Lecture by Kevin M. Cahill, M.D. at The Boutros Boutros-Ghali Memorial on Preventive Diplomacy

The Boutros Boutros-Ghali Memorial


Kevin M. Cahill, M.D.

A UN Alliance of Civilizations Forum

United Nations Headquarters

March 20, 2017

Boutros Boutros-Ghali played many roles in a long and full life; some can be captured in the various titles that characterized his decades of public service. There were common threads that linked these official roles into a cohesive tapestry, but only those privileged to know Boutros on a personal level could fully appreciate the exceptional qualities that made him such a unique individual. I knew him for many decades as his physician, confidant and friend. He was a fiercely independent man, one of exceptional integrity and honesty, with an endearing, self-effacing humor. He possessed a rare modesty and humility that came from a long noble struggle to help his nation, family, friends, and a world in desperate need of his generous insights.

The topic I have chosen for this Inaugural Lecture in honor of Boutros Boutros-Ghali, is one that was very close to his heart. In a final interview, shortly before his death on February 16, 2016, at age 93, reflecting on his life’s work, Boutros was asked what he considered his most important legacy: he responded, "my work with Doctor Cahill in the mid-1990s on preventive diplomacy". There is a lovely story behind that response. For many years Leia, Boutros, my wife Kate and I would gather for a week-long retreat to discuss difficult issues that were likely to arise in the United Nations or other international debates. From these retreats came many long-term projects, including his commitment to Preventive Diplomacy.

Boutros, in a remarkable gesture of confidence in the importance of creative ideas, and in the capacity of his physician to explore — and explain — the concepts of preventive diplomacy, asked, in 1995, that I convene and Chair a plenary conference on the concept at the United Nations. The invited speakers were to view the topic through the prism of public health, seeing if the latter’s strict methodology could bring clarity to the vaguer outlines and approaches that characterize diplomacy. Speakers were asked to present their arguments using the universally understood semantics of health, disease and medicine.

Ambassadors, as well as the general public, often use common medical words, and diplomats can readily adapt these terms in explaining the evils of spreading discord, and the multiple methods employed in efforts to restore peace. Conflicts — like malignant tumors — can metastasize if appropriate therapy is not provided, can become endemic in innocent populations, defying early diagnoses. There are contagious effects in conflicts that may cause political paralysis, and the hemorrhaging of societal understanding leading to mental scars, post traumatic psychological syndromes, physical deformities, amputations, the terminology of sexual assaults and the escalation to epidemic levels of uncontrolled local feverish fighting. We talk of the search, usually futile, for instant cures, for DNA-like analyses of impending strife, of seeking the proper peace-keeping prescriptions for warring patients, of using quarantine and isolation to contain diseased states with diplomatic tools, of maintaining treatment protocols until remission is realized by adjusting the dosages of, for example, sanctions.

So also, with Preventive Diplomacy, we suggested that it might be helpful to use public health cost-benefit examples to justify the large expenditures often necessary to alleviate conflict-prone situations. In conflict resolutions one tries to identify obstacles to — and blockages in — the search for peace as if one were diagnosing and treating an impaired circulatory system. We can argue for the long-term involvement of peacekeeping operations by citing preventive chemotherapy, and the public understands such analogies. These are but a few of the benefits of utilizing universally known medical terms to explain the often arcane goals and methods of diplomacy, goals that must now convince a citizenry that demands increasing transparency to sustain costly international interventions and relief operations.

The conference speakers included leading figures at the United Nations including Boutros as Secretary General, Kofi Annan, then in charge of peace-keeping operations, UNRWA’s Peter Hansen, Jan Eliasson, the first Undersecretary General of the UN Department of Humanitarian Affairs, the former Secretary of State of the United States, the former Foreign Ministers of the United Kingdom, France, Sweden, and Sudan, the President of the International Court of Justice in The Hague, the Secretary General of the Organization of African Unity, as well as distinguished Professors and a Nobel Peace Prize Laureate. I edited the manuscripts into book form, and that text, in follow up editions and translations, is widely used in academic and diplomatic training programs throughout the world.

