It's not the Bullets, it's the Bacteria


What kills most civilians during wartime? It's not the bullets, or the missiles, or the shrapnel from bombs. It’s unsafe water, lack of food, inadequate medical care, unsafe communities -- the absence of public health.

IT’S NOT THE BULLETS, IT’S THE BACTERIA – by Barry S. Levy, MD and Victor W. Sidel, MD

What kills most civilians during wartime? It's not the bullets, or the missiles, or the shrapnel from bombs. It’s unsafe water, lack of food, inadequate medical care, unsafe communities -- the absence of public health.

Public health is what we do, as a society, to assure living conditions in which people can be safe and healthy. It is made up of many things that we, in the United States, generally take for granted. We drink water and assume it is safe and plentiful. We eat food and assume it is safe. We breathe air and assume it has relatively few pollutants. We assume that medical care is available and of reasonably good quality.

We also assume that public health measures to prevent disease, such as immunizations, and to prevent injury, such as seat belts in cars and health and safety regulations at work, have been implemented. We assume that it is generally safe to walk in our neighborhoods and to go about our daily activities. We assume that basic human rights are protected.

We know that war is dangerous to health. But we don't usually recognize that most civilian deaths during war and the immediate post-war period are due to breakdowns in public health, not due to innocent people caught in the crossfire or fatally injured from missiles or bomb fragments. And, over the past decade, nine out of every ten deaths during war have been civilian deaths.

Truth may be the first casualty of war. But public health is a close second. People drink contaminated water or none at all when water treatment plants and electrical power supplies are damaged; contaminated water leads to diarrheal disease that may be disabling or fatal. People become malnourished, or actually starve, when food stores close (or are looted), food-distribution systems break down, and agricultural areas become battlefields; malnourished people are more susceptible to infectious diseases that are more likely to be fatal among those who are underfed.

Air becomes unsafe to breathe as a result of fires and explosions, a particular hazard to those with asthma, chronic bronchitis, or congestive heart failure. Medical care becomes marginal or not available at all as health care facilities are overwhelmed with the sick and injured, medical supplies are exhausted, doctors and nurses are unable to get to their places of work, and hospitals are looted. And war displaces thousands of peoples from the psychological support of their families and their communities.

Public health preventive measures are usually not implemented at all during wartime; people are just trying to survive. During wartime, security in communities is usually non-existent. And human rights are routinely abused: men, and often boys, are conscripted into the military; women are raped; and, some civilians, caught up in ethnic hatred or in acts of reprisal, kill and maim other civilians.

And beyond all of this is the gross diversion of resources from public health and other human services to use for military purposes -- often in countries that have barely enough resources to survive during peacetime.

Chemical, biological, and nuclear weapons can cause indiscriminate mass destruction. But so can any serious wartime disruption in the protection of public health.

Now that the war in Iraq is ending, all measures need to be taken to restore and strengthen public health and human rights in Iraq. This will require cooperative efforts by the people of Iraq, non-governmental aid organizations, governments of many nations, and the United Nations. Without public health, there can be no stable peace and no stable representative government in Iraq or elsewhere.


Drs. Barry S. Levy and Victor W. Sidel are co-editors of the books "War and Public Health" (American Public Health Association, 2000) and "Terrorism and Public Health" (Oxford University Press, 2003). Dr. Levy is an Adjunct Professor of Community Health at Tufts University School of Medicine. Dr. Sidel is Distinguished University Professor of Social Medicine at Montefiore Medical Center and Albert Einstein College of Medicine. They are both past presidents of the American Public Health Association. Dr. Levy is former executive director and Dr. Sidel is former president of the International Physicians for the Prevention of Nuclear War. Their email addresses are: and

Drs. Levy and Sidel are co-authors of the chapter “Water and War: Averting Armed Conflict and Protecting Human Rights,” in Water and Sanitation Related Diseases and the Environment: Challenges, Interventions, and Preventive Measures, a Wiley-Blackwell collaboration with Horizon International published November 2011.



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