ABSTRACT

War legitimizes the right to kill for its participants, equating victory with moral justification; however, this perceived legitimacy is largely constructed on the deaths of civilians and other living beings. Medicine, by its very nature, is grounded in the principles of preserving life, doing no harm, and adhering to scientific and ethical standards, and is therefore fundamentally opposed to the philosophy of war. Wars lead, directly and indirectly, to deaths, disability, displacement, poverty, and long-term public health disasters. Attacks on health facilities, restrictions on access to food and water, environmental destruction, and air pollution disproportionately affect vulnerable populations, particularly women and children. The psychological consequences of war often evolve into persistent neuropsychiatric conditions, including post-traumatic stress disorder, depression, and moral injury. Peace is not merely the absence of war; it is a prerequisite for health, environmental sustainability, and social well-being. The concept of positive peace strengthens health indicators through well-functioning institutions, equitable resource distribution, and the protection of human rights. Within this framework, health professionals and civil society organizations are critical actors in advocating for peace and in making human rights violations visible. The Turkish Thoracic Society regards peace as an indispensable condition for public and respiratory health, affirms its opposition to all wars—particularly the ongoing atrocities in Gaza—and reaffirms its commitment to sustained, health-based advocacy for peace.

INTRODUCTION

War, by its nature, confers upon its participants a perceived legitimacy to kill. Not only among those directly involved, but also within dominant historical narratives that shape our present, “winning” and “victory” are often portrayed as forms of moral justification. Nevertheless, such notions of victory and moral justification are built on the deaths of countless individuals and other living beings on both sides. The violation of the right to life thus becomes normalized and, ultimately, legitimized. Medicine, by contrast, is fundamentally grounded in the preservation of life. It is both an art informed by scientific methodology and a moral stance rooted in the principle of doing no harm. The existential philosophies of war and of medicine are inherently incompatible. Wars are commonly driven by a combination of economic interests, geopolitical ambitions, control over resources (such as oil), and the subjugation of populations.¹ Cultural, religious, racial, and ideological differences are frequently exploited to persuade societies that war is inevitable or necessary. Once war begins, the values humanity cultivated over centuries can be rapidly eroded. Dominant historical discourses often present wars as unavoidable facts of the past or as natural components of human history, encouraging societies to perceive them as ordinary. The phrase “history is written by the victors” obscures massacres and civilian deaths committed by the victors, implicitly suggesting that the defeated deserved their fate. Meanwhile, the deaths, injuries, displacement, and impoverishment of countless individuals remain hidden behind narratives of success and triumph. Those who control economic power continue to cause death, disability, and disease among populations in pursuit of greater dominance.

Advancements in technology have also transformed weapons and methods of warfare, amplifying both their destructive capacity and their short- and long-term adverse health effects.² War is inherently destructive to human and societal life, as it seeks to achieve objectives through the annihilation or permanent impairment of individuals. Parties to conflict frequently target health facilities and personnel or disrupt health service delivery, thereby obstructing the fundamental right to health.³

Health Impacts of War

Wars cause death both directly and indirectly, through injuries, diseases, disabilities, and the breakdown of health services. They lead to mass displacement and forced migration, with profound and cumulative long-term health consequences. Bombs and missiles directly take the lives of individuals, killing thousands of people who are not involved in hostilities. Approximately 80% of those killed in wars are civilians, with women, older adults, and children—among the most vulnerable populations—disproportionately affected.⁴

Children are particularly defenseless during armed conflict. Every child has the right to grow up with their parents in a healthy environment that provides homes, schools, playgrounds, and health facilities. The 1989 United Nations Convention on the Rights of the Child explicitly affirms children’s rights to healthy development and access to the highest attainable standard of medical care, while emphasizing obligations under international humanitarian law to protect civilians during armed conflicts. In this context, article 37 clearly states that no child shall be subjected to unlawful or arbitrary deprivation of liberty.^5-7

