries approaches can be taken to address such challenges.29 that are at risk of war, is crucial in decreasing the effects As a bridge for peace (HBP), health is a multidimensional of lack of peace on health. Strengthening the civil society, policy and planning framework to support health workers i.e. health-related NGOs, to help people and provide basic in delivering health programmers within war and post- care during war, while placing health and humanitarian conflict situations. Indeed, health can also simultaneously issues at the heart of foreign policy, are fundamental to contribute to peace-building.30 HBP entails a meaningful planning of all countries, particularly in the Middle East, collaboration among organizations, institutions, and in galvanizing their path towards sustainable development. individuals from various backgrounds. This approach is crucial in tackling two fundamental and catastrophic Authors’ Contribution problems during conflict, which have direct and AT conceived the study. GR conducted data collection with AT contributing to analysis and interpretation of findings. Both authors indirect consequences on health: blocking of sufficient approved the final draft of manuscript. AT is guarantor. humanitarian assistance and direct intentional attacks on the health care system as a weapon of war.30 Conflict of Interest Disclosures In conclusion, health and peace are interchangeable; None. achieving either is impossible without the other. Health Ethical Statement is fundamental to sustainable development, which is also Not applicable.

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Geneva: watson.brown.edu/costsofwar/files/cow/imce/papers/2015/ International Committee of the Red Cross: 1996 War%20Related%20Casualties%20Afghanistan%20and%20 29. WHO. Health and sustainable developments. Key Pakistan%202001-2014%20FIN.pdf. Health Trends. Available from: http://apps.who.int/iris/ 15. Taleb ZB, Bahelah R, Fouad FM, Coutts A, Wilcox M, Maziak handle/10665/68755. W. Syria: health in a country undergoing tragic transition. 30. Medecins sans Frontieres. Syria: Urgent need for cross Int J Public Health. 2015;60(Suppl 1):S63-72. doi: 10.1007/ border aid for Syrians. Available from: https://www. s00038-014-0586-2. doctorswithoutborders.org/what-we-do/news-stories/news/ 16. Bcheraoui CH, Jumaan A, Collison M, Daoud F, Mokdad A. syria-urgent-need-cross-border-aid-syrians.

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S26 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 ARCHIVES OF Arch Iran Med. April 2020;23(4 Suppl 1):S27-S32 IRANIAN doi 10.34172/aim.2020.s6 http://www.aimjournal.ir MEDICINE

Open Review Article Access Peace through Health and Medical Education: First Steps in Inclination of Healthcare Workers Toward Conflict- Preventive Activities

Erfan Taherifard, MD Student1; Hossein Molavi Vardanjani, PhD1; Neil Arya, MD2; Alireza Salehi, MD, MPH, PhD3*

1 MPH Department, Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, Iran 2Family Medicine (part-time) McMaster University, Adjunct Professor Environment and Resource Studies University of Waterloo, Waterloo, Canada 3Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran

Abstract Background: The number of deaths and disabilities due to all types of violence has increased; violence and especially war heavily affect public and individual health and all sectors, including the health sector, are responsible for making attempts to take part in mitigation of war effects. However, “peace through health” has not been so far included globally in the curriculum of basic medical schools. The study aims to prepare data on responsibilities that could be devolved to health sector, and the importance and role of education for those health workers who are willing to participate in the peace field Methods: A systematic search in Web of Science, PubMed, Scopus and ERIC was conducted looking for relevant documents following combination of the key terms: peace, health and education. Results: Health professionals consider war as a serious contagious disease that needs to be prevented like any other diseases. Prevention maneuvers at the primordial, primary, secondary and tertiary stages are important tasks that can be carried out by health professionals; there is an increasing demand for establishment of some courses; the roles and the manner of performing these tasks are not part of medical curriculum and for better execution of these roles, peace through health courses should be developed and then integrated to the current curriculum of health-related universities. Conclusion: The work of developing peace through health courses has been started before and it will continue until it completely becomes an accepted global course. Keywords: Education, Conflict (psychology), Health promotion, Medical, Violence Cite this article as: Taherifard E, Molavi Vardanjani H, Arya N, Salehi A. Peace through health and medical education: first steps in inclination of healthcare workers toward conflict-preventive activities. Arch Iran Med. 2020;23(4 suppl 1):S27–S32. doi: 10.34172/aim.2020.s6.

Received: March 2, 2019, Accepted: October 12, 2019, ePublished: April 1, 2020

Introduction peace is the most significant factor for the attainment of War/violence has profound devastating influences on health for all”.6 human health; it affects all aspects of human life and Almost all healthcare professionals including physicians, can destroy a society completely.1 Its complication and nurses, public health workers, mental health practitioners, consequences are divided into two categories: direct etc. can assist in peacebuilding and/or peace-making but consequences of war that include injury, disability, not only through humanitarian relief activities.7-9 and death, often affecting civilians; and indirect ones Despite the importance and the great potential of that include chronic physical disabilities, long-term healthcare professionals in peace-promoting activities, psychological trauma, destruction of the infrastructure of “peace through health” has not been globally included in society, increased number of refugees in other countries the curricula of medical schools.10 Introducing the basics, etc.2 It has been projected that war and violence will principles and key concepts, opportunities and dilemmas be one of the top 10 causes of disability and death, of peace through health to graduates and undergraduates globally.3 Therefore, the humankind has to promote of health-related disciplines could be a highly effective peace throughout the world if they want a healthier life. peace-promoting program.11 This study aims to shed more As peace is part of public health,4 the health sector has light on the importance of developing a global course for the responsibility to work toward peace in alliance with “peace through health”. other sectors including political, economic, social and ethnic divisions.5 Accordingly, the World Health Assembly Materials and Methods announced, “The role of physicians and other health Search Sources and Strategies workers in war/violence preservation and promotion of We conducted a systematic review for relevant publications

*Corresponding Author: Alireza Salehi, MD, MPH, PhD; Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. Email: [email protected] Taherifard et al on three subjects, responsibilities that could be devolved were selected based on meeting the inclusion criteria to health sector, importance and role of education for which are demonstrated in Table 1. those health workers who are willing to participate in the The full-texts of the remaining articles (n = 104) were peace field and current or previous training courses on evaluated and those articles were included that contained “peace through health”. The Preferred Reporting Items information about at least one of the three abovementioned for Systematic Reviews and Meta-Analyses (PRISMA) subjects. guideline was used in the current study.12 Data was gathered from two different sources; one from online Data Extraction databases and the other consisted of various courses in the An Excel spreadsheet was created to extract information field of medical peace-building and peace-making activities about study title, first author’s name, journal, year of derived from personal correspondence to authors, asking publication, country of study, methods, study design, other experts and review of eligible articles of the former postgraduate or undergraduate trainees, measures, and source. Online databases used for the systematic literature limitations and a paper code was given to each article. search were: Web of Science, PubMed, Scopus and ERIC. Then, in the summary table, study codes were listed and The search was conducted by the first author on February the findings from each study were qualitatively described 15, 2019. In order not to miss any data, we developed a beside its code; also, they were categorized into three broad search strategy for combination of non-specialized groups based on the data they provided about the three key terms and the keywords were reduced to only “peace”, main question of the study. “health” and “education”. The following search strategy was used in each of the databases: Results and Discussion • PubMed ((peace [Title/Abstract]) AND health [Title/ Why Health Professionals Should be Involve in Peace- Abstract]) AND education building Activities • Scopus: TITLE-ABS-KEY (“peace through health” By the definition of World Health Organization, health is OR (peace AND health AND education)) “the state of complete physical, mental and social well-being • Web of Science: ALL FIELDS: (peace) AND ALL and not merely the absence of disease or infirmity”13-15; So, FIELDS: (health) AND ALL FIELDS: (education) any factor that damages the physical, mental and social well- • ERIC: peer-reviewed AND peace AND health being status is endangering one’s health. Thus, health and health-related sectors should make all attempts to remove Study Selection the hazardous factor. Violence, conflict and especially war Seven hundred fifty-seven articles in Web of Sciences, 558 have been proven to be the leading cause of disability and articles in Scopus, 262 articles in PubMed and 76 articles death in many parts of the world16,17 and constitute one of in ERIC were found following the search and then their the most serious threats to the three components of health. citations were exported into Endnote X9. First, duplicates War directly accounts for thousands and even millions of (262 documents) were removed from the library and then deaths every years and a dramatically higher number of the first round of screening was initiated; in this step, physical and mental disability; furthermore, by destroying titles and abstracts of the articles were evaluated to remove the infrastructures of the society and jeopardizing people’s articles which were clearly irrelevant; those studies which access to healthcare centers and medical needs, it can cause did not contain the data needed for our study were excluded even more catastrophic consequences and more disability in this initial screening; however, those articles which were and death.18,19 Also, disruption of infrastructures allows unclear whether they met the study inclusion criteria or not the spread of infectious diseases and in these situations, were kept in the study for subsequent screening (Figure 1); malnutrition emerges at a higher rate.20 Moreover, these relevancy was considered where the studies provided data consequences can also lead to an increase in the level of in each of the following three topics: the reason why health conflict and violence and thus a “vicious cycle” is born that professionals should take responsibilities in peace-making tends to be more devastating (Figure 2). So, presence of and peace-building activities, how they can assume this peace is a component of health and health workers should role and why there is a vital demand for establishing peace have peace-building and peace-making activities. through health courses. In the second screening, articles The “vicious cycle” should be disrupted by multi-sector

Table 1. Inclusion/Exclusion Criteria

Inclusion Criteria Exclusion Criteria Population Studies on medical trainees or health workers Studies on non-medical students Study language English Other languages Study type All designs Letters and editorial papers Study appraisal Studies subjected to the process of peer-review Not peer-reviewed studies Full texts Available full-text articles Publications whose full-text material could not be retrieved

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Courses identified through other Records identified through sources database searching (n = 10) (n = 1653)

Identification

Records after duplicates removed (n = 1391)

Records screened (initial Records excluded screening) (n = 1221) (n = 1391)

Screening Articles excluded which Related records screened for didn’t meet the inclusion the second time (n = 170) criteria (n = 73)

Full-text articles assessed Full-text articles excluded, Eligibility for eligibility with reasons (n = 97) (n = 45)

Records reviewed Included (n = 62)

Figure 1. PRISMA Flow Chart of the Study Selection Process.

peace workings21; health workers, in addition to their What Health Workers Can Do in Peace-Making and direct effects on conflict-ceasing, can fuel the engines of Peace-Building Processes political arguments, social and economic agreements and As discussed earlier, conflict and other types of violence popular involvement. Generally, “Peace though Health” compromise the condition and status of health in the or “Health as a Bridge for Peace” involves the adoption involved society23; thus, we can consider violence as of a public health point of view by health workers a serious contagious disease that spreads rapidly and regarding conflict, war and other forms of violence, that entangles all layers of the public.24 As a matter of fact, aims to impede or lessen violence as a cause of death and attempts toward addressing this “serious disease: violence” morbidity, and promoting peace as a major determinant of and launching of peace process are not only done after health for all.21,22 the emergence of violence; like other diseases, health workers could identify several layers of prevention and Emergence and obviously, they should support initiatives that contribute exacerbation of risk factors such more to prevention and not cure; because they need a deterioration of as low 25 SES and quality of socioeconomic smaller budget and have better results and better efficacy. lives status, social Initiatives for prevention like prevention from any other exclusion, low income public health diseases are arranged in four sets: primordial, primary, secondary and tertiary preventions26 (each set itself includes a variety of measures and interventions). Primordial prevention, the first level of prevention, refers to impeding the development of risk factors that disruption of 27 infrastructures; predispose arenas to different types of violence and progession of risk dramatic numbers factors of conflict of death and this level includes initiatives that change the societal disability structures28 or environmental factors29 such as exclusion by policy or suppression of feelings and identities30; holding peace classes or shaping new attitudes are examples of this all types of type of activities. The next level, primary prevention, aims violence such as conflict and war to limit risk factors after being developed and not let them progress into conflict.31 This level concerns prevention of

21, 22 Figure 2. Vicious Cycle of Conflict: How Conflict Can Lead to Itself and violence from eruption. Examples of this level could Make the Situation More Complicated and Worse. be seen in global works of “International Physician for the

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Prevention of Nuclear War” (IPPNW) that tries to drew conflict-laden area’s health facilities can turn into the foci global public attention to the dangers of utilization of and the sources of devastating agents of diseases.46, 47 nuclear weapons32,33 The third level known as secondary These backgrounds need to be taught to the graduates prevention is employed when the big problem has and undergraduates of health-related disciplines.48 occurred and encompasses measures that focus on peace- Unfortunately, no global training courses have been making and prompts effective interventions to de-escalate designed in management of health system’s approach a violent conflict and extenuate the perilous impacts in during conflict-ridden periods and in guiding healthcare the conflict-laden arena. Example of the third levels can workers about what roles they should play for peace- be seen in humanitarian ceasefires, for example in central building and peace-making. Without such education, Africa known as “five days for peace”34 or El Salvador full prevention and limitation of wars, negotiation of peace works.35,36 The last level, tertiary prevention, direct conflicts and promotion of health by health workers may primarily at recovery and rehabilitation in post-conflict seem just like an optimistic reverie and conflict-mitigating situations and is meant to promote adjusting to limitation activities could not be accomplished with the highest in health, attempts to minimize severity of suffering from possible efficacy and may be ceased. MacQueen et al the on-going trouble and stabilize the arena affected by the stated, “there are thousands of people around the world cascade of violence.37 studying or working in medicine and health care who are aware of the health impacts of war and who wish to help Why There Is Need for Holding Courses and Workshops lessen war. Many of them have experienced war in their in this Field own societies. They took up health sciences for altruistic Now, an important question is posed, “how can healthcare reasons; now they want to make a positive difference, for workers play the roles discussed above without any their societies and for the world. But their textbooks and background?” The fact is that without educating the their teachers are unable to give them the guidance they basis, concepts and principles of “peace through health” seek.”49 This statement is representative of the importance to healthcare workers, it is really hard (maybe even near of demands for transformative medical education. The impossible) and troublesome for them to implement their deficits in knowledge, skills, values and utilities that aforementioned measures.38 These days, the health sector’s are essential and necessary for the purpose could be tasks do not just belong to the backside for taking care of eliminated by appending “Peace Through Health” courses the injured or the wounded and their new duties transferred to medical curriculum as mandatory or optional. In order them from the home front to the front line,39 where they to develop these courses, it may be better to seek help directly encounter the barrage of weapon fire40 and engage from health professionals with a wealth of experiences or straightforwardly in conflicts or their risk factors. Hence, representatives from international organization working any mistakes may put their lives in danger41 or worsen the in this field such as “Health as a Bridge for Peace”50 and situation and make conditions more complicated. “Violence and Injury Prevention”51 or non-governmental On the other hand, as discussed earlier, waging of war and organizations such as “Doctors Without Borders”52 and violence has always been accompanied by dramatic increases “Physicians for Human Rights”.53 in the prevalence and incidence of diseases and rapid For the first time, Peace through Health university dissemination of infections.42 Conflict may lead to large courses were launched in McMaster University, Hamilton, population displacement into overcrowded encampments Canada.54 These courses mainly focus on “how health or undeveloped cantonments with incomplete access to safe workers contribute to peace” and “how they can water, poor sanitation, inadequate basic necessities of life demolish conflict in every level of prevention and settle and partial access to medical services.43,44 These conditions tranquillity”.55 The discipline is collaborative, innovative increase the chance of exposure to disease agents. In the and optional for undergraduate students of health-related other word, it is reputed that war is the mother generator disciplines.56 Afterwards, another university in Canada, of epidemics and outbreaks of diseases. Thus, in the case of the Waterloo University, held courses for undergraduates occurrence of a severe conflict, the health sector’s approach in Peace through Health57 and similar programs and should be changed toward early detection and treatment courses have been introduced sporadically throughout the of diseases; now, again our question is posed, “how can universities in different countries,58 such as the University healthcare workers play the roles discussed above without of Tromsø Peace through Health courses administrated any background?” A study conducted in Mexico City with by Faculty of Health Sciences, Eastern university of Sri the goal of analyzing the health system status in the times Lanka and Washington university conducted by Dr. Evan of peace and war, showed a complete alteration of health and Dr. Hagopian, 4-credit classes on “health and war” sector attitudes and programs after that the civil war broke for both graduates and undergraduates.59 Some well- out.45 Without a suitable background of knowledge of known courses in this field were once established and may these situations and management, it may lead not only not be active these days, which are depicted in Table 2. to uncontrolled amplification of outbreaks but also the However, the field has not been yet globally integrated

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Table 2. Some Courses in the Field of “Peace Through Health”

