Marie-France Guimond
Noah S. Philip
Usman Sheikh
McGill University - 2001
INTRODUCTION
“When I read all that, it made me glad that I was not going over to that country.” (Gordon, 1992) This statement, made by Lieut. Col. Harry Clark, the chief of the Africa-Mideast division of the U.S. Army Intelligence and Threat Analysis Centre, was made in reference to the tremendous amounts of both conflict and non-conflict related perils that awaited American troops during their mission in Somalia which were documented in a 140-page guide published by his office. The purpose of this essay is very much the same as Lieut. Col. Clark’s guidebook. In order to emphasize the tremendous dangers of peacekeeping, we, too, will methodically address the more prevalent conflict and non-conflict related health risks that form a very real part of every peacekeeping mission.
Our study derives examples from a variety of countries (e.g., Sierra Leone, Rwanda, Iraq, and the former Yugoslavia) in order to explore and discuss the health-risks, in general, confronted by peacekeepers. For the purposes of this essay, therefore, we have adopted the definition of a ‘peacekeeper’ provided by the Convention on the Safety of United Nations and Associated Personnel (Bloom, 1995). This Convention covers two types of personnel who carry out activities “in support of the fulfillment of the mandate of a United Nations operation.” The first is “United Nations personnel,” which are persons who are engaged or deployed by the UN Secretary-General as members of the military, police or civilian components of a UN operation. This group is what we normally consider to be peacekeepers, e.g., members of the United Nations Protection Force in the former Yugoslavia (UNPROFOR), etc. The second group are those who fall within the definition of “associated personnel.” One sub-group is those persons who are assigned to a mission by the UN Secretary-General or an intergovernmental organization with the agreement of the competent organ of the UN. One example would be the forces of the North Atlantic Treaty Organization (NATO) deployed to assist the UNPROFOR forces in Bosnia-Hercegovina. Another sub-group is those persons deployed by a humanitarian non-governmental organization (NGO) or agency under an agreement with the Secretary-General or a UN specialized agency.
This study also intends to provide a degree of analysis. It will elucidate the current policies related to peacekeeping health risks, derive lessons to be learned from the successes and failures of these policies and, finally, will suggest areas of policy reform to minimize health risks and to ultimately ensure the safe return of all peacekeepers.
SECTION I: CONFLICT-RELATED HEALTH RISKS
It would first be useful to understand the types of health risks each peacekeeper encounters or has the potential to encounter during a mission. This particular section will focus on those health hazards that a peacekeeper faces while directly dealing with belligerent parties – in other words, conflict-related health hazards. This section will focus on the following potential problems: death by direct violence, harm caused by chemical or biological warfare, and landmine-related injuries.
A) Death by Direct Violence
The most obvious health risk faced during a mission is the possibility of death of a peacekeeper due to direct conflict. Despite countless Security Council resolutions which have demanded that all belligerent parties ensure the safety of UN forces and humanitarian personnel, [i] statistics produced by the United Nations give strong indications that peacekeepers and other personnel involved in peacekeeping are being attacked and injured or killed at an alarming rate. In fact, since its first peacekeeping mission in Palestine in 1948, the UN Department of Peacekeeping Operations (DPKO) has noted almost six hundred peacekeeper fatalities due to a hostile act (DPKO, 2001). The examples of Somalia and Rwanda clearly convey the dangers of violence directed at peacekeeping forces.
Somalia
The UN Operation in Somalia (UNOSOM II) was established to take over from the US-led multilateral force, United Task Force (UNITAF). It was ordered to take appropriate action, including enforcement measures, in order to bring about a secure environment for humanitarian assistance. Its main responsibilities included monitoring the cessation of hostilities, preventing the resumption of violence, seizing unauthorized small arms, maintaining secure ports, airports and lines of communication, continuing de-mining operations, and assisting in the repatriation of refugees in Somalia (DPKO, 2001).
To this end, on 5 June 1994, Pakistani UN peacekeepers decided to inspect clan-leader General Aideed’s weapons compounds and also to close down his radio station which was broadcasting scathing anti-UNOSOM attacks. When the peacekeepers entered this station, however, they were met with angry crowds of Aideed supporters and, in addition to rock-throwing, they also faced attacks by members of his militia. Although the US Quick Reaction Force and Italian armored units responded to the peacekeepers’ pleas for help, once the dust had settled 24 Pakistanis were dead; many were savagely mutilated. In addition to the casualties, dozens of others were injured. Only a few months later the threat to the lives of peacekeepers became all the more apparent as the body of a US soldier – having been killed during a botched attempt to capture General Aideed – was dragged throughout the streets of Mogadishu (Daniel et al, 102-104).
Rwanda
Another such tragic incident occurred during the genocidal massacres in Rwanda. The UN mission of 2,500 members, under the command of Canadian Maj.-Gen. Romeo Dallaire, was established to monitor a power-sharing agreement between Hutu and Tutsi factions. It was Dallaire’s hope that by escorting the moderate prime minister Agathe Uwilingiyimana from her home to a radio station, that her appeals for peace over the radio would ease the tensions in Kigali. At the military inquiry that was held many months later, however, such a decision was described as “homicide by default” (Wallace, 1996). On 7 April 1994, the troops arrived in the morning to escort the Prime Minister and were immediately surrounded by hostile Hutu soldiers. Not only did they find Uwilingiyamana and kill her, but they also disarmed the ten Belgian peacekeepers assigned to escort her, brought them to a Hutu military camp in the middle of Rwanda’s capital, and bludgeoned them to death (Wallace, 1996). In the past, and, in addition to killing peacekeepers, belligerent parties have also been known to beat and take peacekeepers hostage, which reinforces the point that peacekeeping involves the very real threat of death or physical harm due to direct conflict during a mission.
