Conflict and Public Health: Prevention, Responses, Recovery, Rehabilitation, and Reconciliation

“War is a man-made public health problem and it is preventable.” – Borisch (WFPHA)

“It will take decades for Ukraine to bring its public health system to the prewar level.” – Majrooh (Former Afghan Minister of Public Health)

The ongoing conflict in Ukraine has triggered a global health crisis, with people in the country experiencing death, suffering, and displacement, as well as, food and fuel insecurity. Moreover, the crisis has reduced donor funds for addressing other health issues. Unfortunately, the situation remains far from ideal at the global level as well.

According to the World Health Organization (WHO), nearly a quarter of the global population, which amounts to 1.8 billion individuals, currently resides in regions affected by conflict. The adverse effects of such circumstances on public health are significant. Warfare results in elevated mortality rates, the breakdown of social and economic systems, food scarcity, repeated disruptions to healthcare services, the collapse of medical supply chains, the flight of healthcare professionals, and severe epidemics.

The 17th World Congress on Public Health, taking place in Rome from May 2nd to May 6th, will feature Prof. Bettina Borisch, a WFPHA CEO, and Dr Wahid Majrooh, a Former Afghan Minister of Public Health, who will discuss war and conflicts during one of the Plenary sessions.

“Today under international humanitarian law we monitor more than 110 armed conflicts. Some of these make the headlines, while others do not. Some of them started recently, while others have lasted for more than 50 years. War is a man-made public health problem and it is preventable. War and armed conflicts have devastating consequences for the physical and mental health of all the people involved, for the social life within and surrounding the war regions, and for the health of the environment. War diverts, essential and often very scarce resources needed to survive. In addition, there is a vast amount of people that are also negatively impacted by the wider effects of war”, explains Prof. Borisch, a public health expert who proposed the session on war and global health.

The main consequences of the armed conflicts include:

• Displaced populations
• Limited access to clean water, food, and sanitation – the basis of public health
• Increased risk of communicable diseases
• Impacts on women’s and children’s health: According to a recent study, in 2017, at least 10% of women and 16% of children globally were either displaced by conflicts or lived dangerously close to conflict areas, making them vulnerable to sexual assault, early marriage, harassment, isolation, and exploitation.
• Impacts on mental health: The psychological consequences of war are devastating, with post-traumatic stress disorder (PTSD), anxiety, depression, and somatoform disorders becoming more prevalent in wartime and post-conflict situations.

“Epigenetics taught us that even for generations after the war the mental health consequences are there”, specifies WFPHA CEO.

Furthermore, wars seldom affect only local areas but instead, have worldwide repercussions. The global consequences of war can range from food and energy crises to inflation and financial speculation, as demonstrated by the recent conflict in Ukraine, which extended its impacts beyond national borders.

The impact of the war on the Ukrainian healthcare system:

The war in Ukraine has increased the need for healthcare services while simultaneously reducing the system’s capacity to provide them, particularly in active conflict areas. As a result, the Ukrainian health system must deal with an increasing number of injured and polytraumatized patients, as well as health services that suffer from a lack of medical equipment maintenance, shortages of drugs and medical supplies, and inadequate personnel. The quality of health care varies from region to region.

Given that the overall nature and impact of war on the health and well-being of societies and health systems are similar, Dr Wahid Majrooh provides a comparative analysis of the the Afghan and Ukrainian contexts.

“Prior to the conflict the health system of Ukraine was operational and was at a fairly good level but unfortunately because of the conflict, there are several impacts which the system and people are suffering from. There is a huge division of political focus and concentration in leadership on how to oversee and meet the health needs of communities and people. The risk of a pandemic is still there while the level of the required leadership and political attention is not. It means that there is a competition of priorities: security prevails now over other human needs including health care. Unlike Ukraine, in Afghanistan, we had decades of experience in managing health emergencies. Our experience on the ground has proven that the resilience of human capital and the resilience of the system play a crucial role because it takes courage and a new way of thinking, and a new way of managing resources and providing more supportive leadership”, – explains Dr Wahid Majrooh.

The WHO has sent large shipments of medical supplies to Ukraine and released $5.2 million from its Contingency Fund for Emergencies to address the country’s urgent health needs. Numerous other international donor programs are also aimed at achieving the same goal. However, are they truly capable of resolving all the aforementioned issues?

