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close this bookThe Medical Profession and the Effects of Weapons - Report of the Symposium (International Committee of the Red Cross , 1996, 62 p.)
close this folder4. The Symposium
View the document4.1 Programme
View the document4.2 Opening remarks
View the document4.3 Presentations
View the document4.4 Mission statement
Open this folder and view contents4.5 Working groups
View the document4.6 Conclusions

4.3 Presentations

Participants wishing to make a presentation were asked to submit background papers, which were distributed beforehand. A summary of each paper was presented for discussion by the Symposium. A range of specialized subjects was covered, including medical and legal aspects of weaponry, wound ballistics, scientific research and public advocacy.

The papers served to introduce the participants to the range of interests represented at the Symposium, and underlined the need to synthesize traditionally disparate disciplines into a new, discrete field of study.

The following is a summary of the presentations. The background papers can be obtained from the ICRC Health Division.

A.1 Ms Louise Doswald-Beck

Examples of international treaties addressing the effects of weapons on health.

The presentation began by stressing the important role that the medical profession had in upholding international humanitarian law (IHL). It went on to outline the various international treaties that comprise IHL, from the St Petersburg Declaration of 1868 to the 1980 UN Convention on Certain Conventional Weapons and its subsequent review.

The paper introduced legal concepts including proportionality (the balance between military necessity and humanitarian restraint), superfluous injury and unnecessary suffering, and the Martens clause (which states that the victims of war should at all times be protected by the dictates of the public conscience).

In the ensuing discussion it was noted that the 1972 UN Convention on Biological Weapons and the 1993 UN Convention on Chemical Weapons constitute the first attempts to eliminate a type of weapon completely. States were required to destroy their stockpiles.

A.2 Mr Peter Herby

Anti-personnel mines - from surgical statistics to international advocacy

This presentation outlined how the ICRC’s current international advocacy calling for a ban on anti-personnel landmines had been prompted by surgical statistics gathered in ICRC hospitals. In relation to the review of Protocol II of the 1980 UN Convention on Certain Conventional Weapons, the presentation described how the ICRC had worked closely with a coalition of non-governmental organizations, National Red Cross and Red Crescent Societies and advocacy groups, and was currently launching its own world-wide advertising campaign.

Mr Herby pointed out that in the past it had been sufficient to secure the agreement of governing elites but that now nothing could be achieved without the mobilization of public opinion. This was why the ICRC, for the first time, was taking a public stand on such an issue. He outlined the complexities of the landmines debate and showed examples of the advertisements designed for the campaign.

A.3 Dr W. James

Consequences of the impersonal mine

The paper described the effects of antipersonnel landmines on civilian populations world wide. There were approximately 100 million landmines deployed in the world today, and their effects were indiscriminate. The global casualty rate was estimated at 2,000 per month, and the victims were predominantly civilian. Owing to the lack of medical facilities in many of the affected countries, the mortality rate amongst landmine victims was high. Mine clearance was extremely slow: at the current rate of clearance in Afghanistan, it would take 4,000 years to clear 20% of the country’s territory. Prosthesis and medical care for the victims were generally inadequate in those countries affected by mines.

The discussion focused on the lethality of different types of antipersonnel mines, post-traumatic stress syndrome and the causes of armed conflict.

A.4 Mr. Peter Herby

Arms transfers: a perspective

The presentation drew attention to the extent of arms transfers to the developing world following the end of the Cold War. Ninety per cent of arms transfers started as legal transactions but then became illegal with later onward transfer. The urgency of addressing the arms trade was highlighted by citing arms sales to the third world by industrialized countries attempting to bolster their own economies; there was now an increased flow of small arms fuelling ethnic conflicts. The scale of arms transfers was such that the receiving countries were unable to train enough people to uphold international humanitarian law with respect to those weapons.

The presentation also described the difficulties of policing arms transfers and of controlling the use of small arms by combatants.

The participants discussed the ICRC’s dissemination activities and its role as guardian of the Geneva Conventions of 1949. There was particular interest in the ICRC’s experiences in promoting common Article 1, whereby States undertake to ensure respect for IHL, since this responsibility was seen as encompassing controls on arms transfers.

A.5 Dr Vic Neufeld

The Health of Children in War Zones project

The paper described activities at McMaster University, Canada, within the framework of Health Reach, a joint initiative of the Centre for International Health and the Centre for Peace Studies. The goal of the Health of Children in War Zones project was to improve the health and well-being of children in zones of armed conflict through the integration of data collection activities, health-related action and peace initiatives. The project was currently running programmes in Sri Lanka, the former Yugoslavia, Gaza and the West Bank.