Courses Sponsor Health and war59 Washington University Medical Peace Work III60 University of Bergen Peace-Building and Health Initiatives62 McMaster University Course in Peace and conflict studies51 Institute for International Studies at Oslo and Akershus University College (HIOA) Summer Peace and Conflict Course Kosovo63 Rochester Institute of Technology Kosovo (A.U.K) Health as a bridge for peace - Training64 WHO Peace, Health and Medical Work65 University of Tromsø Health Systems through Conflict & Recovery55 Scuola Superiore Sant ‘Anna IPPNW, the European Medical Peace Work Network, Physicians for Social Responsibility, and the War and Health66 University of Gezira in the medical curriculum. Furthermore, an online Peace Ethical Statement through Health course was launched entitled “Medical No ethics committee approval was required for this paper. 60 Peace Work”. 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Available from: https://www.academiccourses. policy-statements/policy-database/2014/07/22/13/29/the-role- com/Summer-Peace-and-Conflict-Course-Kosovo/Kosovo/RIT/. of-public-health-practitioners-academics-and-advocates-in- 64. WHO. Humanitarian Health Action; 2018. Available from: relation-to-armed-conflict. https://www.who.int/hac/techguidance/hbp/training/en/. 40. Serle J, Fleck F. Keeping health workers and facilities safe in 65. University of Tromsø. Peace, Health and Medical Work war. Bull World Health Organ. 2012;90(1):8-9. doi: 10.2471/ (PHMW). Available from: http://phmw.wikidot.com/. BLT.12.030112. 66. Karch DL, Logan J, McDaniel D, Parks S, Patel N. Surveillance 41. Webster PC. The deadly effects of violence against medical for violent deaths--National Violent Death Reporting System, workers in war zones. CMAJ. 2011;183(13):E981-2. doi: 16 states, 2009. Morbidity and mortality weekly report 10.1503/cmaj.109-3964. Surveillance summaries (Washington, DC : 2002). MMWR. 42. Councell CE. War and infectious disease. J Public Health 2012;61(6):1-43. Reports. 1941:547-73

© 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

S32 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 ARCHIVES OF Arch Iran Med. April 2020;23(4 Suppl 1):S33-S37 IRANIAN doi 10.34172/aim.2020.s7 http://www.aimjournal.ir MEDICINE

Open Mini Review Access Human Casualties and War: Results of a National Epidemiologic Survey in Iran

Mohammadreza Soroush, MD, MPH1; Zohreh Ganjparvar, MA1; Batool Mousavi, MD, MPH1*

1Janbazan Medical and Engineering Research Center (JMERC), Tehran, Iran

Abstract Background: Limited studies have reported epidemiologic data on the impact of Iran-Iraq war. This study examines the war casualties for both combatants and civilians on Iranians at national level. Methods: Databases of Veterans and Martyrs Affair Foundation (VMAF), Janbazan Medical and Engineering Research Center (JMERC) and Ministry of Health were used to collect the data. The prevalence of injuries for both civilians and combatants was presented. Casualties were studied based on conventional and unconventional weapons attacks (1980–2018), separately. Results: The Iran-Iraq war led to 183 623 lost lives, 554 990 injured and 40 240 captured. The mean length of captivity was 45.7 months (1 month-19 years) and 2.7% (n = 575) died in captivity. There were 1 439 180 war related injuries recorded in databanks, mostly affecting men (98.4%). About 1 439 180 injuries were recorded, most of them related to conventional weapons (938 928 [65.24%]). Remaining artillery and mortar fragmentation in the body (39.5%, n = 371 236), psychological disorders (15.9%, n = 228 944), and exposure to chemical weapons (11%, n = 158 817) were the most prevalent war-related injuries. Conclusion: Human casualties of the Iran-Iraq war on the Iranian side and the health care system are huge even after more than three decades. Keywords: Casualties, Chemical warfare agents, Health, Weapons of mass destruction Cite this article as: Soroush M, Ganjparvar Z, Mousavi B. Human casualties and war: results of a national epidemiologic survey in Iran. Arch Iran Med. 2020;23(4 suppl 1):S33–S37. doi:10.34172/aim.2020.s7.

Received: May 12, 2019, Accepted: March 11, 2020, ePublished: April 1, 2020

Introduction and the resulting injuries, including the types of chemical War is one of the most influencing factors on human warfare agents, as well as injuries or complications are to health. Lasting from 1980−1988, the Iran – Iraq war was be covered next. the longest (conventional) war of the 20th century. This war Information on war-related injuries was extracted from that engaged 1200 km2 of the western and south-western the Veterans and Martyrs Affair Foundation (VMAF). borders of Iran, led to death and injury of hundreds of VMAF regularly provides long-term care services to the war thousands of people and billions of dollars in cost. The survivors called “Janbaz” and their families by maintaining World health organization (WHO) expects wars to be in excellence in health care services through professional the 8th place in burden of disease and disability-adjusted collaboration. The foundation is responsible for salaries life year (DALY) in 2020.1 and pensions, as well as insurance and rehabilitation. It There have been various reports on casualties due to the also has duties regarding occupation, social-cultural and Iraq war against Iran. This study was designed because leisure services, and providing nursing home services for of the discrepancies between data reported in different those in need. The total budget of the foundation in 2019 studies and the need to obtain inclusive statistics on the was about $3 billion. injuries of the war on Iranians. The purpose of this study This foundation is the legal authority that provides was to investigate the epidemiological status of Iranian war pension and health services to Janbazan and civilians casualties more than three decades after the war. living with war disabilities. According to the executive regulations, the various disabilities in each survivor have to Materials and Methods be registered in the databank of the VMAF. The injuries or This descriptive study examines the consequences and disabilities (both physically or mentally) are confirmed by casualties resulting from the Iran–Iraq war. It investigates the special medical commission of the VMAF. Eventually, first the human casualties of conventional/unconventional the cases are referred to the Bureau of Medical Commission’s weapon attacks and the damages of unexploded ordnance Center for investigation and supervision to confirm any and landmines planted during the eight years of the war and further complications associated with the war casualties.2 after that until 2018. History of chemical warfare attacks Survivors are examined by a specialized medical team to

*Corresponding Author: Batool Mousavi, MD, MPH; Janbazan Medical and Engineering Research Center (JMERC), Tehran, Iran. Tel: +989121484364 - +9822412114; Fax: +9822418180; Email: [email protected]; [email protected] Soroush et al determine the injuries as well as the severity of disability. personals have been in danger. The problems caused by VMAF records and updates all war-related injuries. War ERW and landmines in these regions have continued injury conditions include the presentation of a certificate after the war and still take lives or injure people in border of injury due to presence in combat zones as well as missile areas.11 Between 1988 to 2003, about 4000 people have attack/landmines and explosive remnants of war (ERW) in been injured by ERW and landmines, most of them rural and urban areas. civilians and almost half of them children and adolescents. Databases of the VMAF, Janbazan Medical and About 40% of victims underwent amputation of one or Engineering Research Center (JMERC) and relevant more limbs and the most common injuries were reported databases from national studies2-11 were used to update the in lower limbs.5,11 data. This paper presents related data in casualties caused using conventional and unconventional weapons for the Conventional Weapon Injuries first time on the Iranian side at national level. Three decades after the war, many lives were lost and many were injured directly or indirectly. About 1,439,180 injuries Results were recorded, most of which were related to conventional Eight years of Iran-Iraq war led to 183,623 deaths,2,3 weapons (938 928, 65.24%). As Table 1 shows, the most most of them in men (97.1%) with a mean age of 22.8 common injuries due to conventional weapons in war ± 9.04 (median = 20) years ranging from 0 through 104 survivors are related to artillery and mortar fragmentation years. Nearly 3.5% of war-related deaths happened after in body (39.5%, n = 371 236), followed by limbs (15.5%, the war due to complications in survivors, implanted n = 145 833) and face (13.8%, n = 129 443) injuries. The landmines or unexploded ordnances.2 About 554 990 injuries due to fragmentation of artillery and mortar in were wounded, mostly with multiple injuries. In addition body most commonly affected the upper or lower limbs to the combatants, civilians and citizens including women (52.0%, n = 192 955), head (10.5%, n = 39 124) and spine and children were wounded due to conventional missiles,4 (5.6%, n = 20 702), respectively. The rate of amputation in landmines5,6 and even unconventional missiles-chemical upper and lower limbs was similar, while the rate of upper bombs.3 limbs injuries (n = 115 306) was 1.48 times higher than There were 1 439 180 war-related injuries, with the lower limbs (n = 77 649). majority of records registered for men (98.4%, n = The prevalence of spinal cord injuries was 2.9% (n = 1 416 989) in the VMAF databank, and 2093 types of 42 388) which accounted for 40.9% of the head and CNS physical and mental injuries. During the war, 40 240 injuries. Lumbar injuries were the most prevalent form combatants or civilians were captured by Iraqi forces, of spinal cord injury (89.7%, n = 38 009). Hearing loss consisting of 39 142 (99.4%) males and 24 (0.06%) (66.5%, n = 85 232) was the most common ear, nose and females. After the ceasefire in 1988 when prisoners of throat (ENT) injury. war (POWs) were exchanged, 39 164 (97.3%) were released and returned home, while 575 (2.7%) had died in Chemical Attack Injuries captivity. The mean length of captivity was 45.7 months, Despite international agreements, Iraq used chemical ranging between 1 month and 19 years. warfare agents including sulfur mustard and nerve agents In the third week of the war, Iraq attacked the civilian for five years not only against military forces, but also and residential areas, starting with Dezfoul. Most of the against civilians (1983–1988).7 The first UN Fact Finding civilian mortality happened in the cities of Tehran and Mission analysed probable chemically contaminated Dezfoul. Consequently, 2312 civilians were killed and samples in 1984 and declared in 2003 that 54 000 bombs, an additional 11 625 were injured.4 Therefore, this war’s 27 000 short range missiles and 19 500 chemical bombs sphere was not limited to military personal and battle were used against Iran. It also stated that Iraq used 1800 fields but extended to civilians, as well. tonnes of sulfur mustard, 140 tonnes of Tabun and 600 Although 30 years has passed since the end of the war and tonnes of Sarin.8 Overall, 387 chemical attacks occurred, despite better awareness about the dangers of landmines and 30 cities were targeted. The use of sulfur mustard and ERW, the remaining ordnances and landmines are was more extensive than nerve agents. Sulfur mustard, still threating the health of people in five border provinces a persistent weapon, remains on the ground for months and have led to loss of many lives and serious physical and contaminates other soldier’s clothing and equipment. and psychological problems.5,10,11 A total of 12 to 16 This beside, primary symptoms including blisters/ million landmines were planted during the war in an area burnings and causing chronic complications due to of 42 million km2 in western and south-western regions exposure to sulfur mustard led to more use of this agent.9 of Iran: West Azerbaijan, Kurdestan, Kermanshah, Ilam The most severe sulfur mustard attacks against civilians and Khuzestan provinces. These landmines still remain. happened in Sardasht and Oshnavieh. Two villages in During and after the war, civilians in these provinces West Azerbaijan province (Zardeh and Nesar Direh) including farmers, shepherds, children and even demining were heavily attacked by nerve agents.3,9 Hospitals were

S34 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 Human Casualties and War

Table 1. Prevalence of War Casualties in the Survivors of Iran-Iraq War

Male Female Total Type of Injury Number % Number % Number % I. Conventional weapons 923 671 65.19 15 257 68.75 938 928 65.24 Upper and lower limb injuries 143 197 10.11 2636 11.88 145 833 10.13 - Amputation 25 792 1.82 558 2.51 26 350 1.83

o Upper limb 12 662 0.89 264 1.19 12 926 0.90 o Lower limb 13 130 0.93 294 1.32 13 424 0.93 Skin lesions 64 820 4.57 1915 8.63 66 735 4.64 Eye lesions 24 404 1.72 609 2.74 25 013 1.74 - Unilateral or bilateral blindness 6982 0.49 223 1.00 7205 0.50 - Other eye injuries 17 422 1.23 386 1.74 17 808 1.24 Thorax injuries 31 739 2.24 465 2.10 32 204 2.24 Abdominal injuries 62 095 4.38 1331 5.99 63 426 4.41 Face-ENT injuries 128 054 9.04 1389 6.26 129 443 8.99 Head and CNS injuries 103 632 7.31 1406 6.34 105 038 7.30 Artillery and mortar fragmentation in body 365 730 25.81 5506 24.81 371 236 25.79 II. Chemical agents injuries 155 921 11.00 2896 13.05 158 817 11.03 - Skin lesions 44 989 3.17 848 3.82 45 837 3.18 - Eye lesions 48 496 3.42 845 3.81 49 341 3.43 - Lung lesions 62 377 4.40 1203 5.42 63 580 4.42 - Other injuries 59 0.0 - - 59 0.0 III. Both conventional and chemical weapons - Psychological Disorders 225 183 15.89 3 761 16.95 228 944 15.91 IV. POWs injuries 99 435 7.02 49 0.22 99 484 6.91 V. Uncategorized 12 779 0.90 228 1.03 13 007 0.90 Total injuries 1 416 989 100 22 191 100 1 439 180 100

ENT: Ear, Nose and Throat; CNS: central nervous system; POW: prisoners of war. not safe from attacks, as well; Fateme Zahra and Soomar, of injuries through 30 years after exposure. The diagnosis the two medical establishments and field hospitals, were of the injuries and severity of the lesions in lung, skin, and chemically attacked. The biggest problem resulting from eye were determined by a panel of medical experts. Expert chemical attacks on hospitals was impossibility of further panel members include pulmonologists, psychiatrists, use or reconstruction of those facilities. While hospitals neurologists, ophthalmologists, dermatologists, were generally rebuilt after conventional attacks, these cardiologists, forensic medicine experts and nephrologists. were no more utilizable after chemical attacks and were The expert panel members investigate the victim’s demolished.9 documents case by case and record the chemical injury About 100 000 were evacuated from the contaminated associated complications continuously. The records of areas and received basic emergency medical care. One of complications due to exposure were categorized based the reliable databanks about chemical warfare attacks is the on the involved organs (lung, eye and skin). In this evidence recorded by the Ministry of Health and Medical study, we categorized the complications according to the Education (MOHME). Based on MOHME evidence, medical commission of the expert physicians and the about 28 000 hospitalizations have been registered after VMAF guidelines. Currently, 64 190 survivors suffer from exposure to chemical agents; this is only part of the data complications caused by exposure to chemical agents. on those injured by chemical warfare, as we did not The number of chronic complications in this group was have access to all 100 000 records of evacuation from 158 817. About 40.1% were lung, 31.1% eye and 28.8% contaminated areas. Figure 1 shows the distribution of skin injuries (Table 1). The number of chemical injuries survivors exposed to chemical warfare who were evacuated are higher compared to the previously published data.3 from frontline during the Iran-Iraq war (1983–1988), and those hospitalized in field hospitals to receive emergency Mental Disorders health care services at the time of chemical attacks. About 15.9% of injuries were mental and psychological. The VMAF database classifies the data related to the The prevalence of mental disorders might be as high as injuries caused by chemical weapons based on the involved 40.2% in the survivors, if we consider one psychological organs and the severity of late complications, from the time disorder for each person injured. The diagnosis of

Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 S35 Soroush et al

3000 Feb

2500

2000

1500 Dec86

1000 Jan 87

April 86 500 Jan 87 June 87 Mar 88

Number Of exposed to Chemical Weapons to Chemical exposed Of Number Feb 86 Mar 85 Oct 87 Jun/July 88

0

83-84 85 86 87 88

Figure 1. Distribution of Veterans Exposed to Chemical Warfare Who Were Evacuated from Frontline Based on MOHME Database (n = 28 000) During the

Iran-Iraq War (1983–1988).

