Social Science & Medicine 70 (2010) 16
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Social Science & Medicine
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Introduction
Conict, violence, and health: Setting a new interdisciplinary agenda
An interdisciplinary scope of enquiry
Conict and violence are injurious to health simply to validate
this statement would hardly warrant new research time and money
or dedicated space in this journal. Yet issues related to the physical,
emotional, and social consequences of violence still need to be
pushed to the very top of international, national, and local public
health agenda. We know that conict and violence, as manifested
in militarized and interpersonal violence, can produce major phys-
ical, mental, and social scars. But how these might be prevented,
mitigated, or even healed by effective interventions is less clear,
and requires the input of interdisciplinary and comparative
research. We called for papers for this special issue to showcase
a broad range of empirical and theoretical work on conict,
violence, and health, across social, clinical, public health, and
humanitarian elds. To promote interdisciplinary and international
collaboration, three journals Social Science & Medicine, The Lancet
and the Journal of the Danish Medical Association are producing
their own special issues on this theme, to coincide with Global
Response 2010, a conference organised by Global Doctors and inter-
national partners.1
The aim of this special issue of Social Science & Medicine is to
review the quality and robustness of evidence to-date and to eval-
uate the relevance of conceptual understanding regarding relation-
ships between conict, violence, and health in order to assess
whether current frameworks guiding research and practice are
properly contextualised and theoretically informed. We follow
the remarkable examples of the Commission for the Social Determi-
nants of Health (WHO, 2008), which reviewed evidence on social
and health inequalities on a regional and international scale, and
the New Movement for Global Mental Health (Lancet, 2009), a call
for action to strengthen the evidence base and scale-up the provi-
sion of mental health services. These publications have showcased
determinants of ill-health that are patently avoidable, unnecessary,
and unfair, necessitating political will and concerted action to meet
the human rights objectives of equitable access to health. As high-
lighted in this special issue, the linkages between violence and
health are complex, hinging upon forms of violence that are both
spectacular and mundane; policy-making and collective health
interventions need urgent evaluation and systematic review, given
some political blind spots, fragmented lines of evidence, critical
resource scarcity, or fragile governance; and nally, research and
1
Global Response 2010: International Conference on Violent Conict and Health. See
http://www.global-doctors.org.
0277-9536/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2009.10.022
intervention frameworks for understanding the linkages between
violence, wellbeing, gender-based and social adversity need to
transcend some common limitations.
Violence has prompted analysis and advocacy across diverse
disciplines that usually focus on different research questions and
different standards of acceptable evidence. We outline, within the
broad remit of this special issue, three intersecting lines of enquiry.
The rst has been to ask what are the impacts of violence, and which
risk and protective factors mediate short- and long-term impacts
on health. The second is to ask how suffering is articulated, why
certain types of violence have particular signicance, and in what
contexts individual and collective resilience can efface the scars of
violence. A third asks what type of action upstream, at a global
policy level works best to promote downstream, at a local level
effective, sustainable, and equitable health. The trick is to bridge
these perspectives, elicit a broad set of questions and draw answers
using more than one methodology, to provide more than a single,
narrow window on reality. We hope that the papers in this special
issue will attract interest from social and political scientists, epide-
miologists, public health professionals, and critical analysts of
health systems and development policy. We feature nineteen
contributions, grouped into three main domains: (a) violence in
the context of war; (b) social justice, politics, and public health;
and (c) interpersonal violence and social contexts. In this introduc-
tion, we summarise the main research questions and ndings,
highlight their critical contributions, and outline future directions.
Violence in the context of war: reviewing the evidence
A rst set of seven papers have addressed the following ques-
tions: what are the critical determinants of poor mental or physical
health in conict and post-conict settings, and important gaps in
current knowledge? How does this understanding impact interven-
tions, and why does this matter for research and practice in war-
affected populations?
