It’s not every day that you find yourself at a work meeting chatting to a soldier who led the Counterinsurgency Advisory and Assistance Team in Afghanistan and the doctor who directed the largest global health initiative in human history.
Retired US Army Colonel Joseph Felter is now a Stanford University academic with expertise in studying the root causes of political violence. Eric Goosby, an HIV physician at the University of California, San Francisco (UCSF), who was among the first clinicians in San Francisco to treat the disease at the start of the pandemic, led the $US45 billion global AIDS initiative PEPFAR—the US President’s Emergency Plan for AIDS Relief.
What brought these worlds together at Stanford two weeks ago—two dozen academics from the fields of political science and global health—was a shared frustration at the failure of the global health community to tackle the crisis of avertable deaths from infections and maternal, newborn, and child health (MNCH) conditions in politically fragile states.
There is no doubt that in many parts of the world we have made tremendous progress in reducing avertable deaths. To give one example, five million fewer children under five years old died in the year 2011 than in the year 1990, in large part through health sector improvements. That’s an astonishing achievement by any standards.
Yet areas of conflict, instability, and weak governance, particularly in sub-Saharan Africa, have not shown the same progress, and continue to have the world’s highest burden of mortality from infections and reproductive, maternal, newborn, and child health (RMNCH) conditions. These areas fall largely outside the efforts of the global health enterprise. While the “direct” deaths from violence garner the attention of the humanitarian enterprise, the so-called “indirect” deaths—from conditions like malaria, pneumonia, diarrhoea, and neonatal disorders— remain largely under the radar, even though they make up most of the mortality burden.
Take Darfur. The Stanford pediatrician Paul Wise, who chaired the meeting, pointed out that 80% of the mortality in young children was not from combat—it was from the very same conditions (mostly infections) that kill kids in politically stable low and middle income countries.
The aim of the meeting was to plan an unusual new academic initiative across three San Francisco Bay Area universities—Stanford, UCSF, and UC Berkeley—to critically examine the intersection of global health, security, and political governance. The ultimate goal is to contribute practical solutions to the so-called “conflict trap,” in which the highest risk of death is in the most violent and hardest-to-reach zones. A precedent for this kind of university work is the innovative collaboration between Stanford and UNHCR—the UN’s Refugee Agency called Rethinking Refugee Communities—which is studying new ways to better protect and support refugees and internally displaced and stateless people worldwide.
So what can universities offer in helping to address the conflict trap?
The meeting identified at least three key academic opportunities.
The first is broad macro level research to better understand and measure the relationship between health and governance and the health needs of populations in crisis (particularly in violent or complex humanitarian emergency situations).
A recent example of this type of research was an intriguing study exploring the association between governance and health in the Arab world over the period 1980-2010. The researchers examined “the extent to which the quality of governance, or the extent of electoral democracy, relates to adult, infant, and maternal mortality, and to the perceived accessibility and improvement of health services.” Surprisingly, the study found no relation between the extent of democracy and mortality reductions. The authors suggest that “efforts to improve government effectiveness and to reduce corruption are more plausibly linked to population health improvements than are efforts to democratise.”
The second is to create a kind of “implementation lab” or incubator to study new ways to implement health interventions in settings where governance is poor. One question that the initiative may address is: how can governance blockades best be overcome so that people can be reached with essential services? Vaccination ceasefires, in which temporary truces are brokered to allow children to be vaccinated, and using mobile phone technologies to map reports of election violence, are examples of bypassing such blockades. There might even be an avenue of research dedicated to designing health tools adapted for situations of weak governance, such as vaccines that require just a single dose (rather than a course) or a single encounter cure for malaria.
The third is to better understand those groups in fragile states who are dedicated to improving public health. At the Stanford meeting, Jaime Sepulveda, the executive director of Global Health Sciences at UCSF, called these groups “islands of integrity.” How can such groups be identified, supported, and evaluated, and do they have spillover effects in improving a country’s governance?
My own personal interest in this initiative stems from my work on a project called Global Health 2035, which Richard Smith discussed in his BMJ blog. In the Global Health 2035 project, we lay out a forward looking plan for achieving a “grand convergence” in global health within a generation—that is, a decline in avertable mortality from infections and RMNCH conditions down to universally low levels. We think it’s a powerful concept. But it’s pretty clear that convergence can’t and won’t happen if the global health community continues to have a blind spot on the conflict trap.
Gavin Yamey is an associate professor in the UCSF Global Health Group, where he leads E2Pi, the evidence to policy initiative. He teaches masters courses in global health policy at UCSF and the London School of Hygiene & Tropical Medicine.
Competing interests: I declare that I have read and understood the BMJ Group policy on declaration of interests and I hereby declare the following interests: E2Pi has received funding from multiple non-profit organizations and donors who work on reducing avertable deaths from infections and RMNCH conditions (the Bill & Melinda Gates Foundation; the Clinton Health Access Initiative; the Global Fund; UNITAID; the Partnership for Maternal, Newborn & Child Health; DFID; and the Norwegian Agency for Development Cooperation).