psychological disorders was not correctly recorded in There are populations who have been exposed to 61.9% (n = 141 755) of the disorders. In cases where chemical warfare but did not develop acute manifestation the type of psychological disorders was recorded, post- during the war and are not considered as exposed survivors traumatic stress disorder (68.7%, n = 59 875) was found by VMAF. So, 36 years after the chemical attacks, there are to be the most common diagnosis. still some who might have developed nonspecific clinical manifestations and complications due to chemical warfare Discussion and Research Gap agents in the late phase. The health problems of this group We updated the previous studies’ statistics and the human are less diagnosed as they are not referred to experts or casualties of Iran-Iraq war in this survey.1,3 Missile attacks qualified doctors. Moreover, no accurate data is available caused many casualties in military forces and civilians; on some other exposed individuals who have no clinical however, no information has been published on military symptoms. Therefore, the number of registered victims and civilian zones and the resulting casualties. Though the differs from the real number of exposed individuals and authors had access to credible databases, the recorded data the rate might change in the future. Since these people needs to be investigated and updated periodically for the who suffered from war casualties (not all those exposed survivors as well as their family members. Not only the to chemical warfare) are under support of the VMAF, it is Janbazs themselves suffer from war injuries, but also their estimated that the number of registered chemical weapons families are harmed because of the long-term caregiving victims in the VMAF database is far smaller than people which is very costly.12 Due to the necessity of electronic who were exposed. There are two types of veterans exposed medical records for veterans in Comprehensive Services to chemical weapons registered in VMAF. The first type Act, registering and following up the precise information pertains to those who have primary documents about on war victims will be possible in the future. their treatment at the time of exposure (1984–1988). The Several studies have addressed landmines and ERW and second group members manifest symptoms of chronic there is a national database in this field.5,10,11 The databank complications resulting from exposure to chemical warfare has been prepared before 2008. Updating and fixing the without any documents from the war period confirmed by incomplete database of victims of landmines and ERW relevant authorities (trusted expert physicians).3 Some of will provide more accurate information in the future. non-registered exposed individuals might have clinical or During the war about four million were involved in the subclinical manifestations related to exposure to chemical war zone, and one eighth of them were injured; these are agents. One of the most important subject that needs to be the population who registered in the VMAF to receive addressed is the population exposed to nerve agents. There health services and pension. So, the great majority of them has not been a comprehensive study on the health status of left without follow-up, and this population might have this group. The reason for receiving little attention could suffered from non-physical and indirect impacts of the be related to the higher rate of SM exposed survivors war which have a great burden for the health system. The (nearly twenty times higher) versus those injured by nerve health problems of this population who are out of reach are agents. in a state of uncertainty. Accordingly, this research reveals The effect of traumatic head/brain injuries is still unclear, part of the iceberg of these problems. Research focusing on as there is a huge gap in research regarding how extensive this group needs to be undertaken to assess the extent and the problem is and how to address it. Evidence suggests severity of their physical and mental health problems – for a high prevalence of war-related injuries, with increasing example; the population who were exposed to chemical concern about the incidence of depression. Unlike the weapons but were not registered. physical injuries of war, these situations are commonly

S36 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 Human Casualties and War

unrevealed at beginning and remain hidden to other ►Study Highlights health care workers, family members and the society. The • Studies on the human casualties of the Iran–Iraq war and impact often affects multiple health aspects for decades the prevalence of physical and mental injuries at national post-conflict from being in war to middle/late adulthood. level have been missed in research topics. • For the first time, we report the data available and registered Consequently, these conditions are less recognized and on injuries in war survivors based on three national unappreciated. Thus, the health care system needs to meet databases. these gaps for providing better quality health care to all in • Artillery and mortar fragmentation injuries, psychological need. disorders, and exposure to chemical weapons were found to be the most common war-related injuries registered for Our study delivers information on the burden of health the survivors’ health problems. among Iranian populations who experienced prolonged • A total of 40 240 veterans or civilians were captured by Iraqi war and survived while entering older adulthood. The forces (from 1 month through 19 years in captivity). • The total budget for VMAF shows a two-fold increase over pattern of injuries indicates the greatest suffering in the the last five years, emphasizing the greater economic survivors. Meanwhile, limited researches investigate and burden over the time. document the indirect cultural, social and economic impacts including migration, internal displacement, psychological disorders, food resource limitation, and against Iran; an Epidemiological Study. Iran J War Public outbreak of violence and social unrests caused by the war.1 Health. 2015;7(2):115-21. The total budget for VMAF shows a two-fold increase over 3. Mousavi B, Moradi-Lakeh M, Karbakhsh M, Soroush M. Years of life lost among Iranian people killed in the Iraq-Iran war: the the last five years (from $1.5 billion in 2014 to $3 billion 25-year perspective. Int J Inj Contr Saf Promot. 2014;21(4):382- in 2019), emphasizing the greater economic burden over 7. doi: 10.1080/17457300.2013.843569. the time. At the end, investigating inhumane effects of the 4. Khaji A, Fallahdoost S, Soroush MR. Civilian casualties of use of conventional and especially unconventional warfare Iranian cities by ballistic missile attacks during the Iraq-Iran war (1980–1988). Chin J Traumatol. 2010;13(2):87-90. on the environment and documenting the direct and 5. Soroush AR, Flahati F, Zargar M, Soroush MR, Araghizadeh indirect impacts of wars, which have remained unclear, H, Khateri S, et al. Injuries associated with landmines and are among the research needs. The data of this survey was unexploded ordnances in Iran. Arch Iran Med. 2010;12(4):384. based on Iranian war-related casualties. We recommend 6. Mousavi B, Soroush MR, Masoumi M, Khateri S, Modirian E, Shokoohi H, et al. Epidemiological study of child casualties of the conduct of a similar study on the Iraqi side to make landmines and unexploded ordnances: a national study from the results comparable at international level. Iran. Prehosp Disaster Med. 2015;30(5):472-7. doi: 10.1017/ S1049023X15005105. Authors’ Contribution 7. Khateri S, Ghanei M, Keshavarz S, Soroush M, Haines D. MRS and BM were the principal investigators and responsible for Incidence of lung, eye, and skin lesions as late complications the study design. ZG and BM collected the data, extracted records, in 34,000 Iranians with wartime exposure to mustard agent. J analyzed the data and wrote the final manuscript. MRS, ZG and BM Occup Environ Med. 2003;45(11):1136-43. doi: 10.1097/01. actively contributed to all elements of the study. All authors read jom.0000094993.20914.d1 and approved the final manuscript. 8. United Nations Monitoring, Verification and Inspection Commission (UNMOVIC) report. Unresolved Disarmament Conflict of Interest Disclosures issues, Iraq’s Proscribed Weapons Programs 6 March, The author has no conflicts of interest. UNMOVIC Working document; 2003:140-145. Available from: https://www.un.org/Depts/unmovic/documents/6mar. Ethical Statement pdf. The Ethics Committee of Janbazan Medical and Engineering 9. Foroutan A. Medical Experiences of Iraq’s Chemical warfare. Research Center approved the study with ethics code of 96-E-P- Tehran: Baqiyatallah University of Medical Sciences; 2003: 101. 179-188. 10. Mousavi B, Soroush MR, Masoumi M, Khateri S, Modirian Acknowledgement E, Shokoohi H. Epidemiological study of child casualties of We are immensely grateful to prof. Sograt Faghihzadeh (Department landmines and unexploded ordnances: a national study from of Biostatistics, Zanjan University of Medical Sciences) for his Iran. Prehosp Disaster Med. 2015;30(5):472-7. doi: 10.1017/ comments on an earlier version of the manuscript. S1049023X15005105. 11. Soroush AR, Falahati F, Zargar M, Soroush MR, Khateri SH, References Khaji A. Amputations due to landmine and unexploded 1. Zargar M, Araghizadeh H, Soroush MR, Khaji A. Iranian ordnances in post-war Iran. Arch Iran Med.2008; 11(6):595-7. casualties during the eight years of Iraq-Iran conflict. Rev 12. Mousavi B, Seyed Hoseini Davarani SH, Soroush M, Jamali A, Saude Publica. 2007;41(6):1065-6. doi:10.1590/s0034- Khateri S, Talebi M, et al. Quality of life in caregivers of severely 89102007000600025 disabled war survivors. Rehabil Nurs. 2015;40(3):139-47. doi: 2. Taebi G, Soroush MR, Modirian E, Khateri S, Mousavi B, 10.1002/rnj.159. Ganjparvar Z, et al. Human Costs of Iraq’s Chemical War

© 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 S37 ARCHIVES OF Arch Iran Med. April 2020;23(4 Suppl 1):S38-S42 IRANIAN doi 10.34172/aim.2020.s8 http://www.aimjournal.ir MEDICINE

Open Opinion Access “War Epidemiology” Versus “Peace Epidemiology”: A Personal View

Mohsen Rezaeian, PhD1*

1Epidemiology and Biostatistics Department, Occupational Environmental Research Center, Rafsanjan Medical School, Rafsanjan University of Medical Sciences, Rafsanjan, Iran

Abstract Epidemiology can be considered as a responsible public health science the aim of which is to control health problems. One of the most important public health problems is “war”. The aim of the present paper, therefore, is threefold: firstly, to determine to what extent war has been investigated from an epidemiological point of view; secondly, what the definition and scope of “war epidemiology” would be; and thirdly, if it would be possible to introduce a new branch of epidemiology entitled “peace epidemiology”. In the present study, I have tried to fulfill the aims of the study based on my experiences in war and peace epidemiology and also by reviewing the most relevant websites, documents and papers. Evidence suggests that enough epidemiological studies have not been carried out to determine the sheer public health consequences of war. “War epidemiology” can be defined as “the study of the distribution and determinants of war-related events in specified populations, and the application of this study to the control of war”. “Peace epidemiology” is a new branch of epidemiology which “highlights how peace could positively shape our world”. Epidemiologists need to produce more scientific evidence about the negative public health consequences of wars and also the positive public health consequences of peace. The ultimate aim of “war epidemiology” is to control war, usually by secondary and tertiary prevention activities. However, the ultimate aim of “peace epidemiology” is to reinforce peace by primary and/or primordial prevention activities. Keywords: Armed conflicts, Epidemiology, Peace, War-related injuries Cite this article as: Rezaeian M. “War epidemiology” versus “peace epidemiology”: a personal view. Arch Iran Med. 2020;23(4 suppl 1):S38–S42. doi: 10.34172/aim.2020.s8.

Received: February 25, 2019, Accepted: October 12, 2019, ePublished: April 1, 2020

Introduction be noted that in this article, the term “war” includes both Epidemiology can be defined as “the study of the “war” which often occurs on a rather large scale between distribution and determinants of health-related states or two countries, and also “armed conflict” that usually events in specified populations, and the application of happens on a rather small scale within one country. this study to the control of health problems”.1 Therefore, epidemiology can be considered as a responsible public To What Extent Has War Been Investigated from an health science the aim of which is to control health Epidemiological Point of View? problems. Among the most important public health If we focus only on war-related deaths and not the other problems is “war” the extent of which has grown hugely, public health consequences of war, the World Health especially during recent decades.2 Organization (WHO) estimates that in the 17th century, The aim of the present paper is threefold: firstly, to nearly 7 million people lost their lives due to war-related determine to what extent war as a huge public health injuries, while in the 20th century, this figure has increased problem has been investigated from an epidemiological sharply with 191 million people losing their lives. point of view; secondly, if we categorize epidemiological Furthermore, civilian casualties have increased largely studies related to war under the umbrella of “war from 10% in the 19th century to 60% in the 20th century.2 epidemiology”, what its definition and scope would be; These war-related mortality figures clearly highlight that and thirdly, if it would be possible to introduce a new war is a very important public health problem. Therefore, branch of epidemiology entitled “peace epidemiology”. it is essential to determine to what extent war has been As a Middle Eastern epidemiologist, I have developed discussed within epidemiological fundamental textbooks an interest in war and peace epidemiology.3,4 Therefore, and articles. I searched one of the excellent textbooks in within the present article, I have tried to fulfill the aims of epidemiology, i.e. “Modern Epidemiology”5 and found the study based on my experiences and by reviewing the out that wars were not mentioned in this textbook at all. I most relevant websites, documents and papers. It should also read a very important article entitled, “Challenges of

*Corresponding Author: Mohsen Rezaeian, PhD; Epidemiology and Biostatistics Department, Occupational Environmental Research Center, Rafsanjan Medical School, Rafsanjan University of Medical Sciences, Rafsanjan, Iran. Email: [email protected] War Epidemiology Versus Peace Epidemiology

Epidemiology in the 21st Century: Comments from the constant US$) in 2017 (Figure 1).9 As this map shows, leaders of several epidemiology associations.”6 I noticed the 10 biggest spenders in order of decreasing amount of that in this article, wars were not mentioned as a challenge. money spent are the United States, China, Saudi Arabia, Therefore, the most important question is, “Why are India, France, Russia, the United Kingdom, Japan, wars not mentioned in such important textbooks and/or Germany and South Korea. The size of these countries, articles”? especially the United States, has increased hugely. In 2017, the amount of total global military spending has been 1.68 Why Are Wars not Mentioned in Such Important trillion US dollars and the United States alone spent about Textbooks and/or Articles? 35% of this total value. Surely, one can argue several reasons for such a huge The second map depicts the territories resized according negligence. However, in one of my published articles, I to the number of nuclear warheads deployed there in 2017 have argued that the best answer to this predicament (Figure 2).10 As this map shows, there are four countries would come from the geographical point of view.7 that hugely enlarged in size. In 2017, from the total The WHO estimates that only in the year 2000, war- 3760 warheads, 1710 were deployed in Russia, 1650 in related injuries have been the 11th leading cause of death the United States, 280 in France and 120 in the United in the African Region (AFR) and 18th in the Eastern Kingdom. These four countries are among those ten Mediterranean Region (EMR). Whilst in the same year, biggest military spenders. war-related injuries were the 34th leading cause of death All these have led me to publish an article entitled, in the European Region (EUR) and 62nd in the American “Challenges of Epidemiologists of Developing Countries Region (AMR). in the 21st Century”. In this article, I have mentioned that Therefore, based on these figures, in recent years, war- wars and armed conflicts are among the most important related deaths should be considered as a very urgent challenges for the epidemiologists within low- and middle- public health problem only in AFR and EMR and not in income countries, especially in the AFR and the EMR.4 EUR and AMR.3 This might explain why the previously Taking a closer look at one of these region i.e. EMR reveals mentioned epidemiological textbook5 and article6 did not startling results. discuss wars at all since these documents were written by The EMR is a troubled area in which nearly all countries epidemiological colleagues from Western countries, while somehow suffer from wars and their consequences.11 most public health consequences of war-related problems During recent years, Afghanistan, Syria, Egypt, Libya, occur in countries within Africa and the Middle East.3 Tunisia, Yemen, Bahrain, Iraq, Palestine, and Somalia However, for fully comprehending this dilemma, there have witnessed wars, armed conflicts, turmoil and civil is one more issue which needs to be addressed, that is, disturbances leading to major waves of migrations.12 By “Which countries invest the most in wars7”? To answer this the end of 2016, 5.5 million Syrian people and 2.5 million important question, I use with permission two interesting Afghan people are seeking refuge in other countries mainly maps from “worldmapper” (https://worldmapper.org/).8 within the region.13 Furthermore, it has been shown that In producing these maps, a density equalized cartogram based on the Global Burden of Disease (GBD) 2015 data technique has been applied which actually re-sizes each and compared to similar figures in 1990, there has been a country in proportion to the variable being mapped. +1027% increase in war deaths in the region.14 The first map depicts the total military spending (in I also did a piece of research entitled, “Wars versus

Figure 1. Total Military Spending (in constant US$) in 2017. https://worldmapper.org/maps/military-spending-2017/.

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Figure 2. The Number of Nuclear Warheads Deployed in 2017. https://worldmapper.org/maps/nuclear-weapons-strategic-deployed-2017/.