Miller and Rasmussen (2010) provide a thoughtful review of pub-
lished work conducted in Afghanistan, Algeria, Chad, Lebanon, Sri
Lanka, and the West Bank, with the aim of clarifying the links between
war experiences, daily stressors, and mental health in conict and
post-conict settings. For some scholars and practitioners, it is
evident that daily stressors (linked to economic hardship, social
isolation, family violence, and breakdown of basic services) are
strongly associated with poor mental health, particularly distress
and depression. For others, it is gospel that exposure to war-related
violence is the critical factor, particularly in the genesis of Post-Trau-
matic Stress Disorder (PTSD) such that daily stressors might
2 Introduction / Social Science & Medicine 70 (2010) 16
aggravate the impact of war, but not, in themselves, cause mental
health problems in the clinical range. Miller and Rasmussen (2010)
squarely refute the latter view: in war-affected settings, not all
distress or trauma is directly related to armed conict, and this is
because of a considerable backdrop of structural violence affecting
mental health and social functioning in everyday life. Regression
analyses show that only a small proportion of the variance in PTSD
symptom severity is directly related to exposure to military violence,
while other stressors, many of them exacerbated by armed conict,
may have more predictive power than war exposure. The authors
make a strong case for discarding simplistic models that give undue
emphasis to exposure to political violence at the expense of poverty,
social marginalisation, and political exclusion. This has profound
implications for the scope and relevance of trauma-focused and
psychosocial interventions. We note the growing consensus in the
literature that several layers of interventions are needed in emer-
gency and post-conict settings targeting both war-related trauma
and local community resilience (IASC, 2007). Provocatively, Miller and
Rasmussen turn the habitual approach to intervention on its head:
they propose that daily stressors should be addressed rst, in being
more amenable to change than exposure to war, followed by special-
ized interventions for individuals whose scars do not abate with the
repair of the economic and social fabric of society.
The importance of clarifying the direct and mediated effects of
war is also the theme of Betancourt, Agnew-Blais, Gilman, Williams
and Ellis (2010) prospective study on child soldiers in Sierra Leone,
which demonstrates that present struggles, such as experiences
of social discrimination, shape psychosocial adjustment over and
above the impact of past horrors associated with the war. Thus
social stigma is one important pathway mediating the impact of
war-related violence on mental health outcomes. To social scientists,
this statement is unsurprising, but it is certainly worth noting that
stigma was not reported by one-third of ex-combatants interviewed
in this study, four years after the cessation of a deeply divisive war,
and that stigma was associated with poverty and gender, not just
with identication with armed forces. This paper demonstrates
that post-conict experiences of discrimination in local communi-
ties largely account for the relationship between increased hostility
and perpetration of certain types of war-related atrocities, such as
wounding or killing, while stigma also mediated the relationships
between increased depression and surviving rape. To researchers
who realise how difcult data collection might be in one the poorest
countries of the world devastated by civil war, this study is exem-
plary in being one of the rst prospective studies of male and female
child soldiers ever conducted, and in providing robust evidence of
the signicance of social ecology in mediating the scars of war-
related violence.
Social ecology is the framework espoused by Moscardino, Scri-
min, Capello and Altoe` (2010) to investigate how social support,
cultural values, and sense of community mediate the psychological
impacts of a terrorist attack. Based on data collected 18 months
after the 2004 hostage-taking and school massacre in Beslan,
Russia, this study uses path analyses to highlight gender differences
and the relative role of family vs. peer support in mediating associ-
ations between cultural ideology (the endorsement of communal,
collectivist values) and depressive symptoms. This is a good
example of how sophisticated statistical tools help appraise the
extent to which protective resources shape adolescent mental
health over time, with attention paid to how gender expectations,
shaping reliance upon a wide range of sources of social support,
might enhance the relevance of youth-focused interventions.
Tol, Kohrt, Jordans, Thapa, Pettigrew, Upadhaya and de Jong
(2010) provide a landmark review of existing literature on mental
health and political violence in Nepal, highlighting key issues that
transcend the specic context of the impact of a protracted Maoist
insurgency on civilian populations and the plight of tortured refu-
gees from Tibet and Bhutan. Echoing some of the points made in
the above papers, the authors call for the kind of interdisciplinary,
longitudinal, and multi-level research that would inject greater
conceptual breadth and methodological rigour in mental health
research and intervention, and help to bridge social and medical
approaches. The theoretical framework presented associates polit-
ical violence with several layers of social contexts and psycholog-
ical consequences in order to explicitly link the disruption of social
structures with impaired wellbeing, psychological distress, and
mental health disorders. This provides room for identifying several
problematic gaps in current evidence; one is the scarcity of studies
on the salutogenic factors that promote wellbeing, including
agency and community support, while another is the appraisal of
a range of therapeutic treatments for common and severe mental
disorders, including faith healing, primary care, and clinic-based
care.
