REPORT ON THE SECONDWORLD HEALTH ORGANIZATION

CONSULTATION ONHEALTH AS A BRIDGE FOR PEACE

Ecogia, Versoix, 8-9 July 2002

'If the lizard is the summary of the crocodile, the tango is the summary of a life'(P. Conte)

…Could this report be a summary of the consultation ?

Department of Emergency and Humanitarian Action

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Table of content

1. Introduction.………………………………………………...………………………….3

2. Background……………………………………………………………………………..3

A. WHO Health as a Bridge for Peace Program……………………………………………….4B. Achievement……………………………………………………………...………………………4C. Further development and questions…………………………………………………………..5

3. Review of principles, achievements and constraints…………………………………..7

A. Introductory aspects pointed out by the opening speeches………………………………7B. McMaster University experience…………………………………………………………… 7C. Health contribution to peace in the Americas…………………………………………… 8D. Global polio eradication initiative and HBP…………………………………………… 9E. HBP within EHA……………………………………………………………………………… 9

4. What has changed since 1997 in the global context which is relevant to HBP……… 10

5. Working groups on evaluation and HBP development……………………………… 11

A. Review………………………………………………………………………………………… 11B. Adapting HBP to the “new” context……………………………………………………… 12

6. Recommendations…………………………………………………………………… 12

7. Final considerations………………………………………………………………….. 13

ANNEXES:

1. List of participants………………………………………………………………….. 152. Agenda…………………………………………………………………………….. 163. Presentation of McMaster University………………………………………………. 174. Brecht’s Poem……………………………………………………………………… 245. Presentation of the Pan American Organization…………………………………… 256. Presentation of the Polio Eradication Programme…………………………………… 267. Presentation of WHO/EHA………………………………………………………….. 288. Conclusions of the working groups on evaluation…………………………………… 319. Individual suggestions on a subtitle for HBP……………………………………….. 3410. Conclusions of the working groups on HBP development………………………… 36

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1. INTRODUCTION

Five years ago, the first WHO/EHA Consultative Meeting promoted a reflection on therelation between violence, conflict instability and public health and mainstreamed HBP inits global strategies for disaster reduction and humanitarian action. A second consultationwas thought as an opportunity to discuss the acquired experience and the occurred changesduring the most recent past, as well as new trends and ideas for the future.For this purpose an internal discussion was developed within EHA department in order toidentify the main directions the second consultation should have taken. A consensus wasfound on the assumption that goals and objectives of HBP were well accepted and theexperience of the last five years recognized as a generally positive one. The focus of theconsultation should be given to the ways of improvement strategies, tools, methods of works.A preliminary discussion paper was produced and finalized including few commentsreceived by the participants (see: 2. Background).Objectives were worked out.

Objectives

The overall objective was to contribute to a collective reflection on HBP within WHO, withthe support of the external expertise, and more specifically:

• To analyse the occurred changes in the armed conflicts and review achievements andconstraints of the acquired experience on HBP

• To identify scope for further development of methods and criteria for the evaluation ofHBP activities

• To analyse HBP implications of new emerging scenarios of conflict

• To identify new areas and focus of intervention for HBP, including ways to increase therange of stakeholders.

Participants, lecturers and facilitator from WHO (HQ, regions and countries) and otherinstitutions (academic institutions, donors, independent consultant agencies) have beeninvited (ANNEX 1) and an agenda prepared (ANNEX 2).

2. BACKGROUND

WHO definition of health implies the respect and satisfaction of both vital needs andhuman rights.• Recent events have dramatically underlined how much the security landscape is

changing: less state-to-state conflict and more conflict at the community andindividual levels.

• The peace agenda has grown beyond political-military concerns to include economicprosperity, human rights, social development, environmental protection, publichealth, and other issues as well.

• Armed conflicts are referred to as “complex emergencies” . Peacemaking is“complex” too and it is not anymore only a matter of negotiation at the highestdiplomatic level between the two warring countries, but instead a long-term efforttoward the reconciliation of a given population.

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• Equitable access to health is a prerequisite for any long-lasting peaceful process.Health is one of the global goods that needs to be more equally distributed in theworld.

• In achieving the primary goal of health for societies prone to and affected by war,the health professionals have the responsibilities to create opportunities for peace.For this new strategies, awareness, stance, skill and partners are needed1.

A. WHO Health as a Bridge for Peace Program

The basis of the concept of Health as a Bridge for Peace (HBP) is that any public healthstrategy must be built on the principle of equitable unhindered access and must have awide, long-term perspective of strategic planning, involvement of local actors andinternational partnerships. When we speak of HBP, we express the need to integratepublic health - from analysis, policy and planning to the delivery of care - within cross-sectoral work for social capital. Definitely, in the current international context, thisincludes conflict management, social reconstruction, and sustainable communityreconciliation.Within WHO, the Department of Emergency and Humanitarian Action integrates in itswork plan the reflection on the relations between vulnerability and violence, copingmechanisms and conflict, instability and public health, so to mainstream HBP in itsglobal work for disaster reduction and humanitarian action.

B. Achievements

In our view, in an armed conflict work for HBP starts by "being there": being present inspite of the circumstances, as a testimonial of the absolute value of human life , healthand humanity. Violence against the Other always demands his/her de-humanization: justthe vision of health and health needs as based on medical sciences and ethics can be astrong argument to counteract this.

HBP achievements are reflected in a ‘technical space’ where health personnel fromdifferent sides work jointly in the areas of policy, advocacy, training and service delivery.Concerning policy and advocacy, in Croatia, Bosnia Herzegovina and Angola formerenemies were integrated into the same national health system, on the basis of an inter-entity vision and common plans. Training was another area where WHO brought togetheropposite sides, like in FYR Macedonia, Palestinian Occupied Territories and Bosnia andHerzegovina. Specific HBP training activities were organized for health workers in SriLanka, Indonesia and the Caucasus and were followed up by new HBP initiatives.Looking at service delivery, vaccination campaigns through Days of Tranquility are aspecific form of HBP: there have been at least 60 documented instances in 16 differentcountries, so far. Other activities were also undertaken: facilitation of negotiations(Croatia), support to different sides NGOs (FYR Macedonia) and promotion of inter-entity associations (Bosnia and Herzegovina).

Among Health as a Bridge for Peace achievements, we also consider other publicinterventions that would not be strictly related to wars. For instance, the multi-countrystudy on small arms and health (WHO Injuries and Violence Prevention department) 1 Report on the First World Health Organization - Consultative Meeting on Health as a Bridge forPeace Les Pensières, Annecy, 30-31 October 1997

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aimed at providing an understanding of the determinants of armed violence in settingsthat are heavily militarised, and facilitate the development of evidence based preventionpolicies and strategies2.

C. Further Developments and questions

Accepting the objectives of the HBP Program and the concepts behind it, we wouldfocus on two open questions:

a) Can evaluation be applied to HBP ?b) Are there new ideas, experiences, pilot activities where to foresee a futurecommitments from the health sector including WHO ?

a) The issue of evaluation

The HBP Program needs evaluating. Evaluation is a relatively new discipline, it is hardlyever easy and it is definitely more difficult in the area of humanitarian assistance. HBPinitiatives appear difficult to evaluate because they are essentially "contextual" anddependent on the surrounding environment. The very political and social context thatcalls for their application make it difficult to measure their impact. To some extent, thisis a difficulty shared by all social sciences. Even if the objective of the program is quiteclear to all involved i – peace for better public health– and the threats to peace are quitewell identified – eg. ultra-nationalism, polarization, isolation, ethnic discrimination…theway to measure the impact of our work on these threats and consequently closing up on the objective is a lot more difficult. It involves a lot of personal opinions and subjectivefeelings , mostly subtle changes in perceptions and attitudes that are hardly quantifiable.On the other hand, evidence of results is needed to motivate operators and stakeholderat all levels - including donors - and thus move further into field practice.