SARS: Are epidemiological studies biased”? In this article, reducing the adverse consequence of wars. Therefore, I have considered wars with huge ill-health consequences it would be necessary to encourage and promote more that have been with human beings from the beginning war-related epidemiological studies within the affected of the history with 191 million deaths only in the 21st areas. For this purpose, it would be also possible and century, and compared the situation with severe acute necessary to categorize the existing war-related studies respiratory syndrome (SARS) as an emerging coronavirus under the umbrella of “war epidemiology” to help further infectious disease, which was internationally recognized development of this branch of epidemiology. In what in March 2003 with 774 deaths altogether. I did try to follows, I will try to provide a firm definition for “war highlight how epidemiological studies have responded to epidemiology” and also to determine the scope of this these two phenomena by dividing the number of total branch of epidemiology. retrieved epidemiological articles from PubMed by the number of the corresponding deaths. I found out that we What Would Be the Definition and Scope of “War have published 1917/774 (nearly 2.5 articles per death) Epidemiology”? for SARS and 9853/191 000 000 (nearly 0.00005 articles In my point of view, “war epidemiology” can be defined per death) for wars.15 as, “the study of the distribution and determinants of war-related events in specified populations”. In war Why Is Conducting War-Related Epidemiological Studies epidemiology, as we try to quantify all those horrible war- Necessary? related events, we have to have a negative look.17 Although As it has been mentioned, the AFR and the EMR so far within the present article I have only focused on have suffered the most from war-related deaths while war-related deaths, it should be borne in mind that there the EUR and the AMR have invested the most on are other negative war-related events, as well. military expenditures. Furthermore, the insufficiency of One may categorize all adverse impacts of wars into the epidemiological war studies compared to other public three following areas: firstly, health impacts that include health problems is evident. Therefore, the second most mortality, disability, and morbidity including mental important question is, “Why is conducting war-related disorders and rape, torture, etc. Secondly, socio-economic epidemiological studies necessary”? impacts including population displacement, collapse of Levy and Sidel have provided seven reasons for the social harmony and cohesion, failure of social services and necessity of documenting the adverse effects of wars on systems, diverting budget to military expenditures, etc. population health by conducting epidemiological studies. And thirdly, environmental impacts including air, water, These reasons include: notifying policy makers and public soil and sound pollution plus extra use of fossil fuels.18 All about the consequences of wars, determining instant needs these adverse impacts can and should be studied under the of affected people, decreasing the possibility of future umbrella of “war epidemiology”. wars, detecting abuses of international humanitarian law, However, since during war time it would be treacherous shielding human rights, stopping the use of indiscriminate and difficult to gather proper epidemiological data, we armaments such as antipersonnel land mines and need to explore appropriate methods of investigations for biological, nuclear and chemical artilleries, and finally “war epidemiology”. This would help to carry out valid avoiding massacre.16 epidemiological studies on the adverse consequences of As a result, war-related epidemiological studies could wars. For example, by applying a cluster sample survey, provide valuable evidence for documenting and hopefully Roberts and colleagues estimated that nearly 18 months

S40 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 War Epidemiology Versus Peace Epidemiology after Iraq invasion in 2003, 98 000 more deaths occurred concept that is more difficult to measure compared with mainly due to air strikes by the Coalition forces.19 Similarly, war.22,23 by applying another cluster sample survey in Iraq, Nonetheless, in a recent ecological study by Feyzabadi Burnham and colleagues estimated that as of July 2006, and colleagues, the association between peace and life there were 654 965 additional post-invasion deaths.20 expectancy has been examined among world countries Based on the methods developed and the results of war- from 2007 up to 2012. In this article, the authors applied related epidemiological studies, we also need to design the Global Peace Index (GPI) which is a score valued and conduct short- and long-term educational programs. between 1 and 5 in which lower score means higher peace. These might include workshops, summer schools, master’s They have shown that empirically, peace has a considerable and even PhD programs that are conducted through positive impact on increasing life expectancy even after international collaborations. All these efforts would also adjustments have been made for education and economic help to develop educational material including “war levels of the countries.24 epidemiological” textbooks.17 However, in my point of view, the newly developed academic discipline of “Peace through Health (PtH)” has Would It Be Possible to Introduce “Peace Epidemiology”? the potential to reinforce peace epidemiological studies. As By focusing on negative war-related events, it seems that Arya stated, PtH tries to highlight how health interventions the ultimate aim of “war epidemiology” is to control the may contribute to peace in real and probable war regions public health consequence of war usually by accomplishing by developing a framework to conceptualize the role of the secondary and tertiary prevention activities. In other health workers in peace activities.25 As a result, PtH has words, in “war epidemiology”, the epidemiological been also able to mediate between “war epidemiology” and studies will be carried out as soon as a war erupts (Figure “peace epidemiology”. 3). However, it seems that for primary and primordial The other advantages of PtH is that this approach has prevention of war or even to eradicate this social sickness, been transformed into the world’s first university course.26 we have to obtain a positive look. It has been argued that the academia, especially in the fields This encourages me to publish another article entitled, of health and medicine, can contribute to peace-building “Taking the opposite side of issues in epidemiology: efforts all throughout the world.27,28 Therefore, it is hoped ‘peace’ versus ‘war’”. In this article I have introduced that one day, the idea of “peace and war epidemiology” will “peace epidemiology” as a new branch of epidemiology. also transform into a university course. I have stated that “peace epidemiology… highlights In conclusions, epidemiologists need to produce more and documents how peace could positively shape our scientific evidence about the negative public health community, our country, our region, and our world”.21 consequences of wars. At the same time, they need to To put it in another way, in “peace epidemiology”, the produce even more scientific evidence about the positive epidemiological studies should be carried out before a war public health consequences of peace. The ultimate aim of erupts (Figure 3). “war epidemiology” is to control war, usually by secondary As a result, the ultimate aim of “peace epidemiology” and tertiary prevention activities. However, the ultimate is to reinforce peace by primary and/or primordial aim of “peace epidemiology” is to reinforce peace by prevention of war, or hopefully, even by the eradication of primary and/or primordial prevention activities. war. It should be noted, however, that there are very few studies which focus on the positive impact of peace on Authors’ Contribution MR is the sole author of the manuscript. public health. This occurs because peace is a multifaceted Conflict of Interest Disclosures None. Peace War War Ethical Statement Epidemiology Epidemiology Epidemiology Not applicable.

References 1. Porta MS GS, Hernâan M, dos Santos Silva I, Last JM. A Dictionary of Epidemiology. UK: Oxford University Press; War 2014. 2. World Report on Violence and Health. Geneva: World Health Organisation; 2002. 3. Rezaeian M. War is an unjustifiable man-made disaster within

Time the Eastern Mediterranean Region. Middle East J Fam Med. 2008;6:14-6. 4. Rezaeian M. Challenges of developing countries’ Figure 3. Depicting the Difference Of “War Epidemiology” and “Peace epidemiologists in the 21st century. Acta Med Iran. Epidemiology” in Relation to Prevention of War. 2016;54(1):4-8.

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5. Rothman KJ, Greenland S, Lash TL. Modern Epidemiology. 18. doi: 10.1146/annurev-publhealth-032315-021913. USA: Wolters Kluwer; 2008. 17. Rezaeian M. War epidemiology: an urgent plea. Epidemiology. 6. Foxman B. Challenges of epidemiology in the 21st century: 2015;26(1):e10-1. doi: 10.1097/EDE.0000000000000209. comments from the leaders of several epidemiology 18. Rezaeian M. A review on the most important consequences associations. Ann Epidemiol. 2005;15(1):1-4. doi: 10.1016/j. of wars and armed conflicts. Middle East J Bus. 2009;4:7-9. annepidem.2004.09.006 19. Roberts L, Lafta R, Garfield R, Khudhairi J, Burnham G. 7. Rezaeian M. Illustrating wars and armed conflicts from a Mortality before and after the 2003 invasion of Iraq: cluster different perspective: Who suffers and who invests the most? sample survey. Lancet. 2004;364(9448):1857-64. doi: Middle East J Business. 2011;6(1):12e4. 10.1016/S0140-6736(04)17441-2 8. World mapper 2018. Available from: https://worldmapper.org. 20. Burnham G, Lafta R, Doocy S, Roberts L. Mortality after the 9. Military Spending 2017. Available from: https://worldmapper. 2003 invasion of Iraq: a cross-sectional cluster sample survey. org/maps/military-spending-2017/?sf_action=get_data&sf_ Lancet. 2006;368(9545):1421-8. data=results&_sft_product_cat=war-and-peace. Accessed 13 21. Rezaeian M. Letter to the Editor: “Taking the opposite side of December 2018. issues in epidemiology: ‘peace’ versus ‘war’”. Ann Epidemiol. 10. Nuclear Weapons 2017. Available from: https://worldmapper. 2014;24(10):791. doi: 10.1016/j.annepidem.2014.07.015. org/maps/nuclear-weapons-2017/?sf_action=get_data&sf_ 22. Royce A. A definition of peace. Peace Confl. 2004;10(2):101- data=results&_sft_product_cat=war-and-peace. Accessed 13 16. December 2018. 23. Jose-Miguel FD, Alejandra H-d-M, Isabel J-d-L. Culture of 11. Rezaeian M. Age and sex suicide rates in the Eastern peace: An alternative definition and its measurement. Peace Mediterranean Region based on global burden of disease Confl. 2004;10(2):117-24. estimates for 2000. East Mediterr Health J. 2007;13(4):953-60. 24. Feyzabadi VY, Haghdoost A, Mehrolhassani MH, Aminian 12. Mokdad AH, Forouzanfar MH, Daoud F, El Bcheraoui C, Z. The association between peace and life expectancy: An Moradi-Lakeh M, Khalil I, et al. Health in times of uncertainty empirical study of the world countries. Iran J Public Health. in the eastern Mediterranean region, 1990–2013: a systematic 2015;44(3):341-51. analysis for the Global Burden of Disease Study 2013. Lancet 25. Arya N. Peace through health I: development and use of a Glob Health. 2016;4(10):e704-13. doi: 10.1016/S2214- working model. Med Confl Surviv. 2004;20(3):242-57. doi: 109X(16)30168-1. 10.1080/1362369042000248839 13. Mokdad AH. The burden of mental disorders in the Eastern 26. Arya N. Peace through health II: a framework for medical Mediterranean region, 1990–2015: findings from the student education. Med Confl Surviv. 2004;20(3):258-62. doi: global burden of disease 2015 study. Int J Public Health. 10.1080/1362369042000248848 2018;63(suppl 1):25-37. doi: 10.1007/s00038-017-1006-1. 27. Levy BS, Sidel VW. How academic medicine can 14. United Nations High Commissioner for Refugees (UNHCR) contribute to peace-building efforts worldwide. Acad Med. Global Trends: Forced Displacement in 2016. UNHCR; 2017. 2009;84(11):1487. doi: 10.1097/ACM.0b013e3181baa209. 15. Rezaeian M. Wars versus SARS: Are epidemiological studies 28. Khan AM, Janneck LM, Bhatt J, Panjabi R, Marjoua Y, Bharwani biased? Eur J Epidemiol. 2014;29(6):453-4. doi: 10.1007/ A. Building a health-peace movement: academic medicine’s s10654-014-9919-y. role in generating solutions to global problems. Acad Med. 16. Levy BS, Sidel VW. Documenting the Effects of Armed Conflict 2009;84(11):1486. doi: 10.1097/ACM.0b013e3181bab2bf. on Population Health. Annu Rev Public Health. 2016;37:205-

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S42 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 ARCHIVES OF Arch Iran Med. April 2020;23(4 Suppl 1):S43-S48 IRANIAN doi 10.34172/aim.2020.s9 http://www.aimjournal.ir MEDICINE

Open Opinion Access Provision of Peace and Right to Health through Sanctions: Threats and Opportunities

Reihaneh Dastafkan, PhD1; Hadi Salehi, PhD2*; Mohammad Mehdi Hooshmand, MA3

1International Law Department, School of Law, Shahid Beheshti University, Tehran, Iran 2Assistant Professor, Public Law Department School of Law & Political Science, Shiraz University, Shiraz, Iran 3International Law Department, School of Law & Political Science, Shiraz University, Shiraz, Iran

Abstract According to the purposes for the formation of the United Nations, sophistication of institutions like the Security Council must be evaluated based on the provision of peace and how they guarantee human rights. Therefore, in case Security Council does not follow these two mentioned factors, its function would be itself a threat to the international peace and security. This analytical research is based on collecting library theoretical data related to different field studies which investigated the effects of sanctions issued by the Security Council, the United States and the European Union on citizens’ health and tried to assess both their efficiency and legitimacy. The right to health is connected with the right of living. In case enough drugs, appropriate treatment and medical equipment are not provided at the proper time, both physical and mental health might be threatened and this can cause death of a large number of people. Considering the Security Council as an institution which is expected to take into account the citizens’ basic rights and not to ignore its own initial objective, the present paper was an attempt to provide explanations for the above concepts and their relationships and to analyze the findings of previous field studies. The paper concluded that sanctions issued by the Security Council and the United States are potentially functioning as threats to the international peace and so these sanctions are violating the citizens’ right to health. Keywords: Economic sanction, Jurisprudence, International law, International peace, Legal obligation, Right to health, Smart sanction Cite this article as: Dastafkan R, Salehi H, Hooshmand MM. Provision of peace and right to health through sanctions: threats and opportunities. Arch Iran Med. 2020;23(4 suppl 1):43–48. doi: 10.34172/aim.2020.s9.

Received: May 12, 2019, Accepted: October 12, 2019, ePublished: April 1, 2020

Introduction people with special diseases). The theory of ‘smart sanction’ was proposed as a result Therefore, reviewing cases of sanctions imposed against of criticisms imposed on human rights regarding the a number of countries such as Iraq, Cuba, Haiti and direct effect of economic sanctions on citizens’ lives and Iran, this paper questions if harmful consequences of consequently, violation of human rights for the people of these sanctions have surpassed their inhibiting effects. a nation. The aim was to mitigate the negative effects of Also, it investigates if availability of important drugs and these sanctions on citizens, which are common people and, death rate in vulnerable groups have undergone changes instead, point at specific groups at the higher political- in comparison with the time of the start of sanctions. official levels. In addition to considering the legitimacy Another point is whether or not devising these new of sanctions, including smart and non-smart sanctions, sanctions violates the citizens’ human rights. according to the international legal system (which is In doing so, it is necessary to analyze the legal beyond the scope of the present paper), it is necessary to fundamentals of the Security Council in devising these examine the validity of the claims made by the theorists of sanctions in an a priori critical study in light of restoration smart sanctions to check if they comply with human rights. of direct effects on right to the common citizens’ health. This is because if the apparently ‘smart’ sanctions impose These fundamentals are legally analyzed in form of a threats on the right to health, availability of drugs, medical posteriori conclusive study so that a number of practical equipment and effective treatments, macro-variables such strategies would be suggested in line with a human right as public development and the citizens’ welfare, obvious pattern to guarantee the citizens’ right to health. violation of human rights can be seen; this is because as these In addition, the present authors adopted a descriptive/ theorists themselves have acknowledged, such sanctions analytical method by conducting library studies to mitigate can have qualitatively widespread and quantitatively large the damaging effects of economic sanctions issued by the effects such as significant rise in death rate (particularly Security Council and other authorities in charge of this. in vulnerable groups like women, children, elderlies and The aim would be to help the citizens and statesmen, and

*Corresponding Author: Hadi Salehi, PhD; Assistant Professor of Public Law, School of Law & Political Science, Public Law Department, Shiraz University; Practice Lawyer & Legal Consultant, Tehran, Iran. Address: Entrance NO 4, Legal Office, Ministry of ICT, Shariati Street, Tehran, Iran. Cell: 00989128391735, Email: [email protected] Dastafkan et al to optimally manage the resources and then to recommend Nations Charter, in particular, actions of the Security practical strategies. Council in imposing comprehensive sanctions can be essentially considered as a violation of the United Nations Preliminaries and Legal Fundamentals Charter and threatening of the international peace. The term ‘sanction’ refers to a systematic reluctance to Whenever governments have deep economic relations hold social, economic, political and military actions of a with each other, they do not allow the violation of one state or of a specific group of states to penalize another another’s rights and interests. Targeting individuals and state or the sanctioned entity or to force them to accept the a limited number of institutions, smart sanctions reduce intended behavior1; economic sanctions are more common the effects of comprehensive sanctions on economic and than the other types. Although there are some instances of commercial relations of governments,4 though changes penalty in any sanction, they are merely devised with the in the method of imposing sanctions from addressing aim of penalizing the sanctioned country; instead, the aim governments to targeting real and legal persons caused new of sanctions is to create changes in the political behaviors problems. New sanctions mostly deal with the violation of of that country.2 A number of researchers hold that the rights of those individuals who have made some decisions most important function of any sanction is that they are within the official hierarchy, with no legal responsibility; inhibiting.3 additionally, smart sanctions suffer from lack of function Sanctions can be classified into ‘primary’ and ‘secondary’ in comparison with comprehensive sanctions. sanctions. If sanctions are merely related to relations of two countries, they are primary, i.e. with a limited range. Effects of Sanctions on the Right of Hygiene and While if one country expands the range of its sanctions Healthcare (Some Cases from the Past) and bans its economic, financial and other relations Right to health and hygiene was initially defined in the with countries which are in relation with the sanctioned WHO constitution. The Constitution was adopted by the country, the case of secondary sanctions can be seen. International Health Conference held in New York from Although sanctions are followed by economic expenses 19 June to 22 July 1946, signed on 22 July 1946 by the which would color the benefits of internal trade, such representatives of 61 states, entered into force on 7 April expenses are negligible as compared to interruptions 1948. Amendments adopted by the 26th, 29th, 39th and made as a result of military expenses. Sanctions mostly 51st World Health Assemblies (resolutions WHA26.37, impose expenses on the sanctioned country, but most of WHA29.38, WHA39.6 and WHA51.23) came into these sanctions address the citizens rather than the so- force on 3 February 1977, 20 January 1984, 11 July called regime. Sanctions usually happen exclusively by 1994 and 15 September 2005. In the introduction to this the markets of the developed country against the more constitution, it is stated that “health does not only mean dependent weaker state. complete physical, mental and social health or mere lack of Article 41 of the United Nations Charter allows only a disease or disability”.5 In addition, in this introduction, those actions of total or partial stopping of relations when it has been mentioned that “having the highest standards international peace is threatened. This is because the of health, disregard of race, religion, political stance or Security Council is expected to ‘improve international social conditions is basic human right”.6 Moreover, right law and support legal laws of the states’. In addition, in to health and hygiene was known as a basic human right in case there is a controversy between the Security Council article 12 of Covenant on Economic, Social and Cultural Resolution and the United Nations Charter, the charter Right.7 If principles of rights written in this covenant are serves as the reference as the superior law. In the Namibian considered as parts of the legitimate international rights case, the ICJ stated that the Security Council’s powers are (and no one could can deny this), then each action of the not unlimited; on the contrary, it is bound to comply with Security Council which would threaten or limit the right the fundamental principles and the objectives that have to health and hygiene or its sub-rights such as availability been mentioned in chapter 1 of the Charter. of medicine and optimal treatment can be conceived as Nowadays, an increasing consensus of human rights obvious violation of the internal law. is being formed4 which legitimizes only imposition of a The right to health covers a wide range of factors certain limited types of sanctions, to be referred to as the which help people to live healthy lives. The Committee final choice of the United Nations Charter. According to on Economic, Social and Cultural Rights considers these the introduction and clause 3 of article 1 of the charter, ‘to factors to be fundamental components of the right to achieve international cooperation in solving international health: safe drinking water, food safety, appropriate and problems of an economic character’ is an international enough nutrition, healthy work and living conditions, objective. Due to the notion that ‘internal peace’ is information and education on health and hygiene and achieved with cooperation in the economic affairs and due gender equality.8 Health and hygienic services are related to to the obligation of the Security Council to respect human variables such as safe water, appropriate infrastructures in rights and the international law, in general, and the United health, electricity, medical equipment such as ambulance,