“People may say that there are a lot of donations from international agencies and State members but the problem with donations in such a context is that they are not aligned with the national agenda on public health policy and do not fill all the gaps. For example, in some areas, where the conflict is going on, the human capital both in terms of number and morale is badly affected. A humanitarian aid that focuses on urgent needs (e.g. infectious diseases and emergency healthcare and treatment of victims of war) does not look into long-term systematic issues (e.g. mental care and maternity care). It creates a parallel system which in the mid-term weakens the national health system. It also creates a lot of expectations while the system in the state is not able to sustain that.” specifies Dr Majrooh.

The Former Afghan Minister of Public Health believes that given the lack of optimistic forecasts regarding the resolution of the conflict, the aforementioned issues will continue to worsen. How many years will it take for the Ukrainian healthcare system to recover quality parameters similar to those that existed before the conflict?

“The problem of post-conflict is the reconstruction of the system, including the health system, is that it is not only the financial cost which will matter but the time and the level of trust are really huge challenges to cope with. Because in nations that suffer from protracted conflicts, the social fabric is very badly affected. Thus, if the conflict continues, it would take decades for Ukraine to resolve all those problems. For instance, it took us two decades but we still weren’t able to fulfill all the health needs of our society.” estimates Dr Majrooh.

The 1948 WHO founding document states: “The health of all peoples is a fundamental condition of world peace and security; it depends on the closest possible cooperation between individuals and between states”. Similarly, the Ottawa Charter also considers peace to be the primary determinant of health.

What role should public health professionals play in the armed conflict context?

As suggested by Prof. Bettina Borisch, public health professionals must play a vital role during times of armed conflict by raising awareness of the devastating consequences of war, advocating for peace, and working to prevent outbreaks of war and their most severe outcomes.

Prof. Bettina Borisch emphasizes that “Wars are preventable and we, as public health people have to do everything to prevent armed conflicts. Our finest task is to do promotion to prevent diseases. In the context of war and armed conflicts, we have to act against the underlined causes of war: inequity, poverty, and unequal distribution of power, thus it’s very important for the public health people to understand the political background of the problems that we face.”

The Role of Thought Experiments as Sources of Insight and Lessons to Tackle Pandemics and Other Existential Challenges

“We invite people to exercise their imagination and think collectively on the failures of the current global health governance.” – De Souza (WFPHA) and Jadad (Center for Digital Therapeutics)

In February 2022, the World Federation of Public Health Associations (WFPHA) encouraged the use of thought experiments to improve humanity’s ability to manage pandemics and other existential threats. Delegates of the 17th World Congress on Public Health (2nd – 6th May, Rome), the overall public health community, and civil society members are invited to contribute to the further exploration of this method.

“What we tend to see is that the public health problems become visible only during the crisis and that’s why somebody needs to clean the mess. But it’s extremely difficult to do because the mess is getting bigger and bigger. The public health community is pretty powerless to deal with this problem. I think that the 17th World Congress on Public Health provides an opportunity for the public health community to reflect upon its role“, underlines Prof. Alejandro Jadad, a physician from the Center for Digital Therapeutics and one of the promoters of the Thought Experiment.

The imaginative capabilities of the human mind enable us to travel through time and space. Scientists and philosophers use this ability to create hypothetical situations, also known as Thought Experiments, to explore alternative approaches to complex issues, particularly when challenging the existing norm.

The creation of a Thought Experiment, which Albert Einstein used in some of his most important studies, involves five steps: beginning with a hypothesis or question, followed by assumptions, a hypothetical scenario, mental analysis, and communication of findings to others.

“It is important to note that this scenario is entirely fictional and not a recommendation or proposal for action. Our main goal is to help people to reflect collectively on the failures of the current global health governance. What really strikes us is that in 2019 we had international health regulations in place and nevertheless the best-valued countries in terms of capacity to respond to the epidemical crisis failed. Thus, it’s not a problem of the text of the regulation itself but how the members of the World Health Organization (WHO) and the United Nations (UN) took their responsibilities regarding the protection of people’s health”, – explains Prof. Luis Eugenio de Souza, the WFPHA president.

“The Thought Experiment is a very powerful tool. We invite people to exercise the power of their imagination and create situations that due to the knowledge acquired during the pandemic will allow us to come up with solutions to the problems that we face today”, specifies Prof. Jadad.