One of the supreme creations of the human spirit is the idea of prevention. Like liberty and equality, it is a seminal concept drawn from a reservoir of optimism that centuries of epidemics, famines and wars have failed to deplete. It is an amalgam of hope and possibility, which assumes that misery is not an indefinable mandate of fate, a punishment only redeemable in a later life, but a condition that can be treated like a disease, and, sometimes, cured, or even prevented.

During a lifetime in the practice of medicine — in Africa, the Middle East, Asia, and Latin America, as well as my own country — I have seen the daily wonders of the healing arts: lives rescued from once-fatal cancers, disease outbreaks miraculously cut short by new drugs and vaccines, and countless millions of people saved from communicable diseases such as polio and smallpox. Indeed, the conquest of smallpox, one of history’s deadliest scourges, is itself a triumph of prevention attributable not only to Edward Jenner’s inoculation, but to the skills and untiring efforts of thousands of public health workers over a span of 200 years.

I also follow, on a daily basis in the practice of medicine, the wisdom of Hippocrates’ adage from 2,500 years ago: "Primum Non Nocere" — "First do no harm", and to try to help those who seek my care without indulging in public comments to anyone but the patient, family and professional colleagues collaborating in difficult clinical situations.

Caught up in hawkish rhetoric, diplomats and politicians too often embark on interventions without carefully considering the consequences. In today’s world of instant communications, and the apparent need for politicians to appear to personally solve every problem, the fundamental principles of medical practice — careful reasoning, civil dialogue, and a balanced consideration of different options in devising an optimal course of therapy — are frequently absent in political/diplomatic decision making.


In working with Boutros to refine an approach to preventive diplomacy it was only natural for me to think of clinical and public health models in contemplating the disorders threatening the health of the world community as it emerged from the rigid alignments of the Cold War and groped for new organizing principles in an age of high technology, global economic competition and multipolar politics. For power balances, realpolitik, and the other blunt-edged tools of East-West confrontation simply did not fit the need for far more subtle, creative and prospective approaches to the problems complicating the search for peace.

Wanton killing and brutality within supposedly sovereign borders, ethnic and religious strife,millions of starving or near-starving refugees, other millions of migrants fleeing their homes out of fear for their lives or in a desperate search for a better life, human rights trampled down, appalling poverty in the shadows of extraordinary wealth, inhumanity on an incredible scale in what was supposed to be a peaceful dawn following the end of the Cold War: these were the awesome challenges that faced us, and they were quite different from the nation-state rivalries and alliances that preoccupied statesmen during most of the 20th century.

There had to be a new mindset where diplomats would try to sense dangers before crises exploded, invest in early warning exercises, and intervene, if necessary, at latent stages of conflicts. Some problems — maybe most — may have no immediate solutions, but the good public health professional, using all the data of epidemiology and public persuasion, can be positioned to intercede effectively whenever necessary. Diplomats must learn to deal with causes before they are results, to probe societal and political problems when the stress is still manageable, to honor crisis avoidance even more than crisis management.

But if preventive diplomacy was to replace traditional reactive diplomacy, there must be fundamental changes in our international approaches. At present only problems that attain crisis proportions seem to attract the attention of politicians or diplomats. Our leaders simply are not attuned to deal with incipient disorders at a time when prevention is possible. This will not change easily, especially because journalists, even more in an age of instant information overload, will always prefer to report dramatic conflicts and so-called resolutions rather than the non-story, in their minds, of an avoided tragedy.

Preventive diplomacy emphasizes earlier diagnoses and new kinds of therapy. Underlying causes have to be attacked sooner rather than later, before they become fulminating infections that rage beyond rational control or political containment. This is the defining principle of this new preventive diplomacy, which argues that social detection and early intervention should be as honored in international relations as political negotiation and military response. In its pristine form, the idea is simplicity itself; it is reason opposed to irrationality, peace preferred to violence. In the reality of a disordered world, however, preventive diplomacy is incredibly more complex and, in some respects, controversial.

People can disagree on how to define social health and political disease. The tensions between rights and obligations may seem to be intractable. Force sometimes can be necessary to achieve social progress, so it cannot always be condemned. But while violence may be understandable, it rarely leads towards lasting peace. The very breadth of this view of preventive diplomacy suggests that the term itself is far more restrictive than its purpose and conception. For diplomacy, as it has been practiced during most of a now-dying Industrial Age, had been centered on the idea of nation states dealing with each other on a government to government basis with the help of professionals specializing in secret negotiations and political conspiracy.