An excellent example of holistic, comparative, and long-term
research is provided by Pike, Straight, Oesterle, Hilton and Lanyasu-
nya (2010) in their work on the small wars of nomadic pastoralists
in Kenya. Their detailed ethnographic approach is conceptually
informed by anthropological work on the embodiment of violence
and the inexpressibility of pain and terror etched in everyday life,
creating both emotional and physical suffering. This is balanced
with epidemiological work focusing on social and health inequal-
ities at a population-level, unpacking how livelihood strategies
lead to maternal-child health differentials and how social
responses to violence lead to observable shifts in health experi-
ences. The study addresses itself to an interdisciplinary readership,
by examining the costs of violence from a biosocial and public
health perspective, while raising issues of advocacy and human
rights engagement.
Taking a specic focus on child survival and health, Avogo and
Agadjanian (2010) examine the short- and long-term consequences
of forced migration in Angola, drawing on survey data collected in
peri-urban Luanda two years after the cessation of three decades of
civil war. Time-sensitive hazard models are used to compare war
experiences and migration status, in which key predictors of child
health are postulated to be war migration, non-war migration,
and non-migration. The study supports general expectations that
forced migration places children at an immediate mortality disad-
vantage relative to non-displaced populations, but shows mixed
evidence in the longer-term, as refugee populations come to
resemble other migrants and host populations in health proles.
The study points to the heterogeneity of population groups and
health outcomes in conict zones, although we caution that
distinctions between war-related and non-war-related migration
might be heuristically simplistic.
Turning our attention to medical services, Varley (2010) offers
a critical ethnography of obstetric services at the height of the 2005
tension times in Gilgit town, capital of Pakistans Northern Areas,
where ShiaSunni relations have been marked by nearly three
decades of sectarian hostilities. Her analysis of identity or cultural
afliation in the context of sectarian violence is highly relevant to
current understanding of health risks and service provision in other
war-affected countries, such as Iraq and the Occupied Palestinian
Territories. She describes the devastating politics of childbirth in
embattled multi-sectarian settings, in that Sunni physicians were
named on Shia hit-lists and Sunni women had severely limited access
to obstetric care (for fear that the men, who took women to hospital
and waited outside until birth, would be vulnerable to Shia attack).
While unable to estimate excess mortality due to sectarian conict,
the author demonstrates a dramatic drop in access to care, due to
many fewer self-referrals to maternity hospitals for Sunni women
relative to Shia and Ismaili patients, set against the backdrop of high
 Introduction / Social Science & Medicine 70 (2010) 16
pre-existing maternal mortality ratios. In a region where hospital-
based deliveries were common as a result of intensive biomedical
development by the Agha Khan Health Services, conict within
Muslim sects had striking repercussions on medical practices and
access to care. As highlighted in this ethnography, the consequences
of interrupted access to care, as a consequence of identity proling,
is part of the collateral damage of war.
Overview
These papers demonstrate the value of analyses that strive for
conceptual breadth, methodological rigour, and critical examina-
tion of contextual and time-dependent relationships between
violence and health in war settings. They offer several levels of
analyses, drawing strength from contextual, longitudinal, and
holistic appraisals of the direct and indirect consequences of
violence, the relative salience of past and present events, and the
social and culturally dened factors that shape physical and mental
health. We highlight here a shift of paradigm that will affect
research and humanitarian action. Just as in the eld of nutrition,
where interventions to save children from the dramatic effects of
famine had displaced attention and resources from a global silent
emergency of chronic malnutrition (UNICEF, 1998), spectacular
forms of military violence have hitherto detracted attention from
the enduring but mundane emergency of poverty and marginalisa-
tion, a form of everyday violence no less noxious to physical,
emotional, and social wellbeing. The work of social scientists has
made a critical contribution in this respect (Boyden & de Berry,
2004; Das, 2007; Desjarlais & Kleinman, 1997; Farmer, 2004;
Kleinman, Das, & Lock, 1997; Scheper-Hughes, 1996). The papers
in this special issue help to build a more nuanced and relevant
understanding of violence and the pathways through which
violence has critical health consequences.