During armed conflict, homes, factories, and food- and water-storage facilities are destroyed, often by fire, depriving people of their right to safe shelter. Populations living in conflict zones are forced to endure unhealthy living conditions or displacement, and, due to inadequate housing face an increased risk of infectious diseases. Approximately 25% of those who survive bombings subsequently die from poor environmental conditions and infectious diseases. Individuals forced to flee conflict areas often live in refugee camps, where mortality rates increase ten- to twentyfold. While 13% of refugees lack access to primary health care services, this proportion is only 6% among host communities. Similarly, 9% of refugees have no access to a family physician, compared with 4% of the local population.⁴

During armed conflicts, hospitals and health facilities may be bombed, health workers lose their lives, and access to health care is severely disrupted. As a result, both individuals injured during attacks and the general population experience impaired access to routine health services. Access to medications and essential preventive health services is also interrupted. Restrictions on access to food further exacerbate hunger, malnutrition, and violence. These consequences disproportionately affect the poorest and most vulnerable segments of society. The destruction caused by armed conflict severely degrades air quality. Explosives, fuels, and the collapse of buildings lead to increased levels of particulate matter and other toxic substances that pose serious threats to respiratory health. For example, studies conducted in conflict zones such as Gaza, Syria, and Ukraine have demonstrated marked increases in chronic obstructive pulmonary disease, asthma, and acute respiratory infections during periods of war. In addition, the collapse of health systems impedes early diagnosis and treatment of infectious diseases, such as tuberculosis and pneumonia. Among displaced populations, malnutrition, overcrowded living conditions, and air pollution further accelerate the spread of these diseases.^{8, 9} Various weapons and explosives used during armed conflict affect not only humans but all living organisms; beyond their immediate destructive effects, they contaminate the environment by releasing toxic metals and chemicals. By rendering agricultural land unusable, they also disrupt the food chain and threaten long-term food security.

Wars threaten not only physical health but also mental health. The loss of parents and children, limb amputations, destruction of living environments, persistent insecurity, and fear of death contribute to the development of a range of neuropsychiatric conditions, including post-traumatic stress disorder (PTSD), depression, anxiety, and moral injury. These psychological effects are not confined to the period of active conflict; rather, they result in sustained changes in emotional response systems and may persist for many years after the war has ended. While PTSD is a well-recognized and extensively studied condition, moral injury is a relatively new concept. Moral injury is defined as a profound cognitive and emotional response following events that violate an individual’s deeply held moral values and beliefs. Potentially morally injurious events include situations in which individuals perpetrate acts that conflict with their moral convictions, fail to prevent such acts, witness them, or become aware of them. Moral injury has been associated not only with PTSD symptoms but also with emotional distress characterized by self-harm, self-defeating behaviors, and pervasive feelings of hopelessness. These neuropsychiatric consequences often continue for many years after the cessation of armed conflict.^10-13

Throughout human history, wars have caused the deaths, disabilities, illnesses, and profound suffering of millions of people. Among these, the atrocities committed by the Nazis occupy a prominent place in collective memory, both because they occurred in the relatively recent past and because they have been extensively documented in research, archival records, literature, film, and works of art. The fact that such brutality could take place at the very center of Europe—often portrayed as the cradle of enlightenment and civilization, shaped by the contributions of countless scientists, philosophers, and artists—forced humanity into a profound confrontation with itself. This reckoning prompted the development of new legal frameworks and human rights protections, based on respect for inherent human dignity. Following the trials of Nazi leaders, genocide was formally defined and codified in international law as the gravest crime against humanity. While the horrors of the Nazi genocide remain deeply embedded in our collective memory, and despite the belief that humanity would never again witness such inhumanity, the world today faces a genocide unfolding before its eyes in Gaza. In the aftermath of the Nazi genocide, humanity faces the unsettling reality that the concepts and rights established to safeguard human life and dignity can once again be rendered meaningless. At a time when numerous wars and armed conflicts continue worldwide and within our region—each accompanied by its own human tragedies—the openly indiscriminate and relentless assault on the civilian population in Gaza demands particular and urgent attention.