Today, however, international relations have been utterly transformed by instant communication, by better informed and more active publics, by the spread of market capitalism, the fragmentation of politics and a veritable explosion of commercial transactions and nongovernmental activism. Even the supposedly bedrock principle of national sovereignty has been eroded. Furthermore, preventive diplomacy indicates the many disparate efforts aimed at the maintenance of international peace and security is not a matter for diplomats alone. For the current sources of human stress, community breakdown, and group violence are far too diverse and too deeply embedded in social change to be consigned to the windowless compartments of conventional diplomacy. Many problems do not move in a straight line but rather in endless gyres of cause and effect, so that a fall in coffee prices, for example, can trigger economic unrest, genocide, and precipitate fleeing refugees, starvation, cholera, dysentery and other diseases that overwhelm medical workers and relief organizations.

The patterns Boutros and I discussed in the 1990s concerning Rwanda and the Balkans have re-emerged decades later in Syria and Afghanistan, Iraq and the Occupied Territories of Palestine. The cycles of disaster and the search for solutions involve many different disciplines, including medicine, so that prevention calls for a symphony rather than a solo performance by a single profession like diplomacy. It also calls for a new kind of diplomat. But diplomats, unlike physicians, have not fully accepted a preventive ethos and a disciplined method of using tools to avoid conflicts. If that thesis is valid, then the orchestra clearly needed a knowledgeable and committed conductor capable of promoting preventive diplomacy around the world. Secretary General Boutros Boutros-Ghali assumed that mantle at the United Nations.

I had long suggested to Boutros that health and humanitarian issues should be the pragmatic as well as the symbolic centerpiece of the United Nations. If the Organization was founded to beat weapons into ploughshares, then the fiscal and political focus on military peacekeeping was misplaced. The basic question we discussed, over and over, was how to best present the arguments for an emphasis on preventive diplomacy. I suggested to him that the methodology of public health, and even the universally understood semantics and metaphors of medicine, provided a unique basis for a new type of diplomacy.

Five hundred years ago, Machiavelli, utilizing an apt medical analogy, noted, 

When trouble is sensed well in advance, it can easily be remedied; if you wait for it to show, any medicine will be too late because the disease will have become incurable. As the doctors say of a wasting disease, to start with it is easy to cure but difficult to diagnose; after a time, unless it has been diagnosed and treated at the outset, it becomes easy to diagnose but difficult to cure. So it is in politics.

There are several important lessons in that quote. The shrewd and cynical Machiavelli knew that health images would help make his message clear to a skeptical public, and he unapologetically linked medicine and politics as part of life.

The origins of violence, especially obvious in today’s world, clearly lie in incubating prejudices and injustices that inevitably breed contention. But how rarely are these evil forces exposed early enough, or fought with effective tools before predictable disaster strikes. In preventive medicine one begins by searching for fundamental causes, for the etiology of a disease, and for techniques that can interrupt transmission before serious signs and symptoms become obvious and irreversible damage occurs. If a fatal disease threatens to spread, health experts devise control programs based on careful research and laboratory experiments, sophisticated statistical studies and models, field trials and double-blind surveys that try to minimize biases and biological variants, which often contaminate the best intentioned projects. When deaths do occur, scrupulous postmortem analyses are customary, so that the errors of the past become the building blocks for a better approach to the future. One should, we both believed, be able to adapt this approach to the epidemiology of conflict.

Diplomatic exercises should be subjected to similar probes and autopsies. Nations, particularly great powers and international organizations, must become humble enough to learn from failed efforts rather than merely defending traditional practices. If there are new actors in world conflicts, and a new global environment created by, among other factors, a communication revolution, then the therapeutics of international mediation must change. Unfortunately, public figures are obsessed with dramatic solutions, with a fire brigade approach that assures a continuation of catastrophes.