Social justice, politics, and public health: decision-making
agendas
The literature on violence and health cuts across may different
academic and policy-oriented elds of research. This second set of
papers includes several theoretical papers that make the plea for
a more logical structure with which to organise evidence and
formalize the scope of potential interventions. What policy-relevant
frameworks exist with which to map decision-making during conict
and during the process of social, economic, and political reconstruc-
tion? What do specic types of interventions seek to achieve, and
how to they measure up when evaluated from the standpoint of
potential beneciaries in matters of health? We begin with papers
that specically examine how policy-makers and humanitarian
agencies approach health care delivery in post-conict zones.
De Jong (2010) presents a public health framework to prevent
armed conict and its consequences. He offers a 3  3 matrix to
systematise our understanding of global and local interventions
addressing the risk and protective factors related to political violence.
Across rows are featured three categories of interventions sensitive to
the time-course of conict: actions to prevent the emergence, to
shorten the course, and to prevent chronic recurrence of full-blown
armed conict. Across columns feature three types of initiatives, at
international or state-level, local community level, and family and
individual-level. This framework benets from being concise, yet
comprehensive, in integrating the political, economic, social, educa-
tional, humanitarian, and military elements needed for alleviating
or preventing the manifold consequences of collective violence. The
matrix is formulated with the view of stimulating wider debate across
disciplines, without specifying who would have responsibility and
oversight in developing comprehensive initiatives, or how these
3
might be evaluated for efcacy and effectiveness. This is a bold step
towards systematization away from small-scale or tunnel vision in
conceptualising the scope of health-related interventions.
Bornemisza, Ranson, Poletti and Sondorp (2010) tackle the issue
of health inequity in conict-affected fragile states, arising from
ill-conceived or exclusionary economic and social policies of the
kind highlighted by the WHO (2008) and World Bank (2005).
Some 46 countries are fragile states, about half of them affected
by conict. The authors focus attention on the fragility of state
governance exacerbating the baseline determinants of health
inequities. They also propose a 3  3 matrix of interventions: one
category highlights political commitment in promoting policies
that are explicitly pro-equity; a second concerns building health
systems in ways that strengthen equitable service capacity; the
third is about removing barriers of access to care, such as user
fees. They highlight the imperative to devise national health policy
frameworks at the very beginning of the post-war reconstruction
process, as was done in Afghanistan with the implementation of
a Basic Package of Health Services.
The paper by Kruk, Freedman, Anglin and Waldman (2010)
addresses issues related to equitable health systems and gover-
nance in countries affected or recovering from conict, taking as
its starting point the WHO-designated building blocks deemed
essential for functioning health systems (WHO, 2007). Early invest-
ments in the health system are crucial not only for promoting
health, but also for promoting peace, in establishing the foundation
of a resilient state. Their review of the literature encompasses work
in the humanitarian community that promotes health as a bridge
to peace and critical analyses of health systems as core social
and political institutions. Thus health systems and health policies
are the face of a state, just as much as are the police, judiciary,
or military institutions. Good governance in health communicates
a degree of competence, stability, and trustworthiness of govern-
ment capacity the authors argue that the steps specifying how
to revise health systems in post-conict countries require urgent
cross-disciplinary research.
Pham, Vinck and Weinstein (2010) take these issues one step
further: they link post-conict transitional justice, the aims of
which is improved peace, with public health and social reconstruc-
tion, the aims of which are improved wellbeing and social order.
The authors ask a pertinent question: can we make the assumption
that mechanisms of transitional justice, such as trials, truth
commissions, amnesty, and reparation programs, reverse or miti-
gate the deleterious health consequences of war? Their framework
identies short- and long-term health-related goals of transitional
justice as well as ways to evaluate these goals with measurable
indicators. Here too is a call for more systematic research, speci-
cally to evaluate the claim that transitional justice does improve
societal and individual health. The proposed model links trauma,
transitional justice, and health effects as a basis for evaluating
multi-level interventions aiming to promote social reconstruction
and individual healing. Taking two case studies, eastern Democratic
Republic of Congo and northern Uganda, the central aim of this
paper is to discuss how health outcomes can inform on the design
and effectiveness of social justice and reconstruction in countries
affected by mass violence.
The critical ethnography authored by James (2010) provides
a feet-on-the-ground evaluation of such issues, in tackling the
complexity of constructs such as social suffering, compassion, transi-
tional justice, trust, therapy, and advocacy. In Haiti, there is a distinc-
tive lack of moral compass, as poverty and powerlessness exacerbate
the insecurity of armed conict and the brutality of gang violence.