The Humanitarian Toll of the Gaza Genocide

Since 8 October 2023, more than 70,000 people have reportedly been killed in Gaza, the majority of whom are civilians, approximately half of whom are women and children. Despite reports that a ceasefire came into effect on 10 October 2025, people continue to be killed daily. United Nations–supported experts have warned that Gaza is currently experiencing the worst-case famine scenario.

The Integrated Food Security Phase Classification (IPC) is an innovative, multi-stakeholder global initiative aimed at improving the analysis of food security and nutrition. It brings together 21 organizations and intergovernmental bodies, including governments, regional institutions, and international organizations. Through the IPC framework, the severity and extent of acute food insecurity, chronic food insecurity, and acute malnutrition are assessed impartially to inform urgent response and action planning.¹⁴ According to the IPC, there is growing evidence that widespread hunger, malnutrition, and disease in Gaza are contributing to excess mortality, primarily from hunger and malnutrition. At least 30% of children have acute malnutrition. As a result of starvation alone or of the interaction between malnutrition and disease, two per 10,000 people and four per 10,000 children die each day.^{15, 16}

Children in Gaza are unable to adequately access health services due to ongoing conflict and attacks. Their health continues to deteriorate as a result of environmental damage caused by the war. The bombing of hospitals and the destruction or abandonment of health facilities have disrupted disease surveillance and control systems, and the continuity of care, further undermining the capacity to provide treatment and accelerating the breakdown of the health system.^17-19

The war in Gaza has also imposed a substantial mental health burden on individuals, severely undermining overall societal well-being. High rates of mental health disorders related to violence, loss, and displacement have been documented in Gaza.²⁰ Factors such as forced displacement, the loss of family members, physical injuries, and the severe shortage of mental health care resources expose children to a continuous cycle of violence and trauma, profoundly affecting their psychological well-being.²¹

In Gaza, 161,600 housing units have been completely destroyed, 81,000 have been rendered uninhabitable, and an additional 194,000 have sustained partial damage. Approximately 88% of infrastructure has been damaged; schools and universities have been bombed; cultural heritage sites have been destroyed. Nearly 90,000 Palestinian university students in Gaza have been unable to attend university. More than 60% of schools, almost all universities, and numerous bookstores and libraries have been damaged or destroyed. Hundreds of teachers and academics—including university deans and leading Palestinian scholars—have been killed. These systematic attacks have completely eliminated the future educational prospects of children and young people in Gaza.¹ Moreover, the large quantities of bombs and explosives dropped daily on Gaza are expected to cause toxic contamination of the ecosystem, affect the lives of people and other organisms for generations to come, and render the region increasingly unsafe and unsuitable for sustained human life.

Civilians in Gaza, confronted with daily horrors and a profound sense of helplessness, are likely experiencing increasingly severe psychological distress. Children who are critically affected during key stages of development face a heightened risk of long-term mental and physical health problems. The psychological, cultural, and epigenetic dimensions of the intergenerational transmission of trauma may result in suffering that extends across generations. Addressing the mental health needs of these populations is therefore essential to mitigating the deep and lasting impacts of war.²²

Moreover, even when they survive, many are left without protection or supervision and are forced to struggle to survive on their own; at the same time, they continue to die from hunger, disease, lack of access to treatment, or direct attacks. Both situations represent profound humanitarian failures, demonstrating that existing efforts remain fundamentally insufficient. When societies fail to implement effective prevention strategies and are unable to alter this reality, they contribute to the continuation of harm through inaction.²³

However, international humanitarian law, as set out in the Geneva Conventions, clearly establishes that civilians and civilian objects must be protected and may not be targeted.

• Civilian populations and civilian objects, including homes, markets, and residential buildings, must not be targeted; only military objectives may be lawfully attacked.

• Hospitals, health facilities, ambulances, and health personnel are explicitly protected; attacks on facilities providing care to the sick and wounded are prohibited.

