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The “Public Health Argument” for the Will to Intervene

Kirsten Johnson, MD, MPH


Genocide prevention is typically framed as a political and national defense matter. However, the
gross violation of human rights that are inextricably linked to health and the impact on population
health, health services and health economics with damaging spillover effects and consequences to
global health make it a serious public health issue. Furthermore, the fact that violence prevention
has been a cornerstone to the field of public health and that there have been many advances in the
science of violence and injury prevention, make it possible to consider primary genocide
prevention from a public health-based perspective.

The Public Health Impact of Genocide

The public health impact of genocide goes beyond the number of people being killed. There are
many short and long-term impacts to public health that are experienced at the individual level and
in all sectors of society: from education to agriculture, from government to civil society. These
effects not only have profound consequences locally but also nationally, regionally and globally.

I would like to spend a few minutes talking about genocide and its impact on population health,
health services and health economics and how all of this relates to Canadians.

1. Impact on Population Health

Deaths resulting from genocide are estimated to have exceeded war-related mortality in every
historical period. Furthermore, in the latter half of the twentieth century, there have been more
deaths from genocide than from all other public health emergencies of the same period. During
the Rwandan genocide, mortality was 20 times higher than the rate for HIV/AIDS and 70 times
higher than the malaria mortality rate for the entire decade despite Rwanda being located in the
geographical center of these 2 critical pandemics throughout the 1990s.

Refugees and internally displaced people experience a higher mortality due to their migration.
Mortality rates are as high as 60 times the expected rates during the acute phase of displacement.
Infants often die in the peri-natal period and deaths from malnutrition, diarrhea and infectious
disease occur especially in children, while other infectious diseases such as malaria, TB and HIV,
as well as a range of non-communicable disease, injuries and violence typically affect adults.

Health consequences during the acute phase and for multiple subsequent generations after
genocide are also excessively elevated: up to 80 times higher than during times of peace. For
every young person killed, an estimated 20-40 receive injuries from machetes, landmines, gunfire
or other types of violence, requiring hospital treatment and long-term interventions.

Other effects on health include increased rates of low birth weights, malnutrition and preventable
diseases like measles, tetanus and diptheria that often become epidemic. There is also a greatly
increased risk of transmission of HIV infection and other sexually transmitted diseases during and
after genocide because displaced persons are more vulnerable to sexual abuse and violence, they
are more likely to turn to prostitution having been deprived of their livelihoods and displaced
children and unaccompanied minors are at high risk. Down the road, these individuals must face
the stigma and challenges of reproductive health problems such as unwanted pregnancy, sexually
transmitted diseases and sexual dysfunction.

Long-term health consequences include solid organ disease, higher rates of cardiovascular and
gastrointestinal disease, neurological dysfunction and a wide range of psychological and
behavioral problems, including depression, anxiety, psychosomatic ailments, anti-social behavior,
alcohol abuse, intra-familial conflict and suicide.

The health and mental health outcomes of genocide has a massive impact on productivity as a
result of chronic disease, premature death, injury, absenteeism, long-term disability and lost
potential. These individuals experience a diminished quality of life and decreased ability to care
for one-self or others and weigh a heavy burden on the already undermined health system.

2. Impact on Health Services

During genocide doctors, nurses and other health professionals are often targeted and killed.
Infrastructure that is needed for health delivery including public property such as hospital and
government buildings, equipment and supplies, water treatment facilities, transport and food
distribution is destroyed. Finally humanitarian access is often impeded resulting in no emergency
services when they are so desperately required.

3. Impact on Health Economics

Besides the toil of human misery, genocide exacts social and economic costs that are substantial.
People who have survived genocide have more health problems, resulting in more of a demand
for health care services and higher health care costs. Human resources and productivity are
affected, the opportunity costs of development are gone, and there is less progress in extending
life expectancy and reducing infant mortality and crude mortality rates when compared with
other countries in the same region and of similar socioeconomic status. Finally, for the affected
countries, diverting scarce global health dollars toward ameliorating genocide related outcomes
are substantial.

What does this mean to Canadians?

Genocide and mass atrocities threaten core Canadian national interests.

- By not focusing our efforts on genocide prevention, there are costs to our own health and
safety. There is the threat of pandemic disease and hampered efforts to eradicate diseases
that we should no longer be at risk of such as polio.

- Genocide fuels instability in weak, undemocratic and corrupt states and it is in these same
types of states that we find terrorist recruitment and training, human trafficking and civil
strife thus there is a threat to our security both at home and as we travel and live abroad.

- There is a threat to civilian humanitarian workers in conflict zones. In the period 1985-
1998, over 380 deaths have occurred among humanitarian workers with more UN civilian
personnel than UN peacekeeping troops being killed.

- Genocide has long-lasting consequences far beyond the states in which they occur.
Refugee flows start in bordering countries but often spread and humanitarian needs grow,
often exceeding the capacities and resources of a generous world and Canadians are
called upon to provide relief efforts and bear high economic costs in feeding and
delivering assistance to millions of refugees and trying to manage long-lasting regional
crises. The international community spent more than 1.4 billion, primarily in aid to
refugees in the year that followed the genocide in Rwanda while the cost of preventing
genocide would have been $300 million. In Bosnia the US invested $15 billion to
support peacekeeping forces after the genocide began. Canadians expect effective and
accountable aid programs that deliver results and achieve the objectives of helping
developing countries reduce poverty and disease, promote democracy and human rights,
and ensure a sustainable environment. Our foreign assistance dollars could go farther if
we spent them on prevention.

- Finally, Canada’s credibility and standing in the world is eroded when we are perceived
as bystanders to genocide and mass atrocities. We cannot be viewed as a global leader
and respected as an international partner if we cannot take steps to avoid one of the
greatest scourges of mankind.


In conclusion, genocide specific mortality rates are high. The Rwandan genocide that occurred
over the course of 3 months was the leading cause of death from 1994-2004 for all of sub-
Saharan Africa. The health sequelae of genocide may be chronic, lifelong, and difficult to treat,
increasing the burden of disease in affected communities for decades after the killing has ended.
The resultant impact of genocide on the global health economy has been and continues to be
substantial. Genocide, from a public health perspective, is an intractable disease for which there
will never be a vaccine - this means that we need to focus our attention on prevention and
intervention before genocide occurs. Preventing genocide is an achievable goal. It requires
planning and is carried out systematically. There are ways to recognize its signs and symptoms
and viable options to prevent it at every turn if we are committed and prepared.