James presents a case study in which senseless violence is a horror
that has been recounted several times to different audiences: publi-
cally re-enacted and stage-performed for truth commissions;
4 Introduction / Social Science & Medicine 70 (2010) 16
therapeutically elicited in a clinic to help the victims of violence; and
spontaneously narrated in local community settings to elicit compas-
sion. This is a disturbing paper, in focusing attention on a given person,
in learning that truth merges with un-truth in narratives of trauma,
and in confronting ethical and moral issues arising from the authors
three roles as researcher, activist, and therapist in the community.
De Waals paper (2010) addresses a body of work that turns the
above questions on their head addressing the impacts of a health
crisis on security and governance, rather than the impacts of armed
conict on health. It provides a synthesis of some 29 studies
commissioned by the AIDS, Security and Conict Initiative in
2005, to investigate the impact of a HIV/AIDS hyper-epidemic on
state security, functioning, and governance. This initiative was
born from fear and alarmist views that an HIV epidemic would
sweep through societies, precipitating not just a social crisis, but
a political crisis, by debilitating governance and precipitating losses
of military personnel to the point of state non-viability. One
dramatic case scenario is illustrated by the case of Swaziland,
where the hyper-endemicity of HIV/AIDS alongside weak gover-
nance and other social and economic stressors creates a perfect
storm for a new kind of humanitarian emergency. A review of
the evidence, however, leads to a largely negative nding: in hind-
sight, HIV/AIDS is simply not the type of health crisis that causes
a fragile state to fail. De Waal argues that this negative nding
deserves critical examination: for instance, the role of police and
military forces on HIV/AIDS control is still an underdeveloped
research agenda. The paper provides a strong critique of narratives
of fear and doomsday scenarios that existed with respect to HIV,
and also challenges some widespread assumptions of HIV preva-
lence in the wake of war, leading us to reect on how the power
of politics and blunt expectations frame our requirements for
evidence.
A powerful analysis of state policy, coercive detention, police
crackdowns, and other means of regulating prostitution and
curbing epidemics of sexually transmitted infections, along with
their dramatic social and health impacts, is offered by Tucker, Ren
and Sapio (2010) in an analysis of sex worker policies in China.
Through the lens of medical anthropology, public health, and the
law, the authors discuss the implications of state sex worker poli-
cies on sexual health and risk taking, using a framework of social
suffering to understand the draconian detention of sex workers in
re-education through labour camps. To drive home the argument,
the paper provides a case study comparing syphilis and HIV preva-
lence across sexually transmitted infection clinics in cities with and
without labour detention camps in the Guangxi Autonomous
Region. The paper offer rich insights into the cultural and institu-
tional force of social relationships, health services, and state struc-
tures in China.
Overview
One common strand offered in these papers is a clear demon-
stration that health-related matters are closely interlinked with
politics. Health, as a commodity, is hardly value-free, even when
social and political will makes health equity a social priority. Health
is to be carefully wielded as a principled instrument of foreign
policy (Horton, 2006), while trauma has become a central discourse
authenticating suffering and human experiences of war-related
terror and reparation (Fassin & Rechtman, 2009). This set of papers
focuses attention on upstream factors (such as the fragility of state
governance and specic political agenda) as the drivers of health
outcomes and health inequities. Several levels of analyses demon-
strate how human lives, physical, and emotional health intersect
with social, political, and public health initiatives.
Interpersonal violence and social contexts: relevance to policy
The third set of papers offers analyses of interpersonal violence
in relatively stable settings as in the US, India, and Jordan, as well as
war-affected settings in Uganda and Kenya. Leading this type of
enquiry are basic questions such as: what risk factors are salient
in experiences of reported violence? More sophisticated questions
also lead us to evaluate the nature and quality of evidence, the
articulation of gender-based violence in family and community
contexts, and relevance for policy.
Fletcher (2010) presents a quantitative study focusing on one of
the largest datasets collected on adolescent health in the US the
Addhealth study. It demonstrates what we might perhaps already
come to expect: a number of respondents with relationships during
adolescence experience injury as a result of partner violence. It also
shows what we would not expect: among the sexually active
sample, there are no gender differences in reported experiences
of violence, contrary to studies published elsewhere. An explana-
tion of why this nding occurs is not presented, but we may suspect
either a cohort-specic effect, reecting social change in normative
gender roles as a new generation steps into adulthood, or the possi-
bility that commonly used measures of partner violence do not
capture the range of gender-specic patterns of fear, intimidation,
and control. The strength of the work is to provide rigour of the
kind quantitative research does best, in overcoming potential sour-
ces of bias arising from unsystematic sampling and in correcting for
confounding factors in multivariate analysis. This kind of rigour is
necessary, for guiding social policy.