In a hypothetical scenario, a team of public health experts in 2023 discovers a time machine that could take them back to the beginning of the pandemic.

After conducting extensive research, the team identified a trustworthy group of people to represent humanity’s interests and ensure the equitable and efficient use of resources to halt the virus’s spread and mitigate consequences of the pandemic. This group was named the Planetary Health Protection Council (PHPC). The team was transported via the time machine to the UN headquarters in New York City, where they arrived on March 11, 2020, during the President of the Security Council’s presidential statement.

To explore the potential of thought experiments in pushing boundaries and stimulating fresh thinking about how to tackle pandemics and other existential threats, a hypothetical question was formulated:

If we had the power to travel back in time and add one resource to the available resources on March 11, 2020, to improve our response to the COVID-19 pandemic, what resource would we choose?

• “The response to this question can be summed up in two words: a coordination failure. We are failing to coordinate our response and it makes us unable to deal not only with the pandemic but also with climate change, with drought, with hunger, and with the war”, Prof. Jadad says.
• “We came to the conclusion that humanity lacked a species-wide governance system in 2020. There was a lack of accountability on the issues that went beyond the national jurisdiction. To be able to move towards effective global governance, we need to raise some specific questions to promote further reflection on the subject: 1) how far can national sovereignty go? 2) what could be done to protect the democratic decision-making mechanism, and how it can couple with the global one?”, Prof. de Souza adds.

Prof. Luis Eugenio de Souza notes that during the pandemic, the decision-making process was unbalanced. Therefore, it is extremely important to create a completely new, transparent, and impartial system. This role can be potentially fulfilled by the Planetary Health Protection Council (PHPC).

The imaginary composition of the PHPC:

• The government sector: Heads of state of all members of the UN
  Role: Providing high-level political leadership for rapid and coordinated action, advised by UN specialized agencies

• The corporate sector: Members of the World Economic Forum (WEF)
  Role: Facilitating the deployment of privately-owned technical and financial resources within and across national boundaries

• The academic sector: Experts selected by the International Association of Universities
  Role: Strengthening of evidence-informed decision-making by the other groups

• Civil society: Leaders selected from the 24,000 entities registered in the Integrated Civil Society Organizations System
  Role: Involving communities, especially giving voice to disadvantaged populations

“I would like to stress that our proposal to create the PHPC is not mature enough and thus it can be modified. We just want to put it on the table and open the discussion not only with the experts and political leaders but also to listen to the local communities and the people that suffered a lot but weren’t given the possibility to express themselves so far. We want to create such a representation which would give the floor to everybody who wants to participate“, specifies the WFPHA president.

Two independent and closely-related structures complement the PHPC:

• A digital platform to facilitate transparent and equitable participation of representative samples of the world’s population in key decisions (e.g., lockdowns, vaccine certification)
• A system of in-person and virtual tools designed to encourage and facilitate community engagement in controversial issues and adversarial situations, from villages to the entire globe.

COVID-19: Any Lessons Learned?

“We are not ready to face a new pandemic.” – Ricciardi (UNICATT)

“No country is safe until all countries are safe.” – Krech (WHO)

The 17th World Congress on Public Health, taking place in Rome from May 2nd to May 6th, coincides with a critical juncture for our world as we continue to deal with the COVID-19 pandemic, which has caused significant changes and exacerbated existing inequalities.

It is no coincidence that one of the key Plenary Sessions of the event is dedicated to a very pressing and painful subject: COVID-19: The Ongoing Challenge, Lessons Learnt, and How to Prevent the Next Pandemic.

The COVID-19 outbreak resulted in the loss of almost 7 million lives worldwide. This recent pandemic has also been a formidable stress test, examining the resilience of global health systems and exposing weaknesses in public procurement processes. However, managing COVID-19 has brought the healthcare sector, which is usually on the fringes of political debate and largely overlooked by the media, to center stage.

Why the situation went out of control?