Up to now, HBP programs have used different models of evaluation. The process wasevaluated, e.g. by quantifying activities undertaken : how many people were trained,how many meeting involving different parties have been held, etc. These basicmeasurements, can then be enriched by the assumption that certain activities haveanyway a positive impact. For example, it is reasonable to believe that training for healthprofessional of opposite sides in Bosnia and Herzegovina, created "a habit of sharingexperience, keeping contacts, working together and better understanding ”3. In othercircumstances different methods were used such as field observations, surveys of healthprofessionals' attitudes4 and monitoring the emergence of new independent peace-relatedactivities.

Some observers5 criticize the methods above as anecdotal at best . They call forevidence-based assessment tools to quantify progresses. Some authors6 report onevaluations conducted by using control groups (eg. School-based Health and Peace

2 Mozambique and Brazil are the two settings where methods are tested, following which the effort willbe expanded to an additional 6-10 other countries3 Ambrogio Manenti, Decentralised co-operation – a new tool for conflict situations, 19994 WHO-DIFID, Peace through Health Programme, a case study: Bosnia and Herzegovina. September19995 Alex Vass, Peace through Health - This movement needs evidence, not just ideology. BMJ, 3November 20016 Graeme MacQueen and Joanna Santa-Barbara, Conflict and Health – Peace building through healthinitiatives, BMJ, 29 July 2000

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Initiative, Croatian Ministry of Education, UNICEF, CARE, McMaster University), buttheir feasibility is at least questionable.

“Measuring before and after intervention" can provide a better way to evaluate theeffectiveness of HBP initiatives, although it opens another set of concerns, related to therisks, the feasibility and the ethics of taking a hands-off, laboratory approach to themeasurement of human suffering and ( in the "before" phase) of those that arguably arethe contingent causes of that suffering . In no other context such as in a violent conflictthe ancient paradox applies that an event ceases to be natural simply because of thepresence of an observer. The challenge is how to conciliate a humanitarian and realisticapproach with the golden rule of determining the fulfillment of the programmeobjectives in terms of relevance, appropriateness, effectiveness, coherence, coverage,efficiency, connectedness, protection and impact.

b) New Idea (?): increasing the stakeholders…

Mediation and dialogue are good means of reconciliation in a society torn by violentconflict. But too often they stay limited to the higher strata of that society: politicians,diplomats and governments, or professionals, physicians and health practitioners.Political agreement at the highest level can meet with resistance because the " commonpeople " still hate each other. Experience shows that reconciliation requires a bottom-updynamic that starts from the needs recognized as common by people from opposite sides.

Concerning the health sector, one specific limit of the recent HBP experiences has beenthe difficulty to involve the “common people”. The main achievements have beenthrough the involvement of health workers as 'mediators', opening dialogue with theircolleagues and advocate for peace. Armed conflicts are always characterized by theinvolvement of the "common people": it is the common people that under differentpressures always provide war with its workforce of footsoldiers. And today’s conflicts seem to have closed the circle, by having the civil population first become the explicit,primary target of violence and then active protagonists of war. Armed violence ispreceded, catalysed, accompanied and sustained by the deterioration of cultural settings,with increasing polarization, ultra-nationalism, ethnical discrimination, stereotyping ordenying the other, etc.

If we want to redress this, the same people need to be made direct stakeholders. Theyneed to participate in the public health initiatives that we hope will contribute to peace-building.

Can HBP initiatives target "the people" and not only professionals and politicians?. Canpartners in the civil society be involved at grass-root level ? There are examples ofactivities with such a participatory approach but mainly implemented in rural areas whichhave a small population, a relatively cohesive social dynamic, a rather limited spectrumof social interests and more immediate processes of collective decision making. How todo this, for instance in urban environments such as the Balkan or African cities?

Other questions could be addressed concerning the distinctive profile of healthinstitutions in peacemaking and peace-building and how this profile fits with that of otherinstitutions. How can health institutions cooperate with other institutions for maximumbenefit ? What are the things that health institutions are especially good at ? What thingsare they especially bad at ? Within the field of HBP, are there different roles the various

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people and groups around the world can play in order to help each other? For example:what does WHO most need from others in order to be more effective ? What do the restof us need from WHO? And so on…

3. REVIEW OF PRINCIPLES, ACHIEVEMENTS AND CONTRAINTS

The opening speeches and presentations are summarized below.

A. Introductory aspects pointed out by the opening speeches

• There is convergence of thinking between those who seek to reduce conflict and thoseworking for development. As definitions on Security chance, Health has to be positionedas an investment against insecurity and vulnerability. New actors are emerging,“different groups are now camping in this space”, and thus the public positioning of HBPwork is critical.

• In complex emergencies, there is often a paralysis of the state. WHO, through Health asa Bridge to Peace, must position itself as a facilitator and adviser for sustainableinstitution building in these contexts. Re-establishment of the credibility of Stateinstitutions is a part of confidence building.

• There are poor data on evaluation of peace-building and the need of clear indications ofwhat should be focus for investment if Health is to be used to build a bridge to peace. Public health implications should be considered, the message clarified, and the circle ofstakeholders should be widened.

B. McMaster University experience (ANNEX 3)

The HBP mechanisms according to McMaster academic work and field experience are thefollowing.

1. Use of health-related superordinate goalsA superordinate goal is one that transcends the separate goals of parties to a conflict and thatcan best be achieved when the parties join efforts (e.g. the humanitarian ceasefire: thechildren of each party may be dying of diseases that can easily be prevented if warringfactions stop fighting and jointly mount an immunization programme). In this case, thehealth of children has become a superordinate goal.

2. Evocation and extension of altruismHealth care is an institutionalized expression of human altruism. When health care can beextended to out-groups treating enemy wounded with the same compassion andprofessionalism as one's own wounded or through a variety of other means, a major inroadis made against the objectification and demonization that accompany war and that areessential to its long-term pursuance.

3. Discovery and dissemination of factsPropaganda is essential to the long-term waging of war in the modern period. It caneffectively be countered only through the discovery and dissemination of accurateinformation.

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4. Redefinition of the situationThe meaning of war is not obvious. Its meaning for a population is established by particulargroups--social classes, military elites, media and so on. War can be presented as a game, atest of manhood, a competition of civilizations, a cosmic contest of good and evil. Healthworkers can refuse to accept these understandings and definitions and can promote differentones. They can promote the understanding of war as a disaster or as a complex emergency. (ANNEX 4: Brecht's poem)

5. Healing of traumaIn general, the injuries caused by war slow down a society's recovery from war. Trauma thatis specifically psychological may contribute to demoralization and lack of initiative, as wellas to rigid patterns of thinking that perpetuate war and make it chronic. Health careprofessionals can utilize methods of trauma-healing that are linked to social processes ofreconciliation and peace building.

6. Contribution to civic identityIn cases where societies have been divided by identity conflicts, people who have anadequate and equitable health care system are strengthened in their sense of belonging to thesociety or the state that has provided it for them.

7. Contribution to human securityAn adequate and equitable health care system, which addresses people’s basic needs, givesthem an essential form of security. If they do not have this form of security they may resortto violence or war to achieve it.

8. Diplomacy, mediation and conflict transformationHealth workers are not unique in developing skills in diplomacy, mediation and conflictresolution but they will sometimes have unique opportunities to use these.

9. Solidarity and supportMany 'Peace through Health' mechanisms involve solidarity and support for victims of war.

10. Dissent and non-cooperationWhen health workers are called on to collaborate in 'unjust' wars or preparations for suchwars, or in the development of inhumane weapons or war policies, they can refuse to do so.