The paper by Krishnan, Rocca, Hubbard, Subbiah, Edmeades and
Padian (2010) also uses a prospective design on a relatively large
sample of young married women in southern India. The authors
focus on the impact of one main variable changes in spousal
employment on risks of domestic violence, described as stagger-
ingly high across the Indian subcontinent. The odds of violence are
demonstrably raised as women enter employment over the period of
study, and raised also for those women whose husbands experience
unstable employment. Here is a good demonstration of the dark
underbelly of social change some policies explicitly seek to
empower women to enter the work force, but without embedding
initiatives within the wider context of domestic and social relation-
ships, this might well serve to exacerbate conict, tension, and
violence in the home as habitual gender roles are recongured,
particularly for low-income families.
In Jordan, Clark, Silverman, Shahrouri, Everson-Rose and Groce
(2010) specically examine the role played by the extended family
in raising or minimising the risks of intimate partner violence. This
is surely a neglected issue, yet one highly relevant to the Arab world
and other societies where couples do not function, socially or resi-
dentially, in separate nuclear units, but live with or within reach of
their extended relatives. This paper elegantly combines focus group
discussions on norms and responses to domestic violence, with anal-
ysis of reported experiences of violence for a random sample of
participants contacted through reproductive health clinics. Several
important issues are raised regarding the lifelong relevance of
both natal and marital kin in shaping womens risk of partner
violence, which highlight how gender relations (and interpersonal
violence) are reproduced across generations.
Gender-based violence is a critical concern both during and
following war and forced displacement. Annan and Briers paper
(2010) examines the linkages between gender-based violence and
armed conict through the narratives of young women abducted by
the Lords Resistance Army (LRA) in Uganda, a qualitative study under-
taken alongside systematic quantitative data collection on types of
violence experienced. This paper highlights the signicant exposure
to violence and abuse within homes and local communities that
 Introduction / Social Science & Medicine 70 (2010) 16
some women experience, after leaving the LRA. It articulates the
structural factors (such as poverty, interrupted education, corruption
in legal accountability, limited money-making activities channelled
into selling alcohol) that perpetuate conict, social frustrations, and
competition for basic resources in the context of harsh poverty. It
thus advocates the need for a deeper understanding of forms of
violence, which might engender a more comprehensive programme
of social reform. The authors conceptual framework resonates with
recommendations of other papers described above, in drawing atten-
tion to social ecology and in positing several layers of adversity indi-
vidual, family, societal factors that necessitate several layers of
targeted interventions.
Finally, Horn (2010) addresses the important issue of the articu-
lation between traditional community structures and international
agencies such as UNHCR, and the respective effectiveness of social
interventions in tackling intimate partner violence. Her research
takes place in the Kakuma refugee camp in Kenya, where at the
time of study some 96,000 people were squeezed into harsh condi-
tions and their livelihoods were stymied by wage-work regulations
and geographical adversity. How does this community limit or regu-
late intimate partner violence? A hierarchy of responses is in place:
from silence for a wife beaten under locally acceptable conditions,
to the intervention of family and community elders where beating
extends from the spouse to the children, and to leap-frogging over
traditional mechanisms to call at the door of a UNHCR gender pro-
gramme for battered women. The author raises a number of
critiques of UNHCR policies, charged with limited effectiveness
despite aiming for womens empowerment, participatory
approaches, and community-based work. There are immense chal-
lenges of implementing, in large refugee camps, policies that meet
the criteria of social justice and health promotion.
Overview
These papers critique the contexts in which interpersonal
violence ares up yet could be prevented. They urge attention to
context, and also to tipping points such as changes in employ-
ment, the severity of abuse, the presence of children which can
dramatically raise or lower the risks of partner violence as well as
the nature of community responses within relatively stable or
war-affected settings. All papers speak to violence affecting gender
relations in specic population groups, and touch on important
issues of social norms and social change.
