Pick up a newspaper and look at the international section. Most of it will refer to acts of armed violence, to agreements that restrain the capacity for armed violence, new means of inflicting armed violence or just plain threats of armed violence. It takes little to convince that armed violence is very much in our collective conscience; furthermore, many historians argue that our world as we know it, built on the notion of the nation state, is a world born of armed violence, the capacity to inflict it and the restraint of this capacity. Furthermore, the enforceability of our domestic laws by which we abide ultimately depends upon threat of or actual armed violence by legitimate carriers of weapons.

Today, analysis of any war, rebellion or massacre tends to focus on political motives, who is the guilty party or on the kinds of weapons used. However, when the story extends to the victims, somehow rational argument gets lost to sentiment. If we witness directly acts of armed violence and their effects, logic deserts us; there is something about armed violence that is so profoundly shocking, or dare I say exciting, that it defies objective analysis. Perhaps this is as it should be but if we can look past what shocks us, there sits a health issue like all others - for it is undoubtedly a health issue for the victims - and this invites a preventive approach.

The pursuit of the means to find a way of talking objectively and rationally about armed violence and its effects began during my work as a field surgeon with the International Committee of the Red Cross. It has continued during the work with the ICRC on a variety of weaponry issues. Our antagonists would say "What's the difference between blowing somebody's leg off with an antipersonnel mine and blowing somebody's leg off with an artillery shell?" (A buried antipersonnel mine results in a foot or leg amputation in 100% cases because of its design; an artillery shell produces the same effect in about 4% of its victims.) or "So you think it's better to kill someone with a rifle than to blind them with a laser?" or "You can kill someone with a toothpick if you really want to!" or "Why bother with limiting small arms to the developing world, they'll kill each other with machetes if they want to!" or, more confusingly, "We know that non-lethal weapons might kill some people - it just depends on how they're used." And these were the experts speaking, often at conferences attempting to bring rational argument to legal restraints about the design, production, transfer and use of weapons.

The Analytical Framework

Violence can be analysed from a health perspective because, ultimately, it affects people's physical, psychological or social well-being.1 Analysing armed violence in health terms carries the advantage that it permits generic and objective consideration of sensitive, shocking or emotional matters before entering into discussions of the legal, political or "humanitarian" issues of a particular context.2

An analytic framework is a tool for sorting and prioritising a variety of information about any given context. Incoming information is appropriately categorised and the relationship between the categories is established. Obviously, in an analytical framework of armed violence, the effects of an act of armed violence make up one of the categories; the other categories are made up of the determinants of these effects.

How can we categorise the determinants of the effects of armed violence? When people suffer the effects of use of a particular weapon, at some previous time, the weapon has to be transferred into the hands of the user; before this, it has to be produced and before production, it has to be designed and developed.3 Thus, important potential determinants of the effects of armed violence are found in the continuum of "design - to - production - to - transfer - to - use." The vulnerability of the victim or potential victim is also important.

Whatever the nature of armed violence, the key determinants of the effects are:
• the potential of the weapon to cause the effect (corresponding to design);
• the number of potential users armed (corresponding to production and transfer);
• the vulnerability of the victim (the potential to suffer the effect);
• the potential for violence (intentional use of physical force).

An essential part of this analytical framework is understanding the interaction of these determinants; there are two core concepts: first, effects of armed violence are only produced as long as the potential of each determinant is above zero - each is a necessary but not sufficient cause of the effects in question; second, the potential for violence using weapons must be influenced by the user's perceptions of the other three determinants - the complex relationship between weapons and violence is played out in the psychology of the user or users. By extrapolation, the nature of the weapons themselves and their availability are major determinants of the nature, timing and extent of armed violence.

In analysing any act of armed violence the first step is to identify the effects of concern. The next step is to identify the determinants of these effects. Although one of the determinants may weigh more heavily in the interaction than others, no single determinant stands alone; the other three determinants must also come into play. Addressing only one determinant may be ineffective in preventing or limiting any given effect of armed violence unless that determinant is eliminated completely.

Analysing or reporting any act of armed violence involves asking
1. What is the effect or effects that could be reduced or eliminated? Bearing in mind that all four determinants must be present in some way, four other questions follow:
2. What was the potential of the weapon or weapons to cause the effect or effects?
3. How many potential users of the weapon or weapons were so armed?
4. In what way were the victims vulnerable? Given the answers to questions 1 to 4:
5. What conclusions can be drawn or further questions asked about:
• preventing or limiting the effects?
• the context in which the weapon or weapons are, were or would be used?
• the intent of the user or users of the weapon?