Dr Neufeld described how universities and medical schools in conflict zones were encouraged to undertake research and community service activities which not only documented the effects of war on children’s health, but also fostered peace and reconciliation. Coordination with other academic disciplines was central to the success of the programme.

The paper stipulated that the role of the doctor extended beyond treating the wounded. He or she also had a responsibility to participate in community activities and to document and foster education in the health needs arising from armed conflict.

The chairperson of session A underlined the importance to the Symposium of the link between epidemiological data and the upholding of law.

B.1 Dr Georg Scharf

The effects of mortar bombs and similar weapons in limited conflicts

The paper described the military theory relating to and the use of mortar bombs and their effects on individuals, including injury and death due to shock pressure wave and blast overpressure, primary and secondary missiles, shrapnel and incendiary effects.

The paper noted how mortar bombs and similar devices were extremely cheap and likely to be used increasingly in limited conflicts in developing countries, in which most casualties were civilians. Because of the suffering caused, the use of such weapons should be banned in civilian environments. Moreover, such weapons were most often misused in countries with poor medical facilities.

In the discussion, the correlation between the military effectiveness of a weapon and the ease with which it could be misused was identified as a fundamental principle. The point was made that modern weapons, which are increasingly accurate and “efficient”, could target civilians just as easily as military objectives. While the repercussions of the misuse of such weapons were abhorrent, controlling such misuse was extremely difficult.

One participant suggested that the definition of superfluous injury and unnecessary suffering might be directly linked to the local availability of medical services.

B.2 Dr Lennart Johnson

Blast overpressure-induced cardio-pulmonary injury in the pig

The paper described an experiment investigating cardio-pulmonary injuries in pigs induced by blast pressure. The experiment concluded that blast overpressure caused heart injury and that, of the many reactions to the blast, respiratory arrest was the most dramatic. There was no evidence of air or fibrinous emboli. Dr Johnson concluded that such an effect also occurs amongst human casualties. He confirmed that mortality would increase in the absence of facilities for immediate artificial ventilation.

B.3 Dr Timothy Gillow

Psychological, social and economic consequences of blinding young soldiers

The paper evoked the public revulsion at the concept of blinding in warfare It outlined the various types of weapons systems that could blind either as a secondary effect or by intention. The former included systems designed to incapacitate battlefield electro-optical devices; the latter included laser weapons which were prohibited by the 1995 Review Conference of the 1980 UN Convention on Conventional Weapons.

It was noted that adults received most of their sensory input from vision. Loss of sight not only caused physical disability but also entailed heavy psychological, social and economic costs for the individual and society.

Dr Gillow stressed that, with regard to controlling the effects of weapons on health, the medical community had to focus its efforts on stigmatizing weapons that caused injuries to specific organs or bodily functions. Such injuries included not only eye injury but also brain damage, tetraplegia and burns to the hands and face.

The discussion centred on means of protecting the eyes in the event of laser weapon attack.

B.4 Professor Bo Rybeck

Non-lethal weapons

(Editor’s note: it was agreed with the organizers of the Symposium that Professor Rybeck’s presentation would keep this title in the programme but that he would talk principally about the possibility of genetic weapons.)

The paper focused on the military significance of civilian scientific and medical research, particularly with regard to the development of genetic weapons. Despite the prohibitions on chemical and biological weapons, advances in biotechnology and genetic engineering offered scope for weapons that could be targeted against specific ethnic or racial groups. Genetic research into the human genome and racial differentiation was advancing rapidly, and the results were freely available. Professor Rybeck pointed out that while there were many legitimate civilian uses for such research, it could also be used to develop weapons at low cost that combined chemical or biological agents with genetically-engineered vectors to target specific populations.

Professor Rybeck expressed his own fear of the development of such weapons and the possibility of terrorist use, and warned the ICRC that it should be alert to this type of research.

One participant was of the opinion that if the Symposium were able to produce a solid recommendation on this subject alone, it would be an important achievement.

B.5 Professor Norman Rich

A senior professor’s reflections through the eyes of a young military surgeon

Professor Rich said that, as a young military surgeon, his work had been in response to contingencies, treating the sick and wounded. With greater maturity, he had given thought to the role of communication in preventing violence in society. The complexity of aggression in society, seen for example in the urban violence of the United States and the resurgence of a 600-year-old conflict in Bosnia-Herzegovina, reflected, above all, a failure of communication. The epidemic of violence was a public health issue, and the response should be an effective communication strategy to educate humankind away from violence.