“It’s beyond argument that not a single state in the world had adopted a perfect strategy during the pandemic. However, some of the states, like, for example, the UK, the USA, and Brazil have paid a very huge price in terms of losses and deaths because their governments, being directly dependent on public opinion, didn’t listen to the scientists, they didn’t lockdown immediately and they didn’t enforce vital public health measures”, – underlines Walter Ricciardi, Professor of Hygiene and Preventive Medicine at the Catholic University of the Sacred Heart and Scientific advisor to the Minister of Health for COVID-19 emergency from 2020 to September 2022. “It’s necessary to underline”- suggests Professor “that the responsibility still lies in the hands of the national governments. In some cases, the difference between the global response and the national was very divergent”. Ricciardi also emphasized that the so-called “infodemic (* false and misleading information about a disease outbreak) has led to mistrust in health authorities and has undermined the public health response”.

“The COVID-19 pandemic didn’t fall from heaven, it wasn’t the first wake-up call in this young century – we had the bird flu (H5N1), the swine flu (H1N1), Ebola, and in some regions, we had also Zika and then eventually we faced COVID. After each of these crises, external experts around the world looked at what the governments did right and what they did wrong, what the WHO did right or wrong and what is need to be done in the future. There were a series of recommendations already in 2015. However, countries didn’t address the root causes before in order to be better prepared for the epidemical pandemic. We needed a comprehensive understanding of the weaknesses in countries and resolute action to mitigate those weaknesses. Unfortunately, that has not happened”, stresses Dr Rüdiger Krech, a senior official at the World Health Organization (WHO).

What does COVID-19 teach us or should teach?

Now that the COVID-19 pandemic is in a state of transition, it is an ideal time to reflect on the valuable lessons we have learned.

“I’m not sure that the lessons were learned. I would say that certainly the lessons were taught”, Ricciardi says by highlighting two main lessons to focus on:

• Targeted healthcare investments are essential to strengthen public health systems and prevent pandemics in the future;
• A more determined and less selfish attitude toward investments in global collaboration and in human capital is needed.

What if the next pandemic happens tomorrow?

It is impossible to predict when the next pandemic will occur, but as experts suggest it is inevitable. Thus, it is extremely important to understand whether current national public health systems are ready to face another significant challenge.

“It’s not a question of whether or not we are going to see the epidemics or the pandemic but only when we are going to face it. The biggest mistake would be to ignore the weaknesses that we see in our own countries and that we monitor globally. As the pandemic went on, we learned a lot about how it evolves and every pandemic will evolve differently. Therefore, we will always learn with the development of the pandemic but the key benchmarks (for instance, the social distance) needs to be kept and the main 30 risks that can potentially lead to the next pandemic should be addressed“, underlines Dr Krech.

“It depends on the country but the majority of them unfortunately are not ready. Some of them are too relaxed now and it seems like they haven’t made any conclusions from the previous pandemic experience. As we see, less money is invested in public health and in particular in public care”, – says Walter Ricciardi who, nevertheless, hopes that the next time the reaction would faster because “now we are certainly more experienced”.

Solutions on the table:

In March 2023, the World Health Organization began negotiations on a global accord for pandemic prevention, preparedness, and response. The “zero draft” serves as a basis for the negotiations in order to create an accord that will protect nations and communities against future pandemic emergencies.

“The global pandemic treaty should be the first step towards the global management of the future pandemic. We have been discussing this document for the last two years and I have to admit that we are still very slow because major countries are not in favor of this initiative. And the second and the third steps should certainly be the major investment in the public care system and the better coordination“, – Prof. Ricciardi concludes.

In Dr Krech’s opinion, in health promotion it is very important “to codesign, to empower and include in the policies and recommendations the people we want to reach” and to understand “how people behave and what they accept and do not accept”.

At the international level, collaboration should be considered an essential element.

“Virus do not know borders and we shall remember for the future: no country is safe until all countries are safe”, – concludes Dr Rüdiger Krech.

No Public Health Without Planetary Health

“Fighting climate change today is the best public health opportunity.” – Maria Neira (WHO)

“We are all responsible for the health of the planet.” – Emma Te Patu (WFPHA)

Since the outbreak of COVID-19, the concept of “global health security” has become a topic of academic and popular debate as health specialists gather to discuss various approaches to avert the next pandemic. In an increasingly interconnected world, the primary goal of this agenda is to identify and prevent health concerns that impose a burden on populations, society, and the global economy. One of the Plenary sessions of the 17th World Congress on Public Health (2nd – 6th May, Rome) entitled “No Public Health Without Planetary Health” speaks for itself.