B) Chemical/Biological Weapons
Although less likely than having one’s life threatened by an angry mob or by belligerent parties, there is much evidence that suggests the very real threat and possibility of physical harm to peacekeepers during a conflict due to the use of chemical and biological weapons. Recent information obtained under the Freedom of Information Act and by information posted on GulfLINK, a U.S. Department of Defence website, gives compelling circumstantial evidence indicating the use of chemical weapons as well as engagement of sporadic chemical warfare in both Iraq and in Bosnia. It should be made clear that, to date, there have not been any severe chemical injuries or fatalities among peacekeeping forces which indicates that such weapons have not been used on a large scale.
Iraq
Although stated by Defence Secretary William J. Perry and General John M. Shalikashvili, Chairman of the Joint Chiefs of Staff, that “there is no evidence, classified or unclassified, that indicates that chemical or biological weapons were used…”(Tucker, 1997), researchers have been recently uncovering evidence that this may not be the case and that such weapons were most probably used in Iraq. For example, researchers point to the testimony of Sgt. George C. Vaughn. While testifying before the U.S. House Committee on Armed Services on his experiences during the Gulf War, Sgt. Vaughn described the situation when his camp came under a SCUD missile attack. He testified that during the alert he had trouble sealing his gas mask and soon came to experience a “bitter-almond taste” and began to choke. A few days thereafter, he, along with other members of his unit, developed nausea, diarrhea, and severe fatigue. Even upon their return to the United States, physicians noted gastrointestinal symptoms and the development of fatty skin tumors (Tucker, 1997).
Another incident that occurred in different area of Saudi Arabia also deserves attention. As released on GulfLink, the Seabees of Naval Mobile Construction Battalion 24 also claimed to have experienced chemical weapon-related health complications during the Gulf War. They reported that not more than a day after Sgt. Vaughn’s incident, they noticed a bright flash in the night sky followed by a powerful detonation-concussion. The chemical alarms were set off, and troops were ordered to put on their MOPP gear. [ii] After the troops were permitted to remove the gear, they experienced an acrid smell, choking, profuse nasal secretions, facial numbness, a burning sensation on exposed skin, and a metallic taste in the mouth. [iii] Two M256 detection kits, it was reported, tested positive for chemical blister agents. In the days that followed this incident, many troops developed skin rashes and chronic ailments (Tucker, 1997).
Bosnia
Although unable to produce conclusive proof to substantiate their claims, Human Rights Watch issued the results of a two-year investigation that claimed that chemical agents were also used against Bosniaks fleeing Srebrenica during the war in Bosnia and Hercegovina in July 1995. Human Rights Watch based this conclusion on a number of factors, including consistent testimony from survivors that mortar shells produced a “strange smoke” of various colours which did not rise but spread out slowly, and caused the marchers to hallucinate. The smoke also caused the marchers to behave in an irrational manner, and, allegedly forced some to take the lives of their friends or even their own (Hiltermann, 1998). The investigation also cited a previous report issued by Human Rights Watch in March 1997, entitled “Clouds of War: Chemical Weapons in the Former Yugoslavia.” This report uncovered evidence that the JNA had a sophisticated chemical weapons program including nerve and mustard gasses. The investigation pointed to the fact the US government took these allegations seriously enough to conduct its own investigation into the matter, although the results have not been made public. Once again, many peacekeepers and other peacekeeping related personnel were at one point, or are presently, stationed in both the abovementioned areas – Iraq and Bosnia. From the above it is quite clear, therefore, that chemical and biological weapons have the potential to pose tremendous health risks to these individuals.
C) Landmine and UXO Injuries
Yet another potential health risk are injuries due to landmines and Unexploded Ordinances (UXO). Peacekeepers may be called to help clear the often staggering numbers of landmines and other small explosives that kill civilians well after the end of a civil war. It is estimated that there were half a million mines in Kosovo in August 1999 (Gall, 1999), while Cambodia had the dubious distinction of hosting 8 to 10 million landmines in 1995 (Ball, 45). A deminer will die or be maimed by a landmine for every one to two thousand cleared (Cameron et al, 317). In Kosovo, it was estimated that 19 percent of landmine victims were injured while clearing on duty (Gall, A3). The effects of a landmine injury are, of course, often permanent and debilitating. Landmine wounds are “highly contaminated” (Wertheimer et al., 1995) and amputees would ideally be fitted with relatively costly prosthesis. Since anti-personnel landmines are specifically designed to severely harm without killing, the resulting potential injuries to deminers result in high medical costs. Many landmine victims experience ‘phantom pains’, which may leave many amputees “unable to function normally for years, even decades” (Cameron et a., 4). As peacekeepers are often asked to lead demining operations after a conflict, landmine and UXO injuries clearly pose a very serious health risk.
SECTION II: NON--CONFLICT-RELATED HEALTH RISKS
Although there are clearly many health hazards that a peacekeeper can potentially encounter while on a mission and while directly in a conflict, there are many significant health complications that are not directly caused by the conflict itself. These can include accidents and a variety of non-lethal and lethal illnesses that are caused by endemic diseases, by physical and psychological trauma, or by inadequate nourishment and supplies.
A) Infectious Diseases
The current state of global disease profiles cannot be understood, much less be a focus of policy, without understanding how diseases have affected populations throughout history. Diseases have always moved with populations. Populations have always been exposed to diseases carried by migrants or invaders; these diseases may become endemic in the indigenous population. It is crucial to note that disease flows in both directions, between settlers and indigenous populations. Although there is strong evidence that European settlers destroyed the majority of indigenous Americans in the course of western expansion with epidemics of cholera and tuberculosis, there is data that suggests indigenous Americans introduced measles and syphilis to the early European settlers (Diamond, 1997). When sending peacekeeping forces from their native countries, these past lessons need to be remembered, to ensure that appropriate prevention is maintained
The history of the epidemics is also important to understand, when examining health aspects of peacekeeping. As long as there have been large populations, epidemics have existed. In fact, the first documented epidemic was recently proven, through genetic analysis, to be malaria, which swept through Rome approximately 1500 years ago (NYT, 2001). After Rome fell, epidemics resurfaced again during the late Middle Ages, with the Black Death; this was a time when urban populations began to grow at a dramatic rate (Spielvogel, 2000). Today, Incidences of diseases found traditionally in tropical or developing areas, such as Congo-Crimean Fever, West Nile Virus, Malaria and Tuberculosis (TB), are on the rise in non-native areas. Health and government officials have watched this increase with growing alarm: most of these diseases are extremely expensive, or impossible, to treat on an individual basis; if these diseases become endemic in the general population governments will be forced to commit astronomical funds to treat the situation. Clearly, a cost-effective strategy would include efforts focused on preventative measures, such as identifying potential risks for peacekeeping soldiers on their missions, and taking appropriate action to prevent them from acquiring and transmitting diseases to their home populations. The following examples of infectious diseases are provided to demonstrate the extent of the problematic issue of peacekeepers acquiring infectious diseases.