B.6 Mr Beat Kneubuehl

Wound ballistics: a health science?

The paper introduced wound ballistics as a discipline which combined medical and scientific research. Medical professionals could document the effects of weapons on health (a descriptive approach), while scientists built models to explain those effects (a general approach.) Mr Kneubuehl went on to point out that the effect of a bullet was dependent on many factors such as organ hit, angle of entry and point of impact, and so scientific modelling had limitations in relation to the effects on health. However, the effectiveness of a bullet was related to its profile of energy transfer along its track and was hence measurable in a scientific setting.

The paper argued that the science of wound ballistics provided a useful means of measuring the effectiveness of weapons, thus giving a scale of reference for judging what was legal.

It would then be possible to advocate bans on weapons according to their effectiveness rather than their technical specifications. Mr Kneubuehl outlined a proposal for legal consideration which interpreted human damage from missiles in terms of the profile of their energy release in a dense medium.

Participants noted the importance of collecting evidence from the field to support the results of laboratory experiments. One participant pointed out that a weapon’s effectiveness, as described by Mr Kneubuehl, represented a measurable effect on health.

C.1 Dr Robin Coupland

Can we define superfluous injury and unnecessary suffering?

Dr Coupland argued that the measurable effects of conventional weapons as witnessed by surgeons in the field and as documented in the medical literature could be used to establish a baseline against which the legal and yet hitherto philosophical concept of “superfluous injury and unnecessary suffering” could be measured. This could then be related objectively to a weapon’s military utility.

The paper listed certain parameters that could be taken into account for establishing the baseline, such as field mortality, hospital mortality, the number of operations needed and the extent of severe or permanent disability amongst survivors. Another parameter which could be included to differentiate between the effects of conventional and non-conventional weapons was whether a particular aspect of human anatomy, physiology or biochemistry was targeted. A weapon system which overstepped any of these parameters could then be judged as causing superfluous injury or unnecessary suffering.

In the discussion, there was agreement amongst the participants that such objective classification would make an invaluable contribution to the operation of international humanitarian law, and that further work should be undertaken to study the proposal further.

It was also agreed that baselines had to be universal if they were to function effectively as a legal device. Discussion focused on how universality could be achieved in a world in which local conditions - access to medical facilities, geographical location and cultural norms - varied widely. There was a suggestion that psychological injuries should also be included in any clinical parameters.

(The background paper has been published as: Coupland RM. The effects of weapons: defining superfluous injury and unnecessary suffering. Medicine and Global Survival 1996; 3:A1 on the World Wide Web

C.2 Ms Franse J. Hampson

Giving substance to the prohibition of superfluous injury and unnecessary suffering in international humanitarian law and human rights law

The paper focused on the importance of quantifying superfluous injury and unnecessary suffering so that proportionality between military necessity and human cost could be effectively judged. Ms Hampson referred to the previous paper in this respect. Pointing out that neither military necessity nor human cost were quantified at that point, Ms Hampson suggested that it was the role of lawyers to encourage such quantification.

She stated that objective criteria for measuring suffering would provide a useful tool for lawyers, and would encourage the military community to quantify military necessity. She pointed out that it would be hard for the military to argue against medical criteria backed by strong supporting statistics. In this regard she emphasized the importance of medical data collection, and added that only the medical profession could quantify injury.

Ms Hampson pointed out that the current international campaign to ban anti-personnel landmines had focused almost entirely on the fact that civilians were often the victims. The fact that these weapons inflicted horrific wounds on combatants and civilians alike had, in her opinion, been largely forgotten; if the problem is the effect on civilians this points to the need for greater restrictions on use but if the issue is the unacceptable nature of the injuries caused, this points to a need for a ban on use.

The participants agreed with the rationale for objective criteria. However, it was noted that in the past weapons had been banned more often for reasons of public abhorrence or political expediency than for reasons of health. The discussion also referred to the ineffectiveness of the Marten’s clause without the opinion of an educated public.

C.3 Mr. William Arkin

Humanitarian issues regarding non-lethal weapons

The paper focused on the definition, development, and potential dangers of non-lethal weapons including acoustic weapons, eye-attack weapons, directed-energy weapons, riot control agents, calmatives, and biotechnological and genetic weapons. Mr Arkin stated that such weapons had been developed for use outside the context of conventional military operations.

