Development, Health and Conflict

Olympio Barbanti, Jr.

August 2004

Three Millennium Development Goals relate to health: the reduction of child mortality; the improvement of maternal health; and the reduction of HIV/AIDS, malaria, and other infectious diseases.

Millennium Goal 4 - Reduce Child Mortality

In the majority of developing countries, reducing child mortality rates can be achieved with quite simple and straightforward measures. For example, many children die from dehydration. In these cases, a simple home-made serum would be effective. Yet, this is often not done because high-tech solutions are preferred. In fact, most of the programs aimed at reducing infant mortality face enormous difficulties. One reason is the lack of sensitivity to native and traditional practices and beliefs. Local health interventions must pay special attention to local cultures and this requires special consensus-building approaches.

In many cases, development practice has been accused of transferring knowledge and technology to the so-called underdeveloped societies without paying enough attention to indigenous methods and knowledge. This is particularly clear in medical interventions designed to reduce child mortality. Often indigenous methods which are beneficial (or at least not harmful) are condemned or banned when outside medical aid is provided. This generates lack of trust, as people do not see their cultural traditions and practices as being recognized or honored. These identity issues often create serious conflicts, which prevent child mortality programs from being successful.

Two Examples

The Kangaroo Mother Care Program is an example. This local program suggests that babies should be carried next to an adult's chest, so the child can feel the parent's warmth and heartbeat. It has been reported that such care makes it less likely that the premature child will get ill or die. Yet this program is often not trusted by hospitals. According to Miriam Leno, the obstetric nurse responsible for implementing the Kangaroo program in two hospitals of Belo Horizonte city:

In a place where there is all the technological apparatus for premature babies' treatment, doctors prefer to keep premature babies in the incubator all the time. I think it is harder to implement a program such as the Kangaroo program, when there are adequate technological resources, even if the objective is exactly to incorporate the mother as a soft assistance technology with excellent repercussions for the baby's health.

Doctors have insisted on continuous incubator use, even though it has been proved that babies' mortality rates can be decreased by the simple "Kangaroo" approach. Effective childcare does not necessarily require expensive or complex technologies - but because such technologies exist, the simpler technologies are seen to be inferior and irrelevant. 

Similar problems have been faced by the Minas Gerais Health Department in training lay midwives. In some areas, lay midwives were reported to be forbidden from entering hospitals along with the pregnant women who they were attending. In the more secluded rural areas, lay midwives are responsible for assisting the childbirth. But in more complicated cases, they take the pregnant woman to a hospital in the nearest urban center. This is where they have been refused entry, as doctors and other health professionals do not recognize lay midwives' traditional knowledge. This causes distress to the rural woman and the midwives feel ill-treated. According to Ms. Leno:

The medical doctor thinks he is the only one who knows, who has the power of knowledge and then he is the only one who knows how to act. He doesn't believe in the mothers potential to know how to act and to learn how to act - and it all is more intense in the case of premature babies, because they need professional care for a long time.

Another example is illustrated by the pedagogical work of the Movimento Luta Pro-Creche (MLPC, or Pro-Nursery Movement). This is an NGO that works to strengthen public nurseries, helping them improve their work and be in a better position to work with the local government. According to MLPC, social workers attending children came from destitute origins, just like the children they serve. Therefore, they cannot see other possible futures for the children--they expect them to live their whole life as destitute people. The astonishing result is that poor people treat poor people badly. As Cintia Paixno, from the MLPC has narrated:

Because social workers usually come from the community and the nursery itself, they are people from the low classes that didn't have great opportunities, didn't have good education, didn't have professional training. Therefore, they end up reproducing not only the school model, but also the family model [in which they have lived]. Then, when you propose a new way of acting, they resist the change.

Identity Issues

Identity issues, thus, appear to be a main constraint to development assistance. This problem was mentioned in other interviews as well. Poor people, several respondents observed, do not see themselves as deserving better. So before changing social realities, it may be necessary to change the identities of those who work in social programs through empowerment. Only then will they see the possibility of change and be able to work for social progress and effective development.

There are also cases in which the identity of well-educated professionals, such as medical doctors, may be a major factor restricting change. For example, as illustrated above, there is a view that local technology is not as good as imported technology. While Western technology may sometimes be superior, local methods can be more cost-effective and appropriate.