Conclusions: three recommendations
We know that violence creates unacceptable spirals of pain and
disadvantage for men, women, and children. In this special issue,
a call has been made for espousing models that eschew conceptual
narrowness and analytical navete, when evaluating which risk
factors are the most critical determinants of ill-health, as well as
which steps to take to appraise the effectiveness of health-related
policy. The next step our recommendation for a forthcoming
research agenda relevant to violence and global health would
be threefold.
First, we recommend an interdisciplinary review of the effective-
ness of interventions that would prevent or minimise violence, and
that would heal physical and emotional suffering, in settings of
collective and interpersonal conict. In short, what interventions
work best, under which conditions, for whom, with what resources,
and why? Such a review would offer a solid picture rather than
piecemeal evidence on key intervention priorities. Second, we
think that an interdisciplinary review on resilience, as opposed to
risk and vulnerability in negotiating conict and violence, is now
timely. This would focus on the processes that help individuals,
5
families, communities, and state structures negotiate good health
despite exposure to recurrent violence. Resilience is the next fron-
tier knowledge in the eld of violence and health: much of the
literature to-date, especially in conict settings, hovers around
this intuitively useful construct without specic articulation or
explicit comparison across social, economic and cultural settings
(Hobfoll et al., 2007; Pedersen, 2002). In brief, we need to know
under what conditions specic social, political, and health inter-
ventions work best to efface the scars of violence. Third, given
the volume of humanitarian activity responding to conict and
violence globally, research needs be prospective, holistic, and linked
to policy. Such research will require interdisciplinary synthesis to
remove the disciplinary fault lines of academia and bridge the
distance between academic and humanitarian concerns, which
arguably constrains the breadth and depth of student training,
the scope of research funding, and the publication content of
reputed international journals.
This special issue, in featuring a set of relatively diverse articles,
makes a clear case in favour of stronger conceptual models that
allow us to transcend narrow discipline-based interests in disorder
and suffering, physical and mental wellbeing, health systems and
individual experiences. It also argues in favour of longitudinal
and mixed-methods approaches that will both strengthen the
evidence base for epidemiology and public health policy, and take
a critical stance with respect to cultural meaning and relevance.
References
Annan, J., & Brier, M. (2010). The risk of return: intimate partner violence in
Northern Ugandas armed conict. Social Science & Medicine, 70(1), 152159.
Avogo, W. A., & Agadjanian, V. (2010). Forced migration and child health and
mortality in Angola. Social Science & Medicine, 70(1), 5360.
Betancourt, T. S., Agnew-Blais, J., Gilman, S. E., Williams, D. R., & Ellis, B. H. (2010).
Past horrors, present struggles: the role of stigma in the association between
war experiences and psychosocial adjustment among former child soldiers in
Sierra Leone. Social Science & Medicine, 70(1), 1726.
Bornemisza, O., Ranson, M. K., Poletti, T. M., & Sondorp, E. (2010). Promoting health
equity in conict-affected fragile states. Science & Medicine, 70(1), 8088.
Boyden, J., & de Berry, J. (Eds.). (2004). Children and youth on the front line. Oxford:
Berghahn Books.
Clark, C. J., Silverman, J. G., Shahrouri, M., Everson-Rose, S., & Groce, N. (2010). The
role of the extended family in womens risk of intimate partner violence in
Jordan. Social Science & Medicine, 70(1), 144151.
Das, V. (2007). Life and words: Violence and the descent into the ordinary. Berkeley:
University of California Press.
de Jong, J. T. V. M. (2010). A public health framework to translate risk factors related
to political violence and war into multilevel preventive interventions. Social
Science & Medicine, 70(1), 7179.
de Waal, A. (2010). Reframing governance, security and conict in the light of HIV/
AIDS: a synthesis of ndings from the AIDS, security and conict initiative.
Social Science & Medicine, 70(1), 114120.
Desjarlais, R., & Kleinman, A. (1997). Violence and well-being. Social Science & Medi-
cine, 45(8), 11431145.
Farmer, P. (2004). An anthropology of structural violence. Current Anthropology,
45(3), 305317.
Fassin, D., & Rechtman, R. (2009). The empire of trauma: An inquiry into the condition
of victimhood. New Jersey: Princeton University Press.
Fletcher, J. (2010). The effects of intimate partner violence on health In young adult-
hood in the United States. Social Science & Medicine, 70(1), 130135.
