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Michael Loevinsohn: Environment-Health Research: Challenges and Opportunities
1. First Global Symposium on Health Systems
Research, Montreux
Environment-Health Research:
Challenges and Opportunities
Michael Loevinsohn
STEPS Centre
Institute of Development Studies
November 17, 2010
2. • Creating conditions favouring new health
threats – and the re-emergence of old ones
• Creating multiple health threats, linked to
the same suite of changes
• Health systems face new demands yet their
capacity may be eroded by those same
changes
• Classic environment-health research (one
environmental factor, one disease) ill-
adapted
Rapid, multi-faceted
environmental change
3. • Develop/adapt methods to understand the
dynamic, cross-sector production of risk
• Methods to identify the changes that may
be loosening structures of risk –
opportunities to advance especially primary
prevention
• Methods to clarify and support decisions:
Locating risks and opportunities
Valuing “prevention dividends”
Working out the needs for collaboration
New demands on health-
environment research
4. • Important: economic and ecological drivers
are increasing food insecurity in countries
with generalized HIV epidemics
• Complex: each is cause and consequence of
the other
• Poorly elucidated by conventional methods
e.g. cross-sectional or longitudinal survey
Issue: Food insecurity and
HIV/AIDS
5. • An increasingly vulnerable rural population,
dependent on maize in one season and casual
labour
• Two poor harvests 2001-02 and poor
administrative decisions → maize price surge
• Unequally felt: by location, occupation, gender
• Accounts described people pushed by hunger
into situations of infection risk
Survival sex – exchanged for food or work
Distress migration to towns/cities, less affected
rural areas
Loevinsohn M. 2011. Seasonal hunger, the 2001-03 famine and the dynamics of HIV in Malawi. In Devereux S, Sabates Wheeler R,
Longhurst R (eds) Seasonality, Rural Livelihoods and Development. London: Earthscan.
Loevinsohn M. submitted. The 2001-03 famine and the dynamics of HIV in Malawi: an (un)natural experiment
The Malawi famine and HIV:
an (un)natural experiment
7. Change in HIV vs. rural hunger
Rural antenatal sites
0
0.5
1
1.5
2
2.5
3
10 20 30 40 50
Rural population in need of food aid (%)
Relativeprevalence2003/1999
8. Change in HIV vs. rural hunger
Non-rural antenatal sites
■ cities ▲ towns
Nsanje
0.4
0.6
0.8
1
1.2
1.4
0 10 20 30 40 50
Rural population in need of food aid (%)
Relativeprevalence2003/1999
9. • Further analysis shows they were
mostly farmers, young (<25 years) and
uneducated (< primary)
• Moving in distress, they would have
been at high risk of falling into
dangerous situations
• 2004-05 survey confirms a surge of
young rural women migrating during the
famine, suggesting more than a
transient movement
Who were these migrants?
10. Conclusions
The famine had a rapid and
substantial effect on HIV prevalence
and population distribution across
the country
Structural determinants e.g. poverty
can change rapidly
Declines in urban HIV prevalence
may have other causes than
“behaviour change” esp. rural out-
migration
11. Evidence of “prevention dividends”
• In the rural areas where hunger was
least, prevalence of cassava (rugged,
high caloric yield) was greatest
• Peak market maize price was lower
where cassava was widely grown
• Not a panacea but a useful element of
diversity
• S. India: Watershed Development, by
reducing distress migration, averts
substantial HIV infections
synergistic with condom promotion
(simulation – Loevinsohn 2006)
12.
13. Cassava and hunger
Dec 2002 – Mar 2003
0
10
20
30
40
50
60
0 20 40 60 80 100
Households growing cassava (%)
Householdsneedingfoodaid
(%)
North
Centre
South
Peri-urban
14. Cassava and maize price
February 2002
0
10
20
30
40
50
0 10 20 30 40 50 60 70 80
Households growing cassava (%)
Maizeprice/kg
North
Centre
South
Peri-urban
Editor's Notes
The boundaries of the system. Times, places where it needs to take in other sectors in order to understand and respond to the determinants of disease and ill health.
Talk to all of these. Some only tangentially in the presentations. Discussion. 10 min. Panel
Method : natural experiment – an under utilized resource in HSR
Draws on AN surveillance. Prior to the famine (1994-2001) rural prevalence ca. 50% of urban/semi-urban mean; after (2003-05) it was 70%. Also survey at the peak – food needs to b e supplied
Prevalence increased across the famine at rural sites in a non-linear (quadratic) relationship with hunger at the famine’s peak in the surrounding district. Consistent with widespread survival sex.
Prevalence declined over the famine at sites in towns and cities as hunger in the surrounding rural district rose. Consistent with accounts of migration. Rural prevalence being lower, migrants would have depressed prevalence in towns/cities. The greater the hunger-induced migration, the greater the “dilution”. Corroborated by changing composition of the antenatal population over the famine: fewer farmers relative to non farmers at the rural sites where hunger was greatest (farmers were most affected); the opposite trend observed at non-rural sites. Multilevel analysis indicates the migrants were predominantly young and poorly educated. Corroborated by a later household survey (2004-05) that assessed migration patterns in previous years.
Poverty, food insecurity are generally considered structural determinants of HIV, slow to change and beyond the reach of near-term intervention.
Cassava expanding in the region after decades of neglect. Much more to be said – how to exploit that synergy – and others.