Lessons learned• 'Be there' during a conflict. Method and process are more important than content.• Look for peace oriented people in the local context.• Focus on pleasure and play. Open to creativity.• Consider the importance of the symbols.• Learn how to evaluate.

C. Health contribution to peace in the Americas (ANNEX 5)

Following the experience in the Americas, the main issues concerning health and peace canbe summarized as follows:

• Increasing inequity within the target population (e.g. refugees as privileged population);• Contradictions between health and peace (e.g. the embargo against Haiti that was

intended to support peace was not promoting health); “Some action officially targetedat bringing peace can jeopardize the health of the population” (Dr. Poncelet);

• Health is not always neutral (e.g. physicians or drugs are an important resources for theguerrilla movements);

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• Peace building initiatives are frequently coming from outside and do not pay attentionto the small efforts going on at local level.

D. Global polio eradication initiative and HBP (ANNEX 6)

• Days of Tranquillity were first used for polio immunization in El Salvador in 1985 whenPAHO, UNICEF, Catholic church and other organizations organized three days oftranquillity to implement vaccination campaigns.

• The concept of cease-fires for immunization was first discussed globally in 1990 duringthe World Summit for Children when 159 nations signed a declaration and plan of actionendorsing the need for DoT and relief corridors.

• DoT have been used (more or less successfully) since that time in Afg, Burundi, DRCongo, Lebanon, Liberia, Nicaragua, Sierra Leone, Sri Lanka and Sudan.

Lessons learned• Conflict causes ill health • Health initiatives can be successfully implemented in complex emergency countries

• How, if at all, do health initiatives such as polio affect conflict ?

Outcome to the peace- Temporary cessation of conflict during Days of Tranquillity- Common goal for parties in conflict, therefore opportunity for dialogue- Reaching vulnerable and destitute populations- Re-established management & infrastructure

Contribution to the peace- Beneficial - mechanisms used to obtain access for vaccination can contribute to long-

term peace-building efforts- Neutral - mechanisms have no positive or negative impact on long-term peace- Detrimental - mechanisms allow parties to exploit and manipulate resources and

infrastructure put in place by partner agencies.

E. HBP within EHA (ANNEX 7)

1. HBP in the DG's words during the WHA 2002 are related to health, conflict and WHOrole."I .. stress the need to protect health systems and ensure access to the basic necessities forlife - even when there are hostilities. ...a troubling tendency of modern military tactics totarget the underlying infrastructure of whole societies ...We must do all we can to resist this. ...systematic attempts to undermine the operation of medical services during conflict. Wemust confront (this) growing tendency""WHO will.. continue to be active in conflicts and crises, taking exceptional action to sustainhealth systems, to ensure continued delivery of health services and to protect the health ofthe population."

2. WHO HBP milestones can be summarized in the following field experiences:Central America: 'Health as a Bridge for Peace' (Mid 1980s)Mozambique & Angola: Health care for demobilisationHaiti: Health humanitarian assistance programThe Balkans: Peace through health

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Somalia: Basic Development NeedsThe Horn of Africa InitiativeThe Thai-Myanmar ProjectColombia: Health coordination for IDPsSri Lanka & Indonesia: Self-sustaining country programmes

3. Did Health and WHO bring Peace to countries in conflict ?A vision, a strategy and a programme did contribute to deliver health care, thus mitigatingthe impact of conflict and facilitating the transition to peace.Health is the objective.At country level, anywhere, HBP should not be perceived or undertaken as a separate, free-standing project. HBP elements should be identified, highlighted and/or factored intoexisting or planned public health work"Being there or here" as health workers is HBP, because it states that human life and healthare the overriding concerns.

4. WHAT HAS CHANGED SINCE 1997 IN THE GLOBAL CONTEXT WHICH ISRELEVANT TO HBP

The outcome of a short discussion in working groups and plenary is summarized below.

GROUP 1:

HBP – Not ‘a programme’ – a space forreflection/philosophy, informing, SPIRIT,Principle.

Changes:• Equity – public health priorities less clear,

loss of strategy.• Fragmentation of Actors or Analysis (‘lens’)

in conflict endangers ‘neutrality’ of healthworkers.

• Health as ‘a Right’ more understood• Access to health services a more critical

issue, including basic needs (water, food,etc.)

• Protracted crises.

GROUP 2:

• ‘Securitisation’ debate/concern [can be(mis)used differently]

• Evidence/Hard data more important• New Analysis of conflict (‘network war’ etc.)• Danger of ‘pacification’ function/HBP• North/South trade variations• Note on role of health services in social control• Political/Economy/effects Structures

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GROUP 3:

• Regional ‘Destabilisation’• ‘Securitisation’• New definition of ‘Threat’• Wider awareness of Human Rights versus

Erosion• Root causes• Public health deadlines• More evident impacts of Globalisation –

Media, political, economy• Shift from public to private health.

GROUP 4:

• Security− Changing discourse – ‘security’ over civil

rights – emergence of human securityDebate

− Changing conflict trends− Civilian deaths blurring− Erosion of IHL

• Linkages− Foreign and domestic political agendas− Globalisation/economic− Military/humanitarian− Role of media• Aid− Blurring: humanitarian and political action− Professionalisation humanitarian ‘industry’− Return to vertical programming− Deterioration of security− Selective response

Conclusion:

According to the outcome of the discussion, for the past five years, the following trend pointsshould be taken into consideration:

• the dominance of security agendas• increasing vulnerabilities of population in face of the erosion of human rights• increasing inequalities• the multiplicity and shifting role of actors responding to and being a part in protracted

crisis• the intractability of armed conflicts.

5. WORKING GROUPS ON EVALUATION AND HBP DEVELOPMENT

A. Review

Three working groups worked on the issue of evaluation in general terms. More precisely,wide questions were formulated to guide the group discussion overtaking the strict meaningof evaluation:• Have WHO been ‘on track’ in the HBP programme ?• Is it worth evaluating HBP programme ?• What methodologies are needed/required/useful ?• If it is not worth to evaluate which are implications ?

During the plenary sessions the groups presented their conclusions (ANNEX 8) and a generaldiscussion was implemented particularly focused on the general goals and objectives of HBPwith minor references of specific evaluation methods (see individual exercise on theformulation of a subtitle for HBP – ANNEXE 9).The facilitators and organizers of the consultation in a small working group re-elaborated themain outcomes of the discussion in some essential points that should represent a commonpoint of view within the participants.

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Below the main points for a HBP framework, including comments from the plenary session,are presented.

