Reacting to terrorism: 
The response should be through law not war 

Editorial / British Medical Journal 13oct01

The first reactions of almost everyone to the atrocities in New York and Washington must have been horror and sadness, followed, understandably, by anger, fear and, for many, the urge for revenge. Deep sympathy for the victims and their families will continue, but there will be controversy over the relative role of military action and of a more measured response.

Military action has begun. Currently this is being directed at the Taliban's (fairly limited) armed forces and al-Qaida training camps. There are said to be no immediate plans for undercover "special forces" to capture Osama bin Laden. Calls for a massive attack on other countries supporting Islamic terrorists, including Iraq, Lebanon, and Syria, seem to have subsided. Even this more limited strategy has drawbacks. There have already been deaths; time will show how many of these are Taliban fighters and how many civilians. All will be regarded as martyrs, and revenge for their killings will lead to more terrorist violence. This process has been called the cycle of violence1: we constantly see it at work in Israel/Palestine. Secondly, Afghanistan was facing a humanitarian crisis before 11 September; this was exacerbated by the threat of bombing and is likely now to turn into a major disaster. Aid agencies say that airdrops of food will be ineffective in preventing mass starvation.

The events of 11 September were an appalling crime against humanity. The hijackers themselves are beyond punishment or revenge, but others behind them are equally guilty of mass murder. Perhaps, though, they can be punished through the process of diplomacy and law, though this too has difficulties. It is tedious, leading to complaints that nothing is being done. Several years after the Lockerbie jumbo jet atrocity only two men have been tried and one found guilty. It will be questioned whether those accused of the 11 September attacks could get a fair trial in the United States. As with the Lockerbie suspects, they could be tried under US law at the Hague, or by an ad hoc tribunal such as that dealing with war crimes in former Yugoslavia. An international criminal court will exist when enough countries agree its statute. President Clinton signed this, but his successor refuses to ask the US senate to ratify it. Some good may come of evil if the international criminal court comes into being sooner.

The tragic events of 11 September must also lead to longer term efforts to deal with wider threats to global security, which have serious implications for health care worldwide. Acts of terrorism merge into genocide over a few weeks, as in Rwanda,2 and mass killings over several years, as in Angola and the Congo (former Zaire), where millions have died out of sight of CNN and other media. Weapons of mass destruction (chemical, biological, and nuclear) could be used by non-state groups. Such fears led to the suspension of crop spraying in the US after 11 September, though experts differ on whether the largescale use of these weapons is possible without the involvement of hostile states.3 The missile defences planned by the Clinton and Bush administrations would be useless against such threats.

Measures in international law to counteract the threats exist or are in the pipeline. UN Secretary-General Kofi Annan has called for a Convention against Terrorism. As with the international criminal court statute, some of these have been opposed by the US, such as the Convention on the Illicit Trade in Small Arms and the verification protocol for the Biological Weapons Convention.4 Commentators, including Robert MacNamara (John F Kennedy's defense secretary during the Cuban missile crisis), have pointed out that the US must ask itself why it is so disliked; its attitude to multilateral treaties is one reason. Retreating into a laager is no solution.5 There is time for second thoughts on the Biological Weapons Convention protocol at its November review conference.

International conventions are no better than the states party to them (witness Iraq's programme of weapons of mass destruction), and they do not recognise non-state actors, so the ultimate need is the eradication of the causes of terrorism and other intrastate violence. These are territorial, such as Kashmir (the site of another recent act of terrorism), Northern Ireland (which shows how slow the political process can be), and the Middle East. US support for Israel is a principal cause of its unpopularity, but President George W Bush's apparent acceptance of a Palestinian state raises hope.

The second need is for global equity and sustainability. Afghanistan, Kashmir, and the West Bank and Gaza are among the world's poorest areas, and terrorist groups flourish in Colombia (FARC) and Peru (Sendoro Luminoso). The richest 26% of the world's population use 80% of its energy, the poorest fifth less than 1%.6 Afghanistan and Colombia fuel the drugs trade.

Dealing with these major economic and political problems will be time consuming and difficult. It requires a strengthened and reformed United Nations able to intervene early by non-military means against unacceptable regimes such as that of Saddam Hussein and the Taliban.7 For health professionals the attraction of such a programme, apart from its security aspects, is long term benefits for global health,8 such as access to clean water and vaccination programmes (the current crisis may delay the eradication of polio). We in Medact hope that many others will join us in promoting this exercise in preventive medicine.

Douglas Holdstock, editor, Medicine Conflict and Survival.

Medact, London N19 4DJ mary.holdstock@ntlworld.com 

1. Rogers P, Elworthy S. The United States, Europe and the majority world after 11 September. Oxford Research Group, 2001 (51 Plantation Road, Oxford OX2 6JE). 

2. Melvern LR. A people betrayed: the role of the West in Rwanda's genocide. London: Zed Books, 2000. 

3. Mackenzie D. Invisible enemies: are chemical and biological attacks a serious possibility? New Scientist 2001;6 Oct:6-7. 

4. How not to make friends. Nature 2001; 412: 463. 

5. Rogers P. Losing control: global security in the twenty-first century. London: Pluto Press, 2000. 

6. World Commission on Environment and Development. Our common future. Oxford: Oxford University Press, 1987 (Bruntland report). 

7. Commission on Global Governance. Our global neighbourhood. Oxford: Oxford University Press, 1995. 

8. McMichael T. Human frontiers, environments and disease: past patterns, uncertain futures. Cambridge: Cambridge University Press, 2001.

Stop military strikes and ship in aid, doctors say 

Roger Dobson / British Medical Journal 13oct01

Medact, the UK pressure group of health professionals, has led calls for an end to military action in Afghanistan and for an international humanitarian aid programme. Several relief agencies have also urged an end to the attacks and called for food and medical supplies to be shipped in before the winter snow begins in mid-November.

The agencies point out that Afghanistan, the poorest country in Asia, was already facing the prospect of a winter of severe food shortages before the terrorist attacks on the United States and the military strikes by American and British forces. Agencies then estimated that the combination of three years of successively worsening drought, and the continuing war between the Taliban and the Northern Alliance, had put five million people at risk.

"Some 40000 tonnes of food aid alone are needed each month over this winter for the areas of Afghanistan under the control of the Taliban to stop five to seven million people starving to death. A total of 160000 is needed, and that is 16000 trucks," said Professor David Southall, medical director of Child Advocacy International.

Medact, which has 1600 members including more than 1000 doctors and which is committed to non-violent resolution of conflicts, said that the attacks on New York and Washington on 11 September were terrible crimes against humanity.

"However, we fear that the bombing of Afghanistan will delay rather than promote bringing those responsible to justice. The attacks will claim more lives, and whether these are Taliban fighters or civilians, they will be regarded as martyrs and their deaths will result in more terrorism," it said in a statement on the conflict.

"We call for an immediate end to military action and a massive aid programme to prevent hundreds of thousands of deaths from cold and starvation. Afghanistan is on the verge of a massive humanitarian crisis. The attacks could turn this into a worse disaster."

Most of the concern has focused on getting humanitarian aid for the people of Afghanistan. Oxfam said: "We are gravely concerned by the vulnerability of Afghan civilians men, women and children who may be endangered by conflict in Afghanistan."

The president of the Royal College of Physicians, Professor George Alberti, also voiced concerns: "The attacks are an understandable response, but they will lead to human tragedy. People who will suffer will be the non-combatant public, and afterwards we will be dealing with more starvation, more disease, and more injuries in a country which was very poor to begin with. Leaders of extreme governments of any kind have an awful lot to answer for because they always end up damaging their own people."