University of New South Wales. Institute for International Health, C37 Newtown Campus, The University of Sydney, Sydney, NSW 2006, Australia.
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Introduction |
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The difficulties of conducting epidemiological work in situations of conflict were explored by Armenian2,3 from his experience in Beirut more than a decade ago. Among the difficulties identified by him and others4 are the fact that wars and instability are dynamic, constantly changing and adapting, as are the affected populations, many of which may respond by migrating. This makes enumeration difficult: neither numerators nor denominators are stable. Surveillance systems may be undermined or paralysed by lack of resources: skills, materials, and money. A dearth of trained personnel means that whatever limitations were previously associated with routine data collection and analysis may be further compromised. Security concerns on the part of both researchers and participants in research may undermine the validity and completeness of data collection; with researchers themselves often facing risks, or perceiving risks, to their own security.
The authors of this report have done well to uncover a human rights problem, and using traditional epidemiological techniques, to reveal aspects of its magnitude and form. Mian et al. employ a case-control study design to examine the risk factors for homicide in a low socioeconomic area of Karachi, Pakistan, over the period 19941997. They focus on a neighbourhood in which homicide levels were particularly high, and in which the Mohajir community, descendants of Indian Muslims who fled to Pakistan in 1947, are the main ethnic group. The paper concludes that the victims of homicide were far more likely than controls to have been politically active.
The authors identify the key limitations of their research. Two methodological concerns stand out head and shoulders above the others: these relate to the potential for both selection and information biases. Firstly, the cases were victims of homicide identified through local community organizations. Could these cases have been selected because they were politically active, hence revealing, as a result of this bias, a much greater relative risk of political involvement, however measured? It is difficult to assess the potential magnitude of such a bias, although the authors seek to reassure us that the community organizations involved were not politically active per se and would not have had any motive for selectively identifying cases with greater degrees of political involvement.
Secondly, the authors identify a risk of information bias. In particular, information elicited from the families of the controls. They were live members of the same communities from which the homicide victims had been identified and may have been much more reluctant to reveal details of political leadership and participation than the equivalent family informants of the cases, who had been killed earlier. Such an information bias may arise in any situation of political instability and victimization, in which family members would have sought to protect their live family members by denying any involvement in politics, while the opposite may be true among family members of those who had died, about whom there may have been greater willingness to reveal evidence of political involvement, especially at an organizational level. Both these biases would have served to increase assessment of whether homicide victims in Pakistan in the period concerned were more likely to have been politically active than general members of their communities.
The methodological limitions need to be considered alongside the work, but do not invalidate it. In fact, evidence from human rights organizations confirms that the groups identified as at increased risk of political violence in this study had been widely targeted by state security forces in Pakistan in the mid-1990s.5
Classical teaching in epidemiology suggests that we err on the side of conservatism and that the methods adopted underestimate rather than overestimate risks. Being provocative, one could highlight a potential ethical question here as this insensitive approach may lead to an under-identification of risks to the health of communities, especially worrying where these risks are imposed by others, such as the state and its associated security forces as in this case.
Developing and refining models and frameworks to understand the circumstances in which violence against individuals and groups occurs is an important challenge. The authors refer to ethnic violence as the main problem. However, in many places where ethnic violence has been examined, other inter-group differences, whether in relation to socioeconomic status or access to political power, for example, are present. Ethnicity or religious identity may be used by unscrupulous leaders as a rallying point in order to rationalize discrimination, repression or structural violence. The work by Mian et al. highlights the importance of understanding the context within which violence occurs in communities. While we have the bones of an analysis, there is far more to understand, emphasizing the importance of interfacing public health and epidemiology with anthropology, political science, history and sociology, among others. A particularly worrying feature of the study presented here was the involvement of the police and other security forces, groups which under normal circumstances should be charged with protecting the security of the community, not threatening it.
Later this year the World Health Organization will release the first World Report on Violence6an attempt to place the issue of violence on the public health and policy agenda. It will seek to stimulate debate around the pressing need to respond to violence at all levels in society and will devote particular attention to the need to develop more effective interventions, involving a range of sectors, to the range of forms of violence affecting all societies.
This study is valuable and more like it are to be encouraged: placing experience from the micro-level into the public domain serves a purpose in allowing such material to be contested and debated. If there are other explanations for the unusual patterns of violence presented here, they should be offered for debate. If what is presented is an accurate representation of the forms of abuse taking place in the time and place studied, then other issues demand our attention, such as whether such trends could be detected much earlier on in order that advocacy around prevention and human rights promotion could be supported with data at a time when it might have made a difference.
There remain immense challenges in how health-related organizations can work with human rights groups to promote a safer and more secure environment: more accurate identification of problems and abuses is one important step along the way.7 As stated by Leaning: From the human rights perspective people are approached as persons who can claim rights from the state and must be protected from the predations of power.8 A recent analysis of the role of health professionals in South Africa under apartheid draws attention to how physicians and health workers generally played a role both in perpetrating and perpetuating apartheid, while others in the profession both individually and collectively played a crucial role in opposing the abuses under apartheid.9 Drawing on the health submissions to the South African Truth and Reconciliation Commission places it in the public domain. It is a valuable catalogue and analysis of the complicity of apartheid-supporting professionals and of the many activities which concerned professionals and their organizations engaged in as part of the anti-apartheid struggle.
Epidemiology and public health must engage in the study of political violence, of its effects, and in responding to it, if we are not to hear, time and time again, the lament that good men stood by.
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References |
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2 Armenian HK. In wartime, options for epidemiology. Am J Epidemiol 1986;124:2832.[ISI][Medline]
3 Armenian HK. Perceptions from epidemiologic research in an endemic war. Soc Sci Med 1989;28:64348.[CrossRef][ISI][Medline]
4 Zwi AB. Numbering the dead. Counting the casualties of war. In: Bradby H (ed.). Defining Violence. Understanding the Causes and Effects of Violence. Aldershot: Avebury Press, 1996, pp. 99124.
5 Human Rights Watch (www.hrw.org); report on Pakistan for 1997.
6 See brief description of World Report on Violence and Health as mentioned at http://www.who.int/violence_injury_prevention/worldreport.htm; the report is due out in the last quarter of 2002.
7 British Medical Association. The Medical Profession and Human Rights: A Handbook for a Changing Agenda. London: BMA, 2001.
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Leaning J. Health and human rights. (Editorial) BMJ 2001;322:143536.
9 Baldwin-Ragaven L, de Gruchy J, London L. An Ambulance of the Wrong Colour. Health Professionals, Human Rights and Ethics in South Africa. Cape Town: University of Cape Town Press, 1999.
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