HIV/AIDS
According to the WHO’s Global Programme on AIDS (acquired immunodeficiency syndrome), over 21.8 million people have died of AIDS, and 36.1 million people are currently infected with HIV (human immunodeficiency virus); there were 5.3 million people infected in 2000 alone. AIDS has orphaned 13.2 million children, in addition to severely affecting infant and maternal mortality, economic growth and life expectancy. In at least 16 countries, predominantly in Africa, more than one tenth of the productive population, aged 15 to 49 is infected with HIV; almost 40% of adults in Botswana are infected with HIV; almost 20% in South Africa. The cost of treating HIV/AIDS is currently prohibitive, even with major price reductions. At this point, the only possible way to control the HIV pandemic is with a vaccine.
As physicians Craig Hendrix and Stuart Kingma write, “military forces are among the world’s most susceptible populations to HIV/AIDS” (Yeager, et al, 2000). Not only is this because peacekeeping troops are deployed in developing, war-torn nations that do not yet have the resources to deal with the HIV/AIDS pandemic, but the nature of the peacekeepers themselves compounds the problems of sexual disease transmission. Peacekeeping forces are “predominantly young and sexually active, are often away from home and family, are governed by peer pressure than by established social norms, are specifically trained in risk taking and in self-perceptions of invincibility,” (ibid) and are usually surrounded by opportunities for sexual encounters.
These ‘opportunities’ were clearly presented to a number of UN peacekeepers in the form of a brothel; these UN troops were allegedly from Canada, New Zealand, France, Ukraine and an African country. According to news reports, UNPROFOR peacekeepers regularly frequented a Serbian-run brothel outside Sarajevo, where some of them took sexual advantage of Muslim and Croatian women who were forced into prostitution. The visits were apparently made in the summer and autumn of 1992 at Sonja’s Kon-Tiki, a restaurant-pension in Vogasca, about six miles north of Sarajevo. According to the Branislav Vlaco, the Bosnian Serb commander of the camp from May to November 1992, the UN troops would come to eat, watch television on his satellite receiver, “and they came for the girls, too” (Aikman, 1993). Although the problem of acquiring HIV and AIDS is more prevalent in Africa, UN troops were reported to have contracted the disease through visits to Bosnian brothels and were also claimed to have transmitted the disease to several Croatian women. In fact, according to a UN official who spoke with The Boston Globe on the condition of anonymity, a verbal fighting match ensued between the government of Croatia and the United Nations; Croatia demanded that peacekeepers be tested before deployment. The United Nations strongly responded that they would not and “privately told them they should get their own people tested to protect our troops” (Lauria, 200).
Tuberculosis
TB is responsible for at least 8 million cases annually, 2 million deaths, and contributes to the death of nearly 1 million people infected with AIDS (Dye et al, 1999). Therefore, TB and AIDS are the largest cause of mortality worldwide from infectious disease. TB affects approximately 16 million people worldwide, and has a fatality rate of nearly 50% for untreated cases. With HIV co-infection, the mortality rate can be quite high: in a recent autopsy study in Africa, TB was the cause of death in 32% of AIDS cases, and a contributory cause in an additional 15 to 25%. The peak age of incidence of the disease is 15 to 25 years, but can persist for a lifetime. Clearly, TB also generates significant economic and social problems. TB is naturally impervious to many antibiotics, so drug resistance (DR) develops rapidly, while globalization and migration have facilitated the transmission of DR-TB. Tuberculosis is particularly rampant in eastern Europe, with extremely high rates in warn-torn regions, such as the Balkans, where refugee camps contribute to the spread of TB, and inadequate access to the required treatment, Directly Observed Treatment, Short-course (DOTS), results in rapid increasing frequencies of DR-TB. A TB vaccine is currently being administered across the world, but with variable results.
The UN operation in the former Yugoslavia, once again, is an excellent example of how easily such diseases can be transmitted to UN troops. Due to the emergence of refugees, poor nutrition, and the lack of screening and medical treatment available for the population of Bosnia, a significant portion of this group has been afflicted with TB. In fact, the WHO issued a report indicating the alarming increase in TB cases in Eastern Europe and the former USSR; an increase of cases in 20 of 27 countries and, specifically, over 2000 cases of active TB were reported in the area of Bosnia-Herzegovina alone (Emmons et al, 1999).
Such conditions produced a major TB scare during the deployment of more than 20,000 US troops to this area in support of the Dayton Peace Accords and Operation Joint Endeavour. In order to support the logistical and support needs of this very large-scale military endeavour, members of the local population were employed to take on a variety of tasks, including cooking, dishwashing, carpentry, and construction work. As there were no systematic health screenings of the hired local workforce prior to employment, it was more than two weeks until the medical staff finally diagnosed one of the workers with active pulmonary TB (Emmons et al, 1999). Upon ordering all troops to complete a tuberculin skin test at their local medical treatment facility, out of 80 who worked with the individual, 35 had a positive skin test reaction. The possibility of acquiring tuberculosis and other diseases through the local population is clearly a major risk for all peacekeepers on mission.