However, development aid seldom comes alone. Developing countries are often obligated to buy products from the donor country or organization. This causes technological dependence and generates the view that imported technologies are better suited to local needs when they may not be. 

Millennium Goal 5 - Improve Maternal Health

There are direct linkages between economic factors and women's health. Since the beginning of the implementation of neo-liberal measures for the structural adjustment of developing countries' economies, it was clear that pervasive side effects would fall on women and children, among other vulnerable groups in society. Despite the world-renown UNICEF report on the theme (Cornia, Jolly and Stewart, 1987), women's health has not improved in any measurable degree. Rather, there is clear evidence that it has deteriorated in many countries and regions.

Causes of Health Deterioration

Globalization and Economic Insecurity

One major reason for the deterioration of women's health is the increasing globalization of the economy. New production and distribution standards have reserved the functions of technological development, planning, marketing and logistics for industrialized countries. Production has been largely transferred to developing countries, which now compete to lower production and transaction costs. This has resulted in widespread fragmentation of production chains, enormously increasing sub-contracting and employment insecurity. In order to lower costs, employers hire as many people as possible without signing working cards, which means that they do not have to pay benefits. This reduces costs, and allows for quick employee changes when companies need to meet the demands of a very competitive environment.

As a consequence, the informal employment has expanded quickly in developing countries. Examples of informal activities are street-peddlers, housekeepers, baby-sitters, wash women and many other service providers. Compared to the formal sector, informal sector salaries tend to be lower and job insecurity higher. An increasing number of women work in this informal sector. Typically, employers in the formal sector are less willing to hire women because their benefits are more costly mostly because of pregnancy and related expenses. This means that many women do not have any job security if they become pregnant, nor do they have maternity leave. Also, if a poor woman faces an income shortage, she will often deny herself food or medical care to enable her to provide for her children, even if it is extremely detrimental to her own health.

Cultural Barriers

Many times, women's health is aggravated because of cultural barriers that then create actual physical barriers. Reaching women for health campaigns can be difficult, for example, because many work in their own homes and their husbands forbid them from opening their doors to anyone. Thus, health workers cannot reach them and the women are more vulnerable to domestic violence. In a number of developing countries, such isolation is culturally accepted and justified. 

Maternal Health

The specific Millennium objective is to reduce maternal mortality by three quarters, between 1990 and 2015.  Virtually all countries now have safe motherhood programs, but according to UNDP, maternal mortality is still a major problem in African countries. Overall, in the developing world, the risk of dying in childbirth is one in 48.

In other developing countries, the problem of death at childbirth is not as high, but there are other issues. In Brazil, for example, there is a great increase in the number of unnecessary cesareans. Obstetric nurse Miriam Leno attributes this to a culture which values Western concepts of beauty so highly that many women commonly undergo plastic surgery to improve their appearance. Cesareans are just seen as an extension of that. She says:

In Brazilian culture, women today take great risks only to satisfy a beauty requirement. They undergo plastic surgeries to put something in, to take something out, to everything. Then, how can you expect these women to refuse undergoing a Cesarean if they think it is unnecessary? They don't have the body integrity culture; they don't claim this right.

This behavior also brings about social policy problems. Brazil has an astonishing rate of cesareans--85% of births in Brazilian private hospitals and 35% in public hospitals. Cesareans are more expensive for hospitals and further, this practice may harm both the mother and the baby.

On the other hand, there are also cultural barriers which prevent changing traditional practices. In the more rural areas of the country, childbirth is done by lay midwives who use procedures based on superstition. According to nurse Marcia Rovena, in these areas, the lay midwife puts the bloodied thread cutter used for cutting the umbilical cord under the baby's pillow to give luck. Unfortunately, it may give the baby problems instead.

Millennium Goal 6 - Combat HIV/AIDS, Malaria and Other Diseases

Brazil, together with the Netherlands, has one of the most advanced programs for sexually transmitted diseases (STD) and AIDS prevention in the world. To achieve this, it was necessary to overcome existing social prejudices and intergroup conflicts, especially those between health professionals and the public sector. From health professionals' perspectives, it was necessary to take socially difficult measures, such as distributing condoms to the general population and syringes to drug addicts. These are very controversial measures because they involve moral values about right or wrong behavior. Many public officials were apprehensive about adopting such measures because they feared negative political consequences.  

