Family Medicine in Times of War

PHYSICIANS CAUGHT UP IN CONFLICT

The conflict in the Middle East between Israel and Hamas is an exceedingly complex state of affairs with a long history and a multiplicity of claims and counterclaims. Sadly, the mainstream media often represents it in soundbites that do not fully capture the inherent nuances and generally focus on one side or the other without taking a holistic, contextual, or balanced approach. The arguments often attempt to provide moral equivalency or, alternately, to promote taking sides. Both approaches are deeply flawed. Moral equivalency often draws unfair and even distorted comparisons, whereas the taking of sides ignores the impact of war on relevant populations and makes finding solutions acceptable to all impossible.

As the nature of war has evolved in the last century, the physician’s role has shifted in scope from what once involved simply treating military casualties such as those sustained on the battlefields of the US Civil War to what now includes treating the mass casualties of entire regions of the globe brought about by immensely destructive modern armaments.³ The role of family physicians in wartime has expanded even further, however. This expansion is underscored by examples from other countries where family physicians have been engulfed by war. In 2022, a Ukrainian family physician wrote the following:

Wartime family medicine is more than just primary care. In addition to the fact that doctors take care of the health of their patients (often working overtime) we have additional roles, including non-medical volunteer work. In the first months of the war, family physicians were often treating internally displaced Ukrainians, who were experiencing stress and needed support. The day-to-day work of family physicians has changed, because patients have increased mental health needs, often requiring a consultation with a psychologist. We must also provide medical care to the wounded.⁴

What can family physicians do when faced with tragedies such as the Ukrainian or Israel–Hamas wars, now months to years in length, which have already become regional conflicts and which may further enlarge at any time? Given the relative dearth of research and the near total absence of training for war in our family medicine residency programs (except those associated with the US military), there are few guideposts to assist with answering this question.

A STARTING POINT: FAMILY MEDICINE’S ROOTS

One place to start may be with our discipline’s intellectual and philosophical roots. Family medicine deeply adheres to Engel’s biopsychosocial model,⁵ which provides a framework for our approach to health care that includes psychological and social factors in addition to the biomedical. This approach is consonant with major global consensus statements, such as the World Health Organization (WHO) Alma-Ata Declaration of 1978, which identified primary health care as key to the attainment of the goal of health for all. It also reaffirmed that,

… health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.⁶

This declaration, relevant in peacetime, may be even more pertinent during wars wherein multiple sectors must work cooperatively to ensure even basic survival.

The sentiments of the Alma-Ata Declaration have continued to resonate through family medicine, beginning with its roots. G. Gayle Stephens, in The Intellectual Basis of Family Practice published in 1982, noted that “the unique managerial skills of a wise and compassionate physician” were needed for a variety of concerns, including those that resulted from conflict or stress.⁷ Further evidence of such resonance is reflected in the adoption by the World Organization of Family Doctors (WONCA) European Family Physicians of a recent appeal to stop war.⁸ Their group, headed by an Israeli family physician who was the WONCA Europe President at the time (2022), stated that war violates human rights, leads to oppression, and is an avoidable cause of lifelong suffering and disease. They noted the following, in consonance with the Alma-Ata Declaration:

As family physicians, we take care of our patients during their entire life cycle. In our daily work, we are all aware of how extreme life events may harm human beings. Without fundamental human rights, health and quality of life is not possible to achieve. We see health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” and as a fundamental human right.⁸

The WHO and WONCA sentiments are similar to approaches suggested by US medical organizations. For example, the American College of Physicians Ethics Manual: Seventh Edition notes the following:

The physician’s primary commitment must always be to the patient’s welfare and best interests, whether in preventing or treating illness or helping patients to cope with illness, disability, and death. The physician must respect the dignity of all persons and respect their uniqueness.⁹

Such ethical principles are upheld in US military medical ethics codes as applying in wartime. For example, “An Overview to Military Medical Ethics” provides clear guidance:

In summary, these require that parties to conflict (state armed forces and non-state armed groups) ensure that anyone (combatant, prisoner, shipwrecked or civilian) who is wounded or sick ‘shall be treated humanely and shall receive, to the fullest extent practicable, without distinction except on medical need, and with the least possible delay, the medical care and attention required by their condition.’¹⁰

The ethical principles above fit well with family medicine’s commitment to the 4Cs—first contact, comprehensiveness, coordination, and continuity.¹¹ The principles are also consistent with the new definition of primary care:

[T]he provision of integrated, accessible health care services by physicians and their health care teams who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.¹²

How might family medicine respond to the war in the Middle East and to other conflicts? I believe that we must recognize that the suffering for those caught up in wars and armed conflicts is often terrible and transcends nationality, ethnicity, political affiliation, religion, and the like. Such sentiments reinforce the commitment of family physicians to treat everyone, with equity and without malice. There is much more that can be done, however, as elaborated below.

RESPONDING TO WAR AND CONFLICTS

CONCLUSIONS

As we join others in asking what happens next in Israel and Gaza, as well as in Ukraine, we can find ways to support our family medicine colleagues and acknowledge their profound personal and national losses and to address the health effects of trauma for generations to come. Activities may include taking time to work alongside these physicians; helping them educate future family physicians and supporting faculty development; creating forums wherein residents and medical students might share their narratives and discuss their shared values; and supporting educational, research, and advocacy efforts through joint projects on multiple levels. It is critical that we humanize the people—including family physicians and their families and friends—support them, and not only help them make sense of the present, but also embolden both them and ourselves to ensure a better future.