Malaria
Malaria the number one killer in the world. Over 300 to 500 new malaria infections occur each year, along 1 to 3 million deaths annually transmitted by the female anopheles mosquito. The malaria burden has remained unchanged over the last 25 years, and in some cases has increased. Malaria alone is thought to reduce the annual gross domestic product in sub-Saharan Africa by 1-4% (Sachs and Spielman, WHO, in press). Treating malaria is also expensive, as drug-resistant strains of the malaria parasite are becoming more common, especially in Southeast Asia, such as Cambodia and Vietnam. There are several strains of Malaria; for example the Vivax Malaria strain of the disease is often not fatal, but Falciparum Malaria is often highly dangerous or even deadly. The disease was a major cause of death during the Vietnam War.
Since preventing mosquito bites is difficult in field operations, post-infection treatment of peacekeeping forces in this region has often been necessary. In addition, of all the major infectious diseases, the prospect for an effective malaria vaccine is the bleakest (Letvin, et al, 2001). A study malaria acquired by United States soldiers in Southeast Asia, indicates that symptoms often only develop after redeployment of troops to the United States (Shanks, 1992). The female anopheles mosquito is rare in the United States; therefore the rate of exposure to potential contagion in the United States is very low. However, the treatment of malaria can be challenging in a country where the disease is rare and where health care professionals may not immediately recognize the symptoms.
Lassa Fever
The WHO reported a case of Lassa fever in the Netherlands in July 2000. A health worker previously stationed in Sierra Leone had imported the disease (WHO Outbreak Report 2000). This example demonstrates the difficulties associated with diseases developing after redeployment to the peacekeepers’ country of origin for both the treatment of patients and, in some cases, the potential contagion to a population that may not have natural exposure-based immunity to a particular disease.
Lassa fever has an incubation of up to three weeks, which makes it possible for an affected individual to travel without knowing his or her medical condition. Such cases can be problematic, since any person exposed to the Lassa fever patient can become infected and/or be a vector for the disease in a country where medical facilities may not be equipped for such outbreaks. Any person in contact with a victim of Lassa fever should be under surveillance for three weeks following the initial outbreak. The contagious nature of the disease calls for particular measures at the hospital where a patient is treated to reduce the risk of more infections, for example when handling blood samples. Potential contagion is especially high in an hospital environment, where contaminated blood and other bodily fluid are tested. The symptoms for Lassa fever correspond to that of other diseases, like yellow fever or severe malaria, and may be very difficult to diagnose. The World Health Organization moreover reports that “definitive diagnosis requires testing that is available only in highly specialized laboratories. Laboratory specimens may be biohazardous and must be handled with extreme care at the highest level biosafety containment”. While this case of the Lassa fever may be an isolated incident, it does bring up some important elements of concern that may need to be addressed.
Miscellanous Aspects: Supplemental Information
It is important to note here that not all peacekeepers will have the same vulnerability to diseases; moreover, they may not receive the same treatments. At a fundamental level, the military or support units that are used in peacekeeping missions are residents of their respective countries, and are therefore subject to the health situation of their country before and after deployment. Since national health conditions can vary greatly, the native health environment of the soldier is very important, as units from developing nations will have had a drastically different disease exposure from their counterparts from Western nations. To understand and subsequently limit disease exposure within a variegated peacekeeping force, identification of regional differences in disease profiles is critical.
Over the last one hundred years, the disease profiles of developed and developing countries have diverged dramatically. Infectious disease, such as tuberculosis (TB), gastroenteritis, measles and polio, was the leading causes of disability and death in highly populated areas of the entire world until the early 20th century. Stomach and other major cancers were also extant but contributed relatively small mortality and morbidity rates. However, the general pattern of disease diverged in the early to mid 20th century, as the disease profile of western nations changed from predominantly infectious mortality to predominantly non-communicable mortality, such as heart disease and cancer. The general trend for developing countries over the last century was that of a slight decrease in infectious disease burden. Some of the decrease may be attributable to increased access to nutrition, while other aspects of the decrease may be due to health education, prevention and vaccination programs, such as the World Health Organization’s (WHO) efforts to remove polio, smallpox and Haemophilus influenzae by vaccination. Notably, such programs were not limited to developing counties. Infectious disease is still a major cause of death in developing nations: of WHO member countries, infectious diseases are responsible for approximately 35% of total deaths in countries with middle to low incomes. Infectious diseases are still present in developed populations, although they comprise only approximately 6% of deaths. The only major trend observed in both developing and developed countries throughout the latter half of the 20th century was a massive increase in lung cancer incidence, due to smoking, primarily in males (Franco, 1997).
B) Illnesses
Post Traumatic Stress Disorder
Psychological illnesses affecting military personnel, especially in the form of Post-Traumatic Stress Disorder (PTSD), have been given more attention in the literature in recent years. Post-Traumatic Stress Syndrome has been included in the official nosology of the American Psychiatric Association in 1980. The third edition of the Diagnostic and Statistical Manual (DSM III) defines Post-Traumatic Stress Disorder as the memory of an event “outside the range of normal human experience” which would cause “significant symptoms of distress in most people”. The memory of the traumatic event, unassimilated by the brain because of the extraordinary circumstances surrounding its occurrence, causes symptoms. Re-experience, for example, in the form of dreams; symptomatic numbing, for example, self-dosing with drugs and alcohol; avoidance of triggers of the traumatic memory, and physiological arousal, including irritability and sleep-disorders (Young, 1995). While war-related PTSD is a sub-category of general PTSD, “the origins of the PTSD diagnosis are inextricably connected with the lives of American veterans of the Vietnam War” (Young, 1995).
While the threat of stress-related psychological disorders for military personnel has been known for year, it seems that it is only recently that the same problem is being discussed for peacekeepers, since PTSD has usually been associated with combat-related stress. Recently, however, many studies recognize that the peacekeepers’ role as a buffer between warring parties while restricting the demonstration of any forms of aggression can indeed have a very severe impact on peacekeepers (Mehlum, 1999). The mental preparation for a combat mission varies widely from that which is needed for peacekeepers; they have to deal with the pressures of the needs and expectations of the population helped, as well as cope with frequent isolation while deployed (Britt, 1999). Moreover, many activities associated with peacekeeping can involve very high stress and trauma levels, for example mine clearing and disposal of the deceased (MacDonald et al, 1998). Recently, a new sub-category of traumatic stress disorder has emerged to address the symptoms associated with peacekeeping operations: peacekeeper’s acute stress syndrome is associated with the stress response of “rage, delusion, and frustration; feelings of impotence and helplessness when confronted with violence and atrocities but unable to respond” (Pearn, 2000).
