By Dean Ana V. Diez Roux, MD, PhD, MPH

I was not expecting to write about war this month. Although anticipated for weeks, Russia's invasion of Ukraine and what it signals about the world today and where it could go in the future has come as a shock. Perhaps we should not be surprised given the currents of nationalism and its closely linked sibling ethno-centrism that still swirl underneath what sometimes appears to be a world that is making some albeit slow social progress. It seems almost trivial to talk about the public health consequences of war: death of course, and displacement, and the collapse of health and social systems as well as basic infrastructures critical to life. But the health consequences of war can be even more far ranging with long-term effects on physical and mental health, quality of life and mortality that extend well beyond the most direct and immediate impacts and that can span geographies and generations.

In addition to its direct health effects, war can have fundamental and long-term population health consequences through environmental impacts, through the diversion of social and economic resources, and through what is essentially the prioritization of killing and destruction over the creation of the environments, infrastructure and systems needed to protect health. It is not a surprise that the health impacts of war are largest among the children, the poor and those who are at the bottom of social and economic hierarchies. Sadly, the recent war in Ukraine is only one example. For many decades wars of one kind or another, some declared some not, but all equally harmful, have festered often unrecognized or ignored across the globe including in many countries of Africa, Latin America, and Asia. It is impossible to calculate the cost to life, health, and just plain human suffering of all this but there is no doubt it has been enormous. And most dangerously, in a world in which so many nations are armed with atomic weapons, any armed conflict including the present one in Ukraine, could evolve into a nuclear conflict that would be the end of everything, let alone harm health. Sadly, despite arguments that nuclear arms are only a deterrent, we have seen them used, and their mere existence implies that they could be used again.

Physicians, among many other health professionals, have raised their voices against war through movements like International Physicians Against Nuclear War and its U.S. affiliate Physicians for Social Responsibility. Although to be truthful I have not thought of myself as a “real” physician for a long time, the voices of these physician anti-war activists have reconciled me somewhat to my medical roots. There is after all at the core of medicine the mission and moral imperative to protect life. The same of course can be said of public health. Much has been written in public health about the need for public health professionals to take on the prevention of war as a critical public health issue. It has been argued that war should be considered a “man-made public health problem” and there have been calls for public health to systematically document the true and far-ranging population health impacts of war. The prevention of all armed conflicts is therefore critical and fundamental to the mission of all public health professionals, scientists, and advocates.

Many years ago, as girl, I remember my teacher at Estabrook School in Lexington, Massachusetts telling us that for the first time in our lives there was no war in our world. It was the end of the Vietnam War. Alas, I don't think the statement was true, as I am all but certain there were other wars going on at the time. But I remember the hope and emotion with which the teacher said this to us. I don’t think we fully understood, but I remember vividly feeling that this was something momentous, and telling my parents about it at home. The teacher's name was Mr. Loscoco, he was young (maybe in his thirties), clean shaven and had a crop of dark hair, and he stood in front of the blackboard as he said this to us, his voice shaking. I have often wished I could find him to thank him for saying this. Hopefully for the sake not only of public health but of humanity, his statement will become true one day.