The effects of Afghanistan’s 375 ton per year opium and heroin export are also felt at home through direct use and passive exposure such as  second-hand and third-hand exposure.  A new study that will be finalized this summer is expected to show that in Afghanistan 1.5 million people out of a total population of 30 million are addicts and that a quarter of those users are thought to be women and children.

Another study funded by the International Demand Reduction Program sought to determine if there were unwilling addicts exposed to opium by evaluating the indoor environment of the homes of known opium users.  Air, surface, and hair samples from all the inhabitants living in the homes of the opium users tested positive for opium products.  Direct contact and hand-to-mouth transfer from items such as eating utensils, toys, pillows, and bedding may be a significant route of exposure to opium for children.  The long term consequences of this passive exposure on mental, physical and emotional development to the children are unknown.   We should not wait to see what these long-term effects will be and something should be done immediately to put an end to this abuse.

Another theory as to why and how early these addictions begin suggests that the easily accessible opium fills a void that results from lack of access to doctors and medicines. Opium is used to treat physical pains and ailments as well as the psychological pains brought on by decades of war and poverty. One mother described how her children became addicted:

“When my son was born, he had earache. We couldn’t get to a doctor, so I gave him opium to help him get rid of the pain. After my daughter was born, she got stomach aches, and I only had opium to give to her for medicine, so now they’re both addicted.”

Other factors leading to increased use are the high unemployment rate throughout the country and the return of refugees from Iran and Pakistan who became addicts while abroad.

The disagreement about how much criminal groups, insurgents and terrorists are funded by the drug trade has made it more difficult to develop and follow a unified plan to end this problem.  I agree with President Medvedev’s sense of urgency, but how do we begin to put an end the destruction resulting from the opium trade?  Is it better to start from scratch or to work on coordinating the existing agencies that are evaluating the damage and setting up interventions?

On December 22, New Zealand and Belgium became the 25^th and 26^th nations to ratify the Convention on Cluster Munitions (CCM). The convention needs only four more ratifications to achieve the 30-state minimum to enter into force. Once in force, it will enact a ban on the use, stockpiling, production, and transfer of most cluster munitions, which include bombs, missiles, or rockets that open midair to scatter tens to thousands of small submunitions over a wide area. The CCM also requires that states destroy their stockpiles in eight years, clear contaminated land within ten years, and provide victim assistance.

This convention is necessary due to the wide, indiscriminate, and persistent effects of cluster munitions on civilians and communities. Ninety-eight percent of all recorded casualties of cluster munitions are civilians. In several countries, children account for roughly 60% percent of the victims. In 2007 alone, 5,426 casualties were reported due to cluster munitions. Conservative estimates suggest that unexploded submunitions have caused at least 55,000 casualties, though the number may be well over 100,000.

Victims of cluster munitions require medical, mental health, rehabilitation, and vocational services. They sustain burns and blast and shrapnel injuries, often to multiple limbs as well as their chest, abdomen, and face. Victims should also receive rehabilitation services, including mental health care, physical therapy, and prostheses if needed. Many of these services are unavailable or scarce in conflict zones, and the added burden of these patients can overwhelm an already strained health system, especially in post-conflict settings.

Victims of cluster munitions also need assistance with integration back into society. In many affected areas, people living with disabilities face stigmatization, marginalization, and a lack of economic opportunity. Efforts to promote the rights of the disabled — such as those spearheaded by Handicap International — are essential to any long-term approach to addressing the effects of cluster munitions.

Though cluster munitions are often compared to landmines in that they both litter areas after a conflict is over and pose a threat to the health and human rights of individuals and communities, there are notable differences in their effects. Cluster munitions are more likely than landmines to cause multiple injuries per incident, and they are more likely to kill or injure children under the age of 14 due to their small size and bright coloration.

Unexploded cluster submunitions slow humanitarian, recovery, and resettlement efforts after overt hostilities have ended. Humanitarian and relief workers may be unable to enter an area due to cluster munition contamination. In Kosovo, Laos, Vietnam, Afghanistan, and Lebanon, casualties peaked as populations returned home after the conflict ended. Returning populations are injured while attempting to access their houses, farms, pasture land, water supplies, and health facilities. In Afghanistan, many people have been injured by explosive remnants of war (of which cluster munitions are one form) in the past decade, and these deadly devices have deterred people from accessing health services and from sending their children to school.

The short- and long-term effects of armed conflict and political violence continue to undermine the health and human rights of populations around the world. An international ban on cluster munitions will be an important step toward protecting and promoting health and human rights and toward allowing those whose lives are ravaged by wars to farm their fields and walk the streets of their communities without fear.

Steven Kanter presents the series by echoing the World Health Organization’s definition of health as more than the absence of disease and noting that “peace is not simply the absence of war.”

Ali Khan and colleagues point out that “Violence, manifest in myriad forms, exists in our own backyards and clinics. Just as international conflict zones provide an entry point for physicians to rebuild health systems and societies alike, so too do low-income urban neighborhoods, the halls of Congress, and the steps of the United Nations.”

Barry Levy and Victor Sidel, veterans of organizing physicians in support of peace through the group International Physicians for the Prevention of Nuclear War, argue that the medical establishment should begin building peace at home by “(1) fostering cooperation in relationships among themselves and others, (2) preventing conflict by promoting transparency and ethical behavior, and (3) promoting mediation and arbitration to resolve conflicts before they result in serious adverse consequences.” These suggestions may seem far removed from what most of us think as preventing violence, but as peace scholars have pointed out for decades, efforts to construct and sustain peace must begin long before we reach the cultural and societal breaking point of war.

In a another essay, Hagopian and colleagues call on health and medical associations to “change the dominant framework so that failing to act against war would be the more peculiar act of health professionals, rather than the opposite.”

My favorite quote, however, is in Seiji Yamada’s essay, “Academic Medicine Should Start at Home”, in which he exhorts American academics to quantify and expose the morbidity and mortality caused by military, diplomatic, and economic actions of our own government. Yamada writes about some students, “At the mention of history or political economy, our learners groan. We are not interested in politics, they say. But unreflective learners repeat the blather that they are fed by the corporate media. Their interest in politics extends only as far as protecting physician reimbursements. But academic medicine has the responsibility to produce physicians who advocate for the cause of health – in particular for the health of those whose voices are otherwise unheard, whose deaths are otherwise uncounted, unmourned, unopposed, and unorganized against.”

As health professionals, it is our responsibility to raise our voices, to count and bear witness to the deaths and injuries, to mourn with our patients and their loved ones, to oppose injustice, and ultimately, to organize a system that better builds peace.