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Interview with Dr Paul Wise

Dr Paul Wise is the Richard E. Behrman Professor of Child Health and Society and Professor of Pediatrics at Stanford University School of Medicine and Senior Fellow in the Center for Health Policy, the Center on Democracy, Development and the Rule of Law and the Center for International Security and Cooperation, in the Freeman-Spogli Institute for International Studies, Stanford University. He is also co-Director of the March of Dimes Center for Prematurity Research at Stanford University.

Explosive weapons have a reverberating effect on a child’s life, far beyond the moment of a blast. How do should we approach the question of attribution in order delineate the effects of explosive violence? 
It depends what the objective is. We can think about this politically in terms of the transition to peace. In other words, the opportunity to mitigate the effects of an explosive attack becomes more prominent when you have a change in governance. For example, let us say a water system is attacked and there are reverberating effects from the destruction of the water system. When do you begin to attribute the harm that is still being done not to the explosive attack, but the failure of the regime to mitigate those effects? If ten years after the attack, with six years of a new government or occupation forces being in control, and if there still is not any good quality water, at one point has there been a shift in responsibility for the ongoing reverberating effects because of the failure to mitigate them? If your objective is looking at the transformation of war to peace, then that political shift becomes your limit for attribution.

We can also look at this through the lens of time. This is extremely arbitrary. Time is a proxy for attribution. It is not a perfect proxy, but as time becomes more prolonged, questions of attribution become more difficult.

We need to be honest and confront the problem of attribution. In a cholera epidemic it may be easy to attribute the cause to the destruction of water systems. The destruction of water systems was conducted strategically in Yemen by Saudi Arabia led airstrikes. However, eight years after an attack, after families have been displaced and are living in a refugee camp for five years, to attribute what is happening to them at that point to explosive attack which initiated the series of events- is more tenuous. But it is still real. It is not just about time, rather we can see the issues as ripples in a lake.

There are somethings that we can identify that are clearly attributable, other are less so but are real and you need to consider when you release and explosive weapon in a populated area. Nobody has figured this out. Without clear reasons for attribution or a framework that is honest it undermines the whole field of indirect effects.  

Why has there been a neglect of the indirect effects of explosive violence? Is it because of fatigue or a lack of capacity? In your essay ‘The Epidemiologic Challenge to the Conduct of Just War’ you argue that with technological advances we should be able to calculate indirect effects more accurately. Why is that not happening now?
All the above. The laws of war and international humanitarian law have been primarily focussed on direct effects. Direct effects are easier to identify and have therefore been the predominant concern. Indirect effects have been less well addressed morally and legally in international humanitarian law. Indirect effects are less compelling because they are not morally clear. This tends to undermine the requirement for accessing indirect effects.

Interestingly, counterinsurgency is an ally of reverberating effects. So much of counterinsurgency is about winning hearts and minds and stabilisation. In doctrine, counterinsurgency has always emphasized building projects, improving healthcare, implementing water systems. Hearts and minds are won through not harming civilians. NATO and US forces in Afghanistan introduced ‘courageous restraint’ as a programme to reduce civilian casualties because it was undermining the strategy of counterinsurgency. It serves to elevate reverberating effects.

In the First Gulf War the US took out Bagdad’s electric grid, the impact of Iraq’s health service was devastating. Tens of thousands of people died due to the damage to the heath and water systems. In the Second Guld War, the US chose not to attack the electric grid. This was in part because of the human impact of reverberating effects, but also because they were planning on occupying the area. In two or three months they themselves were going to be there, and they did not want to deal with all the reverberating effects. Thus, in some ways counterinsurgency in recent wars has elevated this issue of reverberating effects. 

At Stanford we have an initiative looking at the humanitarian impact great power conflict. NATO and US militaries have shifted their outlook, from counterinsurgency to great power conflict. The humanitarian world is lagging. If there is a conflict on the Korean peninsula and North Korea shells Seoul what are the humanitarian impact of that? What happens in Russian pushes harder into the Ukraine and the Baltic states? At Stanford we have an initiative on reverberating effects, and another on great power conflict and we are examining where they merge.

How can we guard against the indirect effects in conflict, what would you advise the UN, for instance?
I would look at the prohibitions already built into international human rights law, in the Geneva conventions or subsequent accords. There are prohibitions against attacks on civilian objects and dual-use objects. No one is following them- so I would start there. In attacking a water system, you are not going to initially kill many people, other than those who work in the water plant, but it could have an impact on millions of people- that is why it’s prohibited. There are prohibitions in the law against undermining the essentials of life, but they are not being addressed adequately. For the UN I would say, look at these cases: Yemen, Syria and Libya. Death has its own way of defining itself, but attributing death is more complicated.

How do children who suffer blast injuries in armed conflict experience the effects later in life?
There are three. For children who do not die they may suffer prolonged injuries. Rehabilitation, ongoing medical requirements, and reduced productivity are all associated with the injuries sustained in attacks. The second is the mental health effects of an attack. Children who witness of experience a blast may not be physically inured but the mental health effects can be debilitating and require assistance, support, medical care just as much as if it was a physical injury. The third, is when unexploded ordinance have been left, which not only continues to injure and maim children, but it also renders areas unusable for decades- and there are productivity issues associated with that.

The evidence base to support the ‘Golden Hour’ has been questioned, but is there a difference in the urgency of care required after injury for adult and child patients?
As a paediatrician, I believe that children have special medical needs. There are clinical differences. However, I would not say that the special requirements for children are so dramatic that it alters how we approach the prevention of the use of explosive weapons or the response. In other words, we need to make sure nobody experiences explosive violence, and children will benefit from this.

Children are special because of their social claims. Some would say its sentiment that makes them special not their physiology. When you see a baby in ambulance in Aleppo, days after having been pulled out of the rubble, it goes viral not because of their physiology, rather their claims to our public understanding of justice. These claims are more based in a deep moral understanding which elevates child suffering, questions of innocence and beauty.

The Golden Hour is ridiculed by trauma surgeons in the field because it was created as a public relations term by people who wanted to emphasize the need for the right care at the right time for the right patient. It is not a specific time per se, but a match of service to need. For children it will be different.

Is the elevation of the child always helpful?
It is a double-edged sword. It is very powerful in generating humanitarian responses, prevention of war, and putting pressure on belligerent parties to stop attacking civilians. But it can be used as a weapon that inadvertently attacks people with similar claims, pregnant women for instance. As a paediatrician, people who worry about child suffering can inadvertently undermine women’s claims to justice. You can elevate child claims by diminishing the claims of others, in the end that is not usually that useful.