MISCONCEPTION: PUBLIC HEALTH AND PEACE ARE SEPARATE PURSUITS

Ronald Waldman

Professor of Clinical Epidemiology
Mailman School of Public Health at Columbia University

Recently, a new discipline has been developed in public health. Development agencies are implementing programs to determine the best ways to deliver health services in confl ict and post-confl ict environments. In some places, like Iraq and Afghanistan, substantial investments are being made to strengthen fl edgling Ministries of Health. Although the levels of investment are more modest in other countries like the Democratic Republic of Congo, Sierra Leone, Liberia, and East Timor, the problem is well-recognized.

Health parameters in many postconfl ict countries are among the worst in the world. There is no doubt these countries need to improve maternal and child health programs, control communicable disease threats, and reconstruct primary healthcare facilities. But public health authorities should also be aware of the very high recidivism rate of conflict in countries torn apart by civil strife, one that approaches seventy-fi ve percent within ten years of an initial cessation of hostilities. Pneumonia, diarrhea, malaria, HIV/AIDS, and malnutrition are obviously important, but none can be adequately addressed in a violent environment, despite the existence of safe, effective, and affordable interventions.

If public health aims to reduce the risk of morbidity and mortality and if, as the data suggest, confl ict is an important risk factor, then investments in public health should perhaps be directed toward activities that help establish and maintain the peace. Can the construction of health facilities and the provision of traditional public health services in confl ict-affected societies lower the rate of resumption of hostilities? We don’t know. The evidence for or against has not been established. What we do know, though, is clear: war and public health are incompatible pursuits.

MISCONCEPTION: EMERGENCY CONTRACEPTION HAS NO ROLE IN THE RESPONSE TO HUMANITARIAN CRISES

Carolyn Makinson

Executive Director, Women's Commission for Refugee Women and Children

For women and girls displaced by confl ict, access to emergency contraception (EC) after unprotected sexual intercourse to prevent unwanted pregnancy is not only a right but also a critical need. War increases incidents of sexual violence such as rape and sexual exploitation, particularly among young females. As a consequence of war, women and girls may exchange sex for resources to meet their survival needs.

Displaced women and girls who are not granted access to EC may be forced to experience an unwanted pregnancy and may, as a result, die from childbirth or complications of unsafe abortion. To address the reproductive health of refugee women and girls, EC should be made available from the beginning of a response to a humanitarian crisis. Oral emergency contraceptive pills (ECPs) are an effective way to prevent unwanted pregnancies in these settings, but two common misconceptions inhibit the use of ECPs.

Some erroneously believe that ECPs cause abortions. In fact, ECPs do not disrupt an established pregnancy following implantation. They are not considered a form of abortion by authoritative agencies such as the World Health Organization (WHO).

There are also misconceptions about the timeframe in which ECPs are effective. Original guidelines specifi ed that ECPs could be used effectively within seventy-two hours of unprotected intercourse. Since 2002, research shows that they are effective for up to 120 hours. Still, hardly any recent public references to EC indicate that treatment should be given to women seeking ECPs on the fourth or fi fth day. Regardless, women and girls should be encouraged to take ECPs as soon as possible after unprotected intercourse.