Natalie J. Grove

Violence: a priority for public health? (part 2)

Violence continues to grow as a priority for public health practitioners, particularly as its causes and consequences become better understood and the potential roles for public health are better articulated. This article provides the context to “Violence: a glossary (part 1)” published in the last issue of this journal, and updates some of the data, concepts and population approaches presented in the 2002 World report on violence and health. The paper addresses the following questions: What is the magnitude and global burden of injury from violence? What causes violence? Is resilience important? What is the role for public health? What are the key challenges and opportunities? We aim to engage the general reader and to increase understanding of violence as a potentially preventable issue.

Violence: a glossary

Violence has been explicitly identified as a significant public health problem. This glossary clarifies widely used definitions and concepts of violence within the public health field, building on those promoted through the 2002 World Report on Violence and Health. We provide definitions and concepts that can be usefully applied to identify points for public health intervention to prevent the social and health impacts of violence.

Placing ethics in the centre: negotiating new spaces for ethical research in conflict situations.

Abstract Issues of power and consent, confidentiality, trust, and benefit, risks to researchers, and potential harm to participants, are all contested when working with different cultures and within environments marked by violence and insecurity. Difficulty resolving these dilemmas may paralyse ethics committees, may fail to give the guidance sought by researchers, and will not help populations who are among the worlds most vulnerable. Even where efforts are made to respond to ethical guidelines and to improve practice, considerable impediments are present in many developing countries, including lack of formal ethical review structures in unstable settings, lack of required skills, limited political and institutional recognition of ethical issues, competing interests, and limitations in clinical and research practice (Elsayed 2004, Macklin 2004). In conflict settings, these limitations are more marked, and the responsibilities of the researcher for ethical practice are greater, but the mechanisms for oversight are weaker. Moreover, the constant focus on vulnerabilities and problems, and the often almost total lack of recognition of strengths and resilience, can further disempower already exploited groups and individuals. The capacity of refugees and communities in conflict to take an active role in the research process is seldom acknowledged, and undermines the potential for more innovative research which can help generate the evidence for better policy and practice.

An Australian childhood obesity summit: the role of data and evidence in 'public' policy making

BackgroundOverweight and obesity in Australia has risen at an alarming rate over the last 20 years as in other industrialised countries around the world, yet the policy response, locally and globally, has been limited. Using a childhood obesity summit held in Australia in 2002 as a case study, this paper examines how evidence was used in setting the agenda, influencing the Summit debate and shaping the policy responses which emerged. The study used multiple methods of data collection including documentary analysis, key informant interviews, a focus group discussion and media analysis. The resulting data were content analysed to examine the types of evidence used in the Summit and how the state of the evidence base contributed to policy-making.ResultsEmpirical research evidence concerning the magnitude of the problem was widely reported and largely uncontested in the media and in the Summit debates. In contrast, the evidence base for action was mostly opinion and ideas as empirical data was lacking. Opinions and ideas were generally found to be an acceptable basis for agreeing policy action coupled with thorough evaluation. However, the analysis revealed that the evidence was fiercely contested around food advertising to children and action agreed was therefore limited.ConclusionThe Summit demonstrated that policy action will move forward in the absence of strong research evidence. Where powerful and competing groups contest possible policy options, however, the evidence base required for action needs to be substantial. As with tobacco control, obesity control efforts are likely to face ongoing challenges around the nature of the evidence and interventions proposed to tackle the problem. Overcoming the challenges in controlling obesity will be more likely if researchers and public health advocates enhance their understanding of the policy process, including the role different types of evidence can play in influencing public debate and policy decisions, the interests and tactics of the different stakeholders involved and the part that can be played by time-limited yet high profile events such as Summits.Overweight and obesity in Australia has risen at an alarming rate over the last 20 years as in other industrialised countries around the world, yet the policy response, locally and globally, has been limited. Using a childhood obesity summit held in Australia in 2002 as a case study, this paper examines how evidence was used in setting the agenda, influencing the Summit debate and shaping the policy responses which emerged. The study used multiple methods of data collection including documentary analysis, key informant interviews, a focus group discussion and media analysis. The resulting data were content analysed to examine the types of evidence used in the Summit and how the state of the evidence base contributed to policy-making. Empirical research evidence concerning the magnitude of the problem was widely reported and largely uncontested in the media and in the Summit debates. In contrast, the evidence base for action was mostly opinion and ideas as empirical data was lacking. Opinions and ideas were generally found to be an acceptable basis for agreeing policy action coupled with thorough evaluation. However, the analysis revealed that the evidence was fiercely contested around food advertising to children and action agreed was therefore limited. The Summit demonstrated that policy action will move forward in the absence of strong research evidence. Where powerful and competing groups contest possible policy options, however, the evidence base required for action needs to be substantial. As with tobacco control, obesity control efforts are likely to face ongoing challenges around the nature of the evidence and interventions proposed to tackle the problem. Overcoming the challenges in controlling obesity will be more likely if researchers and public health advocates enhance their understanding of the policy process, including the role different types of evidence can play in influencing public debate and policy decisions, the interests and tactics of the different stakeholders involved and the part that can be played by time-limited yet high profile events such as Summits.

Child health in armed conflict: time to rethink.

