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May 7, 2007 The Intersection of Sociopolitical Conflict and Public Health Severe malnutrition. Widespread domestic violence. Stalled AIDS research. Speakers from the Bloomberg School of Public Health who appeared at a Johns Hopkins University-wide symposium on April 27 drew on their own research and field experiences in Africa to illustrate how sociopolitical conflicts can give rise to devastating public health outcomes. In a panel at the Hopkins All-University Seminar on Africa (HAUSA), Epidemiology Professor Chris Beyrer, MPH student Ting-Hway Wong, and Jennifer Wagman, a researcher with the School’s Rakai Health Sciences Program, addressed the public health damage associated with political and social conflicts in the Democratic Republic of Congo (DRC), Angola and Uganda. “Civil disruption and subsequent political strife obviously have a big impact on infectious diseases,” said Beyrer, MD, MPH ’90. “But they also affect data collection in research and the ability of those of us working in public health to try and continue our work.” The Congo war of 1998 to 2002—which claimed some four million lives from violence, disease and hunger—provided the catalyst for Beyrer and his colleagues to undertake what he described as a “novel analysis” assessing the impact of the conflict on HIV/AIDS and malaria research over a 25-year period. “In the early period of HIV research the Congo was one of the critical places where work was being done in Africa,” he said. An extensive review of the literature on HIV and malaria found similar research timetables for both diseases. Beyrer said the data showed that published studies peaked in the mid-1980s to 1990. Publications dropped sharply over the next couple years and then stopped completely, with no new studies initiated for approximately 13 years. According to the analysis, however, most of the research efforts actually came to a halt in 1991 and 1992, several years before the war, as increasing civil unrest made it unsafe for researchers to remain in the DRC. “The critical message is we can only make very indirect assumptions about what the impact of the conflict was on HIV/AIDS [and malaria],” Beyrer said. “Political crises ended the research efforts and closed off our ability to understand what happened with these diseases.” MPH student Ting-Hway Wong shared her experiences working in a therapeutic feeding center at an Angolan refugee camp in 2001. Wong belonged to a team from the humanitarian aid organization, Doctors Without Borders, which had established the feeding center to treat people displaced during Angolan Civil War. The 27-year conflict ended in 2002. Wong said malnutrition rates in the country were particularly high because humanitarian agencies did not have access to many hard-hit areas.
“If you read most of the [scientific] literature it’s about child malnutrition,” she said. “But in Angola, because of the length and nature of the war, people of all ages were affected by it.” Wong said that the staff at the feeding center did what they could, in difficult conditions and with limited resources, to help those most in need. When patients arrived at the center, the health care workers conducted weigh-ins and took measurements. The severely malnourished were admitted to the center, where they stayed in tents, and less critical cases were given food rations. Wong recalled that before long, “normal people began to look abnormal to me, because I had become so accustomed to seeing skinny people.” Although Wong saw that the center’s prescribed feeding programs could have positive outcomes for patients, frequently any progress was temporary. “There were patients who did not comply with the feeding program [after discharge],” Wong said. “We suspected that the patients may not have taken severe malnutrition seriously because there were so many other things to die from.” Researcher Jennifer Wagman’s work with the School’s Rakai Health Sciences Program (RHSP) in Uganda takes place at the intersection of domestic violence and HIV/AIDS. Wagman, MHS, who has lived in Rakai since 2000, said that a growing body of scientific literature suggests a strong relationship between high levels of domestic violence and HIV infection. “Violence has been found to be cause and consequence of HIV,” she said. From a public health perspective in Rakai, where violence against women is widely accepted, this association is especially problematic. In a survey of more than 5,000 women, RHSP researchers found that 30 percent had experienced physical abuse or threats. Additionally, both men and women overwhelmingly indicated that under certain circumstances, including infidelity, a man is justified in beating his wife or female partner.
Based on the research findings, RHSP developed the Safe Homes and Respect for Everyone (SHARE) project in 2005 to reduce levels of physical and sexual violence, promote changes in attitudes surrounding domestic violence and raise awareness of the association between gender-based violence and HIV/AIDS. Prevention and intervention strategies include training local HIV counselors, police and social workers on effective ways to address domestic violence; working with community leaders to develop education programs; and running support groups for female survivors of domestic violence. This fall, RHSP researchers will begin a two-year evaluation of the SHARE project to assess its effectiveness. “We recognize that this kind of social change project is going to take a long time,” Wagman said. “You can’t really have any kind of positive impact without doing the work for five years.” -- Jackie Powder |
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