He pointed out that many non-lethal weapons were illegal, but that their proponents defended them by comparing them favourably with existing conventional weapons. It was the role of the medical community and lawyers, Mr Arkin said, to counter such arguments with medical data. Potential users would then have to prove the military necessity of the weapon in question. He referred to the ICRC’s approach in seeking a ban on mines and blinding laser weapons; documenting or evaluating a weapon’s effect on individual and public health forced an evaluation of its military utility.

C.4 Dr Peter Knudsen

Moral and legal obligations of the wound ballistician

Dr Knudsen explained that, as a military doctor, he had felt it his duty to investigate the wounds produced by the Danish 7.62 mm military rifle bullet because foreign bullets of similar design had been reported as having a tendency to fragment. Therefore, the legality of the bullet was questionable under the Hague Convention of 1899. Following autopsy investigations and experiments in ordnance gelatin, the Danish bullet had indeed been redesigned.

However, Dr Knudsen questioned whether the Hague Declaration should apply to the police as well as the military. The police fired only in self-defence and to stop criminals from injuring innocent bystanders. The ballistics requirements of a bullet for the police were very different to those of a military bullet. For the police, rapid incapacitation, minimum over-penetration and effectiveness at short range are needed. He argued that bullets which comply with the Hague Declaration do not meet these requirements and therefore it was a mistake to apply this aspect of international law to police ammunition.

Dr Knudsen insisted that a bullet’s legality should be determined by its effect rather than its design.

C.5 Mr Mark Granat

Small arms ammunition, international law and reality

The paper discussed the applicability of the Hague Declaration of 1899 (dealing with bullets which flatten or expand on impact with the body) in the light of modern small-arms capabilities and ammunition design.

When the Declaration was drafted, the paper stated, any rifle had enough stopping power to put an adversary hors de combat. Nowadays this was not always the case. The modern combatant frequently fought alone and had to be able to rely on his personal weapon to stop an enemy with a single shot. In terms of personal survival, Mr Granat argued, this was a military necessity. However, some modern bullets did not have the necessary stopping power because, despite their velocity, they did not release their energy to the victim’s body. To give such bullets adequate stopping power would contravene IHL.

Mr Granat felt that the unique relationship that a soldier had with his rifle justified legal reappraisal of the bullets that the soldier could use. By removing the means of self-protection for the soldier, the law might simply endanger the life of the person it was designed to protect.

While not qualified to say whether or not explosive bullets should be allowed, Mr Granat argued that ammunition should be regulated in terms of energy release rather than design.

One participant said he believed that only a shot to the central nervous system, or possibly to the central chest, would fell a man immediately and that “stopping power” was a myth.

Two participants believed that IHL had suffered from an excessive focus on bullet construction.

D.1 Dr Brian Davey

The role of the doctor in investigations of the alleged use of chemical weapons

Dr Davey spoke of his experiences investigating alleged chemical weapons attacks. He detailed the requirements in terms of logistics and personnel for such investigation. He argued that it was the doctor’s responsibility to ensure that all technical work be carried out in a forensically credible manner even when conditions made this difficult. He also warned that the results of such investigations could be used for further development of chemical weapons. Difficulties encountered during such investigations included the lack of standard procedures for sample collection and analysis, political pressure, and the difficulty of identifying clinical symptoms and of differentiating between the effects of chemical attack and the symptoms of regular ailments.

Dr Davey reported on the establishment of the Organization for Prohibition of Chemical Weapons which was an independent monitoring agency created under the UN Conference on Disarmament of Chemical Weapons Convention.

In the discussion it was asked why the notion of chemical warfare was considered abhorrent. Although there were no clear answers to this question, factors discussed included the indiscriminate nature of chemical warfare, its ability to overwhelm medical services, the possibility of long term effects, and the innate psychological fear of being poisoned.

D.2 Dr Howard Champion

Physician advocacy and weapons control: lessons from the United States

The paper presented the continuing work of the Coalition for American Trauma Care based in Washington, DC, USA, of which Dr Champion was the President.

Detailing the numbers of deaths and injuries from handguns and their availability in the United States, Dr Champion outlined the Coalition’s focus on political advocacy. This was presented as an example of the “data-policy link.” Through political sponsorship and alliances with other health organizations, the Coalition had achieved certain successes. However, opposition from special interest groups and apathy amongst the general population had hampered the Coalition’s work and forced it to compromise.