S44 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 Peace and Right to Health laser, etc. More vulnerable countries are those which This highly damages the nature of targeted sanctions. depend on imports to a greater extent. In these countries, Using expressions such as ‘ballistic missile technology’, effects on citizen are increasingly raised due to lack of ‘heavy water related facilities’, ‘materials related to military currency resources for importing the urgent health-related and army technology’ caused the inclusion of materials in goods and lack of time needed for management of the the lists of sanctions, which have uses for both military and required resources.9,10 nuclear purposes and medicine, pharmacy, hygiene and As an example, Cuba was geographically, and not environment purposes.21 Also, petrochemical materials politically, isolated. However, despite US sanctions, many can be cited among these examples. These materials are so countries continued to maintain their economic relations highly significant in industry and the related equipment with Cuba. The borders between Haiti and the Dominican and materials that the Security Council itself has noted the Republic helped then to import fuel. However, Iraq did relationship between the materials required in the petro- not have any of these chances and, as a result, was more chemistry and nuclear fuel cycles.4 affected.10-12 It is also necessary to refer to techniques for analyzing In Iraq, sanctions began with forbidding of all imported and measuring nanometer-level molecular levels using goods, except for medicine. They were extended by the machines such as SEM and TEM, which are widely used Security Council in January and February 1991 after the in the identification of the accuracy of methods employed Gulf War. In April 3, Iraq was allowed to import food in production of materials on molecular scales (nano- beside medicine. From 1991 to 1993, humanitarian scales).22 Among the uses of these materials are use in organizations could help the import of only 5% of pharmacy industries, where they are used to improve the the urgent medicine and food. This was because those efficacy and absorption of medicine; also, they are used countries which were enemies of Iraq did not dedicate to reduce the side effects of drugs when they are taken adequate budget to this country.13 In August 1991, the in large amounts. In addition, these equipments are Security Council issued the resolution 706, after which used in the production of various types of heavy metals selling oil was allowed for importing humanitarian goods. such as titanium and germanium; these alloys are used In 1996, Iraq accepted the ‘oil for food’ program and the for manufacturing equipment in medical and dentistry first humanitarian package was sent in 1997.14 equipment, ranging from surgical tools to bone plates and In Cuba, despite the problems in a number of areas, implants.3 The 1929 resolution has obviously affected the since 1992, the health of infants, children and mothers import of these parts and equipment which are related started to improve. In 1998, infant mortality dropped to to the petro-chemistry industry. Followed by imposing 1.7 per 1000 live births. Despite a significant decrease in sanctions on goods and equipment of this industry, a the amount of calories, the percentage of all the births significant damage can be expected on other industries, below 2.5 kg dropped by 6.7%. During this period, more too. Sanctions on petro-chemistry goods such as povidone than 99% of births occurred in health centers, and fewer iodine, which is an important material in producing than 47 mothers died per 100 000 births.10,15,16 betadine, and poly-propylene, which is the main material Two widespread field studies were carried out in 1999, used to produce the container and caps of drugs, can lead evaluating changes in mortality rates among infants under to harmful effects on citizens’ healthcare.22 5 in Iraq.17-19 Both of these studies confirmed that death Although the 1929 resolution has apparently devised rate was doubled after 1995 in comparison with the 1980s many smart sanctions, considering that a number of and that the rate of mortality was smaller in northern equipment and goods are two-functional, it has in fact compared to southern and central parts.20 They concluded violated the basic rights of the citizens including the right that a significant increase was occurring in mortality rates in of life, the right to health, the right of the environment Iraq. It was indicated that such an increase in the mortality and even the right of free treatment; and this would cause rate was higher than what Iraq government claimed; it was irreparable effects. about 300 000 in infants and children under 5.17 Despite these sanctions, healthcare condition has With these points in mind, it is time to question improved after the Islamic Revolution and such the effects of sanctions on Iran. The Security Council improvement is a result of healthcare programs taken by approved its sixth resolution and the fourth resolution the state.19 Rural areas enjoy this healthcare improvement against Iran in June 2010.21 Before this, the 1803 to the same extent as the urban areas. In 2006, life resolution which was the third resolution against Iran was expectancy was 70 for men and 74 for women. In the approved by the Security Council in 2007 and the 1737 same year, healthy life expectancy was 60 for men and resolution was approved after a consensus of the members 62 for women. In 2004, mortality rate was 29 per 1000 in 2006. Studying these resolutions, particularly the 1929 for infants, which was almost half of that in 1999, which resolution, can reveal important points. One of these was 54 per 1000. Nowadays, morality rate is 24.6 deaths points is that clauses 6, 7, 8 and 9 of the 1929 resolution per 100 000 for mothers, while it was 91 per 100 000 in have covered two-function materials in sanctions regime. 1990. In 2007, morality rate was 18.9 deaths for infants

Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 S45 Dastafkan et al and 22 deaths per 1000 for children under 5. Between to health for all, especially children and other vulnerable the years 2000 and 2007, 7% of the infants suffered from people. This special human right includes various rights underweight while this rate was 11% for the children like medical care, access to medicine and drugs and other under 5, with 2% being in a bad condition. Malnutrition qualifications which economic sanctions would inevitably and underweight were more than the average in different violate. Several prominent international law regulations parts of the country. In 2008, rate of cancer was 100 in are referred below: 100 000 and this caused 11.86% of all deaths.23 Article 25 of the United Nations’ 1948 Universal Although it seems that medicine is not included in the Declaration of Human Rights states that “Everyone has list of sanctions, Iranian medical companies need to pay the right to a standard of living adequate for the health and in advance for importation and this is due to limitations well-being of himself and of his family, including food, on the banking and insurance related transactions.23,24 The clothing, housing and medical care and necessary social current situation in Iran regarding medicine is indicative services.” of unfavorable effects of sanctions on common people and “The right to public health, medical care, social security public health. This undesirable effect is not only related and social services” is mentioned in Article 5 of the to the difficulty in buying medicine; it would endanger International Convention on the Elimination of All Forms public health in the long term. On the other hand, with of Racial Discrimination, which was adopted in 1965 and lowering of the country income and the value of the entered into effect in 1969. national currency, the ability to buy foreign medicine and Several important statements are mentioned in Article raw materials has reduced. 12 of the International Covenant on Economic, Social and On top of all, the impact of economic sanctions can Cultural Rights; for example: be human rights violation from a legal point of view. “The right of everyone to the enjoyment of the highest Economic sanctions inevitably cause further retrogression attainable standard of physical and mental health” or “the of human rights status. Moreover, extensive sanctions, creation of conditions which would assure to all medical especially those inflicted multilaterally, assume to cause service and medical attention in the event of sickness.” greater integrity rights abuses than limited sanctions.25 Health is mentioned on several instances in the Regarding sanction goals, practical results indicate that Convention on the Rights of the Child (1989). Article 3 human rights sanctions are also deleterious, resulting in a calls upon parties to ensure that institutions and facilities greater possibility of infringement of integrity rights. In for the care of children adhere to health standards. Article addition, just like the direct result of sanctions, economic 17 recognizes the child’s right to access information that is coercion leads to violation of human rights, the longer the pertinent to his/her physical and mental health and well- sanctions last.25,26 being. Article 23 makes specific reference to the rights This study can have several inferences as far as the study of disabled children, in which it includes health services, of economic sanctions is concerned. First, it appears that rehabilitation and preventive care. Article 24 outlines child economic sanctions not only often fail to achieve their health in detail, and states, “Parties recognize the right intended policy goals, but they also lead to unintended of the child to the enjoyment of the highest attainable negative impacts on human rights. In addition to the standard of health and to facilities for the treatment of evidence presented by earlier case studies, this study illness and rehabilitation of health.” attempts to provide a cross-national-empirical evidence Table 1 presents a summary of some of the most confirming the deleterious effects of sanctions on human remarkable literature in the field of economic sanctions rights.27 and their impacts on human rights. Many international legal documents insist on the right

Table 1. Remarkable Literature review

Author Title Year Results Substantial suffering by vulnerable groups in Iraq, former Yugoslavia, and Haiti has led to a 'bust' for this foreign policy tool. Sanctions can be designed to Weiss et al28 Weighing Humanitarian Impulses 1999 be more effective and less inhumane than they are at present, but much more research is required about their precise impact on civilians and on targeted regimes. Based on the research findings of this study, it is evident that the use of Better or Worse? The Effect of Economic Peksen25 2009 ‘sticks’, at least in the form of economic coercion as a foreign policy tool, Sanctions on Human Rights does not contribute to the advancement of human rights. Sanctions in Haiti: Human Rights and Sanctions may cause disproportionate stress on ordinary citizens, while Gibbons29 1999 Democracy Under Assault allowing the targeted regimes to avoid the cost of coercion. Economic Sanctions, Reconsidered: Hufbauer et al30 1990 Economic sanctions fail frequently in achieving their intended policy goals. History and Current Policy Sanctions have succeeded in 5 of 115 attempts, and thus, there is no sound Pape27 ‘Why economic sanctions do not work’ 1997 basis for even qualified optimism about effects of sanctions.

S46 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 Peace and Right to Health

Conclusion Ethical Statement Multilateral and comprehensive economic sanctions in Not applicable. countries which are highly dependent on imports and References which are not implemented hesitantly and which are 1. Evans G, Newnham J. The Penguin Dictionary of International followed by other socio-economic pressures, have the Relations. London: Penguin Books; 1998. greatest impact on public health. Iraq had all these factors 2. Hadadi M. International sanctions, tools for national politics or guarantees for the international actions. Portal of Islamic and therefore, the country was particularly vulnerable. and Human Sciences. 2002;32:9-12. Haiti was involved with a number of disturbances 3. Gostaresh-e Sanat Newspaper. 2017;47:2. Available from: occurring among the families both simultaneous with and http://www.sanatnewspaper.com/repository/47/2.pdf. after the imposition of sanctions. No sanctioned country 4. Zamani S, Mazaheri J. Sanctions of the Security Council in light of the 1929 resolution: preserving or threatening peace? can compensate for its lost income via humanitarian International Journal of Law. 2011;28(44);115-61. relief; as a result, the economic, social and political chaos 5. Zarif MJ, Mirzaee S. US Unilateral Sanctions against Iran. continues for many years after the end of the sanctions and Iranian Journal of International Affairs. 1997;9:1-20. this might deepen the crisis. 6. Akande D. The International Court of Justice and the Security Council: Is There Room for Judicial Control of Decisions of Furthermore, it was found in some cases that infant the Political Organs of the United Nations? Int Comp Law Q. deaths in some sanctioned countries decreased even when 1997;46(2):309-43. there was a shortage of resources. This occurs when rare 7. Berggren G, Castle S, Chen L, Fitzgerald W, Michaud C, resources are properly managed and distributed, health Simunovic M. Sanctions in Haiti: crisis in humanitarian action. officials and national authorities promote child health, Boston (MA): Harvard School of Public Health, Program on Human Security; 1993. and parents are taught to take specific actions in this 8. Cheraghali AM. Cost effectiveness of Iran national plasma regard. In Iran, after the imposition of the sanctions, death contract fractionation program. Daru. 2012;20(1):63. doi: rate decreased after primary healthcare was offered for 10.1186/2008-2231-20-63. women and infants. Even after imposing sanctions, some 9. Cheraghali AM. Impacts of international sanctions on Iranian pharmaceutical market. Daru. 2013;21(1):64. doi: medicines and medical equipment were produced inside 10.1186/2008-2231-21-64. the country. 10. Fitzmaurice SG. Namibia case (dissenting opinion), ICJ In sanction conditions, non-governmental organizations reports; 1971. Available from: https://www.icj-cij.org/files/ need to make close relationships with those authorities who case-related/53/053-19710621-ADV-01-08-EN.pdf. 11. Clawson PA. Oil for food or the end of sanctions. Policy are involved with human rights in order to re-identify the Watch. 1998. power and resources of the country and its people. Such 12. Concluding Observations of the Committee on Economic, approaches require creativity and leadership and objectives Social and Cultural Rights.1997: Iraq (E/C.12/1/Add.17). of economic sanctions also need to be more accurate and Available from: https://www.refworld.org/docid/3ae6ae5817. html. clear. 13. Concluding Observations of the Committee on the Rights of On the other hand, sanctioning authorities are not the Child, 1998; Iraq (CRC/C/15/Add.94). Available from: totally free in devising these sanctions and they need http://hrlibrary.umn.edu/crc/iraq1998.html. to consider the basics of human rights. A review of the 14. Country Cooperation Strategy for WHO and the Islamic Republic of Iran. 2010-2014, EM/ARD/038/E. WHO Regional previously sanctioned states shows that economic sanctions Office for the Eastern Mediterranean; 2011. have not been able to reach the goals for which they were 15. Fassbender B. Uncertain steps into a post-cold war world: The once devised. In most cases, they caused mere damage on role and functioning of the UN Security Council after a decade health, welfare, and lives of common people. Therefore, of measures against Iraq. European Journal of International through making sanctions targeted, accurately mentioning Law. 2002;13(1):273-303. 16. International Covenant on Civil and Political Rights [GA / sanction-excluded goods, accurately defining two- Res/2200A(XXI)]; 16 December 1966. functional goods, increasing supervision and development 17. Garfield R, Santana S. The impact of the economic crisis of humanitarian measures and devising national policies and the US embargo on health in Cuba. Am J Public Health. for the support of vulnerable groups using reasonable 1997;87(1):15-20. doi:10.2105/ajph.87.1.15 18. General Comment No.14 on the right to health. The Committee healthcare actions, one can mitigate the humanitarian on Economic, Social and Cultural Rights; 2000. damages resulting from sanctions, particularly smart 19. World Health Organization. The health conditions of the sanctions. In this way, loss of lives would not occur and population in Iraq since the Gulf crisis. Baghdad: WHO/ the sanctioned country would be rebuilt more easily in the EHA/96.1; 1996. 20. Haiti 1995 Nutrition Surveys by Department of Port-au- future. Prince. Haiti: Ministry of Public Health and Population; 1997. 21. Kondoch B. Limits of Economic Sanctions under International Authors’ Contribution Law: The Case of Iraq. Int Peacekeep. 2001;7:267. RD designed and analyzed the data and co-wrote the paper. MMH 22. Ochoa FR, Pardo CM. Economy, politics, and health status in is scientific editor and co-wrote the paper. HS as corresponding Cuba. Int J Health Serv. 1997;27(4):791-807.doi: 10.2190/ author, co-wrote the paper and supervised the research. HBXE-6KWM-0H9V-1DCF. Conflict of Interest Disclosures 23. UNICEF. Disastrous Situation of Children in Iraq. UNICEF; 4 None. October 1996.

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24. UNICEF. Child and Maternal Mortality Survey, Preliminary Security. 1997;22(2):90-136. Report. Baghdad, Iraq; 1999. 28. Weiss TG. Sanctions as a Foreign Policy Tool: Weighing 25. Peksen D. Better or worse? The effect of economic sanctions Humanitarian Impulses. J Peace Res. 1999;36(5):499-509. on human rights. J Peace Res. 2009;46(1):59-77. 29. Gibbons ED. Sanctions in Haiti: Human Rights and 26. Lucena Carneiro C, Apolinário L Jr. Targeted Versus Democracy under Assault. Praeger; 1999. conventional economic sanctions: What is at stake for human 30. Hufbauer GC, Schott JJ, Elliott KA, Economic Sanctions rights? International Interactions. 2016;42(4):565-89. Reconsidered: History and Current Policy. Peterson Institute; 27. Pape RA. Why economic sanctions do not work. International 1990.

