9
4. What are the greatest barriers to the introduction and implementation of
health-to-peace projects and how might they be overcome?
The initial hypothesis was sceptical of some of the claims made by health-to-
peace theorists, and of the real possibility to link health initiatives to other
strategies to strengthen peace-building processes.
P.3 Research methodology and data collection techniques
The research methods employed in the development of this dissertation can be
summarised as follows:
ƒ A literature review was carried out in order to: firstly, explore the key
terminology and concepts utilised in the research; secondly, examine
theories for the establishment of a conceptual framework; and, thirdly,
analyse case studies to support the policies outlined.
ƒ A case study was undertaken of Gulu, Northern Uganda (10 March – 23
April 2004). The fieldwork included interviews with local and expatriate
personnel of NGOs, clergy, medical staff and representatives of the local
council.
ƒ Data, information and statistics on health, clinical care, main diseases,
mortality rates and other relevant medical issues was gathered through the
records of patients admitted to Lacor Hospital, to understand the impact of
the conflict in Northern Uganda on the health of the population.
ƒ Participation in surveys and activities organised by the NGOs in Gulu
offered an insight into the main problems of the area and provided an
invaluable firsthand experience and a precious direct contact with the
population.
10
ƒ Meetings and long invaluable conversations with local people were held in
Gulu town and in a few surrounding villages. Notes were kept throughout
the placement and photographs were taken as proof of the atrocities
occurring in Northern Uganda.
P.4 Structure of the dissertation
The dissertation is divided into five chapters and is structured as follows:
Chapter One: Health, War and Development. This chapter explores the key
terminology and concepts utilised in the research.
Chapter Two: Health-to-Peace Initiatives. This chapter provides a conceptual
framework for a general understanding of health-to-peace activities.
Chapter Three: Northern Uganda: Setting the Scene. The case study area is
introduced and the areas for the implementation of health-to-peace initiatives are
indicated.
Chapter Four: Implementation of Health-to-Peace Initiatives: Identifying the
Barriers. This chapter identifies the barriers to the introduction and
implementation of health-to-peace initiatives, with particular reference to the case
of Gulu, Northern Uganda.
Chapter Five: Conclusions and Recommendations. The scope, key concepts and
findings of this research are given. In addition, the incentives for other
programmes and future research are also given.
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Acknowledgements
This study was made possible thanks to the hospitality of Dr Dominique Corti and
Dr Bruno Corrado of St. Mary’s Hospital Lacor in Gulu, Northern Uganda. In
addition, I am most grateful to the people of Gulu for welcoming me in their town
and houses, and for their invaluable help during my research.
A specific recognition of the following persons and organisations must be made
for their unique contributions:
ƒ The ‘night commuters’ that opened their hearts to me and gave some of
their valuable sleeping time to answer my questions.
ƒ The staff of Lacor Hospital, with special mention to Dr Antonella Ninci
and Dr Maurizio Surian, for their support and advice.
ƒ Annett Krurui, Corti Paul Lakuma, Onen Cosmas, Kizito Luke Stephen
and all the staff of Noah’s Ark, for providing data and information on the
‘night commuters’ and for allowing me to spend some nights with the
children at the centre.
ƒ The Médecins Sans Frontières (MSF) team, led by Cameron Kiss, for
sharing their knowledge and involving me in their activities.
ƒ Roses Kiekie of the International Organisation for Migration, for the
information about the IDP camps.
ƒ Stella Ojera, Paul Kello and Edmond Keerto of Save the Children
International, for providing guidance in the design of the interviews with
the children.
ƒ The Archbishop of Gulu, John Baptist Odama and Father Carlos
Rodríguez, for their open and sincere opinions.
ƒ The Gulu Support the Children Organisation (GUSCO) for supplying the
material on the initiatives for former child soldiers.
ƒ The staff of Human Rights Focus, for their technical support.
ƒ Michael Niyitegeka, for his invaluable help during my research time in
Kampala.
Finally, I would like to express my gratitude to my supervisor, Dr Roger Pierce
for his encouragement and guidance in the preparation of this dissertation.
However, any errors are entirely my own and the final responsibility for the
research rests, of course, on me.
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Map of Uganda
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Chapter One
Health, War and Development
It is no measure of health
to be well adjusted
to a profoundly sick society.
Krishnamurti
1
1.1 Introduction
The overall objective of this chapter is to provide a framework for the research
through the definition of the notions utilised in this study.
The chapter aspires to establish a connection between the concept of health, the
impact of war on health and the actions that link relief to development initiatives
in the health sector. In order to trace this frame, three aims have been identified.
The first is to provide the reader with the definitions of the concepts of health,
public health, and primary health care so as to show that different theoretical
perspectives have diverse impacts on the way health care is approached. The
second target is to illustrate the impact of war on health, offering an overview in
terms of the data that need to be collected to facilitate a proper evaluation of the
effects of war on health.
The third aim is to introduce the concept of the relief to development continuum
and to indicate the role of the health sector in this process, so as to set the scene
for the rest of the research.
1
Krishnamurti (1895-1986), Indian philosopher.