“There is no such thing as the health of only one country. We are all responsible for the health of the planet and understanding and drawing on the Indigenous people’s knowledge systems that have been in place from time immemorial and authentically engaging with this knowledge and using it to inform our global health needs collectively and from an understanding that health is a human right and is, therefore, a priority above all”, – underlines Prof. Emma Te Patu, WFPHA Vice President & MAORI.

The promotion of global health is a vital mission in the modern world of globalization. It requires the cooperation of governmental bodies, global health organizations, medical professionals, educators, volunteers, and advocates within local communities.

Prof. Te Patu has defined the five global health initiatives that play a crucial role in the current context:

• Decolonising public health – Removing systemic barriers to Equity
• Proper resourcing of public health
• Legislative mechanisms to ensure countries are accountable for public health
• Health and growth of the public health workforce
• Accessible and relevant public health education

The WFPHA Vice President has also classified the biggest public health threats:

• Ego and the commercial financial imperative
• Reactionary responses as opposed to strategic responses
• Lack of proper resourcing

Why should climate change be considered the biggest global health threat of the 21st century?

Global crises are closely linked with climate change. Therefore, we must not overlook the existential threat that ecological degradation poses to planetary and human health.

“Climate change is definitely touching all the pillars and supports of our health: access to food, to safe drinking water and to clean air. It is changing the way we will protect our help and the way we need to prevent the worst impacts of climate change. People need to understand that climate change is not just something that will happen to the Planet in the future but it is affecting our health right now: it affects our lungs, and it causes diseases. We are already paying for it. I am convinced that addressing the causes of climate change today will be the best public health opportunity. It will bring benefits to the health system, to the economy, to the population, and make our society more sustainable. We need to increase the speed at the national level, set more ambitious goals, and, therefore, provide ourselves with well-covered health insurance. Our life and survival will depend very much on that.”, – underlines Maria Neira, Director of the Department of Public Health and Environment at the World Health Organization (WHO).

According to the WHO’s estimates:

• Between 2030 and 2050, it is expected that climate change will cause approximately 250 000 additional deaths per year from malnutrition, malaria, diarrhea, and heat stress.
• The estimated direct damage costs to health (i.e. excluding costs in health-determining sectors such as agriculture and water and sanitation) are between USD 2-4 billion per year by 2030.

The destabilizing impacts of climate change disproportionately affect the most disadvantaged. Many low-income countries are particularly vulnerable to sea-level rise, natural disasters, and food and water scarcity. As a result, the lack of resources can lead to forced migrations. How can we safeguard these “unhealthy” territories?

“We know that an unhealthy environment is responsible for 13 million deaths every year due to the lack of safe water or to the lack of clean air. The toxic air alone kills 7 million people annually. The creation of healthier environments will be the best investment we can make to protect our health by guaranteeing access to safe water, safe food, and clean air and by stopping to pollute our oceans with millions of tons of plastic. It’s important to bear in mind that plastic can end up on the human body because fish contains a high number of microplastics that we throw into the oceans. Only if people see the connection between climate change and their health, they will start to act and become more responsive and more determined to fight the causes of climate change”, says Prof. Neira.

The COVID-19 pandemic has exposed the weaknesses and inequalities in our health systems in the face of global crises. The world requires equitable investment in research, surveillance, and preventive health to strengthen global resilience against these emerging risks. What measures should be taken to ensure global health security?

Prof. Te Patu has laid down the following list of priorities:

• Pandemic treaty – an instrument designed to prepare the world for the next pandemic
• More consultation with civil society
• Decolonising public health
• Greater collaboration between international, regional, national, and local public health communities
• Government transparency in messaging and addressing public health and what it entails

“We are all citizens of the world now. Pandemics do not recognise borders, so a united international response is vital. The same approach is used when we deal with the environment. If, for example, we do the deforestation in the Amazonia, in one way or another it will affect all of us”, concludes Maria Neira.

Public Health Impact of Uganda’s Anti-Homosexuality Act: WFPHA Stands with the Ugandan LGBT Community

The World Federation of Public Health Associations (WFPHA) stands in solidarity with the Ugandan LGBT community and denounces Uganda’s Anti-Homosexuality Act (2023). The legislation raises serious concerns for public health, human rights, and access to healthcare, while threatening decades of progress in HIV prevention and control.