The international system is always in transition and the contours of the post-Cold War age are still far from clear. But there are already a number of fascinating trends that are central to the development of the preventive diplomacy concept. One is a tentative shift in the direction of individualism that focuses international attention on personal human rights rather than only on the rights and privileges of national sovereignty. Medicine and public health also teach us that diplomatic tools are more effective than coercion. In the case of AIDS, for example, attempts to curb the disease through legal enforcement failed. Only persuasion, education, and cooperation had any success in altering lifestyles that contributed to the problem. In the same way, force has proven to be a poor treatment for violence. Indeed, military intervention and sanctions often do more harm than good. And that is the attraction of preventive diplomacy in international relations — to stop wars before they start.

Even if, as we must fully expect, that noble goal proves elusive, this approach offers the best, and maybe the only viable alternative to the failed practices of the past. Even after conflicts have begun, this new diplomacy, based on a philosophy that focuses on root causes and promotes early involvement can help de-escalate violence and hasten the restoration of peace. The development of sanitation, vaccines, and, more recently, environmental controls have produced phenomenal progress against the enemies of health. In the case of human societies, the promotion of liberal democracy and individual rights marked an historic advance beyond such ancient concepts as slavery and the divine right of kings.

It was for these many reasons we believed that 50 years after the founding of the United Nations, there was the possibility that the principle of prevention just might take its place as a significant improvement over inaction or coercion in dealing with conflict, and we were determined to try. We knew there were no final answers to offer; there cannot be in our finite and imperfect state. But in the presence of disease, there is common pain that makes no distinctions of race or religion or class or wealth. No matter where medical disaster strikes, all the strands of shared humanity converge in shared suffering. A tumor or tubercular lesion or an arrhythmia present in an identical manner, and it makes no difference whether the patient is an ambassador or a street cleaner.

I shall now provide, in some detail, ideas that Boutros delivered in a powerful keynote address to the 1995 UN Conference, where he used, as you will appreciate, many similes and analogies of medical parlance. Most of what I shall present here are direct quotes from his speech. Almost in the role of a public health professional, he opened his talk by noting that in matters of peace and security, as in medicine, prevention is self-evidently better than cure. It saves lives and money and it forestalls suffering.

He defined the main types of such action available at the United Nations: the use of diplomatic techniques to prevent disputes arising, prevent them from escalating into armed conflict if they do arise, and if that fails, to prevent the armed conflict from spreading. The Secretary General can use negotiation, inquiry, mediation, conciliation, arbitration, judicial settlement, resort to regional agencies or arrangements, or try any other peaceful means, which the protagonists may choose. To these techniques can be added confidence-building measures, a therapy that can produce good results if the patients, i.e. the hostile parties, will accept it. Central of course to the idea of preventive diplomacy is the assumption that the protagonists are not making effective use of techniques on their own initiative and that the help of a third party is needed.

The techniques employed in preventive diplomacy are the same as those employed in peacemaking (which, in United Nations parlance, is a diplomatic activity, not the restoration of peace by forceful means). The only real difference between preventive diplomacy and peacemaking is that the one is applied before armed conflict has broken out and the other thereafter. But today, as in health, there are many endemic situations where the causes of conflict are deeply rooted and chronic tension is punctuated from time to time by acute outbreaks of virulent fighting. In such cases it may be artificial to make a distinction between preventive diplomacy and peacemaking or indeed between preventive and post conflict peace building. Those who want to help control and cure such chronic maladies need to maintain their efforts over a long period of time, varying the therapies they prescribe as the patient’s condition improves or deteriorates.

One is sometimes asked to give examples of successful preventive diplomacy. It is not always easy to do so. Confidentiality is usually essential in such endeavors, as it is in the practice of medicine. Time may have to pass before one can say with assurance that success has been achieved. Many different peacemakers may have been at work, and it can sound presumptuous for just one of them to claim the credit.

Preventive humanitarian action addresses, in addition to its healing purpose of bringing relief to those who suffer, the political goal of correcting situations, which, if left unattended, could increase the risk of conflict. A wide range of measures can be required. They can include planning for the humanitarian action that will be required if a crisis occurs, e.g., the stockpiling of relief goods in certain places. But they can also include action to create conditions, which will help to persuade refugees or displaced persons to return to their homes, e.g., improvements in security and greater respect for human rights, creation of jobs, etc.