HBP FRAMEWORK

• Health is the main goal of HBP approach for WHO

• Cooperation amongst stakeholders - including the health sector - from all parties in conflictimprove health outcomes

• Integration of peace-building concerns, concepts, principles, strategies and practices into healthaction for prevention, response, rehabilitation and development is essential

• Skills, such as conflict analysis, negotiation, application of human rights and humanitarianprinciples, beyond traditional public health field are required for effective health interventions

in complex context

• Equity, Access and Health for All principles are fundamental tenets of HBP

• Functional cooperation among health workers and communities of all parties can contribute topeace

• Documentation and research are essential to build the credibility of HBP

B. Adapting HBP to the 'new' context

Three working groups discussed the HBP development according to a changed contextcharacterized by four main phenomena collectively grouped within the above mentioned list(see B): Human Security, Equity/Rights, Multiplicity of Actors and/Roles Shifting,Globalisation and Protracted Crisis.The groups' discussions followed the HBP main components such as cooperation, advocacy,communication, knowledge and skills and networking. (ANNEX 10).The discussion was also stimulated by a short presentation by the Development andCooperation Department of the Swiss Confederation (ANNEX 11). The gap betweenvisions/aspirations and concrete realisations of the humanitarian aid was underlined as wellas the requirement to translate Health and Human Security concepts into action. 'Humansecurity could brings a new perspective in the field of security and particularly provides fora clear referee to whom all should agree: the people'

6. RECOMMENDATIONS

In light of the trends and what has already been done within the HBP framework (see above),the recommend actions are as follows:

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1. Consolidate and establish credibility

• Define clear products based on past experience – e.g. training package – and makeknown for internal and external advocacy

• Formulate clear and consistent message and identity• Create a leadership to drive HBP internally and externally (full time person? resources?)• Produce documentation, evaluation and research

2. Strengthen HBP activities

• Look for new opportunities• Expand networks

3. Address strategic positioning of HBP in prominent global agendas

• Positioning HBP within the Health and Human Security and Right-based programming,drawing from existing experiences

• Lobbying and providing WHO senior management with tools to bring HBP to globalforums

NEXT STEPS

- A full time HBP staff should be dedicated to take the above agenda forward- A paper on Health and Human Security and Right-based programming should be

produced- A cross cluster task force should be established, with EHA providing the leadership in

order to formulate HBP message, research, evaluation, lobbying and networkingstrategies and collaborative action plans. Other Departments should be involved (e.g.chair can be rotated amongst departments/clusters)

- An inventory of HBP initiatives in WHO (especialyy the unreported ones undertakenby other departments) should be made

- concrete joint initiatives between the departments should be undertaken (e.g. in thetraining area)

- Information should be posted on the web (or any other means) on HBP for external andinternal circulation. Add database of persons in the network.

7. FINAL CONSIDERATIONS

The assumption that the goals and objectives of HBP were clear for everyone proved to betoo optimistic. Due to the complexity of the subject, we intended to simplify it by taking forgranted that the same HBP idea and vision were commonly shared.From the beginning of the discussion it was obvious that the range of background, positionsand opinions of the participants was so wide and conflicting that it appeared naive to thinkof enlarging strategies, tools and activities with new ideas. The objectives of the consultationwere therefore consequently downsized.Nevertheless, in spite of the frustrations of dealing with issues that were already discussedfive years ago (Annecy consultation), and the challenge of condensing the richness,heterogeneity and differences of the debate in a unique fashion, some key points were agreedupon (see recommendations and HBP framework).

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On the one hand, the HBP framework could be considered too general, referring to the'accepted' WHO principles such as equity, and on the other hand too narrow, tightening HBPwithin a pure health frame. This is probably true, and the weaknesses of the present HBPframework simply reflects the limits of the current general debate on war, peace, conflictprevention, etc. Essential issues like the involvement of people in peace-building as well asin other social processes remain basically unaddressed in spite of the rhetoric on communityempowerment and community participation.

However, this consultation represented a further development in HBP idea within WHOfrom the previous meeting. This could be used to better link HBP to the future internationalagenda and to generally strengthen the WHO commitment at central and local levels.

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ANNEXE 1: LIST OF PARTICIPANTS

Ø Guests- Graeme MacQueen, MacMaster University, Canada- Gregory Hess, Peace Path, Rome- Mark Duffield, Leeds University, Institute of Politics and International Studies, UK- Flavio Del Ponte, Medical Adviser for the Department of Humanitarian Aid & SwissHumanitarian Aid Unit, Berne- Anna Klara Berglund, SIDA, Swedish Government- Ian Macduff, New Zealand Centre for Conflict Resolution- Suzanne Innes-Kent, management consultant

Ø WHO Regional/Country Offices staff- Ahmer Akhtar, Indonesia- E.K. Rodrigo, Sri Lanka- Abdullahi Ahmed, Horn of Africa- Altaf Musani, EMRO- JL Poncelet, PAHO

- David N. Nabarro, WHO Executive Director, Sustainable Development and HealthEnvironment

- Nevio Zagaria, WHO/CDS/CPE- Cynthia Veliko, WHO/Polio- Reinhilde Van de Weerdt, WHO/Polio- Mark Van Ommeren, WHO/Mental Health Department

v Facilitators- Gabriella Arcadu, Scuola Superiore Sant'Anna, Pisa- Judith Large, independent consultant in conflict analysis and policy- Louisa Chan Boegli, WHO Office in Washington

Ø EHA staff and secretariat- Johanna Larusdottir, Director a.i. EHA- Alessandro Loretti- Gaya Gamhewage- Stéphanne Vandam, Brussel- Ambrogio Manenti- Doreen Brown- Candie Cassabalian

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ANNEXE 2: AGENDA

Hrs 8 July Hrs 9 July

9-9:30 § Opening speech by Dr. Nabarro,Executive Director of the ClusterSustainable Development &Healthy Environment

§ Rationale & Objectives by Dr.Johanna Larusdottir, Director a.i.Department of Emergency andHumanitarian Action (EHA)

9:30-10:30 Review of the current context ofarmed conflict – Discussion

10:30-11 Review of HBP work to date:presentation by Prof. G. MacQueen,McMaster University

9-11 Working groups discussion

11-11:30 Morning break 11-11:30 Morning break

11:30-13 Review of HBP work to date:presentation by Dr. J.L. Poncelet,Chief Emergency and PrepardnessProgramme, PAHO, Ms. C. Velikoand Dr. R. Van de Weerdt, PolioEradication Initiative Department, andDr. A. Loretti, EHA Coordinator -Discussion

11:30-13 Working groups discussion, Writing ofthe presentations

13-14 Lunch 13-14 Lunch14-15 Presentation Working group 1,

Discussion14-16 Working groups discussion

15-16 Presentation Working group 2,Discussion

16-16:30 Afternoon break 16-16:30 Afternoon break16:30-17:30 Presentation Working group 3,

Discussion16:30-18 Working groups discussion

17:30-18 Wrap-up, Conclusion19 Dinner

Ø Working groups on:

1) Evaluation of HBP activities methods and criteria – facilitator:Ms. Judith Large

2) New areas and focus of intervention for HBP (eg. "Increasing the range ofstakeholders") – facilitator: Ms. Louisa Chan Boegli

3) Public health implications of new emerging scenarios of conflict – facilitator:Ms. Gabriella Arcadu

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ANNEXE 3: PRESENTATION OF MCMASTER UNIVERSITY

McMaster University's Experience with "Peace through Health"WHO "Health as a Bridge for Peace" Consultation

Geneva, July 8, 2002

Graeme MacQueenCentre for Peace StudiesMcMaster University

The contribution of the World Health Organization to the development andimplementation of the principles of Peace-through-Health has been outstanding, and I amhonoured to have been asked to take part in this consultation.

I wish to begin with a very brief overview of the work our Center for Peace Studies hasdone in this area. I will then describe what I believe are some of the distinctive elementsof our approach, and I will end with "lessons learned."

History:

McMaster is a medium-size university in Hamilton, a city of about 400,000 people in theprovince of Ontario, Canada. The university is especially strong in health sciences. In1989 McMaster founded two centres, the Centre for Peace Studies and the Centre forInternational Health. It took about three years for these centres to discover what they hadin common.

In 1991-92, two young physicians, graduates of McMaster's medical school--EricHoskins and Robert Chase--found themselves on the Iraq Study Team carrying outresearch on the health effects of the Gulf War on the population of Iraq. They decidedthat there should be a place in Canada where crucial health research related to war zonescould be carried out on a regular basis. They proposed that our two centres collaboratein developing such a capacity. Their proposal was well received, and we began acollaboration. (I was at that time Director of the Centre for Peace Studies.) Ratherquickly, we secured funds from the Department of Health, Canada, and begancollaborative work in several war zones, notably Croatia, Gaza and Sri Lanka--eventually, Afghanistan as well. We began to develop our approach, which involvesdoing what academic institutions do best--research, theory and teaching--but with strongpartnerships with groups in war zones.