The health of populations depends on inclusive societies, equitable access to services, and the protection of human rights. Laws that increase stigma, discrimination, and barriers to healthcare can have consequences that extend far beyond the individuals directly affected.

Uganda’s Anti-Homosexuality Act (2023)

On 21 March 2023, the Ugandan Parliament passed the Anti-Homosexuality Act (2023). By criminalizing same-sex conduct, the Act criminalizes lesbian, gay, bisexual, and transgender (LGBT) Ugandans, the provision of services to LGBT Ugandans, and the dissemination of information about LGBT communities.

The Act also requires Ugandans to report individuals suspected of being LGBT and prohibits the sheltering of LGBT persons. It further provides for the death penalty in cases defined as “aggravated homosexuality.”

At the time of the original WFPHA statement, President Yoweri Museveni indicated that he would assent to the Act following amendments related to what was described as “rehabilitation.”

Why the Act Is a Public Health Concern

Beyond its legal implications, the Act has significant consequences for public health.

By undermining access to healthcare services among already vulnerable populations, the legislation threatens Uganda’s longstanding achievements in HIV prevention and control. Public health evidence consistently demonstrates that stigma, discrimination, and criminalization create barriers to healthcare access, testing, treatment, prevention services, and health-seeking behavior.

The World Health Organization and other international health bodies have long recognized that discrimination can negatively affect population health outcomes and contribute to widening health inequities.

Evidence on the Health Effects of Anti-LGBT Legal Environments

LGBT persons have existed throughout human history and across cultures. Natural variations in sexual orientation and gender identity exist regardless of enacted laws and policies.

Research cited in the original statement demonstrates that structural anti-LGBT legal environments are associated with:

Increased Hostility and Violence

Studies have shown that anti-LGBT legal climates can contribute to increased hostility, harassment, and violence directed toward LGBT individuals.

Poorer Mental Health Outcomes

Research has linked discriminatory legal environments to:

• Higher levels of psychological distress
• Reduced life satisfaction and well-being
• Increased risk of psychiatric disorders
• Greater risk of suicidal ideation

These impacts are not limited to those directly targeted by legislation. Family members, friends, and broader communities can also experience psychological harm resulting from hostile public discourse and discrimination.

Human Rights Obligations and International Law

In 1995, Uganda acceded to the United Nations International Covenant on Civil and Political Rights (ICCPR).

For decades, international human rights mechanisms have interpreted the Covenant as providing protections against discrimination based on sexual orientation, gender identity or expression, and sex characteristics.

The original WFPHA statement noted that United Nations legal experts stated that imposing the death penalty under the Act would constitute an arbitrary deprivation of life and would be incompatible with Article 6 of the ICCPR.

The statement further emphasized that obligations under international law are not superseded by domestic legislation or constitutional interpretations.

Developments Since the Original 2023 Statement

Since the publication of the WFPHA statement, Uganda’s Anti-Homosexuality Act has remained the subject of legal and international scrutiny.

In April 2024, Uganda’s Constitutional Court upheld most provisions of the Anti-Homosexuality Act while striking down several sections, including provisions related to mandatory reporting and certain restrictions that were found to conflict with constitutional protections. However, the Court left the core provisions of the legislation in place, including criminal penalties for same-sex conduct.

Human rights organizations and public health advocates have continued to express concern that the law contributes to discrimination, barriers to healthcare access, and increased vulnerability among LGBT individuals. Reports published since the law came into force have documented ongoing concerns regarding harassment, evictions, loss of employment, denial of healthcare, and other forms of discrimination.

As of 2026, the Act remains in force and continues to generate concern among international public health and human rights organizations. Recent reports indicate that arrests and legal actions under the legislation continue to raise concerns about the health, safety, and well-being of LGBT individuals in Uganda.

The WFPHA’s Call for an Inclusive and Healthy Society

The WFPHA calls on the Ugandan President, Parliament, and Government to foster an inclusive and safe environment for all citizens while safeguarding the human rights of every individual, irrespective of sexual orientation or gender identity.

Protecting public health requires protecting human dignity. Policies that promote inclusion, reduce stigma, and ensure equitable access to healthcare are fundamental to improving population health and advancing health equity.

Co-Signer

The World Federation of Public Health Associations gratefully acknowledges the support of:

• European Public Health Association