By Marion Birch - Medact
10 years after the September 11th attacks on the World Trade Centre, reports of the sorrow of those that lost family and friends, are accompanied by an ongoing debate about the number of deaths caused. The officially recognised 2,976 deaths is not the final estimate. The directly attributable longer term health effects - particularly as a consequence of the dust created - are difficult to establish. However, in 2007, newly-diagnosed asthma post-9/11 was reported by 3.1% of workers or 12 times the normal rate among adults. Post-Traumatic Stress Disorder (PTSD) among rescue and recovery workers was 12.4% or four times that of the general USA population.[1] The Zadroga Act which became law in January this year, authorised a further $4.7bn (£2.9bn) for monitoring, treatment and compensation for victims. The health consequences from this tragedy are far from over.
Every death should be documented and hold equal weight. There is no comfort for those that have lost loved ones in the United States, Afghanistan or Iraq in comparing 2,976 deaths with the hundreds of thousand of excess deaths from the ‘war on terror’ triggered by the attacks. At the same time this anniversary has to be a constant reminder that those in power used the event to launch the ‘war on terror’ on hundreds of thousands of individuals with no connection to 9/11. This was a massively disproportionate response, and the resulting number of civilian deaths in Iraq and Afghanistan has since been played down.
The war on Afghanistan, launched in retaliation for 9/11, has no clear end in sight and the number of civilian deaths continues to rise. In the initial absence of clear and coordinated recording, the aggregation of various estimates of civilian deaths between 2001-2003 (direct and indirect) is estimated at 6,300 - 23,600.[2][3][4][5] The United Nations Assistant Mission to Afghanistan established its Casualty Monitoring site in its present form in January 2007; in the month of May 2011 they recorded 368 conflict-related civilian deaths - the highest monthly figure recorded.[6]
Tragically, the attacks on the World Trade Centre were also used to justify the invasion of Iraq, despite well-known doubts about any links between Saddam Hussein and Al Qaeda. In 2006 a survey carried out by a group of experts estimated excess deaths since the invasion of Iraq to be 654,965, and the survey results were published in The Lancet[7]. This was the second survey of mortality in Iraq using the methodology of the random cluster sample survey – a methodology used in many other situations where the results were not challenged. Questions about implementation were also responded to in detail by the authors[8]. However, the Iraq surveys were widely criticised and their findings dismissed by key figures in the both the UK and US governments. Later it was revealed that the UK government’s own scientific advisors had recommended at the time that the methodology was sound[9].
In the United States, coverage of Afghan civilians deaths has tended to gave the impression that the main problem was that they undermined the ‘Allies war on Taliban’[10] rather than being tragedies in their own right.
9/11 has also been used to question international law designed to prevent such disproportionate and indiscriminate responses to violent attacks. Drawn up by countries following the death and destruction of the Second World War, the ‘laws of war’ - or Geneva Conventions - establish rules to try to mitigate the human cost of conflict, particularly for civilians, injured combatants, and prisoners of war[11]. The Conventions and their Additional Protocols also recognise the need to respect health workers, health facilities and medical supplies. Their key principles of proportionality (to likely military advantage) and discrimination (between combatants and civilians) should play a particularly important part in limiting death, sickness and injury. Yet 9/11 acted as a trigger to question them, which has persisted despite legal judgements,[12][13] and ignoring them has resulted in many more tragic civilian casualties in the ‘war on terror’.
Following the 2003 invasion of Iraq, health facilities were not protected. An estimated 12% of hospitals were damaged initially[14] and 12 % were looted. Al-Rashad hospital – a 1200-bed long-stay psychiatric hospital – was one of the first to be looted and many of the patients fled. There are indications that this was not inevitable: the Ministries of Oil and of the Interior were protected by the occupying forces, and there are examples of successful local action to stop looting.[15]
Medical neutrality continued to be violated even after there had been time to review what occurred during the initial invasion. During military operations in 2004, Fallujah General Hospital was occupied by Coalition forces[16][17] and Iraqi soldiers beat up staff at Al Numan Hospital in Baghdad. During the attacks on Fallujah, ambulances came under fire and humanitarian convoys were denied access.[18]
There were also dire consequences for those detained during these wars. The US Government denied the protection afforded to prisoners of war by the Geneva Conventions on the grounds that those they detained were ‘unlawful or enemy combatants’, despite the opinion of international legal experts, Amnesty International and others.[19] This created a climate of impunity which had severe and now well-known consequences for the health of these prisoners. Medical neutrality was also severely compromised. Psychologists originally working with the military on techniques which can be used to withstand torture, became members of the Behavioural Scientific Consultation Teams at the Guantanamo Bay detention facility designed specifically for those detained after 9/11. Their roles now included developing interrogation techniques based on an assessment of individual stressors,[20] a clear breach of medical neutrality which has been criticised by both the American Psychological Association and the American Medical Association.[21]
Closer to home, the mental health of those fighting these wars has also been a growing concern, although a recent study in the UK indicated alcohol abuse to be more worrying than Post-Traumatic Stress Disorder.[22] A UK soldier suffering a major traumatic injury in Iraq or Afghanistan will have an "unexpected survival" rate of 26%, much higher than for a UK civilian.[23] Survival for many will bring its own challenges in terms of disability and mental trauma; it has been estimated that the US has spent $31.3 billion since 2001 in providing medical care and disability benefits to veterans of Iraq and Afghanistan.[24]
9/11 was used to push the concept of the “new wars” and to suggest that this was a totally new situation in which, by implication, the old rules did not apply. But this ignored numerous recent conflicts that had many of the characteristics of the “new wars”: Mozambique’s war of independence and subsequent conflict, the battle for Katanga province in what was then Zaire, to name but a few. Really this was just part of the excuse to ignore the universal principles of the Geneva Conventions; a convenient way to wipe the slate clean, ignore past accountability issues and justify unlawful action. The result has been the use of a catastrophic and tragic event to create death, injury, disability and destruction on an unimaginable scale.
