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Not everyone is ignoring social chaos
Correspondence
Richard Horton contends, in his Offline (Jan 11, p 111),1 that key global stakeholders have not only failed to discuss the impact of social chaos on health, but have actively stymied the conversation. We welcome Horton’s focus on a topic that has not received the attention or action it deserves. However, Horton fails to account for the considerable work done by non-governmental organisations (NGOs), advocacy groups, and others to document social chaos and its effects on health, and hold the people in a position to improve the situation responsibly. From 2000 to 2007, the International Rescue Committee (IRC) did a series of mortality surveys in the Democratic Republic of Congo—one of which was reported in this journal,2 showing that millions of people, not 100 000 as previously reported,3 had died as a result of the breakdown of state and social institutions. In 2012, the IRC documented how the legacy of war was manifested as intimate partner violence for a large proportion of women in three conflict-affected west African states, through a toxic combination of civil society disruption and widespread impunity. In 2013, the IRC showed how war and social disruption led to high levels of violence against women and girls in and around Syria. The IRC with these reports and through presentations at conferences and to donors and global health leaders shared its first-hand experience of how social chaos has harmed the health of civilians, and in particular of the most vulnerable among them. The IRC’s work has not been confined to diagnosis of the problem. The IRC’s mortality surveys were credited by negotiators with helping to bring warring parties in DR Congo, faced with an objective assessment of the costs of war, to a peace accord. The IRC’s programmes have worked to prevent and mitigate the consequences of violence against www.thelancet.com Vol 383 March 22, 2014
women and girls, providing services but also changing laws and building social institutions, such as a network of women’s shelters in Sierra Leone. IRC’s governance team has worked with local government and with their colleagues in the social sector to build programmes that provide immediate relief, but also address underlying institutional weaknesses. The bulk of IRC’s health work involves precisely the post-conflict support that Horton calls for.1 These IRC examples are by no means unique. Organisations such as CARE and Médecins Sans Frontières have also helped to bring attention to the close link between politics, social institutions, and health. They have done so because any global health worker who has spent any time in the field rapidly becomes aware of the futility of doing humanitarian relief or even health system strengthening without addressing the political and social roots of the problem. “We in humanitarian NGOs can try to stop the dying; we need politics to stop the killing.”4 WHO has reorganised its health systems framework to highlight that governance is the most fundamental system, from which all the others take their lead. Concrete recommendations are needed. Attention alone will not help people living with conflict, displacement, and fragility. First, there needs to be more humanitarian work in conflict-affected communities, but the right kind: informed, context specific, and led by local and national actors. Donors need to demand and fund much more careful contextual work, and have it evaluated by people familiar with each context—including people who were born and grew up there. Second, implementing agencies need to spend more time and resources, both in the design and implementation of programmes, to listen to their local staff, allowing them to share their analysis and create solutions. Donors can help by requiring concrete evidence that this has been done. Implementing
agencies can help by doing this even before a donor mandate. Third, donors and agencies need to move aside and allow local and national voices to take the lead in advocacy, rather than appear as mere anecdotes in the fundraising narratives created by others. These local voices, we know from experience, will, when allowed to, bring the focus back to the social and political issues that, as Horton correctly infers, underlie so much of the global health disparities in evidence today. And, most importantly, they will bring the discussion back to where it needs to go: practical solutions.
iRC/Chris de Bode/SV
Not everyone is ignoring social chaos
I am President and CEO of the International Rescue Committee. I declare that I have no competing interests.
David Miliband [email protected] International Rescue Committee, New York, NY 10168-1289, USA 1
2
3
4
Horton R. Offline: Social chaos—the ignored tragedy in global health. Lancet 2014; 383: 111. Coghlan B, Brennan RJ, Ngoy P, et al. Mortality in the Democratic Republic of Congo: a nationwide survey. Lancet 2006; 367: 44–51 Fisher I, Onishi N. Chaos in Congo: a primer. The New York Times. http://www.nytimes. com/2000/02/06/world/chaos-congo-primermany-armies-ravage-rich-land-first-worldwar-africa.html (accessed March 4, 2014). Miliband D. David Miliband’s Ditchley lecture: After the “decade of war”. www.newstatesman.com/politics/2013/07/ david-milibands-ditchley-lecture-afterdecade-war (accessed Feb 11, 2014).
