Lecture assesses impact of violent conflict on public health

[Correction (Thursday, Feb. 7): The original version of this article stated that Khoshnood’s current research focuses on public health issues such as drug use. In fact, Khoshnood’s focus on public health issues includes the transmission of HIV/AIDS via drug use.]

[Correction (Sunday, Feb. 10): The headline of this article was changed from “Lecture assesses impact of violent conflict on mental health” to “Lecture assesses impact of violent conflict on public health” to accurately reflect the article’s contents.]

[Content Warning: This article discusses violent conflict and forced displacement.]

On Monday, Jan. 29, Yale School of Public Health Associate Professor of Epidemiology Kaveh Khoshnood spoke on violence and population displacement as issues of public health. Rachel Chernet ’19, a biochemistry major and President of the Vassar Foundation for International Medical Relief for Children (FIMRC), organized the evening’s event. Early arrivers gathered around a box of munchkins beneath the projector while Chernet conversed with Khoshnood, preparing the presentation. Attendees took their seats as Chernet walked to the podium in the room’s center to introduce the guest speaker.

Khoshnood began his lecture by explaining how his interest in public health emerged when he was a teenager, after having witnessed first-hand the effects of chemical warfare on civilian populations in Iran during the Iran-Iraq War. Unprecedented quantities of chemical agents were used against civilians, which resulted in approximately 60,000 casualties. For those who survived, the effects of blister and nerve agents lingered mentally and physically. Khoshnood’s research today focuses on violent conflict as the origin of public health issues, such as HIV/AIDS and its transmission via drug use. Khoshnood related, “I had a sabbatical in 2013, and I did not have any teaching obligations, so I decided to study that. In fact, one of the projects I’m working on right now in Lebanon is to what extent [those] in displaced populations turn to drug use and become infected with HIV/AIDs resulting from people sharing infected syringes.”

The lecture considered the ethical concerns associated with studying public health in post-conflict regions. How does one study the spread of HIV/AIDs in the tented settlements in Lebanon, when doing so could negatively impact many people’s ability to seek asylum? How does one offer preventative services and treatment without reinforcing negative stigmas about those receiving it? The way in which public health officials operate matters and history tells stories from which we should learn. Chernet later shared: “Something that really struck me from [Khoshnood’s] presentation was the statistics he presented on the ten deadliest conflicts in the 1990s. Their estimated deaths had a range as large as half a million people, likely due to the numerous indirect results of conflict. For instance, a family may be displaced to a neighboring country due to a conflict and therefore lose access to a medication needed for survival.”

Khoshnood also discussed the implications of The World Health Organization (WHO)’s vague definition of violence, which leaves room for individual interpretation of terms such as “intention” and “likelihood of harm.” Khoshnood elaborated on these nuances, saying, “[V]iolence is such a broad issue. It includes everything from self-directed violence like suicide, which is harm against oneself; it can be interpersonal, such as domestic violence; and then, it can be collective violence against groups of people.”

Likewise, structural violence, rooted in existing institutions that fail to protect people, is also ambiguous in its culpability. For example, when an infant dies because of a disease otherwise preventable by vaccination, there is no clear culprit. According to Khoshnood, this was the case during the various Central American Civil Wars that took place in the 1980s, when the infant mortality rate was 80 per 1000 live births in El Salvador, Guatemala, Honduras and Nicaragua—compared to 25 per 1000 live births in neighboring countries. Only when warring factions brokered a temporary ceasefire were The United Nations International Children’s Emergency Fund (UNICEF) and The Pan American Health Organization (PAHO) able to administer immunizations and humanitarian aid, after which the infant mortality rate dramatically decreased. However, providing such intervention has proven difficult in many of today’s active combat areas, such as those in Syria, because there are too many groups at war for safe-zones to be securely negotiated.

In an interview following the lecture, Khoshnood further commented on similarities and differences in violence between regions such as the United States, the Middle East and Central America. “One of the things I would say is that there are social determinants of violence, and there are deep socio-political causes that no one pays attention to,” he said. “This is one thing that is the same everywhere. Dealing with it at a superficial level won’t solve the problem.”

At the beginning of the Syrian Civil War, the Assad regime diverted funds from services such as vaccinations to reinforce the military state. A phenomenon referred to as brain drain crippled the previously robust health system as thousands of public health officials, including doctors, fled the violence. Sophie Schoenbrun ’22 remarked, “I had totally overlooked how displacement could cause a lack of access to vaccinations. It was also really concerning to learn that doctors and other professionals are the first to leave when there is a conflict, even though they are needed the most.”

The bombing of remaining health institutions became the new norm, as sites where medical aid is administered were purposefully targeted. Medical schools were shut down due to a lack of staff and resources. Syria’s future doctors turned to the United States for aid, and Khoshnood recounted how the faculty of Free Aleppo University restarted operations in 2015 with 500 students. Students attended classes in undisclosed locations and reached out to several American institutions to create online classes for medical specialization. In 2017, a former faculty member helped launch the Collaboration for Health in Conflict initiative with Harvard, Yale and the University of South Carolina. Despite attempts to undermine healthcare in a setting devoid of humanitarianism, these Syrian doctors show resistance and resilience. Schoenbrun observed, “Public health is, to me, a means of protecting already vulnerable populations, such as the displaced populations in the Middle East … There is so much complexity that comes with war that still needs to be studied and understood.”

Khoshnood ended the lecture with a quote, “You have to understand, that no one puts their children in a boat unless the water is safer than the land,” from the poem “Home” by British writer Warsan Shire. The lecture pointed out the painful ramifications of violence and forced displacement in both the short and long term. Rehabilitation is a treatment that public health officials and civilians alike contend for even years after a conflict. Chernet reflected, “[I feel] Vassar FIMRC…is a culmination of a lot of the hard work we have put into something we are all very passionate about. To see other people, and especially those from the younger classes here at Vassar, excited about global health and FIMRC’s mission makes me optimistic … I believe we will start thinking more about events we can do to really challenge the way we think about health.”

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