Application of the framework to using explosive weapons in a populated area

Civilian injuries in a populated area under bombardment always generates headline news. The hospital images are usually heart-rending. Analysis revolves around whether the act of bombardment intentionally targeted civilians or whether the target was a legitimate military objective. If we apply the analytical framework of armed violence, the effect we are concerned about (and should not lose sight of) is the number of civilians killed or injured. The presented framework, by placing reduction or prevention of a particular effect foremost, forces us to think beyond the political situation and beyond whether the combatants have broken law or whether the wounded receive adequate surgical care in hospital.

What contributes to the civilians vulnerability? Are they injured by flying glass as the windows in their homes are shattered? If so, distribution of adhesive plastic sheeting may reduce injuries while resolution of the conflict is negotiated. Are they injured in bread queues or at water distribution points? If so, the distribution of these vital commodities could be changed in time or space so as to reduce the number people waiting in an exposed location. Alternatively, the bombarding party may agree to withdraw their weapons to a greater distance. However, if the bombardment then continues, any inaccuracies are likely to be multiplied and, in addition, the users are unable to see or verify the damage produced; the number of civilian deaths and injuries may increase. A defending commander might place military objects in a populated area with a view to protecting a town. But does this not also increase the vulnerability of the inhabitants? Commanders on both sides have a legal obligation to ensure the protection of civilians on whichever side; this approach may help to frame dialogue between for example, a commander working under a United Nations mandate and two belligerent parties. These are just some of the approaches that may be generated by bearing the analytical framework in mind. In brief, considering the determinants of "collateral damage" permits its prediction; prediction is the first step in prevention.

Application of the framework to use of biological weapons against civilians

The effects of concern in this example are disease or diseases intentionally inflicted on civilians. This phrase distinguishes the effect from "bioterrorism" which refers to the weapon and the motivation behind its use. The framework encourages systematic consideration of preventive strategies from public health preparedness to criminalization of the transfer of pathogens.

It is generally held that biological weapons are easy to produce. The reason that they have been infrequently used in warfare is the difficulty of finding a safe and efficient delivery system. The analytical framework explains how a small group or even one person can deliver an agent in such a way as to terrorise a population given selection of the right agent. To maximise the delivery for this effect, one or a small number of people must use a simple system or an existing system that would achieve the intended effect, i.e., the postal service.

Prior to October 2001, an assumption was made that the objective of an act of terrorism using anthrax spores would be to kill many people, i.e., the starting point for consideration was the intent. This generated predictions of means of delivery (e.g. a crop sprayer) and how the target population would be vulnerable (e.g. a dense population or football crowd). The analytical framework shows that the only effect that was considered was "number of deaths." If the effect under concern was thought of as "number of people suffering fear of intentional infection" or "extent of breakdown of civil services" it would be clear that other possibilities could have been considered regarding the intended target, the agent and, in turn, the delivery system. We should not have been so surprised that anthrax spores were delivered via a postal service even though, at the time of writing, the intent was unknown.

Future use of biological agents, especially against a civilian population is very much in the minds of policy makers. If thought is given to reducing effects such as the chances of suffering a particular and intentionally inflicted disease or the psychological effects brought by use of a biological agent, the analytical framework forces consideration of who is vulnerable and how, the likely agent and the likely means to deliver the agent. Together these may indicate the human resource or technology needed to carry out the attack and in turn may even provide pointers to potential perpetrators.

Conclusion

Our world has been shaped by armed violence, the capacity for it and the means to restrain it. It seems likely that our future will continue to be likewise influenced. Is it not time to take a multidisciplinary, coherent, and objective look at armed violence and not let logic desert us? The first step is to consider the effects of armed violence for what they are: a health issue.

Notes

1. Definition of violence - the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a likelihood to result in injury, death, psychological harm, maldevelopment or deprivation (World Health Organisation); Definition of health - a state of complete physical, mental and social well-being and not merely the absence of disease (World Health Organisation); Definition of Weapon - material thing designed or used or usable as an instrument for inflicting bodily harm.
2. R. Coupland Armed Violence, Medicine and Global Survival, 2001, vol. 7, pp. 33-37.
3. R. Coupland, The Effects of Weapons on Health, Lancet, 1996, Vol. 347, pp.450-451.
Robin M. Coupland is the adviser on armed violence and the effects of weapons for the International Committee of the Red Cross. He joined the ICRC in 1987 and worked as a field surgeon in Thailand, Cambodia, Pakistan, Afghanistan, Yemen, Angola, Somalia, Kenya and Sudan. As part of his current position he has focused on the effects of conventional and anti-personnel weapons. He has paid particular attention to the effects of antipersonnel mines and, by using the Red Cross wound classification, fragment injuries and the disruption of bullets. In promoting the concept of weapons as a health issue, his work led to the organisation in 1996 of the Montreux Symposium and initiated the "SIrUS Project" which, in turn, has led to an examination of international legal responsibility of governments to review new weapons and weaponsÕ systems. He has developed and published an analytical framework of armed violence as a tool for reporting and communication.

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