BMJ 2001; 323: 822 13. Oktober 2001
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.