Recent studies with previously-stationed peacekeepers from the United States, Canada, Australia and Norway indicate a PTSD prevalence between 5 and 20 percent (Mehlum, 1999). The level of stress disorders resulting from a peacekeeping and humanitarian operations by all United Nations peacekeepers within 3 years of deployment is between 2 and 8 percent (Pearn, 1999). A study of New Zealand peacekeepers, mostly deployed to Cambodia and Somalia, indicate generally worse mental health six months after redeployment than during deployment, with high levels of “anxiety, depression, and psychological distress” (MacDonald et al., 1998). Another study focussed on the suicides of three peacekeepers in the first month of deployment of the Operation Uphold Peace in Haiti, an occurrence that was unseen in Somalia or Iraq. It was determined that “frustrated aggressive drives” where in great part to blame, because the soldiers had been mentally prepared for combat but the mission was changed just hours because their arrival in Haiti to a much more passive observer role (Hall, 1996). A recent CBC report also focussed on PTSD. One of Canada’s most infamous case of traumatic stress disorder was that of its troops in Rwanda in 1994 who had to remain passive while individuals, especially Hutus, were stockpiling arms prior to a massive massacre of the population. Among the main problems identified was the lack of funding for the Canadian military:
Sending Canada's soldiers around the world extracts a terrible human toll. In a military cut by one third in the past decade, the same peacekeepers keep getting sent away over and over again. Canada can't seem to say no to the world and the soldiers arepaying the price. (CBC, 2000)
Notably, these recent studies are augmented by recent events in Calgary, in which a former peacekeeper drove his truck into a Canadian Forces military base, in an apparent suicide attempt (Globe and Mail, March 16th)
Gulf War Syndrome
In the last decade, a few illnesses have been reported by military personnel that were stationed in the same region. One that gathered much medical attention is the Gulf War Syndrome, which was first noticed by redeployed American soldiers in 1992, but also affected soldiers in Canada and Europe. Symptoms include “fatigue, headaches, joint pains, sleep disturbances, cognitive difficulties, and other physical (somatic) symptoms” (Hyams and Roswell, 1998). A high number of birth defects were also reported for parents who served in the Gulf War (Quinden, 1994). Since, many studies have tried to determine what could have caused these symptoms and whether they form a syndrome. Potential causes include “psychologic stress and exposure to chemical and biologic warfare agents, pesticides, pyridostigmine bromide [iv] prophylaxis, depleted uranium, oil well fire smoke, vaccinations, and endemic infectious diseases”; researchers were especially concerned with exposure to gas from the explosion of an Iraqi depot (Shenon, 1997). However, research has been generally inconclusive about both the causes and the existence of GWS (Hyams and Roswell, 1998). It was determined, however, that Gulf War veterans have a Post-Traumatic Stress Disorder rate two times higher than the rate non-Gulf War veterans; moreover, they display levels of alcoholism 15 percent higher than non-Gulf War veterans, which may signify a high rate of trauma for Gulf War veterans.
Depleted Uranium
More recently, 24 European soldiers died of cancer following a peacekeeping operation; the alarm was sounded in January 2001 after the death of 10 Italian peacekeepers that some claimed was caused by exposure to depleted uranium (Simons, 2001). Potential risks of exposure to depleted uranium also include birth defects and neurological impairment (Mitrovica, 2001). The depleted uranium was used on the tip of NATO warplane anti-armor ammunition in Bosnia and Kosovo. Two European laboratories found traces of uranium 236 from fragments of American weapons from Kosovo (Simons, 2001). A recent study by the Canadian Department of National Defence determined that no evidence was found of “uranium levels among CF veterans of either the Gulf War or Balkans peacekeeping missions. The tests do not support the theory that members were exposed to toxic levels of depleted uranium. Canadian results are the same as those obtained by Canada’s allies ‑ the United States, Belgium, France and Germany”. Nevertheless, the Globe and Mail reported on February 17, 2001 that two Canadian doctors would conduct more testing in the Balkans (Mitrovica, 2001).
Despite the unsubstantiated evidence on these illnesses, they attract much media attention and affect the lives of many peacekeepers. In a 1999 paper on somatic illnesses, such as GWS and depleted uranium-related symptoms, Drs. Barsky and Borus claim that “the functional somatic syndromes have acquired major sociocultural and political dimensions. Their definitive status in public consciousness and popular discourse contrasts markedly with their still uncertain scientific and biomedical status”. (Basrky and Borus, 1999) Also to be considered is the cost of lawsuits and health benefits to those affected by deployment-specific illnesses.
C) Vaccination
Vaccinations have been one method governments have utilized to combat health threats. The most prominent issue in vaccination has been the Anthrax vaccine (AV). The necessity of AV was first stated in 1968, when it became apparent that Anthrax was being developed as a biological weapon, and could pose a risk to military units. However, administration of the anthrax vaccine came under criticism from the US congress, and the as well as members of the military who have refused to obey vaccination orders. AV has also been suggested as one of the culprits of the Gulf War Syndrome (GWS), as well as other potential post-combat syndromes. A US Department of Defence (DoD) report on the effectiveness of AV concluded that the dangers of AV are outweighed by the possible danger of anthrax infection. However, the study concluded that AV was not an effective large-scale defence against Anthrax, since the long-term effectiveness and safety of AV have not been sufficiently tested (DoD, 2000). Currently, AV is required for all personnel with potential exposure to Anthrax, such as those serving in the Middle East, however the US military is currently slowing or ceasing vaccination rates in forces stationed in other areas. Despite high-profile court-martial cases, CF Health services still considers AV safe and effective, and is still used when warranted (CANFORGEN Highlights, 2000).