Could active case finding reduce the transmission of tuberculosis? The social dimension of tuberculosis is reflected by its high prevalence in immigrant, socially deprived, and vulnerable groups in some boroughs of London, UK.1,2 Public Health England proposed the screening of immigrants from tuberculosis-endemic countries followed by chemoprophylactic treatment of all latently infected individuals.3 The delivery of treatment for several months to prevent the reactivation in a minority (about 10%)
For IRC 2012 report on Domestic Violence in West Africa see http://www.rescue. org/sites/default/files/resourcefile/IRC_Report_DomVioWAfrica. pdf
For IRC 2013 Commission on Syrian Refugees see http:// www.rescue.org/sites/default/ files/resource-file/IRCReportMid East20130114.pdf
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
1035
Richard Horton contends, in his Offline (Jan 11, p 111),1 that key global stakeholders have not only failed to discuss the impact of social chaos on health, but have actively stymied the conversation. We welcome Horton’s focus on a topic that has not received the attention or action it deserves. However, Horton fails to account for the considerable work done by non-governmental organisations (NGOs), advocacy groups, and others to document social chaos and its effects on health, and hold the people in a position to improve the situation responsibly. From 2000 to 2007, the International Rescue Committee (IRC) did a series of mortality surveys in the Democratic Republic of Congo—one of which was reported in this journal,2 showing that millions of people, not 100 000 as previously reported,3 had died as a result of the breakdown of state and social institutions. In 2012, the IRC documented how the legacy of war was manifested as intimate partner violence for a large proportion of women in three conflict-affected west African states, through a toxic combination of civil society disruption and widespread impunity. In 2013, the IRC showed how war and social disruption led to high levels of violence against women and girls in and around Syria. The IRC with these reports and through presentations at conferences and to donors and global health leaders shared its first-hand experience of how social chaos has harmed the health of civilians, and in particular of the most vulnerable among them. The IRC’s work has not been confined to diagnosis of the problem. The IRC’s mortality surveys were credited by negotiators with helping to bring warring parties in DR Congo, faced with an objective assessment of the costs of war, to a peace accord. The IRC’s programmes have worked to prevent and mitigate the consequences of violence against www.thelancet.com Vol 383 March 22, 2014
women and girls, providing services but also changing laws and building social institutions, such as a network of women’s shelters in Sierra Leone. IRC’s governance team has worked with local government and with their colleagues in the social sector to build programmes that provide immediate relief, but also address underlying institutional weaknesses. The bulk of IRC’s health work involves precisely the post-conflict support that Horton calls for.1 These IRC examples are by no means unique. Organisations such as CARE and Médecins Sans Frontières have also helped to bring attention to the close link between politics, social institutions, and health. They have done so because any global health worker who has spent any time in the field rapidly becomes aware of the futility of doing humanitarian relief or even health system strengthening without addressing the political and social roots of the problem. “We in humanitarian NGOs can try to stop the dying; we need politics to stop the killing.”4 WHO has reorganised its health systems framework to highlight that governance is the most fundamental system, from which all the others take their lead. Concrete recommendations are needed. Attention alone will not help people living with conflict, displacement, and fragility. First, there needs to be more humanitarian work in conflict-affected communities, but the right kind: informed, context specific, and led by local and national actors. Donors need to demand and fund much more careful contextual work, and have it evaluated by people familiar with each context—including people who were born and grew up there. Second, implementing agencies need to spend more time and resources, both in the design and implementation of programmes, to listen to their local staff, allowing them to share their analysis and create solutions. Donors can help by requiring concrete evidence that this has been done. Implementing
agencies can help by doing this even before a donor mandate. Third, donors and agencies need to move aside and allow local and national voices to take the lead in advocacy, rather than appear as mere anecdotes in the fundraising narratives created by others. These local voices, we know from experience, will, when allowed to, bring the focus back to the social and political issues that, as Horton correctly infers, underlie so much of the global health disparities in evidence today. And, most importantly, they will bring the discussion back to where it needs to go: practical solutions.
iRC/Chris de Bode/SV
Not everyone is ignoring social chaos
I am President and CEO of the International Rescue Committee. I declare that I have no competing interests.
David Miliband [email protected] International Rescue Committee, New York, NY 10168-1289, USA 1
2
3
4
Horton R. Offline: Social chaos—the ignored tragedy in global health. Lancet 2014; 383: 111. Coghlan B, Brennan RJ, Ngoy P, et al. Mortality in the Democratic Republic of Congo: a nationwide survey. Lancet 2006; 367: 44–51 Fisher I, Onishi N. Chaos in Congo: a primer. The New York Times. http://www.nytimes. com/2000/02/06/world/chaos-congo-primermany-armies-ravage-rich-land-first-worldwar-africa.html (accessed March 4, 2014). Miliband D. David Miliband’s Ditchley lecture: After the “decade of war”. www.newstatesman.com/politics/2013/07/ david-milibands-ditchley-lecture-afterdecade-war (accessed Feb 11, 2014).
Could active case finding reduce the transmission of tuberculosis? The social dimension of tuberculosis is reflected by its high prevalence in immigrant, socially deprived, and vulnerable groups in some boroughs of London, UK.1,2 Public Health England proposed the screening of immigrants from tuberculosis-endemic countries followed by chemoprophylactic treatment of all latently infected individuals.3 The delivery of treatment for several months to prevent the reactivation in a minority (about 10%)
For IRC 2012 report on Domestic Violence in West Africa see http://www.rescue. org/sites/default/files/resourcefile/IRC_Report_DomVioWAfrica. pdf
For IRC 2013 Commission on Syrian Refugees see http:// www.rescue.org/sites/default/ files/resource-file/IRCReportMid East20130114.pdf
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
1035