Like its post-conflict cousin, preventive peace building is especially useful in internal conflicts and can involve a wide variety of activities in the institutional, economic, and social fields. These activities usually have an intrinsic value of their own because of the contribution they make to democratization, respect for human rights, and economic and social development. What defines them as peace-building activities is that, in addition, they have the political value of reducing the risk of the outbreak of a new conflict or the recrudescence of an old one.

The United Nations should, ideally, have the clinical capacity to prescribe the correct treatment for the condition diagnosed. To fulfill this condition, the Secretary-General needs to be able to assess both the factors that have created the risk of conflict and the likely impact on them of the various preventive treatments that are available. Making those judgments in an interstate situation is easier than in an internal one. In the first case, much can be learned from consultation with the states concerned, and with their neighbors, friends, and allies. In the second, the crisis is often due to ethnic or economic and social issues of an entirely internal nature and of great political sensitivity, and the potential protagonists may include non-state entities of questioned legitimacy and with shadowy chains of command. If in such circumstances the Secretary General probes for the information needed to identify the right treatment, he can find himself accused of professional misconduct by infringing the sovereignty of the country concerned.

Another potential source of difficulty for the Secretary General at this stage of the process is the need for triage. His analysis of the symptoms may lead him to conclude that there is no preventive action that the United Nations can usefully take. This could be because he judges that, contrary to the general impression, conflict is not actually imminent and that what is being observed is posturing or shadow-boxing rather than serious preparations for war. Or he may judge that there is no effective treatment that would be accepted by the parties, or even that there is no effective treatment at all.

Sometimes the situation is so threatening that the United Nations’ efforts should be concentrated on stabilizing the patient and that, for the moment, the modalities for longer-term treatment become a matter of second priority. Unless the patients take their physician’s advice seriously, most physicians would turn elsewhere. In internal conflicts, sovereignty is an added complication, and the Secretary General has to proceed with great delicacy and finesse if he is to succeed in persuading both patients to consult the doctor and take the medicine he prescribes.

The salient fact that emerges from this analysis is that the Secretary-General’s ability to take effective preventive action depends most critically on the political will of the parties to the potential conflict. In international politics, as in human medicine, the physician cannot impose treatment that the patient is not prepared to accept. Important improvements have been made in the Secretary General’s capacity to diagnose and prescribe. Failure to take effective prevention action is, in any case, only rarely due to lack of early warning; the symptoms are usually there for all to see. What is too often lacking at present is a predisposition by the parties to accept third party assistance in resolving their dispute.

Once a course of therapy has been defined and agreed upon by all concerned, decisions have to be taken on the modalities for its application. There is no fixed pattern. Specific modalities have to be worked out for each case. The Secretary General’s role can take many different forms. He can do the work himself, directly or through his Secretariat. He can refer the patients to specialists, such as the agencies of the United Nations system, regional organizations, individual Member States, or nongovernmental organizations, and work with them to apply the therapy. He can coordinate the work of others or simply provide them with political and moral support.

Such public manifestations of the Secretary General’s concern can sometimes have a useful therapeutic effect. But more often he will prefer to provide his good offices quietly, especially where the looming conflict is an internal one. Quite apart from sovereignty-related sensitivities, it is easier for parties to make concessions when it is not publically known that they are being urged to do so by the Secretary General of the United Nations who can guarantee little or nothing in return. As already mentioned, preventive diplomacy is usually best done behind closed doors, which can make difficulties for the Secretary General if the world is clamoring for the United Nations to do something but he knows that to reveal what he is actually doing would impair his chances of success, as well as being the diplomatic equivalent of violating the Hippocratic oath.

Peace building is even more complicated. It can require a wide range and variety of actions not all of which will fall under the direct executive responsibility of the Secretary General. His functions in his context are essentially those of a general medical practitioner. He can diagnose the patients’ condition and advise them that certain general measures of a political, economic, or social nature will help reduce the risk of conflict. He must persuade the specialists to apply the therapy that he has prescribed and the patients have accepted. The best way of doing this, of course, is to associate the specialists with the earlier consultations and make them a part of the diplomatic process through which the parties are brought to accept the desirability of preventive action and the nature it should take.