We established a separate committee to reflect on the relationship between health andpeace. Our original goals had been circumscribed by fairly traditional concepts of healthresearch in war zones. Gradually, in 1993-94, some of us began to feel that we were notbeing creative and we were not utilizing the special knowledge and skills of Peace

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Studies. It began to dawn on us that health initiatives had great potential, if they wererightly grasped and directed, to be forces for the building of peace. Initially, we thoughtthis was our own, unique idea, but a little research uncovered the PAHO "Health as aBridge for Peace" work of the early 1980s and several other fascinating undertakings thatcould be classified under the heading of Peace-through-Health (we used, at that time, theexpression "Health-Peace Initiatives"). We therefore wrote a concept paper, "The Useof Health Initiatives as Peace Initiatives" and in due course had it published in a PeaceStudies journal, Peace and Change (1997; 22: 175-97). Simultaneously, we created, in1996, a manual, edited by Mary Anne Peters, entitled, A Health-to-Peace Handbook:Ideas and Experiences of How Health Initiatives Can Work for Peace. (This manual canbe found on-line at the Centre for Peace Studies website: see the end of this document.)I am happy to say that this manual has been used in very practical ways by a wide varietyof people over the past few years. I am also happy to report that it is now out of date andneeds to be re-written. Major initiatives of the past few years, most of them carried outby WHO, have carried the PtH concept far beyond our early examples. We havecontinued to promote basic PtH concepts in journals such as Medical Crossfire;Medicine, Conflict and Survival; the British Medical Journal; and Lancet.

As we were thinking through some of these ideas about the relation of health to peace wewere also carrying out work of various kinds in war zones. The work we did in eachregion was distinct; we had no template.

In Gaza we carried out, with regional partners, a classic piece of research--a study of themental health of youth in Gaza (a summary of the initial work, since published as alengthy report, is given in Thomas Miller, et al, "Emotional and Behavioural Problemsand Trauma Exposure of School-age Palestinian Children in Gaza: Some PreliminaryFindings. Medicine, Conflict and Survival, vol. 15, 368-378, 1999). The despair of manyyoung Palestinians, a measurable finding of this study, has since the time of the studymanifested itself in dramatic and often tragic ways. This sort of research cannot be saidto contribute inevitably or directly to peace and is not in itself a PtH initiative, but it canbe used to contribute to the goal of just peace in the region and we have tried to use it inthis way.

In Croatia we carried out, again with regional partners, a project in six schools with about250 grade 5 children, aiming to combine two aims--one usually thought of as a peace aimand one a health aim--in an experimental curriculum. The teaching of concepts crucialto a culture of peace (tolerance of diversity, appreciation of nonviolence, and so on) wascombined with an interactive exploration, guided by the teacher, of the mental andemotional suffering experienced in war. The guiding concept was that trauma-healing andreconciliation can sometimes best be pursued in an integrated way. An attempt was madeto evaluate this initiative, and although the changes noted were modest they seemundeniable. ("Psychological Trauma and Social Healing in Croatia," Medicine, Conflictand Survival, vol. 15, 355-67, 1999.)

In Sri Lanka we carried out a research project on the mental health of youngsters inseveral areas of heavy conflict (The Health of Children in Conflict Zones of Sri Lanka:A Study Sponsored by Health Reach of McMaster University. Colombo: SarvodayaVishva Lekha Press, Sri Lanka, 1996). After the study we initiated the construction of ahealing garden/play area for children in Batticaloa (the "Butterfly Garden") that was

19

designed to contribute both to the emotional health of the youngsters involved and thesocial healing and reconciliation of their divided (Hindu and Muslim) communities. (Theflourishing of this extraordinary initiative, which continues to the present, is to becredited to creative artists, Canadian and Sri Lankan, to the extraordinary children of theButterfly Garden, two volumes of whose stories have now appeared in print, and to avariety of funding agencies.) A recent attempt has been made to begin evaluating thisinitiative. (Robert Chase, The Butterfly Garden, Batticaloa, Sri Lanka: Final Report ofa Program Development and Research Project 1998-2000. Sarvodaya Vishva LekhaPress, Sri Lanka, 2000).

In Afghanistan we have combined conflict transformation work with the use of a psycho-social model that takes into account the severe effects of war on the human mind andemotions and the implications of this for peace-building. In addition to a major "train thetrainer" programme we have created a series of storybooks for Afghan children thatpromote both peace-building and psychological rehabilitation. With numerous local andinternational partners, we hope to distribute these stories widely. We have had twofunded projects in Afghanistan and hope to mount a new PtH project there in the nearfuture.

Since the early, intense days of our work we have continued to develop and sustain thecollaboration of peace workers and health workers at our university. The Institute forPopulation Health Research has come to replace the Centre for International Health aspartner of the Centre for Peace Studies, and we have taken a number of measures toensure that our work will be sustained beyond individual projects. Three such measuresdeserve mention. First, we are sponsoring, in partnership with Lancet, a series ofconferences on the health-peace connection. An initial conference took place in Octoberof 2001 and we hope to have at least two more. Second, we have been given approval byMcMaster University for a Chair in Peace through Health. If we are successful in raisingthe necessary funds (the university is committed to matching whatever we raise) we shallhave a full-time faculty member devoted to research and teaching in PtH. Third, theCentre for Peace Studies will in the fall of 2002 bring to the university a proposal for a13-week undergraduate course in Peace through Health, to be offered for the first timein 2003. The curriculum has been a collaborative effort of faculty and students atMcMaster University.

Distinctive Emphases of our Work:

Most institutions involved in PtH initiatives have been strong in health expertise but lessstrong in peace expertise. We have tried to balance these areas of thought and skilldevelopment. Interdisciplinary collaboration has been very stimulating for all of us, andwe continue to learn from each other.

Within this interdisciplinary collaboration there are two specific approaches that havebecome central to our work.

(a) We have paid great attention to the connections between mental/emotional well-beingand peace-building. I should make it clear that we do not claim that this is the best or theonly approach to PtH work; it is simply one in which we have come to specialize. We do

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not assume all people in war zones are "sick," and we do not rush to treat them accordingto Western models. We also do not assume that all conflicts are caused by pathologicalthinking (or, indeed, wrong thinking of any kind). But we have found that all attemptsto deal with conflicts in humane ways must take into account those non-rational factorsthat enter into people's perceptions and feelings about conflict as well as the ways inwhich people become emotionally wounded by violence. Moreover, we believe it issometimes useful to carry out trauma-healing and reconciliation as related tasks.

(b) We do not approach Peace-through-Health as if there is something magical about thehealth-peace connection. We situate PtH initiatives within the context of Multi-trackPeace Work.

Each sector of society--the educational, the health, and so on--has its own contributionto make to the complex task of peace-building. The job cannot be carried out bydiplomats and other explicitly political actors by themselves. Each social sector has itsdistinctive profile, its own distinctive mode of peace work. We may refer to these modesas different "tracks" to peace, tracks that combine to constitute Multi-track Peace Work.The health sector is a large and significant sector of most societies and has its owndistinctive track. It also commands a good deal of respect because it is thought toincorporate certain key values, such as impartial altruism and a scientific orevidence-based approach to human problems.

Currently, we find it useful to think of 10 PtH mechanisms that, taken together, constitutethe distinctive health track to peace. None of these mechanisms is, in itself, unique to thehealth track but the specific list and the way the mechanisms combine is unique to thehealth track.