© 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

S48 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 ARCHIVES OF Arch Iran Med. April 2020;23(4 Suppl 1):S49-S50 IRANIAN doi 10.34172/aim.2020.s10 http://www.aimjournal.ir MEDICINE

Open Opinion Access Rights of Citizens and the Classification of People into Believer (Mu’min) and Non-Believer (Kafir)

Seyyed Mostafa Mohaghegh Damad, PhD1*

1Head of the Department of Islamic Studies of Academy of Sciences, Department of Islamic Laws, Shahid Beheshti University, Tehran, Iran

s a researcher in theology I am of the view that jizya on the non-believer. differences, struggles and conflicts among the The problem is further accentuated when the right to people of religion are all due to that categorization of declare the other as a non-believer becomes the prerogative citizensA into believers and non-believers. Religion, through of each and every one. Who decides what constitutes non- categorization of people into believers and non-believers, belief? Worse than that is when believers feel obliged to is accused of dividing people creating enmity, hostility and search out the non-believers within their society. Worse still eventually leading to bloodshed. With such distinctions, it is when the determination of belief and non-belief falls in is natural that followers of a religion would deem followers the hands of the heads of states and politicians. This has of another religion as non-believers and distance themselves resulted in indescribable horrors where for decades, people from the other and eventually lead to bloody conflicts. of faith legitimized killing, plundering and beheading the The only route towards harmony is to abandon such non-believers even to the extent of butchering women and divisions in matter of citizenship and instead opt for the little children. division in terms of “one at peace” (musalim) and “one at Takfirism has claimed countless lives in the history of conflict” (muharib). humankind. Four centuries prior to the common era, There is no doubt that crises resulting from the Socrates was charged with non-belief by a jury. During categorization of believers and non-believers are in the the Middle Ages, enlightened thinkers were charged with interest of those global players who stand to gain from the non-belief and consequently, condemned to be burned internal conflicts caused by such ideas. However, the question at the stake by the church. The interesting thing in all of we need to ask is not who is benefitting from the believer- this was that the people who were condemned claimed to non-believer schism; rather how the schism is created. In be believers but because understanding of faith conflicted other words, what ideological tool and theological rationale with the interests of the church, they were branded as non- are at play that motivate and fuel such divisions? In my believers. view, takfirism is at the heart of this problem. Takfirism is So, we ask, what is the way forward? How can this a theologically based ideology that legitimizes the branding ideology be undermined or at the very least, exposed for of the other as a non-believer and consequently, degrading what it truly is? their human status from being an equal to becoming lesser In my view, belief and faith are matters that are confined than a believer. to the hearts. They should not be influential at the level Takfirism is a historical reality that has existed within of societal interaction let alone be impactful at the level both theistic and non-theistic faith systems. Due to this, of citizenship and collective coexistence. Undoubtedly religions are accused of being the cause of classifying people the Quran does contain notions of belief and non-belief; into believers and non-believers. The followers of each faith however, these distinctions are only used as properties of the deem their own as believers and others as non-believers and human soul and not in terms of societal categorization or consequently, through such a distinction, classify people of in relation to determining the rights of citizens. I feel the state or a society as their own and the other. This distinction yardstick of distinction ought to be ‘one at peace’ (musalim) does not remain confined to the mind only; rather, it and ‘one at war’ (muharib) instead of believer and non- becomes very quickly an attitude that impacts relations at believer. Musalim is one who does not seek to fight, take a societal level, to a level where only a believer has the right up arms and does not disrupt social order or threaten the to live whilst the non-believer is left with no rights at all, lifestyle of others, whereas a muharib seeks to actively fight neither the right to live nor the right of personal ownership against us or disrupt our social order. It is this second group or freedom and ceremonial purity. Not having rights is one that we are commanded to fight by the Quranic ordinances thing but then it translates into religious degrees where the and is termed as defense. believers are ordained to kill, enslave, subdue and impose I have derived this view personally from the Quran.

*Corresponding Author: Seyyed Mostafa Mohaghegh Damad Ahmad Abadi, PhD; Head of the Department of Islamic Studies of Academy of Sciences, Department of Islamic Laws, Shahid Beheshti University, Tehran, Iran. Address: The Academies and National Libraries of IR Iran, Shahid Haqqani Exp., Tehran 1537633111, IR Iran. Tel: +98 9121113174, Email: [email protected] Mohaghegh Damad

It is true that the Quran does state, “He it is Who has be in a state of peace. Accordingly, Islam invites all humans, created you, then from you are those who are non-believers be they believers or non-believers at heart, to harmonious and others are believers and Allah sees all that you do.” coexistence in a state of peace. The word musalim that I have (Taghabun:2). However, it is clear that this is pointing to the chosen to use is an active participle of the word silm as used fact that Allah does not compel any soul. In other words, in the above verse. A person in the state of ‘peace’ (silm) God created you and through freedom of choice, some of is termed as ‘one in a state of peace’ (musalim). Therefore, you became believers whilst others chose non-belief. God musalim is one who, despite his inner beliefs, chooses to could have made you all into believers but the wisdom of peacefully coexist as opposed to a muharib who is in a state God did not allow it in the case of humans. In any case, such of war and conflict with the society. verses do not pertain to societal relations. The following In brief, I am in my seventies at this point of my life. As verse in particular talks of faith at a societal level: a student of seventy plus I have spent the major part of my “The nomads claim we have brought faith. Say you have life, if not the whole of my life, in the study of religion. I not brought faith rather say we have embraced Islam, faith suggest, in order to solve our social problems, that instead of has yet to enter into your hearts. And if you are obedient categorizing people as believers and non-believers (which are to Allah and His Messenger then your deeds will not go the attributes of the soul), we distinguish them in terms of unrewarded (i.e. your societal rights will be accorded to ‘one at peace’ and ‘one at war’, in the sense that we embrace you), indeed Allah is most forgiving, most merciful.” whoever displays peace and friendship as the Qur’an states: (Hujurat:14). “Fight (only) those who fight you and do not transgress. This verse highlights a few things; first, that faith belongs Indeed, Allah dislikes the transgressors.” (Baqara:190) to the hearts and second, that none save God can determine The logical contrary inversion of this proposition an individual’s status of faith. Even the Prophet could only would read “do not fight those who do not fight with inform of what is within the hearts through God, not you.” Consequently, warfare with a non-muharib would independently. The other thing we find from the verse is constitute aggression and transgression whilst God dislikes that individuals who were not believers were allowed to be the transgressors and aggressors. Those committing acts a part of the community and enjoyed full rights. This was displeasing God are His enemies. We ought not to displease true of even the likes of Abu Sufyan whose hypocrisy was God, least of all in the name of God. well known to the extent that he and his children availed Conclusion themselves of the equal opportunities and quickly rose to 1- Belief and non-belief are the concealed attributes of the power. Another verse that clarifies this understanding is the souls. Societal statuses and rights are not based on the following: attributes of the souls; rather, they are based upon what “O you who believe when you go forth in the path of is displayed through actions and attitudes. Allah then take due care in ascertaining the status of others 2- The governing bodies responsible for safeguarding the and do not say to one who bids you peace that you are not rights of its citizens in civilized societies should not a Muslim seeking the gains of worldly life, indeed Allah has distinguish among its people in terms of first class and many treasures. Such was your state prior to Allah bestowing second class citizens based on their status. upon you, thus take due care in ascertaining, indeed Allah 3- According to the above, within the modern world is all-knowing and informed of what you do.” (An‘am:94). with the notion of citizenship, there remains no debate According to this verse, the criterion for coexistence is for the non-discrimination and equal rights of the the notion of musalim. Through the mere act of displaying minorities. Minorities, whether religious or otherwise, the sentiment of peace, no confrontation and friendship, a will in addition have full rights to practice their faiths person will be considered a part of the society. No one is and ceremonies. permitted after that to delve deeper into their inner status Conflict of Interest Disclosures of faith and belief. Consider the following verse that most None. emphatically conveys this understanding: Ethical Statement “O you who believe enter into a state of peace (silm) Not applicable. altogether and do not follow the footsteps of the devil, indeed he is an open enemy for you.” (Baqara:208). Acknowledgments A summary of the speech delivered by Muhaqiq Damad to the The verse is addressing the believers and not the non- Congress of Peace and Security- Shiraz University- Aban Mah 97 believers, which implies that certain believers may also not H.S. [November, 2018].

Received: May 12, 2019, Accepted: October 12, 2019, ePublished: April 1, 2020 Cite this article as: Mohaghegh Damad SM. Rights of citizens and the classification of people into believer Mu’min( ) and non-believer (Kafir) . Arch Iran Med. 2020;23(4 suppl 1):S49–S50. doi: 10.34172/aim.2020.s10. © 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

S50 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 ARCHIVES OF Arch Iran Med. April 2020;23(4 Suppl 1):S51-S53 IRANIAN doi 10.34172/aim.2020.s11 http://www.aimjournal.ir MEDICINE

Open Opinion Access The Health Consequences of Economic Sanctions: Call for Health Diplomacy and International Collaboration

Vahid Yazdi-Feyzabadi, PhD1; Mostafa Amini-Rarani, PhD2; Sajad Delavari, PhD3*

1Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran 2Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran 3Health Human Resources Research Center, School of Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran

conomic sanctions are penalties that are applied trade sanctions on Iran. The United States initiated the by different agents such as the United Nations sanctions on Iran without considering international deals Security Council and one or more countries against and agreements such as the Joint Comprehensive Plan of Eother countries, organizations, groups, and individuals. Action (JCPOA). Now, an array of restrictions is imposed Sanctions on countries include various forms of barriers on banking, shipping, trade, oil, and aircraft industries on such as trade and transaction barriers to change the behavior Iran. of a target country. These sanctions may be imposed as The main objective of economic sanctions is the a type of economic war instead of direct military war to countries’ economies. These sanctions have some negative maintain peace and preserve the world order; nevertheless, consequences on the economy of each country, at least both have negative consequences on public health.1 Thus, in the short term inevitably. Sanctions could cause a fall in terms of effects on public health, war and sanctions are in national revenues and earnings (especially for Iran, two sides of one coin that follow the same objectives. which largely relies on oil exports), and an increase in Unlike wars, sanctions do not reveal destructions and prices, unemployment, and inflation rate.1,3 These are the killing innocent people, and they are named domineering direct objectives of sanctions, but sanctions have many and cruel means that lead to the gradual death of humans. other indirect, adverse, or maybe unwanted effects on While war directs international attention to helping population welfare and health. Economic sanctions affect civilians, sanctions’ effects are not viewed by humanitarian/ all things that are related to economic situations such human rights organizations. In war, other countries and as population health. Health services in Iran are mainly international humanitarian organizations help the warring provided by the public sector 4 which in turn relies on nations and help them to rebuild their infrastructure and government revenues that are reduced due to sanctions. provide them with healthcare facilities. While achieving On the one hand, due to the devaluation of the the objective of sanctions is doubtful, they often lead to national currency, health technologies are becoming more humanitarian disasters.2 expensive than ever, and the price and cost of facilities are In recent years, sanctions are not only used by sharply increased due to sanctions.1,5 So, access to health international organizations but are frequently used by and demand for healthcare have endured adverse changes. countries against each other. For example, the United Undeniably, sanctions have negative effects on providing States applies sanctions against other countries such care, technologies, and drugs, mainly those that are as Iran, Cuba, Russia, and other opposing countries dependent on import-finished or raw materials.6 Previous according to its own rules. Using sanctions is not limited sanctions resulted in a sudden increase in the price of to the US and powerful countries. In June 2017, several pharmaceutical products.7 There is strong evidence on the Arabian countries autonomously imposed land, sea, and lack of medicine in Iran during sanctions. For example, air embargo on Qatar. There are numerous types and medicines and raw medical materials import fell by 30%– uses of sanctions by countries on news and media. Thus, 55%, and the shortage of medicine in type reached 144 sanctions are being used extensively across the globe. from less than 30 during sanctions that were imposed on Iran is one of the countries that have been targeted by Iran in 2012.3 Consequently, health and medical care were economic sanctions by international organizations and profoundly affected by the sanctions, and many people other countries –mostly the United States. In May 2018, could not afford and utilize it,5,8,9 especially those who the United States imposed new and heavy economic and suffered from chronic illnesses. These unjust effects are

*Corresponding Author: Sajad Delavari, PhD; Health Human Resources Research Center, School of Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran. Email: [email protected] Yazdi-Feyzabadi et al not limited to Iran. The same evidence could be seen in Regarding the third element, intermediary determinants, sanctions against Iraq, Cuba, and Syria.1,10-12 including material circumstances and psychosocial On the other hand, from the viewpoint of social circumstances, may be influenced by sanctions mostly in determinants of health (SDH), economic sanctions have a health-damaging way. The two most visible effects of an impact on all three elements of the SDH framework, sanctions related to material circumstances can be seen including socio-economic-political context, structural in housing and food consumption. As previously studied, determinants, and intermediary determinants13 that lead to some aspects of indoor and outdoor housing conditions negative impacts on equity in health and wellbeing. Some have a direct impact on health. Because land and raw of the apparent effects on SDH are as follow: regarding material of housing become more expensive than before, the first element, i.e., socio-economic-political context, it can be said that housing quality declines after sanctions. sanctions can change social and political mechanisms such As for food consumption, along with a reduction in as governance, labor market, educational system as well purchasing power of public goods, households’ food basket as trade, housing and (re)distributive policies which exert mostly experiences an inverse change both quantitative potent influences on people’s health.14 and qualitative. These affect healthy food consumption For the second element, generating and reinforcing and result in dietary issues such as malnutrition and structural determinants (such as income, education, overweight by turning to unhealthy foods, which are and occupation) could be affected by sanctions. Since mostly cheaper and have low nutrients and high calories. structural determinants have a dose-response association From the psychosocial point of view, sanctions can with health, the sanction could change people’s health result in psychosocial stressors like job strain and job opportunities in trajectories with negative effects on insecurity, stressful living conditions, and uncertainty. people’s health status; in particular, for the poor who may For example, due to adverse economic situations (such not have access to health care nor be able to buy high- as high inflation), people lose their purchasing power, quality material resources. experience the shrinking value of their assets, and become

Adverse Effects of Sanctions on Population Health

Indirect effects Direct effects

Socio-economic-political context - Decreased health care delivery - Expensiveness of diverse health - Bad/poor governance technologies - Difficulty in Labor market - Increase price & cost of health - Educational shortage facilities, medical supplies and - Barriers to trading medicines - Poor/unstable housing policies

- Shortage in import-based - Unsustainable (re)distributive policies

medicines Social

- Lack of raw medical materials Determinants Structural determinants - Decreasing access to healthcare of Health - Declining affordability of (SDH) - Decreasingerminants income and aggravate d healthcare income inequalities

- Reducing purchasing power and limited

capacity to pay - Poor Education - Increase in informal employment, unemployment or underemployment - Poor occupation

Intermediary determinants erminants

Material circumstances Psychological circumstances circumstances

- Declining indoor/outdoor - Increase psychological stress and housing conditions distress (e.g. job strain and insecurity) - Minimizing households’ - Stressful living condition food basket - Uncertainty - Frustration and unhelpfulness

Figure 1. Adverse Effects of Sanctions on Population Health Using Social Determinants of Health Approach.