• Objects and infrastructure indispensable to the survival of the civilian population—such as food supplies, agricultural areas, drinking water installations, irrigation systems, and electricity networks—are protected. Deliberate and intentional attacks on such objects, including actions aimed at starving or depriving civilians of water, are prohibited.

• Schools and educational institutions—as civilian educational facilities—must not be targeted; students and educators are entitled to protection.

• Places of worship and sacred sites are protected under international law.

• Cultural heritage and historical property are protected under the 1954 Hague Convention and its Protocols; intentional attacks on cultural property during armed conflict are prohibited.²⁴

Unlawful attacks, including deliberate attacks against civilian targets and indiscriminate or disproportionate attacks, must be investigated as war crimes by international criminal mechanisms or national courts.²⁵ Numerous reports document that the Israeli government has committed war crimes by bombing hospitals, schools, and civilian-populated areas, thereby depriving innocent civilians, including children and women, in Gaza of their right to life. For a ceasefire to evolve into lasting peace, the government of Israel must be held accountable and tried for the crime of genocide.

The Concept of Peace

Health is not merely the absence of disease or disability; it is a state of complete physical, mental, and social well-being.²⁶ This definition clearly demonstrates how closely the concept of peace is intertwined with health. Peace is not simply the absence of war; it is a prerequisite for a healthy and sustainable life.

Interstate and intrastate wars, economic crises, human rights violations, social injustices, and violence arising from adverse conditions such as disease, injury, and death constitute a reality faced by societies worldwide today. Conversely, according to the understanding articulated by Galtung²⁷, the founder of peace studies as an academic discipline, the absence of such a broad spectrum of violence itself constitutes peace.

Peace enables societies to strengthen their health systems, expand preventive health services, and implement effective environmental policies. Routine immunization programs, early detection initiatives, and tobacco control strategies are sustainable under peaceful conditions. Thus, peace is not merely a state of non-violence but a way of life that enables the sustainability of health, environmental balance, and societal resilience.

The right of every individual to attain the highest possible standard of health, without discrimination based on race, religion, political belief, economic status, or social condition, is a fundamental human right. Health represents a shared objective that unites all people, regardless of political views, gender, ethnicity, or religion. These simple yet powerful rights-based approach, which underpins Universal Health Coverage is also recognized by the World Health Organization as a fundamental condition for peace.²⁸

Negative peace is defined as the absence of war and direct violence; however, it does not necessarily reflect a society’s levels of stability or social cohesion.

Positive peace, by contrast, encompasses not only the absence of violence but also the attitudes, institutions, and structures that enable peace, prosperity, and sustainable development. It is characterized by a more durable form of peace, built upon sustained investments in economic development and institutions and on social norms that support peaceful coexistence. Positive peace can be used to assess a society’s resilience, its capacity to absorb shocks without descending into conflict or relapsing into violence.²⁹

The positive peace index (PPI) developed by the Institute for Economics & Peace (IEP) is based on eight key pillars that measure these dimensions: well-functioning government, low levels of corruption, a sound business environment, equitable distribution of resources, acceptance of the rights of others, free flow of information, high levels of human capital, and good relations with neighboring countries. Improvements in positive peace not only strengthen peace itself but are also associated with a range of desirable societal outcomes, including higher GDP growth, improved measures of well-being, greater resilience, and more cohesive societies.³⁰

According to the IEP’s 2024 Positive Peace Report, Türkiye experienced a 7.8% decline in its PPI score between 2013 and 2022, making it the country with the largest decline in the European region. This decline was particularly pronounced in the pillars of “well-functioning government” and “low levels of corruption.” The attempted coup in 2016 and the economic crisis following 2018 weakened societal resilience, and in the 2024 global ranking, Türkiye placed 91^st with a PPI score of 3.^{29, 31}

Positive peace possesses the capacity to anticipate, prevent, and sustain stability. It allows societies to foresee vulnerabilities to crises, serves as a tool for the prevention of violence, and offers long-term, cost-effective solutions. A well-functioning government ensures accessible and high-quality health services; equitable resource distribution guarantees equal service provision; and the free flow of information supports health literacy.²

