By Michael Loevinsohn, STEPS Centre member
On Wednesday I chaired a session on New Directions in Health-Environment Research: Implications for Health Systems.
The topic is a bit off the beam of the Symposium’s thrust: it’s one of 13 concurrent sessions, and about 20 people attend. Setting the stage, I describe the methodological challenges researchers are tackling to uncover how environmental change, of different kinds, is creating health risks. Researchers are identifying developmental processes that are loosening structures of risk, and clarifying how the health sector and other sectors can collaborate to realize these opportunities (View or download my slides).
The first case I talk about is an (un)natural experiment: the 2001-03 famine and its impact on the evolution of HIV in Malawi. Using existing data, I show how hunger profoundly affected the distribution of HIV and of people, by pushing people into “survival sex” (sex in exchange for food, shelter or protection) and distress migration. The data also show that hunger was less severe, maize prices less volatile, and migration and change in HIV prevalence less marked, where people had access to robust crops like cassava alongside the maize staple. Cassava appears to have provided a “prevention dividend”.
Richard Coker from the London School of Hygiene and Tropical Medicine explains how the economic and social changes that have shaken Russia have altered the landscape of TB risk (view Richard’s slides). Driven by the payment system, hospitals release patients in December, regardless of treatment status. Declining budgets have meant patients receive under 2000 Kcal/day, less than a prisoner of war. These and other effects on medical and hospital practice are likely contributing to the spread of drug resistance and the growing burden of TB in the population.
Ashok Dyalchand, Institute of Health Management, Pachod (view Ashok’s slides), describes the emergence of new social norms in Indian villages that have taken up Community-Led Total Sanitation. People are disgusted when they realize that, because of open defecation, they are ingesting each others’ feces. They construct toilets and use them more consistently than where outside schemes construct them. Villages are cleaner and people enjoy greater privacy but diarrheal infections are not yet any less frequent. There may be greater collective commitment now to undertake the additional innovations that will be needed to sustainably reduce these risks.
Working in Java, Paul Forster has been examining the political economy of avian flu risks in poultry systems serving the Jakarta market (view Paul’s slides). Other studies have followed the movement of birds, and viruses, between breeding, rearing, slaughtering and commercial operations. Paul has shown that by following the money, the critical role of brokers is revealed. Through extending credit to different actors, they maintain the structure of the industry and influence the exposure of those actors to birds and the virus. Any attempt at change must take them into account.
Finally, Hayley MacGregor describes the STEPS Centre approach to understanding epidemics and the complex dynamics at play at the health-environment interface (view her slides). She highlights how epidemic narratives, embodying the perspectives of different actors, shape responses, illustrating this with recent research on haemorrhagic fevers. A “global outbreak” narrative has dominated control efforts particularly for ebola virus. Local understandings indicate the virus has long been endemic and suggest several culturally acceptable measures. More effective responses are possible when such diverse perspectives are acknowledged.