S52 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 Health Consequences of Economic Sanctions stressful and frustrated. Frustration leads people to lose Conflict of Interest Disclosures Authors declare they have no competing interests. their hope and, consequently, triggers any form of illness 15 and detrimental effects. These partly explain the health Ethical Statement problems of sanctioned societies. These direct and indirect This study has been approved by ethics committee of Kerman University of Medical Sciences (KUMS) with registration code effects are illustrated in Figure 1. IR.KMU.REC.1397.564. Finally, if the current increasing trends of sanctions continue, countries could not fulfill the Sustainable Funding Sources This study has been funded by the Institute for Future Studies in Development Goals (SDGs), particularly SDG-3 for Health affiliated with Deputy of Research and Technology of Kerman healthy lives and wellbeing, including targets for universal University of Medical Sciences (KUMS) with ID number 97001030. health coverage for everyone and everywhere. As economic References rigor will be vital to the attainment of SDGs, likely 1. Sen K, Al-Faisal W, AlSaleh Y. Syria: effects of conflict and shortfalls in the fulfillment of health-related SDGs will be sanctions on public health. J Public Health (Oxf). 2013;35(2):195- indeed severe, unfair, and undesirable for ordinary citizens 9. doi: 10.1093/pubmed/fds090. 2. Gibbons E, Garfield R. The impact of economic sanctions who live in target countries. Since politics is omnipresent on health and human rights in Haiti, 1991-1994. Am J Public and health is considered a human right inevitably touched Health. 1999;89(10):1499-504. doi:10.2105/ajph.89.10.1499 by political determinants, understanding the influence of 3. Kokabisaghi F. Assessment of the effects of economic sanctions on iranians’ right to health by using human rights impact political activities such as sanctions on health is a global assessment tool: a systematic review. Int J Health Policy Manag. demand, and every nation is accountable for it. Thus, 2018;7(5):374-393. doi: 10.15171/ijhpm.2017.147. achieving international goals named as SDGs and achieving 4. Almaspoor Khangah H, Jannati A, Imani A, Salimlar S, Derakhshani N, Raef B. Comparing the Health Care System of universal health coverage for everyone and everywhere, as Iran with Various Countries. Health Scope. 2017;6(1):e34459. one of the SDGs and the motto emphasized on the world 5. Ameri A, Barzegartahamtan M, Ghavamnasiri M, health day 2019, are strongly threatened due to sanctions. Mohammadpour R, Dehghan H, Sebzari A, et al. Current and future challenges of radiation oncology in Iran: a report from the Health issues have no political boundaries, and imposing Iranian Society of Clinical Oncology. Clin Oncol (R Coll Radiol). intentional health problems on a nation in the form of war 2018;30(4):262-268. doi: 10.1016/j.clon.2017.12.021. or sanction cannot be considered a humanitarian activity 6. Kheirandish M, Varahrami V, Kebriaeezade A, Cheraghali AM. Impact of economic sanctions on access to noncommunicable for any purpose. While a health crisis is happening due diseases medicines in the Islamic Republic of Iran. East Mediterr to sanctions, health diplomats should consider health Health J. 2018;24(1):42-51. 7. Gorji A. Health care: Medical supplies in Iran hit by sanctions. diplomacy as an approach for resolving these types of Nature. 2013;495(7441):314. doi: 10.1038/495314a. disputes between nations. They should consider their 8. Hassani M. Impact of Sanctions on Cancer Care in Iran. Arch population and global health issues in their relationships Bone Jt Surg. 2018;6(4):248-249. 9. Shahabi S, Fazlalizadeh H, Stedman J, Chuang L, Shariftabrizi with other countries. A, Ram R. The impact of international economic sanctions on Now, there is a dire need for grand convergence in Iranian cancer healthcare. Health Policy. 2015;119(10):1309- international policies to improve global health. It is 18. doi: 10.1016/j.healthpol.2015.08.012. 10. Al-Hadad SA, Al-Jadiry MF, Al-Darraji AF, Al-Saeed RM, Al- suggested that international organizations such as the Badr SF, Ghali HH. Reality of pediatric cancer in Iraq. J Pediatr World Health Organization (WHO) expand health as a Hematol Oncol. 2011;33 Suppl 2:S154-6. doi: 10.1097/ bridge for peace program. Also, international authorities MPH.0b013e318230e218. 11. Sen K, Al-Faisal W. Reforms and emerging noncommunicable such as the United Nations General Assembly, Global disease: some challenges facing a conflict-ridden country--the Health 2035 Commission and Commission on Global case of the Syrian Arab Republic. Int J Health Plann Manage. Governance for Health, via right policies, installation 2013;28(3):290-302. doi: 10.1002/hpm.2193. 12. Weeramanthri TS, Gruen RL, Yee TF, Bailie RS, Moore RL. of systems and designing a mechanism to hold nations Economic sanctions and public health--the case of Cuba. Med accountable for their obligations under international J Aust. 2001;174(6):316. conventions can curb the negative consequences of hostile 13. Solar O, Irwin A. A Conceptual Framework for Action on the Social Determinants of Health. Geneva: World Health actions like sanctions on people’s health. Organization; 2010. 14. Chung H, Muntaner C. Political and welfare state determinants Authors’ Contribution of infant and child health indicators: an analysis of wealthy Conception and design: VYF and SD; Drafting of the manuscript: countries. Soc Sci Med. 2006;63(3):829-42. doi:10.1016/j. VYF, SD and MAR; Critical revision of the manuscript for important socscimed.2006.01.030. intellectual content: SD, MAR and VYF; Obtaining funding: VYF; 15. Griggs S. Hope and mental health in young adult college Supervision: VYF and SD. students: an integrative review. J Psychosoc Nurs Ment Health Serv. 2017;55(2):28-35. doi: 10.3928/02793695-20170210-04.

Received: September 22, 2019, Accepted: March 11, 2020, ePublished: April 1, 2020 Cite this article as: Yazdi-Feyzabadi V, Amini-Rarani M, Delavari S. The health consequences of economic sanctions: call for health diplomacy and international collaboration. Arch Iran Med. 2020;23(4 suppl 1):S51–S53 . doi: 10.34172/aim.2020.s11. © 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 S53 ARCHIVES OF Arch Iran Med. April 2020;23(4 Suppl 1):S54-S59 IRANIAN doi 10.34172/aim.2020.s12 http://www.aimjournal.ir MEDICINE

Open Report Access Conception of “Peace through Health” in the “Middle East” Region: Report of the International Congress on Health for Peace, Shiraz, Iran

Hossein Molavi Vardanjani, PhD1; Alireza Salehi, MD, MPH, PhD2*; Faramarz Aminlari, MA3

1MPH Department, Shiraz University of Medical Sciences, Shiraz, Iran 2Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran 3Department of English Language, Shiraz University of Medical Sciences, Shiraz, Iran

Abstract The discussions held by the congress panels can be boiled down to the following convictions. Health professionals, especially those who are working in the Middle East region, have to promote peace as part of their professional responsibility. Moving towards this objective can be realized through a number of measures. It is both necessary and feasible to increase research to identify the causes and consequences of war and violence; and to appropriately translate the findings to politicians, health professionals and masses of people. These can be achieved by means of boosting cooperation between international organizations and of bolstering the position of non-governmental organizations (NGOs) on a global scale. Showing respect to other societies and civilizations, encouraging cultural interactions between societies, and elevating public intellectuality and general demand for reduction of violence can be effective in decreasing the latter and the effects thereof. Of the engagements that health professionals must seriously take on is employing health diplomacy and curbing the accumulation of unrestricted power and unilateralism through enforcing international treaties. Finally, it is essential to make health systems more resilient to complex emergencies caused by wars so that they can survive such conditions. Keywords: Armed Conflicts, Health, Iran, Middle East, Peace Cite this article as: Molavi Vardanjani H, Salehi A, Aminlari F. Conception of “peace through health” in the “Middle East” region: report of the International Congress on Health for Peace, Shiraz, Iran. Arch Iran Med. 2020;23(4 suppl 1):S54–S59. doi: 10.34172/ aim.2020.s12.

Received: July 14, 2019, Accepted: October 12, 2019, ePublished: April 1, 2020

iolence remains at the top of the list of threats held the International Congress on Health for Peace in to man’s health. With the advent of extremist Shiraz, Iran, from November 13 to 16, 2018 (http:// groups in our time and the metamorphosis of healthpeace.sums.ac.ir/en). The congress had as objective traditionalV wars into modern ones, health and security expanding the dialogue on health for peace, and reviewing of the human societies around the globe, especially of and evaluating the roles and duties of health professionals civilians, is endangered like never before.1,2 This makes to reduce violence. The rate of breadth of participation it an indispensable and urgent global necessity to take was quite remarkable. University scholars, health multilateral measures to curtail violence and promote professionals and representatives of health-related and health. non-governmental organizations (NGOs) from all across In an invaluable effort, the concept of “Health as Bridge the globe welcomed the event. These included for Peace” was proposed and recognized in the 1988 • World Health Organization (WHO), country WHO’s general assembly with the objective of making representative and building peace.3 According to this initiative, health • The United Nations International Children’s professionals were to act based on scientific evidence and Emergency Fund (UNICEF), country representative in several trajectories to promote peace. Multiple effective • The United Nations Educational, Scientific and efforts followed, some of which are still in progress. A Cultural Organization (UNESCO), Tehran cluster review of and scrutiny into the present standing of such office efforts to recognize their weak and strong points, as well • United Nations Population Fund (UNFPA), country as the potential opportunities and threats they might face representative along the way, can go a long way to consolidate them. • International Committee of the Red Cross (ICRC), Shiraz University of Medical Sciences and the Research country representative and Technology Deputy of the Ministry of Health, jointly • International Physicians for the Prevention of Nuclear

*Corresponding Author: Alireza Salehi, MD, MPH, PhD of Epidemiology, Research Center for Traditional Medicine and History of Medicine, Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, Iran. Tel: 0098-71-32337589, Fax: 0098-71-32338476, Email: [email protected] Health for Peace in Middle East

War (IPPNW) operations in critical war and post-war circumstances. The • International Campaign to Abolish Nuclear Weapons leading roles these organizations have to play in making (ICAN) such contributions must receive recognition and support • Maastricht University, Netherlands from governments and NGOs and, as a result, from the • Tampere University, Finland global community. • Yale University, US Also needed is international cooperation to enable • University of Waterloo, CA nations and governments to better handle war-induced • Several Iranian universities and NGOs complex emergencies. Efforts to make healthcare systems • Over 100 health professionals from Iran, Germany, more resilient is an area of fundamental importance in India, Finland, Sweden, Netherlands, the US, Canada international peace-promoting cooperation, as they can and England reduce harms done by wars and violence. Presenting More outstanding, however, was the achievement healthcare services to refugees of wars in the receiving made by the congress in terms of being able to draw the countries can also go a long way to ease down their attention from a myriad of various organizations, both pains. International cooperation must work to revive governmental and non-governmental, from within the post-war societies, and to maintain peace and build country, including trust. An important role in strengthening international • Iran’s Ministry of Foreign Affairs collaborations can be played by medical journals, as they • Iran’s Presidential Department of Women and should publish on a constant basis the results of research Families’ Affairs on prevention and control of wars and on promoting • Iran’s ‘Physicians with Social Responsibilities’ (PSR) peace. • Collaboration and Strategic Planning Deputy of Iran’s Ministry of Health 2. Epidemiology and Development of Dialogue on • Education Deputy of Iran’s Ministry of Health Peace through Health • The Department of International Ties of Iran’s On this panel, definition of peace epidemiology, scope of Ministry of Health the field, possible research designs over different phases of • Tehran Peace Museum war and violence as well as the data at hand on the issue, • Janbazan Medical and Engineering Research Center and the challenges facing the field came under discussion. • Tehran’s Shahid Beheshti University The result was a general consensus that, for a variety of • Tehran University reasons, the data on the effects of war and violence are • Iran University of Medical Sciences insufficient and/or not quite reliable, and those on macro • Tehran University of Medical Sciences and micro causes of wars and on effective interventions • Shiraz University are scarce. The ideas and research reports they brought to the As part of healthcare systems, epidemiologists hold congress branched out into nine panels. These are the professional responsibility to ensure the validity of presented in Table 1, followed by a quick account of what health information, and to identify the causes and risk the presentations and discussions in every panel boiled factors of health-related events. Consequently, it is on down to. epidemiologists to design and carry out studies, especially within an interdisciplinary framework, to address the gaps 1. International Cooperation and Development of of information alluded to above. Dialogue on Peace through Health Due to methodological limitations in this area, extra According to the discussions held by the panelists, since effort must go to development of methods to assure the principle of “health for all” is a precursor to peace, quality and precision of the data produced by studies. The which in turn is a prerequisite to “health for all”, striving translation of the knowledge gained from epidemiologic to achieve either one can have a crucial role in obtaining research to become usable by politicians as well as the the other. At the same time, the nature of modern wars public will substantially increase the success rate of efforts entails complicated conditions – a fact that calls for to prevent wars and decrease the risk of consequences doubling of efforts by impartial organizations to preserve thereof. Equally essential is that the novel and growing human rights. The WHO has to advocate and work field of peace epidemiology thrive and be appropriately towards gaining recognition of peace as an indispensable taught to health professionals and students for the sake of part of human rights and global sustainable development; running interdisciplinary studies. the UNESCO has to develop the culture of peace in different societies and build trust in them; the UNICEF 3. Mental Health and Development of Dialogue on has to organize and run initiatives to minimize harms to Peace through Health children under the conditions of war and violence; and the Wars and violence break out as a result of unilateral ICRC has to provide health services and conduct rescue decisions made by those in power. One way of thwarting

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Table 1. List of Panels and Speechmakers

Panel Speechmaker Topics of the Lectures Reza Malekzadeh International Scientific Cooperation, A Model for Peace-building through Health Health System Resilience as “the Capacity of Health Actors, Institutions, and Populations” to Mohammad Assai Prepare for an Effective Response to Crises Christoph Hamelmann The WHO’s ‘Health as a Bridge for Peace’ International Cooperation and Development of Will Parks UNICEF’s Global Interventions on Health for Peace: Examples from the Field 1 Dialogue on Peace Access to SRH and Maternal Health Services to Afghan Refugees Support Building Resilience Soudabeh Ahmadzadeh through Health Capacities of Afghan Young Women Alexander Leicht UNESCO’s Global Interventions to develop Dialogue on Peace through Health Caring for People Affected by Armed Conflicts: The Perspective of the ICRC on How Health Marc Achermann Can Contribute to Building Trust and Peace Mohsen Rezaeian Epidemiology and Peace through Health Hossein Molavi Challenges of Epidemiological Research in Cases of Crisis and War Epidemiology and 2 Development of Dialogue AliAkbar Haghdoost The Scope of Using War Epidemiology in Developing of Dialogue on Peace on Peace through Health Reza Majdzadeh Burden of Conflict and War in the Region of Middle East Kaveh Khoshnoud Teaching a Course on Violent Conflict and Health Ali Firouzabadi The Past Victim, the Future Abuser Amir Hossein Jalali In Memorial of War Destructions, be Hopeful for Peace Mental Health and 3 Development of Dialogue Morteza Nokhostin The Future of Mental Health in the Non-Peace Era on Peace through Health Babak Shamshiri Psychological Approaches for Prevention of Violent Behaviors in Children Mohammad Taghi Yasamy Psychosocial Mediators of War and Peace "Networking of NGOs for Peace through Health" and "The Effects of War and Conflicts on Gunnar Westberg Health Leila Moein The Role of Women in Promotion of Health for Peace NGOs and Development 4 of Dialogue on Peace Arun Mitra The Role of IPPNW in Health for peace through Health Katja Goebbels Working in Complex Situations – What Could Guide you? The Do No Harm Concept Aino Ritva Weyers Humanitarian Consequences of Nuclear Weapons Shakeel Ur Rahaman The Role of IPPNW in Health for Peace Can Health be affected by Interpersonal Violence? A Panel Data Analysis on Countries in the Mohsen Bayati Middle East Health Systems and Reza Majdzadeh Effect of Sanctions on People 5 Development of Dialogue Amir Hosein Takian Peace, Sustainable Health Development and the Place of Government on Peace through Health Sajad Delavari Health Diplomacy and its Place in Peace-building Remco Van de Pas Health professionals and their Role as a Bridge for Peace Hossein Molavi Scoping Review on the Effects of Imposed War on Iranians Effects of War on health: Naser Emadi Health Status of Iranians Exposed to Chemical Weapons in Sardasht Case study of Imposed 6 Batool Mousavi Psychiatric Disorders in War Survivors and its Impact on their Partners war on Iran Ali Khaji A Review of the Health Related Articles of the Iraq-Iran War Zohreh Ganjparvar Human Cost of the Imposed Iran-Iraq War Pir Hossein Kolivand Nature of Complex Emergencies in Cases of War Complex Emergencies Mohammad Javad Moradian The Basics of Complex Emergencies in Cases of War, and 7 Ahmad Soltani The Role of Red Crescent Societies in Complex Emergencies Development of Dialogue on Peace through Health Hesam Seyedin Special Challenges of Complex Emergencies in Providing Healthcare Services Paul Bouvier Health Care in Times of Crisis and Danger Lotf Allah Dejkam Right to Health and Just Health Care: Foundation of Peace Mostafa Mohaghegh-damad Peace in the Islamic Ideology Global Loneliness and the State of Human Mental Health: How Can Religion Promote Mohammad Jafar Mahallati Friendship as a Paradigm of Peace in Post-Modernity? Human Rights, Medical Paul Bouvier Providing Care to the Wounded and Vulnerable: a Core Duty of Humanity Ethics and Development 8 of Dialogue on Peace Rahim Nobahar Holiness of Human Life: the Common Base for Health and Peace through Health The Relationship between Mysticism, Peace and Mental Health on Personal and Social Saeed Rahimian Dimensions The Ebola Crisis: Emergence of “Cosmopolitan Solidarity” as a New Principle in Global Ehsan Shamsi Gooshki Health Ethics Mohammad Yusuf Nayeri Peace and Health in Islamic Persian Culture Anneli Milén Professional Education of Health: A Great Opportunity for Dialogue on Peace through Health

Medical Education and Neil Arya Medical Education and Health for Peace 9 Development of Dialogue Mesbah Shams Exploring Medical Peace Education and a Call for Peace Medicine on Peace through Health Mohammad Bagher Khosravi Curricular Intervention in Peace Education Mitra Amini