There are no guaranteed vaccinations to prevent conflicts from starting and no miracle cures to end them once they have started. The best prevention is for the region or country concerned to follow a strict and healthy regimen of democratization, human rights, equitable development, confidence building measures, and respect for international law, while eschewing indulgence in such unhealthy practices as nationalism, fanaticism, demagoguery, excessive armament, and aggressive behavior. Most of the elements of such a regimen are prescribed in the United Nations Charter and in the corpus of international law.

The difficulties of prevention in the field of peace and security do not arise because the warning signs of conflict are more difficult to detect than those of human disease; on the contrary, they are usually more obvious. Nor is it that the therapies are less effective; many effective therapies have been devised over the years. The United Nations dispensary is well stocked and many experienced consultants and specialists are on call.

The problem is with the patients, and with the friends and enemies of the patients. Human beings may be full of phobias and superstition about disease but they can usually be relied upon to respond fairly rationally to the diagnoses and prescriptions of their physicians. The same cannot, alas, be said of governments and other parties to political conflicts. Many general practitioners would have been tempted to retire in despair long ago if their advice had been disregarded by their patients as consistently as the advice of the United Nations is disregarded by those to whom it prescribes therapies to avert imminent conflict. But the Secretary General of the United Nations cannot abandon his principal duty any more than a conscientious physician can abandon a difficult case. The Secretary General’s duty is to use all the means available to him, be they political, military, economic, social, or humanitarian, to help the peoples and governments of the United Nations to achieve the goal, emblazoned in the first paragraph of its Charter, of "saving succeeding generations from the scourge of war."

I should like to add complementary thoughts from two other contributors to the Preventive Diplomacy conference. Jan Eliasson, who later became the Deputy Secretary General of the United Nations, was, as a speaker at the 1995 conference, the Secretary of State for Foreign Affairs of Sweden. As a direct result of his involvement he instituted an official government policy in his country that all diplomatic actions and decisions should be examined through the prism of preventive diplomacy.

Lord Owen drew the inspiration for his lecture from an 18th century physician’s cautionary advice: "Beware of overly aggressive doctors". In international relations, Lord Owen noted that by understanding — and accepting — limitations, and by using persuasion rather than reflex aggression, one might be able to prevent, or at least limit, a conflict. Alternatively, trying to extricate oneself from an unwise involvement, as in recent decades for Western Powers in Iraq or Afghanistan, can prove very difficult indeed.

In our ever more dangerous world, in the throes of both inter- and intra-state conflicts, the need for a new approach in international relations, seems obvious. Preventive Diplomacy should deal with — and even direct — where a nation can move towards peace rather than replaying where it has been in endless wars. That surely was our intention in promoting this option, and neither Boutros nor I ever abandoned that dream.

It is most fitting that the venue for this first anniversary Boutros Boutros-Ghali Memorial is at the United Nations where his tenure as Secretary-General is remembered fondly by those who continue the search for peace, and that it is sponsored under the broad mandate of the office of the UN Alliance of Civilizations.

I conclude by returning to the importance of ideas. For Boutros believed, passionately, that ideas cannot be extinguished by mere political power. Boutros Boutros-Ghali — the scholar and teacher, the bibliophile and archivist, at the end of a most remarkable career as an unvanquished servant of his fellow man — donated his personal books and papers to libraries so that future generations can study his approaches to alleviate suffering and end conflicts through diplomacy. And, as a final codicil to this Memorial, it is a joy to report that the Francophonie, with the support of the Ministries of Defense of France, Belgium and Canada have established a new Boutros Boutros-Ghali Observatory for Preventive Diplomacy.

Thank you.

Kevin M. Cahill, M.D. is the University Professor and Director of the Institute of International Humanitarian Affairs, Fordham University; President of the Center for International Humanitarian Cooperation. He served as Chief Advisor for Humanitarian and Public Health Issues for three Presidents of the United Nations General Assembly.

Kevin M. Cahill, M.D.served as Mr. Boutros-Ghali’s physician and personal advisor for many years, including during his time as UN Secretary-General.

Kevin M. Cahill, M.D.served as Mr. Boutros-Ghali’s physician and personal advisor for many years, including during his time as UN Secretary-General.