Environmental Peace

Peace is not limited to relationships among human beings; it also encompasses relationships between human beings and the environment. Environmental peace refers to a mode of living that is harmonious with nature and grounded in sustainability. Threats such as air pollution, climate change, and environmental degradation are increasingly recognized as the non-war threats of the modern era.²

Reducing carbon emissions, expanding the use of renewable energy, and implementing clean air policies are not only environmental priorities but also health-centered strategies essential for sustaining peace at the global level. Lung health is one of the most direct and measurable indicators of environmental peace, because respiratory health is strongly influenced by air quality, ecological balance, and climate stability.

The Role of Civil Society Organizations in Peacebuilding

Conflict and peace are phenomena that have coexisted throughout human history—evolving, transforming, and at times replacing one another—while continually being examined and reinterpreted. Peace represents one of humanity’s most fundamental aspirations: a condition that societies seek to establish at every level and across all domains. Peace studies, as a field, emerged particularly in the aftermath of world wars, driven by efforts of international organizations, academic institutions, and civil society actors to prevent the recurrence of such catastrophes.

Civil society organizations (CSOs) are key actors in the defense of human rights and the redress of human rights violations. They raise their voices against abuses, advocate for the rights of victims, and contribute to the protection and promotion of human rights standards at both national and international levels. The contributions of CSOs to peacebuilding are realized through multiple functions, including protection, monitoring, advocacy, socialization, social cohesion, facilitation, and service provision. While these functions may involve engagement with elite-level actors, CSOs primarily operate through interaction with grassroots communities and mid-level actors.

The selection, feasibility, and effectiveness of peacebuilding functions undertaken by CSOs vary depending on the specific context, situation, and society. These functions are also shaped by factors such as the level of violence, the stance of state authorities, media influence, diaspora support, and the positions of external political actors and forces.

Depending on their capacities, CSOs may implement one, several, or, in rare cases, all of these functions during different phases of peacebuilding. Advocacy activities are among the most common forms of civil society engagement and include mobilizing the public to prevent conflict, demanding regime change, protesting human rights violations, condemning structural violence, and drawing global attention to coups violence, massacres, genocide, or attacks in specific regions. Such efforts often take the form of mass demonstrations, public gatherings, protests, and non-violent civic actions.

Another form of civil society advocacy involves lobbying efforts aimed at influencing peace negotiations and safeguarding the rights of affected parties. The ability of CSOs to carry out these functions is closely linked to contextual factors, including governmental attitudes, the intensity of violence, media dynamics, donor engagement, diaspora involvement, and the influence of external actors.

The number of CSOs capable of performing these peacebuilding functions—many of which require a high degree of specialization and professionalization—has increased internationally in recent years. However, in Türkiye, the current distribution and capacity of CSOs are insufficient to provide the infrastructure needed to support peacebuilding effectively.³²

The Role of Health Professionals in Promoting Peace for Health

Health professionals—particularly physicians—whose practice is grounded in the principles of ‘do no harm’ and of preserving life, and who serve as trusted representatives of autonomy and ethical responsibility, occupy a unique and dedicated role in promoting peace. Because the foundational philosophy of medicine centers on disease prevention and the avoidance of preventable deaths, health professionals must consistently oppose war and other forms of armed conflict. This ethical stance renders the promotion of peace not merely an option, but a professional duty for health workers. At times, health professionals may also serve as mediators in conflict settings.

