Peace, Health, and Sustainable Development in the Middle East

1Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran 2Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran 3Health Equity Research Centre (HERC), Tehran University of Medical Sciences, Tehran, Iran 4Department of Community Nutrition, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran


Introduction
The World Health Organization (WHO) constitution (1946) considers the utmost degree of achievable health standard as an essential right of all humankind. 1 Approaches to health that are based on human-right require more emphasis by policy makers on the needs of vulnerable and those left behind, so-called "equity". Such an approach has been also endorsed by the United Nations' (UN) Sustainable Development Goals (SDGs), particularly SDG 3.8 on universal health coverage (UHC). 2,3 SDGs explicitly recognize the fundamental mutual relationship between peace and SDGs, none of which can be attained without the other. SDG 16 is to "promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels". 4 While this goal mentions peace more explicitly, peace is essential to achieving the SDGs as a whole. There are many targets and indicators under other goals that are closely related to the aim of sustainable peace, 4 which is an embedded prerequisite of "sustainable development", 5 which in turn focuses on root causes to build societal resilience. 6 Peace is not simply the absence of violence. There are various types of peace, which reflect a broader spectrum of the quality of peace. A ceasefire can create peace even if it is temporary, as happened with the Syrian ceasefire in December 2016. 7 Peace can be defined as freedom from civil disturbance, a state of security, or order within a community provided by law or customs, harmony in personal relations, or a state or period of reciprocal accord between governments. 8 Theoretically, there are two aspects to peace: 'positive peace' and 'negative peace'. 9 While negative peace is the absence of visible and direct violence, which may refer to quality of peace, 6 positive peace is selfsustaining and is therefore emancipatory in nature. 6 As two dimensions of essential human right, which have been endorsed by the constitution of many countries, health and peace are intrinsically interconnected. 8 Currently, and in the era of SDGs, peace is considered as a prerequisite of quality public health and a resilient health system. 10 Considering the definition of health by the WHO as complete state of mental, physical, social and spiritual health, health is not attainable without peace. Countries in conflict need to prioritize building resilient health systems for delivering productive healthcare. 11,12 The relationship between health, sustainable development and peace has not been substantially studied. This study investigates this relationship and brings some examples from conflicting countries in the Middle East. We aim to draw practical lessons to show how peace can contribute to a resilient health and a healthier society.

Materials and Methods
Our initial search identified a total of 1351 articles. We removed 189 duplicates; as a result, 1162 articles plus grey literature remained. We screened the titles and abstracts for relevancy and further duplication. Finally, 30 articles were included for more detailed analysis.
We included studies that mentioned resilient health system during war, the interaction between heath and peace, health system implication during war and the relationship between peace, health and sustainable development.
We reviewed all remaining articles and summarized their information. Both authors held regular meetings over a period of two months to discuss findings and reach consensus about the categorization of findings.

Results
The impact of war on health is fundamental, and it can ultimately influence the achievement of SDGs. 8 Health often means survival from war and its consequences, which is in turn associated with access to essential life needs, i.e. water, food, healthcare, and many public health outcomes. 8 As an example, armed conflict is recognized as one of the biggest threats to human societies, which affects health in both direct and indirect ways. 13 As a major cause of disease epidemics, such conflicts, e.g. war, are associated with death and injury, reduced or abolished access to healthcare services, increasing incidence of communicable diseases, reduced access to sanitary water, psychosocial effects, and malnutrition. 13 Similar to its direct impact, indirect consequences of war can be serious in terms of increased mortality and endangering public health.
We found nine mechanisms, through which the lack of peace may affect health and achieving sustainable development (Table 1).
Health system strengthening towards building a resilient health system is crucial in reducing the impact of conflict on health and withstanding shocks. 18 During any crisis, resilient health systems must have robust tailored plans to enhance the capacity of health actors, e.g. relevant institutions, to prepare and assist people for effective response.
As described in Table 1, the relationship between peace and health is intrinsically mutual. The role of doctors and other healthcare practitioners is crucial in protecting population health. Indeed, peace is the most significant factor to achieve health for all. In addition, health is innocent enough to play a brokerage role by bringing the conflicting parties to discuss mutually beneficial interventions for all parties involved. 13 Moreover, healthcare staff have a great responsibility to maintain humanitarian interventions and public health during and after armed conflicts, within the context of resilient health systems. 21 This requires to keep channels of humanitarian assistance open, including cross-border assistance, and balancing the control between the government and other parties in action. 22 In the area of health, many humanitarian agencies are responsible to protect and help the victims of war, either through direct actions on behalf of the victims, or providing them with food, shelter, water, vaccinations and medico-surgical care.

