Professor Burkle, MD, MPH, DTM, PhD(Hon.), is a Senior Fellow with the Harvard Humanitarian Initiative, Harvard University, and Visiting Scientist at the Harvard School of Public Health. He is a Senior International Public Policy Scholar at the Woodrow Wilson Center for International Scholars in Washington DC, and Senior Associate Faculty, Department of International Health and the Center for Refugee & Disaster Response, Johns Hopkins University Medical Institutes. He holds Adjunct Professorships at Monash University School of Medicine and James Cook University in Australia and is Adjunct Professor of Surgery, Division of Military and Emergency Medicine, the Uniformed Services University of the Health Sciences in Bethesda, MD. He is the recipient of the prestigious William Crawford Gorgas Medal for "distinguished work in preventive medicine, groundbreaking work in disaster management and humanitarian assistance and the training of an entire generation of U.S. and international personnel. ”In 2007 he was elected to the Institute of Medicine of the National Academies of Sciences. In 2012 he was selected by the National Institutes of Health to give the Joseph Leiter Award lecture recognizing the “best and brightest” in science and medicine. Dr. Burkle has published over 200 scientific articles, 53 book chapters, four books, three on disaster management including Disaster Medicine (1984). He has worked in and consulted on numerous humanitarian emergencies and large-scale international disasters in Asia, Africa, the Middle East, and Eastern Europe. From 2002-03, Dr. Burkle served as Deputy Assistant Administrator for the Bureau of Global Health at the U.S. Agency for International Development and as the Interim Minister of Health in Iraq. A 1961 Saint Michael’s College and 1965 University of Vermont College of Medicine graduate, Dr. Burkle holds post-graduate degrees from Yale, Harvard, Dartmouth, the University of California at Berkeley, University of Geneva, and the Royal College of Surgeons in Ireland. He is qualified in Emergency Medicine, Pediatrics, Pediatric Emergency Medicine, Psychiatry, and holds a Master's Degree in Public Health and Diploma in Tropical Medicine. He is a combat decorated and now retired Naval Reserve Captain, who served with the Marines in Viet Nam, Somalia, the Persian Gulf War, and Iraq. He is a current member of the Board of Directors and Overseer of the International Rescue Committee, the world’s largest refugee organization, the Science Advisory Board of the American Red Cross, and served as Chair of the National Disaster Life Support Consortium of the American Medical Association for 4 years.
The reasons for global health crises and how the world responds to them have dramatically changed over the last half century. Increasingly, natural disasters result in failure of public health and security systems leading to preventable conflict, unconventional war and unprecedented population migration. While scientific expertise exists to mitigate these failures in fragile states and ungoverned territories, inactions are mired by the lack of political will, international legal mandates, and capacity to strategically monitor multidisciplinary public health indicator failures.
In 2004 I was honored to be interviewed for the Lancet medical journal’s Lifeline Series.
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My answer today would be the same. We continue to see how the decades old international legal framework is easily overwhelmed by political inaction, interference and moreover, struggles for relevance given today’s modern challenges. The reasons for humanitarian crises and how the world must respond to them have dramatically changed every decade.
More than a decade after the Iraq war, a broader brand of global health engagement has emerged yet public health’s role within that rubric remains in limbo, is operationally ignored, or is ill defined. What sanctioned interventions exist ‘under international law’ to protect the public health before conditions deteriorate? None are clearly defined. Working from existing laws of war, the ICRC, influenced by the consequences of Iraq and now Syria, acknowledge the overwhelming and dramatic “cumulative impact that stems from the complexity of urban system” collapse and their mutual dependence on country-wide large-scale inter-connected infrastructure loss that the health systems are not able to keep up with.
Today’s domestic and regional crises are increasingly under the influence of widely integrated global changes and forces defined by climate change, biodiversity loss, emergencies of water, food and energy scarcity and rapid unsustainable urbanization. These crises, initially slow moving, are increasingly severe affecting massive populations across many borders. Drought, crop destruction, and famine coincide with loss of vital aquifers. Whatever limited and often primitive public health protections remain, they have proved ineffectual, dangerously managed and selectively denied to the most vulnerable by those in power who persistently ignore wide ranging mitigation advances offered by the scientific community.
New legal preventive protocols and epidemiologic surveillance approaches are needed to protect civilians. Protecting the public health must be viewed both as a strategic and security issue requiring close collaboration with humanitarian, and military logistical and security personnel. Any attempt to redefine public health as a security issue must be coupled with efforts to develop a more comprehensive accounting of the human cost of modern-day fragile and ungoverned territories—not just warfare.
A mandate for a universally accepted system of preventive monitoring of more precise methods and outcome indicators that measure the effectiveness and efficiency of national health and public health systems is undeniable. However, health alone cannot solve these global health problems. While some standard indicators are already available, the most sensitive are often multi-and trans-disciplinary. For example, rates of dengue fever, which escalate when trash collection is inadequate, are sensitive indicators for economists of both poor governance and urban decay.
Crises only gain international attention when they result in conflict. The Syrian conflict is a case in point. From 2011 to 2016, 60% of Syria’s agricultural northeast and south suffered its worst drought, water shortage and crop failure, compounded by failures in governance and management. Poverty accelerated the exodus of farmers, herders and rural families to cities in the west fomenting today’s major sectarian war. Multiple public health interventions were available and could have ceased or mitigated the decline and population exodus.
Indeed, if all the forcibly displaced persons would be placed in one state it would be the 21st largest populated country in the world.
UN sanctioned revisions and rewrites of the IHL and the GC are crucial. The ICRC reports that there is “still room to strengthen and clarify the existing legal framework” to “adapt to new realities”; and, talks of supplemented GC Commentaries that “will give state and non-state actors an understanding of the law as it is widely interpreted today so that it is widely applied effectively in modern armed conflicts.”
More than ever, we need strong international humanitarian laws and an effective accountability and recourse mandate for those who fail to respect the laws that are in place. Why wait for conflicts to occur when we have a clear evidence-based global mandate to mitigate the obvious public health consequences? With public health infrastructure and protections “absent, destroyed, overwhelmed, not recovered or maintained, or denied to populations” it has become a massive global health emergency.
While we have had ‘laws of war’ for centuries, is it time, in an increasingly globalized world plagued by public health emergencies, for laws of prevention? Public health protections are a human right. What can one hopefully say to an emerging global society’s credibility that it has the tools to wage war but not to prevent them? The scientific expertise exists to be a force in preparedness and prevention; the political will and international law mandates must follow.
The opinions expressed in this article are the author's own and do not reflect the view of their affiliated institutions.
Frederick M. Burkle, Jr.: skipmd77@aol.com