Since the Gulf War, there has been increased discussion on the danger of vaccination and preventative medicine for the long-term health of military personnel. Because of a 1990 special permission, the United States Defence Department can administer experimental drugs to their troops (Leary, 1994). Moreover, American troops in the Gulf received anthrax and botulism vaccinations, the former, which was also linked to GWS. In mid-1999, five U.S. marines refused to take the mandatory anthrax vaccination because of fears of harmful side effects; the story received significant press coverage. On February 17, 2000, the Department of Defence released a report on the Anthrax Vaccine Immunization Program (AVIP) recommending the following steps:
any expanded use of the same vaccine should be undertaken only with the greatest care and only to the extent necessary. As currently designed and implemented, the anthrax vaccine program fails on both counts. [...] It expands and distorts the use of invasive and dated medical technology to address perceived weaknesses in detection technology and external physical protection against biological attack. Administration of the anthrax medicine for mass prophylaxes against biological warfare should be considered an off-label use to treat an indication for which it is not explicitly licensed. (AVIP 2000)
D) Other Illnesses
Although not always fatal, the DPKO reports that illnesses were the cause of death for almost 300 UN peacekeepers and peacekeeping personnel (DPKO, 2001). Illnesses can, however, pose health complications, such as scorpion or snake wounds, encountered by UNOSOM troops in Somalia (Gordon, 1992). Peacekeepers may also be faced with more difficult health complications such as diarrhea and other intestinal problems; respiratory diseases, skin diseases, meningitis, and other diseases spread by sandflies or hookworms and other parasites that enter the skin. These illnesses can “degrade the effectiveness of over 10 to 20 percent of the force within 24 to 48 hours” (Gordon, 1992). Then, there are also the major illnesses, such as bronchitis, that can prove fatal for peacekeepers especially for those who are inadequately supplied and nourished. A case in point is the Bangladeshi solider who died of a bronchitis-induced heart attack due to a Bosnia-wide Serb blockade. The battalion doctor attributed the death to a combination of living in unheated barracks without winter clothes in temperatures as low as 18 degrees, poor nourishment and a lack of medicine and medical equipment (Brand, 1994).
E) Accidents
The Department of Peacekeeping Operations (DPKO) reports that over 700 UN peacekeepers and peacekeeping personnel have died due to motor vehicle, air traffic, and other accidents (DPKO, 2001). For example, On 12 March 2001 a 500-pound bomb was accidentally dropped from a U.S. Navy F-18 fighter in the area where the US and other foreign forces have maintained military presence in Kuwait since the Gulf War. This accidental bombing is reported to have killed at least six personnel stationed in Kuwait- five Americans and one New Zealander- and wounded over a dozen more (Barthos, 2001).
SECTION III: POLICY ANALYSIS
Conflict-Related
Mission Mandates
Policy related to peacekeeping missions has changed significantly since the Post-Cold War era, creating problems as witnessed by the UN peace force failures in Somalia. During the Cold War, UN peacekeeping operations, called ‘traditional’ or ‘first-generation’ missions, were rather limited: these fulfilled a conflict management role and were reluctantly established. In 1987, for example, around 10,000 troops from 23 troop-contributing countries were deployed in only five missions. Moreover, the budget allocated to peacekeeping operations was less than US$ 250 million (Berman and Sams, 2000). Such traditional missions generally abided by the following basic tenets: consent of the parties to the conflict, impartiality of the peacekeeping force, and the prohibition of the use of force except in self-defence.
After the collapse of the Soviet Union, however, the international community became more willing to deploy peacekeepers throughout the world. These missions, called ‘second generation’ missions, in addition to simply preserving the status quo, were actively involved in building a firm and sustainable peace in the nations to which they were deployed. A direct by-product of this significant shift was the fact that the tenets of ‘first-generation’ missions were undermined. UN operations have since been perceived as biased, missions have often entered into countries where consent by the parties to the conflict was not established, and force was often used other than in self-defence. This resulted in many of the deaths noted above—notably in Somalia where the peacekeeping forces were regularly attacked and killed as they were seen to be partial to opposing parties by local groups.
Anti-Personnel Land Mines
The recent anti-personnel (AP) mine convention is an important emerging aspect of international policy, which addresses conflict-related risks of deployment. Under article 1 of the convention, state parties are forbidden from utilizing, producing, selling or transferring AP mines. States are also forbidden to assist, encourage or induce any activity prohibited under the convention. Article 2 follows that all signatory states are also responsible for the destruction or their AP mine stockpiles (AP Landmine Convention). Clearly, restriction of AP land mines in combat situations will reduce the danger posed to peacekeeping forces, in addition to having the added benefit of safety for the surrounding populace. Implementation of the convention is not presently a reality, due to the reticence of the US, Russian and other militaries. The AP convention has the potential to become a powerful policy tool towards the prevention of deployment injury and mortality for peacekeeping soldiers, but the actual realization of such potential is still undetermined.
Non-Conflict-Related
General Prevention and Promotion
Health prevention and promotion initiatives have been a recent focus in the Canadian Forces (CF) and US military. Within the CF, the recent Spectrum of Care (SoC) report stated an integrated preventative health program with the other health aspects of being a CF member. In this program, specific attention is to be given to every CF member about communicable diseases, and mandates epidemiological and STD investigations within units, as well as tracking and follow up of TB cases found within units. Several health promotion initiatives have been implemented recently, to address aspects of personal care and lifestyle issues that contribute to incidence of disease and disability within the CF. Last year, the Rx2000 project was launched: its goal is to examine health care deficiencies and improve the general standard of care within the CF (CFHS Bulletin, October 2000). This project was in response to a series of reports that found health care deficiencies in the Canadian military structure. Within the Rx2000 project are many so-called Working Groups, each with a specific project to examine and improve. One of these Working Groups is the Forces Health Protection and Promotion Group, whose mandate is create a CF program to address injury and illness prevention. Specifically, this Group is addressing the problems of deployment-related health issues, such as the traditional issues of hygiene and sanitation, and more modern issues, such as field medical intelligence and indigenous hazards of deployment areas.