Discussion
Peace, health and sustainable development are interlinked. Health is at the heart of SDGs, while achieving sustainable development would be impossible if peace were to be compromised. Peace is not simply the absence of violence. Nonetheless, war, as one of the most prominent examples of lack of peace, has direct and indirect health consequences, 23 i.e. disrupted power supply and water sanitation, reduced immunizations, maternal and child health difficulties, psychosocial consequences, and physical deprivations. 24 Health is a right for all. 25 Hence, hospitals, medical units and health care personnel require special protection during crisis to maintain health promotion, disease control and prevention, treatment of acute illnesses and chronic care, and appropriate responses to emerging public health threats. 26 When peace is compromised, health system strengthening is crucial in enhancing health security. Resilient health systems are able to absorb disturbance and adapt and respond to crisis, through integrated approaches for provision of needed services before or during a disaster. 27 Indeed, a resilient health system should be able to regulate itself.
Reciprocally, health can also affect peace. For instance, healthcare personnel are trained to utilize primary, secondary and tertiary prevention strategies to reduce the adverse effects of war on health. 20 Even when severe conflict is in place, healthcare staff are expected to resume their duties in development and implementation of relevant interventions to promote public health, to ensure that the essential healthcare services are available and healthy and safe physical environments are maintained. These require effective advocacy for human, financial, and other resources that are needed to implement essential and emergency healthcare programs, 8 which may nevertheless face several constraints, i.e. poor security, both for the victims and staff that in turn could slow down the relief operations and very often limit their effectiveness. 28 The role of civil society is fundamental in bringing health concerns to the center of foreign policy, so that effective approaches can be taken to address such challenges. 29 As a bridge for peace (HBP), health is a multidimensional policy and planning framework to support health workers in delivering health programmers within war and postconflict situations. Indeed, health can also simultaneously contribute to peace-building. 30 HBP entails a meaningful collaboration among organizations, institutions, and individuals from various backgrounds. This approach is crucial in tackling two fundamental and catastrophic problems during conflict, which have direct and indirect consequences on health: blocking of sufficient humanitarian assistance and direct intentional attacks on the health care system as a weapon of war. 30 In conclusion, health and peace are interchangeable; achieving either is impossible without the other. Health is fundamental to sustainable development, which is also impossible to achieve without meaningful and widespread peace. As such, peace and justice, i.e. strong institutions are defined as SDG16, without which other SDGs are unattainable. Strengthening health systems towards building a resilient health system, especially in countries that are at risk of war, is crucial in decreasing the effects of lack of peace on health. Strengthening the civil society, i.e. health-related NGOs, to help people and provide basic care during war, while placing health and humanitarian issues at the heart of foreign policy, are fundamental to planning of all countries, particularly in the Middle East, in galvanizing their path towards sustainable development.

Authors' Contribution
AT conceived the study. GR conducted data collection with AT contributing to analysis and interpretation of findings. Both authors approved the final draft of manuscript. AT is guarantor.

Conflict of Interest Disclosures
None.

Ethical Statement
Not applicable.  13 2. Long-term physical or psychological effects on the individuals injured during war Indirect The current situation in Afghanistan may be related to an additional 200 000 indirect deaths. 13 3. Conflict damages the social construction of the society and disrupts all activities of normal life Indirect Extensive increase in the number of casualties during the post-war era in Afghanistan due to military and police injuries. 14 4. Destruction of healthcare infrastructure, e.g. clinics and hospitals, most of which will not be completely restored for months or years to come.

Indirect
Severe decrease in pharmaceutical production in Syria, which was 90% before the war in Syria and reduced to 10%, resulting in a significant shortage of drugs and essential medicines across the country. 15 5. Displacing people as refugees in other countries, or internally displaced people within their own countries. Indirect Every minute, nearly 20 people are displaced as a result of war and conflict.
In 2016, the total number of displaced people reached 65.6 million globally, plus over 10 million stateless people around the globe who are denied a nationality. 16 6. Harming the environment through reduction of nonrenewable natural resources and contaminating the environment with harmful materials. Many cultural heritage and art pieces were stolen during the war and occupation in Iraq, i.e. the national library and the national museum, as well as a number of important cultural monuments that were massively damaged and looted during the period of the occupation. 19 9. Risk for the spread of infectious diseases, while the private sector that is mostly concentrated in urban settings is not capable of tackling the problem even by the use of advanced care services. 10

Indirect
In Yemen, war has had devastating impact on mother and child health. Vaccination rates have decreased, the incidence of diarrheal diseases has increased among children, malnutrition has increased among mothers and children, while both maternal and U5MR have increased. 20