This fear was largely overcome, however, with the introduction of the concept of bioethics. Bioethics stresses the importance of autonomy, non-malevolence, benevolence and justice (equity of treatment). In other words, official programs should be guided by the idea that they cannot oblige anyone to stop doing anything, so they must minimize their risks. Also, no one should be excluded of the program because of their behavior. Furthermore, social programs should be implemented as long as they lead to benefits and do not cause harm.

This new theoretical concept enabled the politicians to reframe the situation, thereby resolving their conflict with the health practitioners. This has important implications for other areas of conflict knowledge because it is a recent and compelling example of a major change in the way a large and quite visible social problem was reframed and thus solved. The lesson that can be extracted from this example is that reframing may need more than improvements in communication and may require a deeper theoretical reconceptualization.

This does not mean to say that communication is not important. In fact, combating diseases like HIV/AIDS, malaria and tuberculosis requires raising the population's awareness, as well as empowering vulnerable social groups such as women, adolescents, homosexuals, transvestites, and prostitutes. As stated by Ms. Mazzili, coordinator of Belo Horizonte City Program on HIV/AIDS Prevention, serious infectious diseases spread rapidly among these groups because of their lack of power. Even though they are aware of how important it is to use condoms, for example, the women do not have the power to insist on condom use. That is the reason why the first step of their program is to empower them via workshops about their rights, ethics, and solidarity (among other factors), in order to change their view of the situation and their options.

However, such empowerment may not work for cultural reasons. According to Carmen Mazzili, there is a sexist culture in Brazil, which prevents public policies from being effective, especially when it comes to sexual behavior. This was exemplified by the distribution of syringes to addicts. A change in culture is needed not only among members of society in general, but also among public servants. They too, had to be convinced that syringe distribution was ethically right.

Sometimes the ethics gets difficult, however. Ms. Mazzili explained her surprise when she learned that public efforts to encourage prostitutes to use the female condom actually led to more violence.

"I participated in an event in Rio when the female condom was launched. Everybody was thinking it would save women, because they would not have to negotiate safe sex with their partners. Rather, they would protect themselves. Then what happens? In the audience there was the president of the Sex Professionals' Association from a Brazilian city. She stood up and said: "All you are saying is crap. We wear the condom but men take it out. They beat us up and they take it out. What power do we have? None."

Structural Aspects of Society and the Economy

Another main cause of health problems is due to the structure of society and the economy. Poor people do not have enough money to buy condoms or medicines. They cannot go to health-education workshops, even if they are free, because they cannot pay the transportation costs to get there. Even health workers sometimes shun workshops. Lay midwives, for example, do not trust the government workshops because they know the government does not trust or value them. 

Public participation, which is an essential step for consensus building, may then be precluded not only by lack of trust, but also buy lack of financial resources. In developing countries financial constraints can be a major impediment for conflict resolution practices, as participation becomes very expensive when it is necessary to gather people from rural areas and to pay for meals and transportation. Donors that recommend participation within their development projects are often very reticent when they see the actual cost figures of planned participation.

The development gap between rural and urban areas is also a factor that fosters inequalities, on the one hand, and concentrates wealth, poverty and diseases on the other. In fact, half of HIV positive people of Minas Gerais state are in its capital city, says Ms. Mazzili. That raises conflicts about social responsibility and economic viability. Belo Horizonte City's Health Department is overwhelmed with HIV positive people who are not originally from the city. This happens, in part, because there is a concentration of health services in the city, but also because in large towns HIV-positive people can live in anonymity, escaping the prejudice they would face in smaller urban centers or rural areas.

Relationships and Trust

It also became clear in the research that those working with social policies must have special communication skills based on technical knowledge, but also on sensitivity, intuition and presence. They need to be able to establish a trust-based relationship to get access to the beneficiaries they intend to help. In addition they also need adequate time and money. 

The balance between technical knowledge and sensitivity is a difficult one and the great majority of public servants are not prepared. A great deal of conflict could probably be avoided, or reduced, if people were trained for this task. Developing countries' societies tend to be more traditional. In many cases, people are firmly attached to folk beliefs that have not been proved by science. This brings about a great deal of conflict, as development aid and government programs are most often based on rational, standardized procedures that come into conflict with and do not recognize local belief systems or practices.

Use the following to cite this article:
Barbanti, Jr., Olympio . "Development, Health and Conflict." Beyond Intractability. Eds. Guy Burgess and Heidi Burgess. Conflict Information Consortium, University of Colorado, Boulder. Posted: August 2004 <>.

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