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1.2 Approaches to health
The literature commonly reports at least four diverse definitions of health, which
arise from different models. The first model is called ‘bio-medical’, and describes
health as the absence of clinically ascertainable disease. The second model can be
described as ‘functional’, and it defines health as the absence of disabilities. The
third model is based on a ‘well-being’ outlook, that depends on the welfare
perceived by each individual. The fourth approach is the one of the World Health
Organisation, which provides a more comprehensive definition of health. Each
approach is now considered in more detailed terms. (Barry and Yuill, 2002;
Clarke, 2001; Cowley, 2002; Pearson, 2002; Purdy and Banks, 2001; Taylor and
Field, 2003)
1.2.1 The ‘bio-medical’ model
The ‘bio-medical’ model describes health as the absence of disease. This
definition is based on a pure aetiological approach, and it looks at the absence of
clinically ascertainable disease. The focus is on the pathogens that can originate
illness and on the biophysical abnormalities. It assumes that diseases have specific
causes, and that the role of medicine is to understand these cause, and to develop
treatments which arrest or reverse the disease process. Therefore, medical
research covers an important position and it focuses mainly on biological,
chemical, and genetic processes which underlie diseases. In this model “the health
of a society is seen as largely dependent on the state of medical knowledge and
the availability of medical resources” (Taylor and Field, 2003:22). While
emphasising the clinical aspects of medicine, this approach seems to neglect other
important factors that have a strong impact on human health. Such factors are, for
example, the living environment, personal behaviour, the diffusion of health
education, and the practice of prevention.
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1.2.2 The ‘functional’ model
The second model can be described as ‘functional’. It defines health as the
absence of disabilities and it is usually used to refer to disabled or older people.
This approach observes the impediments in the conduction of a normal life and it
evaluates “the ability to cope with everyday activities” (Blaxter, 1990:15).
Nowadays, technological supports can knock down most of the barriers that
constitute an obstacle to the practice of common activities, and disabled people
can more easily fulfil their social roles, despite their health status. This idea
introduces the concept of ‘social health’, which implies the capacity of the society
to respond to illnesses and to adapt to impairments, in order to guarantee a normal
life for all. Therefore, health is seen as the capacity of the individual to fit in with
society’s norms and expectations (Twaddle, 1974). Compared with the ‘bio-
medical’ model, the ‘functional’ one includes the living environment factor and
the ability to have an active life. However, it raises the issue of the subjective
perception of what being able to cope with everyday activities means, and such a
question does not find any answer in this approach.
1.2.3 The ‘well-being’ model
The first two models do not provide a positive definition of health, and they
highlight only the lack or the presence of negative biological factors. On the
contrary, the third approach looks at how people feel about their physical state,
and what they consider a good health status. This approach stresses “the ‘reserve’
of health determined by temperament and constitution, and a positive state of
well-being or ‘equilibrium’” (Blaxter, 1990:14). Such view cannot be summarised
into a single definition, but it has the advantage of taking into consideration the
subjective feelings of the individual, including his/her mental health. However,
this model has some limits as well: it is extremely variable, it lacks a scientific
basis, and it permits the definition of health only after the event of illness (Clarke,
2001).
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1.2.4 The World Health Organisation approach
An attempt to bring these models and ideas together has been made by the World
Health Organisation (WHO), which defines health as “a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity”
(WHO, 1948:5). Despite the critiques addressing this definition, it has the merit of
combining the above mentioned conceptualisations. Adopting this wide notion of
health means including, into the sphere of health initiatives, activities such as
capacity building, community development and psycho-social support. In fact,
today, the actions of health care professionals go beyond treating illnesses and
infirmity. They no longer embrace only sick people, but they also focus on those
who are well. This definition has the value of being the most comprehensive, even
if it may sound more like a wish, than an achievable target (Barry and Yuill, 2002;
Pearson, 2002; Twaddle, 1974).
1.3 Defining public health
The previous overview of the models of health leads the discussion to the way in
which those theories embrace issues related to lifestyles and communal choices,
and therefore to the concept of public health. The origins of public health are in
the social, environmental, ecological and economic aspects of health itself. The
WHO (1995:5) defines public health as “the science and art of promoting health,
preventing disease, and prolonging life through the organized efforts of society.”
Public health is about both communal and individual matters, and in order to
decide its policies, information must be collected locally and nationally (Rowe,
2001). Furthermore, the international context is increasing its relevance also in
health issues. Globalisation has its effects on health as well, and boundaries
cannot stop epidemics. Especially, in underdeveloped regions, the outbreak of
contagious diseases can easily spread due to poor hygienic conditions, lack of
medical structures, sudden movements of the population, and inexistence of
emergency response plans.
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According to Barry and Yuill (2002:31), “public health refers to those areas of
health and disease shared by the population in general and which are seen to be
amenable to preventative intervention”. Therefore it is as much about social and
political concepts as it is about medical ones, and the issue that needs to be
addressed is in which sectors these interventions should be put into practice. An
interesting scheme of what public health should include has been drawn by
Dahlgren and Whitehead (1999) and is shown in Figure 1.1. The first sector of
Figure 1.1 indicates the overall conditions in which the individuals live their lives,
and considers the general socioeconomic and environmental situation. At this
level public policies can have a great impact, especially in terms of general quality
of life, crime prevention, social exclusion and isolation. A step below there is an
area dedicated to specific actions and policies, for example housing, education,
water and sanitation and all the other activities which are linked with public health.
The third sector concerns lifestyle factors and it depends on the choices made by
the individual, but it is also strictly connected to the outer rings, which greatly
determine the behaviour of the population. The last sector shows that in each
individual there is a biological heritage that cannot be changed, which is
represented by sex and hereditary factors; age is also included in this sector as it is
an independent factor in human life.
This structure of the determinants of health is particularly useful to understand the
variety of actions that can be undertaken in the health sector. It also helps in
clarifying the reasons for the different definitions of health and why the various
approaches need to be organised and coordinated in a general and comprehensive
framework. All the sectors should be linked in order to guarantee a better if not
complete well-being for the beneficiaries of the health services.
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