1. Health-related superordinate goals

A superordinate goal is one that transcends the separate goals of parties to a conflict andthat can best be achieved when the parties join efforts.

Common health planning by former belligerents is a major example of the use ofsuperordinate goals, one that WHO has been involved in on several occasions. Thehumanitarian cease-fire is another example of the use of superordinate goals. The healthof populations (or of one sector such as the child population) becomes the superordinategoal that each party comes to see can be addressed adequately only if hostilities aretemporarily suspended. Lasting peace outcomes are neither inevitable nor common inhumanitarian cease-fires: achieving them requires special training and effort, as well asauspicious circumstances.

2. Evocation and extension of altruism

Although health care is an institutionalized expression of human altruism, altruism tendsto shrink during armed conflict: it intensely includes "us" and intensely excludes "them."But when health care is extended to out-groups, we are sometimes able to resist theobjectification and demonization that usually accompany war.

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3. Discovery and dissemination of facts

Propaganda is one of the pillars of modern war. Health professionals are often in the bestposition to discover and make known the accurate information that is essential to a properassessment of the situation.

4. Redefinition of the situation

The meaning of war is not transparent: it is established by social groups. War can beportrayed as a game, a test of manhood, a competition of civilizations, a cosmic contestof good and evil. Health workers can promote different understandings of war. They cantreat it as a disaster, for example, or as a complex emergency. They can sometimes helppeople to see that war may not be inevitable and may not be the best way to solve theproblems that confront them.

5. Healing of trauma

Injuries caused by war can slow down a society's recovery. Psychological trauma maycontribute to demoralization and lack of initiative, as well as to rigid patterns of thinkingthat may make reconstruction and reconciliation difficult. Health workers are at home inthis healing role, but they may be even more effective if they can utilize methods oftrauma-healing that are linked to social processes of reconciliation and peace building.

6. Contribution to civic identity

In cases where societies have been divided by identity conflicts, people who have anadequate and equitable health care system are strengthened in their sense of belongingto the society or the state that has provided it for them. They are less apt to join groupswith competing claims on their identity.

7. Contribution to human security

An adequate and equitable health care system, which addresses people's basic needs,gives them an essential form of security. If they do not have this form of security theymay resort to violence or war to achieve it. They may join insurgencies or break-awaystates to assure their own security or that of their children. Such armed challenges maybe perfectly rational and they must be met with a rational response: the provision ofadequate health care.

8. Diplomacy, mediation and conflict transformation

If health workers develop skills in diplomacy, mediation and conflict resolution they willsometimes have unique opportunities to use these. They may have the opportunity tobring groups together around superordinate goals associated with health and to work withgroups struggling to assure their security in a difficult environment.

9. Solidarity and support

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All PtH mechanisms involve solidarity and support for victims of war. But some includethe direct accompaniment of victims or potential victims by health workers, as well asdirect advocacy on their behalf. This mechanism is especially relevant when there aregreat differences of power between the conflicting parties.

10. Dissent and non-cooperation

When health workers are called on to collaborate in unjust wars or preparations for suchwars, or in the development of inhumane policies or weapons of war, they can refuse todo so. They will have the support not only of a wide body of international law but alsoof declarations directed specifically at health workers, such as: The Declaration ofGeneva, the International Code of Medical Ethics, the Declaration of Tokyo, Regulationsin Time of Armed Conflict, and Statement of Nurse's Role in Safeguarding HumanRights.

Lessons We Have Learned:

1. Method can be as important as content. In Croatia, we were surprised to discover thatthe dialogical educational method we had promoted, where teachers gave students agreater voice in the classroom that was common in Croatia at that time, was consideredby some teachers as more important than the actual content of the lessons. We should nothave been surprised, for the "hidden curriculum"--the unarticulated relations establishedbetween learners and teachers--has long been considered crucial by educators.

2. Enormous energy for peace can be set to work by drawing in people whose aspirationsand creativity are often ignored. We found, for example, that artists were often side-linedin Sri Lankan peace efforts. Yet their contributions are necessary to the rebuilding of awholesome society. (There would certainly be no Butterfly Garden in Batticaloa withoutthem!) In connection with this, we have also rediscovered again and again the importanceof creativity and the modeling of creativity in the transforming of conflict. Thesequalities are, of course, the very opposite of those often encouraged by largebureaucracies.

3. In connection with the last point, we have found that, for children especially but alsofor adults, we should not underestimate the importance of play and of the opportunity forrelaxation and simple pleasure in peace-building and reconstruction.

4. We must relearn the power of symbol. Reconciliation and reconstruction require accessto parts of the human being that rational planning and problem-solving can barely touch.Narrative and ritual can sometime take people to these places and must, therefore, becarefully integrated into our work. This does not at all mean that we will use symbol tomanipulate or control people. On the contrary, the appropriate symbols should emergefrom the minds of the people who have experienced the war, and it is important that theyhave some ability to examine and think about these symbols so that they are not victimsof them.

5. It is important to keep attempting to find modes of evaluation, even when this is verydifficult. Unless we wish to be like the physicians of the past who confidently used

23

leeches and other mechanisms to bleed people, on the mistaken and untested assumptionthat this would help them, we have a duty to find out what works and what does notwork. At the same time, peace work can seldom be evaluated in the same ways healthwork can, and we must be persistent and ingenious if we hope to succeed.

6. Peace-through-Health work crosses traditional boundaries and shakes things up: thisis a good thing. It challenges our comfortable categories and our comfortable institutions.When we approach this interdisciplinary work with an open mind and allow ourselvesto get into it deeply we find that we emerge with a deeper understanding of both healthand peace.

Future Work:

There are two different approaches to populations in war zones that we believe must beheld in balance. The first grows out of "the humanitarian imperative," the passionatedesire to help people who are suffering. This approach refuses to be side-tracked ormanipulated by non-humanitarian questions (Who are these suffering people? Do theydeserve to be helped? Are they a threat to us? And so on). The humanitarian imperativemakes us suspicious of such tendencies as "securitization," the tendency to reduce allconcerns to that of "our" security; it may make us suspicious of the inclusion of anyconsideration at all beyond those that involve the immediate welfare of those suffering.The second approach grows out of equally humane motivations. It comes from theexperience of people who are tired of mopping up battlefields and have begun to wonderif they can get rid of these battlefields. All thinking people labouring in the field of warwill at some point become interested in the macro-determinants of health and well-being:they will seek long-term solutions and structural changes and they will hit on the idea thatit may be possible to carry out humanitarian work in ways that promote sustainable peaceand justice.

Both of these approaches have strengths and vulnerabilities. We believe they shouldremain in conversation.

Sources:

For bibliography and on-line documents, find the Centre for Peace Studies within theMcMaster University website located at: www.mcmaster.ca/home.htm

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ANNEXE 4: BRECHT’S POEM

'The war that will comeIs not the first. Before,There were other wars.At the end of the last one,There were winners and losers.Among the losers, the poor peoplewere starving. Among the winners,the poor people were starving. Equally.'