S56 Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 Health for Peace in Middle East such decisions is stifling the accumulation of unrestricted Along this path, positive interaction with politicians can power. Another preventive measure would be leaving a be highly constructive. positive effect on politicians in terms of making a change The members of the panel also came to the conclusion in the outlook they have of global governance. As this that one of the areas of activity for NGOs would be to demands knowledge of one’s past experiences, experts try to sensitize physicians to the macro causes of wars and in psychology and psychiatry are likely to be capable of health-related political issues. Providing medical students playing an effective role to this end. and physicians with education on peace through health, At the same time, wars and violence have profound and collecting and publishing statistics on the destructive and long-lasting impacts on individuals’ mental and effects of wars on people’s health can create in this group social health, of both combatants and civilians, and on the intended sensitivity. the societies involved. The implication is that mental and social health experts need to analyze, out of their 5. Health Systems and Development of Dialogue on professional responsibility, the roots of wars and violence Peace through Health through sophisticated and multi-level models, and while In addition to providing healthcare services, health systems employing cultural resources, design and implement hold other responsibilities such as training the work force interventions to curtail mental and social promoters and and ensuring the required resources for the provision of mediators that fuel wars and violence. health. Health systems must therefore plan for capacity In spite of the presence of powerful external drivers such building so as to ensure health over the long run. as financial goals to start and continue wars, the possibility The mutual relationship between peace and health, i.e. is available of boosting internal peace, inter-personal peace, two major components of global sustainable development, and peace between countries and between civilizations, all demands that health systems make every effort to prevent through enabling individuals and nations to cope with wars and violence and to promote peace. Health systems’ the experience of “being in-between”.4 Elevating mental involvement in making and building peace can result in and social health can be attained through raising nations’ ensuring health both at present and in the future. They intellectuality, achievable in turn by educating them, have the capacity, and the obligation, to contribute to teaching them how to think critically, and showing them sustaining peace and health through empowering, and what the real picture of the consequences of wars and efficiently employing, the potentialities of the global violence looks like. health diplomacy (GHD).5 Convincing governing bodies to provide the right grounds for making appropriate 4. NGOs and Development of Dialogue on “Peace decisions with the objective of reducing wars and violence Through Health” can be the invaluable result of the promotion of GHD. The panel came to the unanimous conviction that since Health systems would also need to make themselves most wars and violence are initiated and sustained by resistant to, and ready for, war conditions and emergencies governments, it would be on NGOs to play their part in in order to govern health-related issues under such preventing and curtailing them. The panelists believed conditions. Health systems must plan for, and work that to augment NGOs’ role in making and building toward the prevention of inter-personal violence. sustainable peace, a number of measures, (similar to those already initiated, and being supported by IPPNW), 6. Effects of War on Health: Case Study of the War can be taken. These include emphasizing peace through Imposed on Iran empowering individuals and societies to cope with war- Wars have quite varied effects on the societies engaged, induced complex conditions; promoting the enforcement ranging from the destruction of infrastructures to harms of, and respect for, multilateral agreements among nations; to the mental health of combatants’ family members, even preventing destructive and unilateral international many years after they end. Today, of the most important rules from being passed; developing and heightening and probably the most vulnerable individuals affected by friendship among societies across the globe; pressuring wars are the civilians. A case in point is the war imposed arms manufacturers to reduce the production of mass- by Iraq on Iran, in which the former made frequent use of destructive weapons; and trying to convince governments chemical weapons against Iranian civilians. The devastating to decrease their military budgets. effects have never ceased to have their grip on the victims, The panelists believed that to operationalize and enforce even after several decades following the termination of the such measures, once they start, NGOs must seek the war. Lack of respect at the time by Iraq for the health of support of economic powers as well as the cooperation another nation backed by its military superiority as well as of trained volunteers. The latter can educate the masses the lengthening of the war led to a substantial increase in on the risk factors (including upstream ones) of wars as war-induced damages. well as their consequences, as a means of strengthening Nonetheless, few studies have been carried out to date public demand for the reduction of all forms of violence. on the effects of that war. It is essential, however, that

Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 S57 Molavi Vardanjani et al research that provides evidence on the short-, medium- cultural assimilation of societies; boosting health equity on and long-term war-induced damages be conducted on a an international scale; and benefiting from cultural and large scale. An increase in the provision of such evidence as religious lessons from different societies to promote peace well as presenting it in efficient ways to communities and and friendship. their leaders across the planet can go a long way to decrease wars and acts of violence. 9. Medical Education and Development of Dialogue on Peace through Health 7. Complex Emergencies in Cases of War, and Promoting peace and preventing violence requires Development of Dialogue on Peace through Health resistance against the latter. The health workforce is the Discussions that were held on this panel can be major body where such resistance can manifest itself. summarized in what follows. Wars normally lead to In their routine education, health professionals are not complex conditions under which the governments lose trained on how to promote peace or minimize the effects control over the elements affecting health and security. of war and violence, especially so in developing and less- An inevitable consequence is extensive displacements of developed countries. At the same time, their professional the surviving residents of the areas involved, a crisis with responsibility requires that they have the capability to play an aftermath that usually lasts for many years. These a role in reducing armed and structural violence. To this displacements impose an incredible burden on the health end, being aware of the components and requirements of of the societies, which is even more massive than that achieving peace in its every dimension can be effective and caused by the devastation directly following the wars, e.g. extremely useful. In fact, for many years now, education casualties and loss of lives. on peace through health has been in place in some high- Health professionals need to strengthen their efforts ranking universities. Ironically, however, in developing and share them with international organizations. It is and less-developed countries, which are more seriously also essential that they are equipped with necessary skills involved in different forms of violence, such education is and training to be able to provide basic healthcare as well non-existent. Identifying models of education on peace, as urgent medical services in the complex emergencies. tailoring them to local needs, integrating them within Furthermore, they must make concentrated efforts to medical education curricula or presenting them in the form pave the way for a boost in the effectiveness of initiatives of optional short- or long-term programs and employing intended to reduce the complexity of emergency efficient education methods to teach them are precursors conditions, both during and after the war. Exchange of to peace through health. past experiences and orchestration of multilateral activities between and among relief organizations and governments Summary are important considerations they need to invest in. Finally, The discussions held by the congress panels can be boiled health professionals can use their health services, during down to the following convictions. Health professionals, the time they are offering them, as a means of stopping or especially those who are working in the Middle East diminishing the severity of wars. region, have to promote peace as part of their professional responsibility. Moving towards this objective can be 8. Human Rights, Medical Ethics and Development of realized through a number of measures. It is both necessary Dialogue on Peace through Health and feasible to increase research to identify the causes and The panelists were convinced that since human rights consequences of war and violence; and to appropriately and medical ethics constitute the main foundations of translate the findings to politicians, health professionals peace through health initiatives, it behooves the holders and masses of people. These can be achieved by means of of different views on these two concepts to bring their boosting cooperation between international organizations paradigms together and edge their differences away and of bolstering the position of NGOs on a global through international cultural dialogues. Examples of scale. Showing respect to other societies and civilizations, principles shared by different viewpoints include belief encouraging cultural interactions between societies, and in “justice” and in “equal civil rights”, “avoidance of elevating public intellectuality and general demand for unilateralism”, “commitment to provision of man’s health” reduction of violence can be effective in decreasing the and “the sanctity of man’s life”. latter and the effects thereof. Of the engagements that Here are some suggestions made by this panel to promote health professionals must seriously take on is employing peace through health initiatives: trying to avert the misuse health diplomacy and curbing the accumulation of of religion for attaching to people labels of blasphemy; unrestricted power and unilateralism through enforcing working to construct plausible agencies to promote international treaties. Finally, it is essential to make health positive and truthful inter-personal and inter-societal systems more resilient to complex emergencies caused by interactions; portraying the consequences of previous wars so that they can survive such conditions. wars and violence; initiating dialogues and materializing

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Authors’ Contribution 2. Guha-Sapir D, Schlüter B, Rodriguez-Llanes JM, Lillywhite L, All authors contributed equally to this manuscript. Hicks MH. Patterns of civilian and child deaths due to war- related violence in Syria: a comparative analysis from the Conflict of Interest Disclosures Violation Documentation Center dataset, 2011–16. Lancet There was no conflict of interest. Glob Health. 2018;6(1):e103-e110. doi: 10.1016/S2214- 109X(17)30469-2. Ethical Statement 3. WHO. Health as Bridge for Peace (HBP). Available from: The International Congress on Health for Peace (ICHP) was https://www.who.int/hac/techguidance/hbp/en/. Accessed approved by Shiraz University of Medical Sciences. March 2, 2019. 4. Franks A, Meteyard J. Liminality: the transforming grace of in- Funding Sources between places. J Pastoral Care Counsel 2007;61(3):215-22. There was no funding source. doi: 10.1177/154230500706100306. 5. Brown MD, Bergmann JN, Novotny TE, Mackey TK. Applied References global health diplomacy: profile of health diplomats accredited 1. Roberts A. The civilian in modern war. Yearbook of to the UNITED STATES and foreign governments. Global International Humanitarian Law. 2009;12:13-51. doi:10.1017/ Health. 2018;14(1):2. doi: 10.1186/s12992-017-0316-7. S1389135909000026

© 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Arch Iran Med, Volume 23, Issue 4 (Suppl 1), April 2020 S59 ARCHIVES OF Arch Iran Med. April 2020;23(4 Suppl 1):S60-S61 IRANIAN doi 10.34172/aim.2020.s13 http://www.aimjournal.ir MEDICINE

Open Meeting Report Access Educating Health Science Students About Peace through Health Topic; A Panel Discussion Mitra Amini, MD1; Mesbah Shams, MD2; Mohammad Bagher Khosravi, MD3; Anneli Milen, PhD4; Neil Arya, MD5*

1Clinical Education Research Center, Shiraz University of Medical Sciences, Shiraz, Iran 2Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran 3Shiraz Anesthesiology and Intensive Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran 4Tampere University, Global Health, Finland 5Fellow International Migration Research Centre and Balsillie School for International Affairs Adjunct Professor and Scholar in Residence Wilfrid Laurier University, Assistant Clinical Professor Family Medicine (part-time) McMaster University, Adjunct Professor Family Medicine Western University, Adjunct Professor Environment and Resource Studies University of Waterloo, Waterloo, Canada

Abstract This report describes an experience of the first international health for peace conference held in November 2018 in Shiraz University of Medical Sciences. This paper discusses the panel on peace education in medical and paramedical schools and the way for the future. Keywords: Curriculum, Education, Medical, Social justice Cite this article as: Amini M, Shams M, Khosravi MB, Milen A, Arya N. Educating health science students about peace through health topic; a panel discussion. Arch Iran Med. 2020;23(4 suppl 1):S60–S61. doi: 10.34172/aim.2020.s13,

Received: February 25, 2019, Accepted: October 12, 2019, ePublished: April 1, 2020

Introduction Health fifteen years ago.5 Since then, educational courses “Since wars begin in the minds of men, it is in the minds about Health and Human Rights have been taught of men that the defenses of peace must be constructed”.1 throughout the United States, especially in public health Peace can be defined not only as the absence of war or schools including Harvard, Berkeley, and Princeton. violence or harm to others but also as creating a state of Furthermore, there is a certificate educational program at positive, dutiful, and cooperative relationships. “Peace Johns Hopkins School of Public Health.6 through health is an academic discipline about studying Nevertheless, the concept of Peace through Health health interventions in real and potential war regions that has not been so far incorporated in medical and health can contribute to peace.” Violence disturbs the lives of sciences curricula. Medical students have expressed a millions of people all around the world, with long-lasting desire for the greater presence of medical humanities in complications.2 Health workers can help to decrease direct their curriculum.6 and structural violence. Violence is defined as avoidable The literature includes topics that might be included insults to basic human needs, including survival needs, in a curriculum of peace education for medical and wellbeing needs, freedom needs, and identity needs; war is paramedical students such as the capacity for conflict an extreme form of violence.3 management, linking peace and health, violence as a major Curricular revision in peace education in health science health conflict, the role of health professional experts in disciplines is an important issue in medical and health peacebuilding, healthcare staff at risk of violence and sciences universities. This activity affords teachers and the concept of peace medicine. There are opportunities students with the chance to be involved not only in the to develop some qualities, tools, and values that can be contents of peace education but also more prominently inculcated in students by such inclusion. Examples of determine the difficulties of peace education. Furthermore, qualities include skills and knowledge for diagnosis and significant engagement with peace curriculum allows treatment of diseases, documentation of health threats to medical and health teachers and students to detect violence populations, and reconstruction of the health sector. Some and prepare a basis for fundamental peace.4 tools are international collaboration and networking, Peace education is reported as an essential instrument access to people and different communities, funds and for the avoidance of violence and war and the construction infrastructure, mediation, and diplomacy. The values of maintainable peace.4 McMaster University in Canada include a commitment to health, doing no harm, human launched the first university course on Peace through dignity, social responsibility, and confidentiality.4

*Corresponding Author: Neil Arya, BASc, MD, CCFP, FCFP, D Litt; Fellow International Migration Research Centre and Balsillie School for International Affairs Adjunct Professor and Scholar in Residence Wilfrid Laurier University, Assistant Clinical Professor Family Medicine (part-time) McMaster University, Adjunct Professor Family Medicine Western University, Adjunct Professor Environment and Resource Studies University of Waterloo,519 783 0021. Email: [email protected] Medical Peace Education

Panel Description means there are many other aspects to be accomplished Peace through health can also be designed as an inter- such as classroom communication and learners’ skills in professional elective for medical, nursing, midwifery, the field of peace education. Similarly, it is also remarkable physiotherapy, and occupational therapy students. By to look at how other stakeholders understand the integrating peace components in existing curricula at an importance of peace education in all countries. They may international level, educational policymakers seem to have have useful and lived experiences. Further, the truth might strong commitments for constructing peace in the society. be so different from what teachers say they teach in peace The main objective of the panel was to analyze curricular education lectures. Therefore, a wide range of quantitative issues in peace education and to explore the understanding or qualitative research designs such as grounded theory, of the key factors involved in the implementation of peace ethnography, and phenomenology may be used to education in medical and paramedical schools. better understand some of the issues raised by this panel A model of peace through health education at an discussion. international level was described in the panel. It described In conclusion, it is necessary to reinforce the need for the activities based on the primordial, primary, secondary, peace education. It might fill the gap between health and and tertiary model of prevention. This model also focused peace in practice, teaching, and research. If a full peace on what we know about this important topic and what we concept is applied in the medical university curriculum, do and how we practice in this field.3 it would include behavioral and cultural factors that are The dimensions of peace education are very wide. specific to that community. Based on such a perspective, Some examples of these dimensions are when students for supporting peace on all levels, and for strengthening the learn which activities will lift people and countries out conflict-handling capability of people and communities, of poverty, how to rebuild countries and nations after it is an urgency to empower our students about this wars, how to create a common understanding between important topic. countries, and how to notice ethical issues. A sample of peace through curriculum was also discussed in the Authors’ Contribution MA and NA designed the panel and wrote the manuscript. MS, MBK panel. Regarding the content of the peace curriculum, and AM helped in designing the panel and writing the manuscript. the objectives can be divided into domains of knowledge, All authors read and approved the final manuscript. attitude, and psychomotor. Some important issues in the knowledge domain are global health, ecosystem health, Conflict of Interest Disclosures None. health professionals’ responsibility in conflict-solving strategies, human rights, violence, building a link between Ethical Statement physical, psychological and social health, local and global Not applicable. peace, and war surgery. In the attitude domain, important References values are responsibility, equity, partnership, non-violence, 1. Building peace in the minds of men and women. UNESCO patience, tolerance, modesty, solidarity, confidence, statement 1945. Available from: https://en.unesco.org/70years/ building_peace. neutrality, commitment, truth, honesty, impartiality, and 2. World Health Organization. Global status report on violence optimism. In the psychomotor domain, the important prevention. Geneva: World Health Organization; 2014. skills are communication skills, stress and conflict 3. Arya N. Peace through Health I: Development and Use of handling, building of self-confidence, conflict analysis, a Working Model. Med Confl Surviv. 2004;20(3):242-57. doi:10.1080/1362369042000248839 public work, teamwork, community mobilization, group 4. Melf K. Exploring medical peace education and a call for leadership and strengthening of self-healing capacities. peace medicine. Thesis for obtaining master degree program For delivering the curriculum, the SPICES model in peace and conflict transformation.2002-2004.Center for peace studies, faculty of social sciences. University of Troms. (student-centered, problem-based, integrated, community- Available from: https://munin.uit.no/handle/10037/146. oriented, electiveness, and systematic approach) will be 5. MacQueen G, Santa Barbara J. Peace building through health considered.7 A range of different teaching strategies will be initiatives. BMJ. 2000;321(7256):293-6. 6. Arya N. Peace through Health II: A Framework for Medical used. These teaching strategies include supervised practice, Student Education. Med Confl Surviv. 2004;20(3):258-62. doi: fieldwork, practical exercises, role play, exchange programs 10.1080/1362369042000248848 for students, group work with case studies, problem-based 7. Harden RM, Sowden S, Dunn, W.R. Educational strategies learning and team-based learning.8 in curriculum development: the SPICES model. Med Educ. 1984;18(4):284-97. doi: 10.1111/j.1365-2923.1984.tb01024.x 8. Brandl K, Schneid SD, Smith S, Winegarden B, Mandel J, The Way for Future Kelly CJ. Small group activities within academic communities The present panel discussion focused on curricula, which improve the connectedness of students and faculty. Med Teach. 2017;39(8):813-9. doi: 10.1080/0142159X.2017.1317728.

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