The United States military has recently instituted programs to address general health concerns. The U.S. Army Center for Health Promotion & Preventive Medicine (USACPPM), established in 1994, actively coordinates research and operating recommendations, designed to deal with health aspects of military missions. While these programs are not specifically designed for peacekeeping missions, the information they provide is clearly relevant. Within the USACPPM are departments specifically mandated to address specific health issues, such as preventative medicine and environmental dangers. In 1998, USACPPM initiated the Force Health Protection (FMP) strategy; FMP is a fundamental re-orientation of the military’s medical forces, “away from acute-care services that emphasize post-casualty intervention and toward proactive, preventive services that strive to prevent casualties” (USACPPM, 1998). The FMP initiative has developed into, amongst other things, a series of annual conferences and courses, entitled Force Health Protection (FHP). Within FHP are courses such as ‘Humanitarian Assistance for Preventative Medicine’, as well as conferences on addressing environmental, clinical and preventative aspects of military health. Within each of these conference types the constant theme has been identification and prevention of health threats to military personnel.
The application of specific policy to reduce the risk of infectious diseases has been varied. For example, U.S. military personnel in the Persian Gulf and the Saudi Arabian Peninsula are given vaccination, prophylaxis, and insect repellents for prevention of diseases such as anthrax, hepatitis, malaria, and tuberculosis. It is necessary that health care workers in a region like the Persian Gulf “will need to consider diseases that they have never before treated or diagnosed” (Baker, 1991). In Haiti, dengue haemorrhagic fever was partially prevented through vector-control methods and personal protection measures, like topical application of DEET (Gambel, 1999). Clearly, peacekeepers have directly benefited from such policies. However, although vaccinations, such as the AV, are currently mandatory, only long-term studies will be able to prove their safety and efficacy.
PTSD
Treatment and prevention are now more common in the US and Canada. In Canada, the CBC reported that five counselling centres across Canada with “a team of psychologists and social workers works with soldiers to come to terms with their emotions,” regarding post-traumatic stress situations. The program also includes a video “to urge sufferers to seek help” and to educate peacekeepers on the potential traumatic experiences they might face while deployed. The video, “Witness the Evil,” contains testimonial by former Blue Berets in Rwanda. Psychologist Jacques Gows, also interviewed by the CBC concluded that “the most important factor that has been shown to prevent combat stress reaction from developing is leadership, and the confidence that soldiers have in their leadership and the cohesion within the unit”. Also, a pilot program workshop was organized in 1996 for Canadian military chaplains who were deployed in NATO or UN peacekeeping missions; The workshop was considered a success (Zimmerman, 2000). In the United States, a mix of primary prevention (prior exposure to environment and experiences) and secondary prevention (group discussion after a traumatic situation) has been introduced for military medical personnel (Baker, 1996). Similarly to Gows’ argument, the study of US peacekeepers’ suicides in Haiti concluded “future deployment of this type [...] may benefit from greater attention by all levels of leadership to the need for stress management in peacekeeping operations” (Hall, 1996). Notably, it is estimated that 80 percent “of all people who are confronted with a trauma utilize their own resources and social support to work through the after-effects”; however, most of these individuals manage this through preventative mechanisms, like trauma debriefing and psychological treatment (Keane et al., 387).
One of the main shortfalls of the above-mentioned PTSD prevention and treatment techniques is the lack of information on the majority of peacekeepers who are not ‘Western’. This is not only significant factor because of the amount of financial resources available to help victims of traumatic stress disorders, which is generally less in developing countries; the problem may also be cultural differences. If, as Allan Young argues, Post-Traumatic Stress Syndrome emerges from a specific socio-cultural environment that shapes responses to trauma, effective treatments may differ between individuals of different cultures exposed to the same traumatic experience (Youn, 1995). However, studies on culturally-diverse peacekeepers seem to be lacking. Another facet of this argument is that the military itself is culture, and a minority culture within the civilian system. Dr David Kutz argues that the U.S. military is “a distinct culture with its own norms, values, and mores” and is partially shaped by the overwhelming number of young males in its ranks; Kutz moreover claims that “like other minority cultures, the military places great stigma on mental illness” (1996). Following this argument, it might therefore be necessary to provide very different treatments and prevention mechanism for the military than for a civilian population experiencing similar traumas.
CONCLUSION: LESSONS LEARNED AND SUGGESTIONS FOR THE FUTURE
The general lack of discourse on this topic is, in and of itself, emblematic of the necessity to improve public discussion of health aspects of peacekeeping. However, examples of emerging coherent policy, such as troop vaccinations and the AP mine convention, indicate that progress is occurring on this issue. From past health problems encountered by peacekeeping troops, several lessons can be learned, to maximize the probability that all future peacekeeping missions are deployed and returned safely.
A) Conflict-Related
Former Commander of the UN Mission in Rwanda (UNAMIR), Romeo Dallaire, based on his experience dealing with the brutal murders of not only his own troops but almost a million Rwandan citizens, offers a number of insightful suggestions in order to ensure the safety of UN troops in future conflict. His experience, and his suggestions, deal directly with the issues of the conflict-related health concerns of peacekeeping, and provide an excellent framework to formulate future policy changes and initiatives.
Consolidate Crisis Management. One suggestion calls on the UN to form a “Multi-disciplinary Senior Crisis Management Cell.” This team, he stated, would “develop and execute an integrated and mutually supporting plan of action.” (Koring, 1997) It would, moreover, be composed of political, military, humanitarian, and logistics personnel – each with a good knowledge of all disciplines yet an expert in one field in particular. This suggestion, Major-General Dallaire claims, would eliminate the ad hoc nature of the current UN peace support operations that made many operations ineffective as was demonstrated in the cases of Somalia and Rwanda.
Establish Contingency Funds. Dallaire further suggests the establishment of a UN contingency fund, whose main purpose would be to help fund emergency activities such as “reconnaissance and/or technical missions, pre-mandate expenses for maintenance and pre-positioning of equipment, and early deployment costs without reference to the slow normal budgetary process.” (ibid) Essentially, this fund would provide the UN Secretariat with the ability to support a rapid and timely reaction to a conflict or humanitarian crisis. Inadequate funds caused a tremendous amount of inefficiency with regards to saving the ten Belgian peacekeepers kidnapped by the Hutus, and contributed significantly to their deaths in Rwanda.