B. BRECHT

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ANNEXE 5: PRESENTATION OF THE PAN AMERICANORGANIZATION

Health contribution to peace in theHealth contribution to peace in theAmericasAmericas

Pan American Health OrganizationPan American Health OrganizationWorld Health OrganizationWorld Health Organization

Jean Luc Poncelet, MD, MPHJean Luc Poncelet, MD, MPH

AMRO’s AMRO’s experienceexperience

•• Central America in 1980’sCentral America in 1980’s–– Refugees and surrounding populationRefugees and surrounding population

•• HaitiHaiti–– embargoembargo

•• ColombiaColombia–– Displaced populationDisplaced population

•• Neighboring countriesNeighboring countries•• Scattered over theScattered over the

countrycountry•• Boarder issuesBoarder issues

Main issues in ColombiaMain issues in Colombia

•• Small but continuous displacement due toSmall but continuous displacement due toviolenceviolence

•• Insecurity of health personalInsecurity of health personal•• Discontinuity between central and localDiscontinuity between central and local

levellevel•• A mix of emergency and developmentA mix of emergency and development

needsneeds•• Displaced not fully aware on their right’sDisplaced not fully aware on their right’s

and dutiesand duties

Main strategiesMain strategies

•• All WR programs dealing with developmentAll WR programs dealing with developmentissues related to IDPissues related to IDP

•• EHA in WR office to deal with emergency issuesEHA in WR office to deal with emergency issuesof IDPof IDP

•• 6 decentralized offices6 decentralized offices–– To assist organizing local health leadershipTo assist organizing local health leadership

•• Web siteWeb site–– Sharing information of all partnersSharing information of all partners–– A coordination mechanismA coordination mechanism

•• Put different health actors together (CoordinationPut different health actors together (Coordinationat national and local level)at national and local level)

General issuesGeneral issues

•• Health is not always neutralHealth is not always neutral–– Increasingly part of the conflictIncreasingly part of the conflict

•• HBP:HBP:–– What does correspond to EHA and what toWhat does correspond to EHA and what to

WHOWHO

•• Improve protection of health missionImprove protection of health mission•• WHO has to better benefit of groupsWHO has to better benefit of groups

working on peace process to make itsworking on peace process to make itscooperation more effectivecooperation more effective

General IssuesGeneral Issues

•• Conflict involves number of actorsConflict involves number of actors•• Long term conflict issues to be address byLong term conflict issues to be address by

development programsdevelopment programs•• The real issue is to offer access to basicThe real issue is to offer access to basic

health services to population affected byhealth services to population affected byviolence.violence.

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ANNEXE 6: PRESENTATION OF THE POLIO ERADICATION PROGRAMME

Polio Eradication

Global PolioEradication

Initiative

Health as a Bridge for Peace Consultation8-9 July 2002

Polio Eradication

Presentation

• Polio Eradication Goals

• Strategies and achievementsin complex emergencycountries

• Polio and Peace

Polio Eradication

1988350 000 cases125 countries

Progress

2001480 cases*

10 countries

*as of 1 July 2002Polio Eradication Polio Eradication

Strategies

Technical

• High Routine Immunization

• National Immunization Days

• AFP Surveillance

• Mop-up campaigns

Access

• Days of Tranquillity, crossborder activities, militarycorridors

Polio Eradication

AfghanistanAchievements• 11 WPV cases in 2001, 2

cases to date in 2002• NIDs since 1997• Well-functioning AFP

surveillance systemMechanism• Days of Tranquillity since

1997

Polio Eradication

DR CongoAchievements• Last reported poliovirus case

December 2000• International review of AFP

surveillance, March 2002• NIDs since 1999,

synchronized since 2001Mechanism• DoT called by UN SG in 1999• Military escorts into difficult-

to-access areas

Polio Eradication

Wild Poliovirus*, 02-July-2001 to 01-July-2002

Data in WHO HQ as of 02 July 2002.

Wild virus type 1 Wild virus type 3

Importation

Wild virus type 1 and 3 Endemic countries

*Excludes viruses detected from environmental surveillance. Polio Eradication

Lessons learned

• Conflict causes ill health

• Health initiatives can besuccessfully implemented incomplex emergency countries

• How, if at all, do health initiativessuch as polio affect conflict?

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Polio Eradication

OutcomesPeace

• Temporary cessation of conflict duringDays of Tranquillity

• Common goal for parties in conflict,therefore opportunity for dialogue

• Reaching vulnerable/destitute populations

• Re-established management &infrastructure

Polio Eradication

Is Polio contributing to Peace?

• Beneficial - mechanisms used to obtainaccess for vaccination can contribute to long-term peace-building efforts

• Neutral - mechanisms have no positive ornegative impact on long-term peace

• Detrimental - mechanisms allow parties toexploit and manipulate resources andinfrastructure put in place by partner agencies

Polio Eradication

“In war zones aroundthe world, guns havefallen silent to allowimmunization days totake place -demonstrating thateven in the mostintractable ofconflicts, warringparties can call a haltto destruction in thecause of life.”

UN SG Kofi Annanadministering drops in Pakistanrefugee camp (March 2001)

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ANNEXE 7: PRESENTATION OF WHO/EHA

World Health OrganizationCluster for Sustainable Development and Healthy Environments

Department ofEmergency and Humanitarian Action

(EHA)

Health as a Bridge for Peace

Geneva, June 2002

Health as a Bridge for Peace

1981, WHA Resolution 34.38:“The role of physicians and other health workers in the preservation of peace is

the most significant factor for the attainment of health for all”.

Health as a Bridge for Peace

...... I .. stress the need to protect health systems and ensure access to the basicnecessities for life - even when there are hostilities.

......a troubling tendency of modern military tactics to target the underlyinginfrastructure of whole societies ..... We must do all we can to resist this.

...... systematic attempts to undermine the operation of medical services during conflict. We must confront (this) growing tendency...

WHO will.. continue to be active in conflicts and crises, taking exceptional action tosustain health systems, to ensure continued delivery of health services and to protectthe health of the population.

G.H.Brundtland, May 2002

Social capital:Health as Capacity

Health as capacity to cope for oneself

Health as capacity to care for one's dependants

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Health as capacity to trust:• one's neighbour• the institutions

WHO/HBP : MILESTONES

Mid 1980s, Central America: 'Health as a Bridge for Peace'1990s• Mozambique & Angola: health care for demobilisation• Haiti: Hum.Assistance Program• Cambodia: Brokerage for health• The Balkans: Peace Through Health• Somalia: Basic Development Needs• The Horn of Africa Initiative• The Thai-Myanmar Project• Colombia: health coordination for IDPs• Iraq:SCR 986 - "Oil for Food"• West Bank and Gaza: Special assistance programme• Sri Lanka & Indonesia: self-sustaining country programmes

HBP in Sri Lanka : the process

1999. WHO organises a regional HBP workshop in Sri Lanka2000. Sri Lanka University organises a national workshop for health managers from"both sides"2001. Sri Lanka organises a T.o.T workshop 2002. Sri Lanka organises a workshop for strategic review and planning

WHO's total investment:approx. US$ 200,000

HBP in Sri Lanka : outputs

1. HBP skills are used in day-to-day health work, in and around conflict areas 2. HBP trainers train provincial level PHC staff3. HBP trainers educate colleagues in the Army4. Ministry of Health conducts HBP training for Tamil population in areassusceptible to race riots 5. Sri Lankan trainees travel as resource persons to start HBP programme in Indonesia.

HBP in Sri Lanka : outcomes

1. Army Medical Services instructed to cater to "enemy" community in newlycaptured areas2. Ministry of Health provided mobile health services in areas not under governmentcontrol3. Sinhala and Tamil villages involved in joint projects in areas around the conflict

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4. Plans to integrate “rebel” health workers into formal health services5. University incorporates HBP into medical curricula

Did Health and WHObring Peace to Sri Lanka ?

.............

A vision, a strategy and a programme did contribute to deliver health care, thusmitigating the impact of conflict and facilitating the transition to Peace.

HEALTHIS

THE OBJECTIVE

Health is the objective

At country level," Health as a Bridge for Peace" should not be

perceived or undertaken as a separate, free-standing project

HBP elements should be identified, highlighted and/or factored into existing orplanned public health work

"Being there or here" as health workers is HBP, because it states that humanlife and health are the overriding concerns.