Dr. Champion pointed out that in the political arena, while it was important to have access to all the facts, logic did not always prevail. Advocates must be patient and make use of windows of opportunity.

In the ensuing discussion, one participant voiced concern about the propagation of the cycle of violence on television and in videos and rap music. The significance of the fact that paediatricians in the US had called for a ban on handguns was underlined.

Another participant pointed out that in Switzerland also most homes had guns and ammunition as part of military policy and that there were few resulting crimes. The hand-gun violence in the US was not due simply to availability of weapons.

D.3 Ms Anita Parlow

How humanitarian concerns have been galvanized by the medical community: case studies

Ms Parlow was of the opinion that the ideological divide inherent in the Cold War had imposed constraints on humanitarian action in relation to weapons. Now there was greater potential for such action. The paper argued that efforts to promote and strengthen international humanitarian law relied ultimately on political will, but that political will could be influenced by the collection and dissemination of data in a credible and professional manner. This was particularly true with regard to weapon-related issues.

The paper documented three studies of cases where the medical profession had played an important role in the international arena: the international campaign to ban anti-personnel landmines; the establishment of torture rehabilitation programmes in the United States and elsewhere; and the recently initiated effort to protect children in war.

All involved medical documentation, the establishment of databases and dissemination of the information to decision-makers.

D.4 Professor Vivienne Nathanson

The role of the medical profession in creating a weapons-wise public conscience and influencing government

Professor Nathanson said that voicing concern and opinion about the effects of weapons on health was a legitimate role for doctors, as it was a form of preventive care. In general, doctors were trusted and so they should accept responsibility for informing the public on health-related issues of weapon use. National Medical Associations are likewise responsible because they are the collective voice of the profession in their countries. However, doctors should take care to avoid becoming embroiled in political aspects of the debate lest they jeopardize their credibility in the eyes of the general public. To be in a position to raise awareness, doctors themselves had to be well-informed. They were then in a position to educate the public and seek its support for efforts to persuade the government to enact relevant legislation.

Professor Nathanson outlined some of the issues on which the British Medical Association had taken action, including smoking, drinking and driving, and the wearing of crash helmets and seat-belts. She stated that a similarly objective approach should be taken towards the effects of weapons and stressed the need for a communication strategy vis-is both the professional and the general press.

The discussion dwelt on human rights abuses and the role of doctors.

D.5 Mr Michael Keating

Professional and political awareness of the effects of weapons: a survey

The paper outlined the results of a survey conducted in France, Sweden, the United Kingdom and the United States, which revealed a low level of awareness of the effects of weapons among politicians, lawyers and the medical profession. Documentation was found to be sparse, and there was little academic publication or teaching. The results showed that while doctors and other professionals shared a common sense of humanity, international humanitarian law was not well understood. As a result there was little understanding of the concept of a weapon exerting superfluous injury and unnecessary suffering in relation to its military advantage.

However, the survey showed that there was undoubtedly great potential to inform and motivate the medical community and a wider public about the effects of weapons. The most effective means of achieving this, according to Mr Keating, would be first to galvanize sympathetic members of the medical profession, then to address the wider medical community, and finally to engage the general public and their political representatives through key multipliers such as the media and other humanitarian agencies.

Mr Keating argued that for such an initiative to be successful the medical community must first focus on documenting the effects of weapons on health, so that it could present its evidence in a professional manner. It also had to ensure that effects on health are recognized by the legal community as a yardstick in decisions affecting weapons. Medical and legal professionals must work closely to achieve this, he said.

The discussion revolved around whether the participants felt that they should express opinion or concern outside their sphere of expertise; some participants felt they might be viewed as unprofessional if they did so. One participant did not believe he should voice his professional opinion about, for instance, arms transfer. Others disagreed; they believed that as weapons constituted a public health issue, responsibility for addressing it fell to all doctors.

Another participant pointed out that the image of the medical profession as representing a conscience was declining.

It was suggested that in discussing the effects of weapons as an epidemic, doctors had a responsibility to determine fact and define the problem as a first step.

Background papers received but not presented

Three additional papers were received (also available from the Health Division of the ICRC) but their authors were unfortunately not able to be present at the Symposium.

Dr Philippe Chabasse

The social and economic impact of anti-personnel mines

Mr Eric Prokosch

Criteria for defining unnecessary suffering

Mr David Guyatt

Some aspects of electromagnetic anti-personnel weapons