[1]Peck P (2008) CDC to Spend Another $30 Million Tracking Health Consequences of 9/11 Attack MedPage Today July 24 2008 www.medpagetoday.com/PublicHealthPolicy/PublicHealth/10246 accessed 28 08 11
[2]Conetta C (2002) Operation Enduring Freedom: why a higher rate of civilian bombing casualties? Project on Defense Alternatives Briefing Report #13 18 January 2002 (revised 24 January 2002) http://www.comw.org/pda/0201oef.html accessed 19 09 11
[3]Conetta C (2002) Strange Victory: a critical appraisal of Operation Enduring Freedom and the Afghanistan war Project on Defense Alternatives Research Monograph #6 30 January 2002
[4]Zucchino D (2004) The Americans… they just drop their bombs and leave Los Angeles Times June 2 2002 http://web.archive.org/web/20020604082553/http://www.latimes.com/templates/misc/printstory.jsp?slug=la-060202bombs
[5]Steele J (2002) Forgotten Victims The Guardian 22 May 2002 http://www.guardian.co.uk/world/2002/may/20/afghanistan.comment
[6] UNAMA (2011) Worrying spike in civilian deaths 17 June 2011 http://unama.unmissions.org/Default.aspx?tabid=1783&ctl=Details&mid=1882&Itemid=14089
[7]Burnham G et al (2006) Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey Published Online October 11, 2006 DOI:10.1016/S0140-6736(06)69491-9
[8]Burnham et al (2007) Mortality in Iraq – Author’s Reply The Lancet, Volume 369, Issue 9556, Pages 103 - 104, 13 January 2007 doi:10.1016/S0140-6736(07)60063-4 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2807%2960063-4/fulltext
[9]Horton R (2007) Counting the Cost guardian.co.uk 27 March 2007 http://www.guardian.co.uk/commentisfree/2007/mar/27/countingthecost/print
[10]Gall & Sanger (2007) Civilian Deaths Undermine Allies; War on Taliban http://www.nytimes.com/2007/05/13/world/asia/13AFGHAN.html
[11]http://www.icrc.org/eng/war-and-law/treaties-customary-law/geneva-conventions/index.jsp
[12] BBC (2006) Q&A Geneva Rules and the War on Terror 5 April 2006 http://news.bbc.co.uk/1/hi/world/americas/4879942.stm
[13]BBC News (2006) Q&A: US Supreme Court Guantanamo ruling 8 July 2004 http://news.bbc.co.uk/1/hi/world/americas/3867067.stm
[14]Garfield R (2003) Challenges to health service development in Iraq. The Lancet 362, 1324, October 18
[15]Bhattacharya (2003) Iraqi looters attack hospital and ambulances, New Statesman April 10
[16]Seth et al (2006) Securing Health. Lessons from nation-building missions Rand Corporation. http://www.rand.org/pubs/monographs/MG321/
[17] Turlan & Mofarah (2006) Military action in an urban area: the humanitarian consequences of Operation Phantom Fury in Fallujah, Iraq. Humanitarian Exchange Magazine 35, December. www.odihpn.org/report.asp?id=83428
[18]Doctors for Iraq (2005) Fallujah – one year on. Briefing note, December 12 http://www.doctorsforiraq.org/
[19]Head to head: Guantanamo prisoners BBC News 6 January 2002 http://news.bbc.co.uk/1/hi/world/americas/1763307.stm
[20]Fink S (2009)Tortured Profession: Psychologists Warned of Abusive Interrogations, Then Helped Craft Them. ProPublica May 5 2009 http://www.propublica.org/article/tortured-profession-psychologists-warned-of-abusive-interrogations-505 accessed 11 03 11 Medact (2011) Preventing torture: the role of physicians and their professional organisations: principles and practice.
[21] Medact 2011 http://www.medact.org/content/health%20policy%20/MED104336%20Medact%20Preventing%20Torture%20WEBSITE%20VERSION.pdf
[22] The mental health of UK military personnel revisited The Lancet, Volume 375, Issue 9727, Page 1666, 15 May 2010 doi:10.1016/S0140-6736(10)60717- 9 Published Online: 13 May 2010
[23]McVeigh K (2011) Soldiers severely injured abroad more likely to survive than civilians in Britain. The Guardian 20 January 2011 http://www.guardian.co.uk/uk/2011/jan/20/soldiers-injured-survive-civilians-britain
[24]Blimes L (2011) Current and Projected Future Costs of Caring for Veterans of the Iraq and Afghanistan Wars. Harvard University http://costsofwar.org/sites/default/files/articles/52/attachments/Bilmes%20Veterans%20Costs.pdf