Hobfoll, S. E., Watson, P., Bell, C. C., Byrant, R. A., Brymer, M. J., Friedman, M. J., et al.
(2007). Five essential elements of immediate and mid-term mass trauma inter-
vention: empirical evidence. Psychiatry, 70(4), 283315.
Horn, R. (2010). Responses to intimate partner violence in Kakuma refugee camp:
refugee interactions with agency systems. Social Science & Medicine, 70(1),
160168.
Horton, R. (2006). Iraq: time to signal a new era for health in foreign policy. Lancet,
368, 13951397.
IASC. (2007). Guidelines on mental health and psychosocial support in emergency
settings. Geneva: Inter-Agency Standing Committee.
James, E. (2010). Ruptures, rights, and repair: The political economy of trauma in
Haiti. Social Science & Medicine, 70(1), 106113.
Kleinman, A., Das, V., & Lock, M. (Eds.). (1997). Social suffering. Berkeley: University
of California Press.
Krishnan, S., Rocca, C. H., Hubbard, A. E., Subbiah, K., Edmeades, J., & Padian, N. S.
(2010). Do changes in spousal employment status lead to domestic violence?
6 Introduction / Social Science & Medicine 70 (2010) 16
insightsfrom a prospective study in Bangalore, India. Social Science & Medicine,
70(1), 136143.
Kruk, M. E., Freedman, L. P., Anglin, G. A., & Waldman, R. J. (2010). Rebuilding health
systems to improve health and promote statebuilding in post-conict coun-
tries: a theoretical framework and research agenda. Social Science & Medicine,
70(1), 8997.
Lancet. (2009). Movement for global mental health gains momentum. Lancet,
374(9690), 587.
Miller, K. E., & Rasmussen, A. (2010). War exposure, daily stressors, and mental
health in conict and post-conict settings: bridging the divide between
trauma-focused and psychosocial frameworks. Social Science & Medicine,
70(1), 716.
Moscardino, U., Scrimin, S., Capello, F., & Altoe`, G. (2010). Social support, sense of
community, collectivistic values, and depressive symptoms in adolescent survi-
vors of the 2004 Beslan terrorist attack. Social Science & Medicine, 70(1), 2734.
Pedersen, D. (2002). Political violence, ethnic conict, and contemporary wars:
broad implications for health and social well-being. Social Science & Medicine,
55(2), 175190.
Pike, I. L., Straight, B., Oesterle, M., Hilton, C., & Lanyasunya, A. (2010). Documenting
the health consequences of endemic warfare in three pastoralist communities
of Northern Kenya: a conceptual framework. Social Science & Medicine, 70(1),
4552.
Pham, P. N., Vinck, P., & Weinstein, H. M. (2010). Human rights, transitional justice,
public health and social reconstruction. Social Science & Medicine, 70(1), 98105.
Scheper-Hughes, N. (1996). Small wars and invisible genocides. Social Science &
Medicine, 43(5), 889900.
Tol, W. A., Kohrt, B. A., Jordans, M. J. D., Thapa, S. B., Pettigrew, J., Upadhaya, N., & de
Jong, J. T. V. M. (2010). Political violence and mental health: a multidisciplinary
review of the literature on Nepal. Social Science & Medicine, 70(1), 3544.
Tucker, J., Ren, X., & Sapio, F. (2010). Incarcerated sex workers and HIV prevention in
China: social suffering and social justice countermeasures. Social Science &
Medicine, 70(1), 121129.
UNICEF. (1998). The state of the worlds children. United Nations.
Varley, E. (2010). Targeted doctors, missing patients: obstetric health services and
sectarian conict in northern Pakistan. Social Science & Medicine, 70(1), 6170.
WHO. (2007). Everybodys business: Strengthening health systems to improve health
outcomes: WHOs framework for action. Geneva: World Health Organization.
WHO. (2008). Closing the gap in a generation: Health equity through action on the
social determinants of health. (Executive summary). Geneva: World Health
Organization.
World Bank. (2005). World development report 2006: equity and development.
Washington, DC: The World Bank.
Catherine Panter-Brick*
Department of Anthropology, Durham University, Dawson Building,
South Road, Durham DH1 3LE, UK
 Corresponding author. Tel.: 44 (0)191 334 1622.
E-mail address: catherine.panter-brick@durham.ac.uk
Available online 22 November 2009