6 Seftel HC. The rarity of coronary heart disease in South African blacks. The health of children is compromised by armed confl ict, complex political emergencies, political upheaval, and forced migration. Children and young people comprise a signifi cant proportion of the population in many countries, and often predominate in refugee or internally displaced settings. These environments expose them to risky situations over which they have limited control. An international symposium in Manila 1 drew attention to these issues. Debate in The Lancet has highlighted the tremendous challenges of achieving the Millennium Development Goals (MDGs), of applying best practice in child-health interventions, and of assuring childrens rights and voices. 2–5 Confl ict and instability are signifi cant impediments to achieving the MDGs: in many countries they have reversed earlier gains from childhood interventions and undermine livelihoods, leading to greater poverty and adverse health. Addressing this challenge to child health is urgent. Children under 5 years of age have the highest mortality rates in confl ict-aff ected settings. 6,7 In some situations, when childhood interventions have been disrupted for periods, older children are similarly aff ected. 8 Diarrhoeal diseases, acute respiratory infections, measles, malaria, and severe malnutrition are the most common causes of death in the early phases of confl ict-related emergencies. 6,7 In addition, outbreaks of other infectious diseases such as pertussis, typhoid, and meningococcal meningitis, can contribute substantially to childhood morbidity and mortality. 8 Little is known about the eff ect on children of chronic conditions (eg, tuberculosis), or of neglected diseases (eg, visceral leishmaniasis, African trypanosomiasis) in such settings. Traditionally we approach health problems through emergency responses, ad-hoc medical services, and vertical disease-specifi c programmes, often targeted , on those aged under 5 years. Although these programmes are successful in decreasing mortality in camp settings, more comprehensive programmes, such as the Integrated Management of Childhood Illness, have potential for greater impact and sustainability but are rarely implemented fully. 9 The disruption and displacement of families and communities during armed confl ict often results in children adopting new roles. They may take on more responsibility in seeking health care for themselves, or as carers for others. Girls in their early teens may themselves be mothers. Children who were previously at school, or had been at home or working in the fi elds, might need to fi nd paid work taking them away from family for long periods. Within the …

Beyond the log frame: a new tool for examining health and peacebuilding initiatives

How do we move from identifying ethical principles to enhancing development practice? How can donors and NGOs move beyond the reporting of technical outputs to explore less tangible aspects of their health projects: contributions to rebuilding trust, promoting social cohesion, and enhancing good governance at community level? This article considers these questions in relation to health and peace-building activities in conflicted settings. It describes difficulties facing practitioners and donors seeking to undertake health and peace work, in particular focusing on the lack of appropriate tools for screening, monitoring, and evaluating projects. It critiques the logical framework, a tool commonly used in project planning, monitoring, and evaluation, and considers it alongside a new tool, the Health and Peace Building Filter, which has been designed to reflect on health programming in fragile or conflicted settings. The authors argue that such tools can help to move us beyond focusing on inputs and outputs to examining processes, relationships, and the indirect consequences of aid programmes.

Psychosocial health and human rights: fair weather friends? Examining post-tsunami interventions in conflict-affected areas

Multiple challenges are present in areas affected by both disaster and conflict. Support to psychosocial recovery and wellbeing is increasingly seen as a core component of responding to disasters and complex emergencies. We consider whether the increased attention and resources directed to psychosocial programs following the tsunami could assist in the promotion of human rights in the fragile settings of north-eastern Sri Lanka and Aceh in Indonesia. We identify ways in which the psychosocial and human rights agendas intersect and consider how progressive psychosocial health programming can assist in the promotion of human rights. We also highlight concerns and cautions arising from too explicit a connection in the absence of a safe environment. We conclude by presenting an emerging research agenda to more thoroughly explore the interface of these important areas of health and social policy response.

Listening to the silence: doing better at responding to disasters

Disasters and emergencies present significant challenges to affected individuals, communities, services and systems. The 2004 Indian Ocean Tsunami wreaked havoc and massive destruction: yet within minutes individuals were responding and providing support and within hours communities and systems were working together to mitigate the disaster which had affected them. Fourteen countries were affected, 227,000 people lost their lives, and 1.7 million people were displaced1• Since the Tsunami, numerous other natural disasters and crisis in the Asia-Pacific, including earthquakes in Kashmir (2005) and Yogyakarta (2006), and another Tsunami, fortunately much less devastating, in the Solomon Islands in early 2007 have occured. Some ongoing, crisis and emergencies, however, barely register a response from the international community. Most notable ofthese are man-made emergencies in which the rights ofcitizens, and their human and collective security is deliberately undermined. In all these crisis and disasters, whether natural or man-made, those who are most seriously affected are typically those most marginalised, and least represented in local and national decision-making. Documenting pre-existing inequities and vulnerabilities, service gaps, and the inadequacies ofour responses to the needs of the most marginalised communities deserves attention. Although natural disasters occasionally strike in unpredictable ways, many of them can actually be forecast and much oftheir impact prevented. Disasters and emergencies will not go away, if anything they are likely to become more frequent as the pace of globalisation intensifies and our environment deteriorates. We identify a number oflessons that the public health community in the Asia-Pacific region could draw from recent experiences ofdisaster and response. While we often devote attention to improving the quality oftechnical interventions, we neglect, at our peril, the social aspects of occurrence and response to complex emergencies and crisis.