The responsibility of physicians extends beyond treating those injured in war; it fundamentally includes advocating for peace and opposing wars and conflicts that threaten human life and health. Much like their role in combating tobacco use, health professionals must actively engage in advocacy for peace. Such advocacy should not be limited to the pursuit of negative peace—the mere absence of armed conflict—but also encompass broader commitments to social well-being, human rights, democratic governance, improved living standards, and societal welfare. Moreover, health professionals can contribute to peace by documenting and reporting human rights violations, thereby supporting efforts to bring such abuses to an end.^{33, 34}

Despite their central role in safeguarding human health, physicians rarely advocate at the global level to prevent or end wars. To fulfill such a role effectively, the health professions must fully recognize the extensive and multifaceted impacts of war on population health.¹ Therefore, medical education and training curricula are of critical importance in preparing future health professionals to engage meaningfully in peacebuilding. Peace education and human rights–based approaches should therefore be integrated into health education programs.³⁵

In addition, given the profound effects of war on health—and particularly its specific consequences for the respiratory system, including chemical exposures, dust, air pollution, and the effects of psychological trauma on respiratory health—the discipline of pulmonology should incorporate a mandatory curriculum component on “lung health in conflict and war settings.”

Caglayan³⁶, in the article titled “How Can Health Be More Effective in Peace Work in Türkiye: Introducing Peace Through Health,” examines how the peace through health (PtH) approach can be applied in Türkiye, how the health sector can play a more effective role in peacebuilding, and how this framework may be integrated into university curricula. Since the 1980s, the PtH concept has emphasized the interdependence of health and peace, advocating for the active involvement of health professionals in peace processes and highlighting the potential of health services to contribute to peace in contexts such as war, migration, pandemics, and disasters. Caglayan³⁶notes that, despite Türkiye’s strategic regional position as a potential key actor for PtH, theoretical work—including academic publications and educational curricula—remains very limited. The absence of PtH courses in universities underscores the need for interdisciplinary collaboration among medicine, law, social sciences, and academia to institutionalize PtH and integrate it into medical education. Strengthening Türkiye’s contribution to regional PtH diplomacy is also emphasized.³⁶

Wars are among the most devastating threats to public health. They kill, injure, displace, and profoundly affect millions of people. Interstate wars fuel civil wars and perpetuate cycles of violence. Peacebuilding is not merely a political or diplomatic endeavor; it is a complex, long-term, and multidimensional process that encompasses cultural, environmental, social, and individual transformation. Peacebuilding is a critical approach to the creation of a culture of peace. Ultimately, peacebuilding is about the continuity of life on Earth. Preventing violence and achieving universal peace are imperatives.³⁷

The peace agenda must not remain confined to the monopoly of the United Nations Security Council; rather, the process of building consensus should serve as a meeting point for the global community. A human rights–based approach alone will be insufficient to eliminate wars, given the limited efforts currently devoted to the protection of human rights. Therefore, the global development agenda must commit to ending all wars by 2030 and should explicitly include goals aimed at de-escalation and deterrence of armed conflict.³⁸ Immediate action is required to achieve a world without war.

Turkish Thoracic Society Declaration on Peace and Health

The Advocacy Committee of the Turkish Thoracic Society (TTS) organized a meeting entitled “Peace and Lung Health” on 1 September 2025, in observance of the International Day of Peace. Following this meeting, the Committee recognized the need to formally articulate the values advocated by the TTS regarding peace, health, and lung health. Accordingly, the TTS declares the following:

• The TTS recognizes peace as a fundamental prerequisite for public health.

• The society advocates for the integration of peace policies with public health strategies, given their positive impact on the right to life and on overall societal well-being.

• The society will actively and consistently advocate, within scientific platforms and the public sphere, that peace is a public health issue and a prerequisite for health, particularly for lung health.

• To enable physicians trained in our country to take a clear stance in favor of peace and health, the Society affirms that the health impacts of war—especially its consequences for the respiratory system, including chemical exposures, dust, air pollution, and psychological trauma and its effects—should be integrated into both pre-specialty and postgraduate medical education programs.

• The society will encourage and support all research initiatives related to peace and lung health.

• The society will promote activities aimed at raising societal awareness by using real patient experiences and case presentations from current and past war settings as educational materials.

• The right to life is inviolable. Accordingly, the Society declares its opposition to all forms of genocide—particularly in Gaza—and reaffirms its commitment to intensify its efforts to protect the right of all people to a healthy life.