For more than a decade, a key role for women's education in reducing mortality among young children in poor countries has been recognized around the world. This issue has important implications, not only where resources are scarce, but in the increasingly common situation of declining resources associated with complex emergencies. Unique among the literature, this study1 shows that father's education was more influential than mother's education both under conditions of war and food crisis in Tigrai-Ethiopia. A dose-response relationship is commonly found in the relationship between women's education and mortality. Here, this relation was found to be important only beyond a threshold of primary education among mothers. Further comparative analysis is called for to determine if this is a culture-specific characteristic or an artefact of the data. Further, it raises statistical questions about the relative importance, and interaction, of male and female education. We still have only limited information on the mechanisms by which education could impact on mortality. We assume that educated mothers both have access to more resources and use them more efficiently for the benefit of the child. But which resources are these, and in which environments are they important? The answers to these questions carry many implications for public policy during humanitarian emergencies.
In this study, urban mortality rates exceeded those in rural areas. This is a rare finding, associated either with successful adaptation to subsistence agriculture in rural areas or administrative neglect in urban areas. The failure to manage limited resources to benefit the population is further implied by the declining impact of education on survival of children as the crisis became chronic. At almost any level of resources, government or others in leadership roles can facilitate improved survival chances through priority allocation of food, assessment of vulnerability among young children, and encouragement of breastfeeding and clean water. In rare instances, these benefits are systematized in population-friendly ways so effective that they attenuate many or most of the health threats caused by the crisis.2 In this case, just the oppositive has happened. Rather than assisting the population, those in authority seem to have ignored humanitarian conditions, leaving each family to discover its own survival means. Such neglect of living conditions may have contributed to the downfall of that government.
Relief workers and national authorities tend to be keenly aware of the lack of adequate information sources for planning and administering services in humanitarian crises. It is far more rare for them to realize that, despite a shortage of good data, there are likely rich but unused data sources available. Household surveys like the one analysed in this paper are common, even in countries with crises.3 Their data have rich implications for health and well-being, but they are seldom used by those in the health sector as they had no part in designing questions or collecting the data. This paper provides a hopeful example of the potential opportunities for quantitative research under conditions of crisis. The glass, rather than being three-quarters empty, may be a quarter full.
Similarly, even where available resources have declined and needs have increased, there are usually potential resources for health which are underutilized. These unapparent resources are usually long-term assets such as education, training, and the cultural and physical infrastructure. We in public health understand that these long-term assets are more strongly associated with health than the short-term assets like medicines and targeted programmes which usually draw more attention. It is time to use this insight, coupled with analysis of available, sometimes rich data sources, to do more for those subject to complex humanitarian crises.4
Notes
Columbia University, Box 6, 617 West 168th Street, New York, NY 10032, USA. E-mail: rmg3{at}columbia.edu
References
1
Kiros GE, Hogan DP. War, famine and excess child mortality in Africa: the role of parental education. Int J Epidemiol 2001;30:447455.
2 Garfield RM, Santana S. The impact of economic crisis and embargo on health in Cuba. Am J Public Health 1997;87:1520.[Abstract]
3 Garfield R. The Impact of Economic Sanctions on Health and Well-being. Relief and Rehabilitation. Network paper #31. London: ODI, 1999.
4 Garfield R. The public health impact of sanctions: contrasting responses of Iraq and Cuba. Middle East Report 2000;215:1619.