HBP: a role for WHO

Clean water is good forHealth

Peace is good for Health

WHO can provide public health evidence basis, advocacy support programmeopportunities to those who work for peace.

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ANNEXE 9: CONCLUSIONS OF THE WORKING GROUPS ON EVALUATION

Instructions:

1. Have we (WHO) been ‘on track’?2. Is it worth evaluating (Credibility) (Validity)?3. What methodologies are needed/required/useful?4. Which implications if not…

GROUP 1:

ISSUES:

− “Changing the name” e.g. Aceh example− “Equity in health care”

1. Have we been ‘on track’?

− Peace building through health programmes can increase confidence withincommunities

− Depends on the track and levels− Peace process− No peace process− UN strategy− If WHO wants to know we need HBP as a programme?− Or is it a spirit?− Output (Health) – Outcome (Peace partners) – Process

Evaluative Methodologies:

“TRACKS”(country level)

HBP Programme – SPIRIT (Implementing Health for All)

Peace Process Types of activities at different stages of conflict.

No Peace Process Types of activities at different stages of conflict

UN Strategy Types of activities at different stages of conflict

Regional?

Types of activities at different stages of conflict

Headquarters?

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GROUP 2:

COMMUNICATE

Awareness Strategic ApproachStance – Position SpiritStrategies Framework for PHSkills PhilosophyPartners

AWARENESS

External / Internal

− Networks− Publications− Consultations− Communication

Summary:

Signs of improvement; but could be much improved.

STANCE (POSITIONING)

− Principles of HBP (Universal and context specific)− Documentation− Position papers

Summary:

− On track− Questions of consistency and application

STRATEGIES

− Consistent approach – No− Training – Yes− Communication/Dissemination – No/weak− Advocacy – No− Monitoring and evaluation – No

SKILLS AND KNOWLEDGE

− Active Learning Package− Conflict Analysis− Negotiation

33

− Human Rights− IHL− Medical Ethics

Summary:

− Reach of training programmes?− Quality?− Other skills?− Better priorities?

PARTNERS

− Increased # Partners – But no consolidation of network(s)− Internal partners – Inconsistent

SHOULD WE BE DOING HBP?

Yes – But need more rigour

HBP - Fosters big picture- Helps change perspectives- Inspires- Aligns activities

Questions:

− Negative consequences?− Should we change the name?

GROUP 3:

− Processes to deliver health initiatives in conflict need more investigation.− Trends – outcomes (What work – What did not and Why?− Link to Peace?− What is the added value in packaging activities that already exist?

If we take the example of Polio eradication there are several initiatives:1. Days of tranquility2. Synchronisation of different bordering countries3. Collaboration between country A and B in order to reach vulnerable pockets.

The output of all these is the immunization coverage and the outcome, a reduction ofmortality and morbidity. This might contribute to peace along with a number of otheroutcomes (e.g. education, etc.).

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ANNEXE 10: INDIVIDUAL SUGGESTIONS ON A SUBTITLE FOR HBP

An individual exercise was done in order to suggest an appropriate subtitle for HBP.Below the proposed definitions are quoted.

Adapting to Complexity

An approach to provide health emergency humanitarian assistance in conflict areas asa contribution to peace

Ensure that health cooperation/activities doesn’t harm health process

A promotion of peace through the provision of basic health in crisis area

Is a strategic approach to promote peace as one of the benefits of health programmes

Modus operandi in the health sector applied to complex situation (conflicts)contributing to regional stability, conflict reduction and sustainable development

Is WHO’s strategic approach in conflict areas to lead the global health communitytowards the achievement of health goals and the transformation of conflict to peace

A framework for developing the partnerships which maximise effectiveness of healthinitiatives and increase functioning of health institutions

A programme managed by EHA which seeks to develop and apply strategies (a) forhealth delivery in areas of armed conflict and (b) for the use of health delivery andhealth initiatives to strengthen peace-making and peace-building in areas of armedconflict.

Is a strategic approach for health planning and serve delivery in crisis, emergencies orconflict situations, that take a broader perspective on the impact of health action onthe context (conflict) and in a manner that is equitable, rights-based on that ultimatelyrealize “Health For All”; which may contribute to long-term peace

Strategic outreach programme that can facilitate the delivery health and protection ofhealth workers/facilities through a core training in planning for health in conflict andconflict prone situations

Is an attempt/process to ensure an equitable access to health and health care during all stages of a conflict, which will help to promote peace

35

Goals þHealth for All, Equity, Access, } all WHO andþCommunity Building other health goals

ù through

Mode: þCooperation, Partnership Advocacy (deliberate outreach) } the HBP

ù developed through

Development: þSkills, knowledge, reflection } framework of context

Legal frame ù measured throughEvaluation: þDocumentation and research

36

ANNEXE 11: CONCLUSIONS OF THE WORKING GROUPS ON HBPDEVELOPMENT

Instructions:

What should we do regarding these areas of changes?1. Human Security2. Equity/Rights3. Multiplicity of Actors and/Roles Shifting4. Globalisation – Protracted Crisis

GROUP 1:

ISSUESSTRATEGIES HUMAN SECURITY EQUITY/RIGHTS ACTORS AND

ROLESPROTRACTE

D CRISiSCOOPERATION − Identify

counterparts− Mechanism to

identify synergies− Define Human

Security for HBP orwithin HBP context

Linkages with keyOrganizations andinternal units

Active pursuit ofbroadpartnerships –beyond healthsector

Needs drivencooperativesand localsocieties’involvement incoordinationmechanismsthrough apragmaticprocess

ADVOCACY − Promote broadvision of Health andHuman Security

− Distinguish HumanSecurity andNational Security

− Human Securityversus NationalSecurity

− How would theworld look ifequity were morethan rhetoric?

− Implications

− Why havepartnerships?

− Where is thesubstance?

− Promote crosscutting roleand HBP

Neglectedconflicts− UN/WHO

advocacyrole

− Civicsocieties’role

COMMUNICATION

Clearly convey conceptsto field counterparts

− Spread existingknowledge insideand outsideWHO

− ArticulateHuman Rights inHBP

− Define peacenourished byEquity andHuman Rights

− Articulateroles, rightsandresponsibilities in HBPnetwork

Data sharingonconflicts/impact on waraffectedpopulation.

SKILLS ANDKNOWLEDGE

− Broadenunderstanding

− Maintain HBP asdynamic framework

− WHO corporateHuman Rightsstrategy – Whatis it?

− Training –

− ArticulateWHO role

− Link withformal peaceprocess

Shift fromemergency tocomprehensivesocial servicedelivery in

37

internal andexternal

− Training by leveland phases ofconflict

− Link‘informal’peaceprocesses inhealth sector

protractedcrisis

NETWORKING Integrate health sectorinto :(1) Peace Process, and(2) Social Sector

Increase link amongcivil societies,academic,international,government, NGOs,community and UNand health providers

Articulate levels:− Global− Regional− Inter-

organization− Intra-

organization− In conflict:

− Peacesector

− Socialsector

Interactionwith“Rebel”/Non-GovernmentActors

GROUP 2:

1. INTERNAL ORGANIZATION OF HBP:

− Focus on a simple product (Health Agenda in the context of conflicts)− Collect, analyse successful experiences and mainstream in a good product− Focal point within WHO to assure leadership – driving role – and coordination

with all departments.

2. EXTERNAL LINKAGE:

− Human Scurity/Security the new reality− WHO to position itself and to elaborate the health aspects of Human Security− Human security/Rights-based agenda

GROUP 3:

AIMIntegrating peace-building with health.

HBPStrategic outreach programme through training for planning delivery of health incoonflict and conflict-prone areas.

Internal Advocacy within WHO.

GlobalLeadership (weak)RegionalRole Vs. obligation