Create a Standing Force, with a Clear Mandate. He also noted the need for a standing UN military force, and equipment, as well as clarification of UN military-force mandates in general. “The UN must get away from being an ad hoc operation resembling that of an old western posse.” (ibid) This force would be entirely self-contained and self-supporting, totally equipped and be available to the UN on immediate notice. Such a force, together with a stronger mandate would involve being able to actively deter and respond to locally overwhelming actions, if necessary—rather than simply having orders to engage in self-defence.
Consolidate Intelligence. Dallaire also suggested the establishment of a UN information/intelligence capability. This idea would involve an information centre in New York, supported by some of the major information agencies of the world, which would have trained information officers who could provide information directly to the field. An intelligence unit would certainly have come in useful in helping to predict the actions of Somalia’s Aideed or the Hutu in Rwanda. Moreover, it would certainly be useful in predicting the chemical and biological weaponry status of the nations in which peacekeepers would be deployed.
B) Non-Conflict
Make Education More Regular. Between March 1995 and December 1996, the first-ever global survey was conducted by the Joint United Nations Programme on AIDS (UNAIDS) and the non-governmental Civil-Military Alliance to Combat HIV and AIDS (CMA). The results were generally impressive: 98% of responding countries reported efforts to provide AIDS education to their troops, yet there were notable problems. For example, only 57% of militaries conduct education sessions more often than annually and regularly scheduled briefings occur less in Africa (75%) and Asia (57%) than in all other regions (Yeager, et al, 2000). Educational sessions on the methods to prevent the transmittal of AIDS or HIV must become more regular, while similar efforts must be made to combat infectious disease and related issues.
Following health advice is of critical importance- mandatory health seminars and conferences could yield troops that are more willing to enforce health mission-specific regulations. Examples abound about those that did not follow their health-related orders. The example of US troops in Somalia, who did not sufficiently follow regulations to use insect repellent, and subsequently contracted dengue fever, is emblematic of the need to further stress the relevance of health education.
Fund Health Initiatives. The efforts of former US ambassador to the UN, Richard Holbrooke, who has asked the UN to pay for one condom a day, directly out of the UN peacekeeping budget, should be supported. Although it is expected to cost $10 per man per month, Holbrooke is correct in making an issue of the fact that UN peacekeepers were acquiring the deadly disease and spreading it at an alarming rate in the very countries they were sent to protect. (Lauria , 2000)
With regard to illnesses and the spreading of TB, the work of the Medical Support Unit of the Department of Peacekeeping Operations (DPKO) and the United Nations Medical Service Division need to be more adequately funded. In 1998, the Medical Support Unit was forced by the General Assembly to cut much of its staff forcing its already over-loaded physicians and staff to work more overtime. “We try to do the best we can, but some things are just not possible. There are too many financial obstacles,”(DPKO, 2001) Dr. Laux, the former Director of the Division, stressed. Making such financial concessions in the area of health which, in turn, affects the quality of training received by troops in order to avoid health hazards in the nation to which they will be deployed, certainly makes peacekeepers much more prone to the health hazards listed above.
Identify Disease Indicators. Identification of disease indicators is critical to establish the potential for exposure, even if local disease profiles are unknown, or populations are in flux due to local violence. Malnutrition is the major contributing factor to disease- in addition to being characterized by insufficient protein, energy and vitamin intake, victims of malnutrition often display frequent infections and disease. While fixing the malnutrition situation of local populations may not be the immediate mandate for peacekeeping forces, correct nutrition of the forces themselves is of paramount importance, especially when they are operating in regions rife with disease. Malnutrition is also a major indicator of poverty, inadequate access to sanitary water and health services.
Basic education about health, nutrition and sexual practice has been proven to be effective in preventing large-scale epidemics in refugee camps; such prevention clearly is also to the advantage of peacekeeping forces. Knowing the basic level of education of the local civilian education on health issues would also help peacekeeping forces avoid unnecessary exposure to local health problems, and serve to focus the attention on specific health education issues for the organizers of the refugee camps. While the education itself may not be the mandate of the peacekeeping forces, maintaining vigilant observation on local practices would provide an additional information source for the appropriate people or organizations.
Further research and communication is essential. Because of the varying health exposures of peacekeeping forces, and of the locals themselves, identification of possible disease exposure needs to be further incorporated into the deployment protocols. Further research of prevention and health promotion programs are of critical importance, to improve establish a concrete standard of preventative care within and between militaries. While coordination of health initiatives between states is a lofty, albeit impossible, goal, perhaps increased coordination through the Medical Support Unit of the DPKO might serve to promote further communication between states on this modern issue of paramount importance.
Notably, there is much less information on the treatment of disease in redeployment areas; treatment presumably occurs, but greater communication between states on treatment regimens would be useful. In addition, since developing countries have significantly fewer resources to devote to medical care, perhaps developed countries could include redeployment health costs in future aid packages.
Also, the sociological nature of illnesses, such as PTSB, requires additional research. If PTSB is truly dependent upon specific cultures, then appropriate measures need to be taken to understand the underlying social issues that may compound or exacerbate the peacekeeper’s condition. Successful treatment, much less isolation of the actual cause of the illness, is impossible without extensive further research.
No prevention is perfect. Lastly, despite the best preventative policies to minimize dangerous exposure of any kind, some number of the peacekeeping forces will always contract and spread diseases, or be injured, etc. In order for health policy initiatives to be evaluated, such incidences must not be viewed as mistakes of the policies themselves, but rather as an opportunity to learn from any possible shortcomings of the policy or administration thereof. Prevention is an active process, and ultimately some mistakes will occur; such incidents cannot be allowed to derail policy implementation, or spiral into unreasonable inquiry that will undermine political will for the progressive nature of health policy in peacekeeping missions.
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Notes