And it's usually short and quick, and sometimes lethal, sometimes not, but it is intended. Then you have the structural violence, which is the social structure and grinding of suffering, like the capitalist system does. Like is done by authoritarian regimes, and it hits people at the most vulnerable points. And those vulnerable points are called basic needs.
So they can hit the wellness, health. So you have misery at the bottom of society. People die to the tune of , a day without anybody firing a bullet.
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But they don't have the money to do anything about it. So the structure is made in such a way that they're just the helpless victims of it. Or politically, they're deprived of freedom. And since they are set on the monochromatic, so to speak, track with no choices, they become much less than they could be. Or their identity is taken away from them, and they're given another identity, like let us say the , Hawaiians in Hawaii when a white man came. And so many of the children were shipped off to the mainland to be taught English, Christianity, and baseball-- becoming good Americans.
The structural violence is not intended, but it's caused by a very important concept, not the actual commission, but the act of omission. The condition for maintaining the structural violence is that nobody does anything about it, so we let it happen.
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And somebody would even say this is normal, this is what normal society is like. It isn't. And here we in the Scandinavian countries, we had a lot of structural violence, but very simple measures. We were able to make the society less vertical or horizontal with health resources available, all of it. Now the gap is opening again because the poor people of yesteryear have become middle class, and have no compassion with those who are suffering today. And the gap is opening again-- the structural gap. They don't intend to harm people, but they don't do very much to prevent it either.
And then the third type of violence, what I call cultural violence, which are the aspects of culture that legitimise one or the other or both of the other two. Social Darwinism, the type of Christianity that sees sickness as God's punishment, been extremely important.
So we have a triangle with three types of violence that feed into each other. One way to understand violence is to categorise it into these three different forms direct, structural and cultural. Another way is to assign different levels or hierarchies of violence by:. But it can be so much more. The World Health Organization defines health as not merely the absence of disease or infirmity, but as the complete state of physical, mental and social well being. In the same way, we can define peace not merely as the absence of violence, but as a positive state or condition of harmony.
It is determined by loving, harmonious acts which elicit the good in each other direct peace , by fair and horizontal relationships structural peace , and by a culture of peace cultural peace. However, what happens when we are faced with conflict? Using a public health approach the epidemiologist can describe the realities of war, its effects on individuals and communities, and the consequences of certain types of weapons, warfare and humanitarian approaches.
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We must think of war not as a natural consequence of life but as a preventable tragedy with multiple long-lasting implications. The decision to use violence must be examined openly and not sanitized [ 43 ]. A less rapid but possibly more respected method for bringing awareness of local health and social issues to national and international levels is publishing research in credible journals. Peer-reviewed work can be a tool to facilitate negotiations between governments, NGOs and communities, and to influence international and national level policy-makers. Effective advocacy for public health includes the ability to use communication skills such as advocacy, consensus development, and negotiation to promote population health to policy-makers [ 23 , 26 , 28 , 42 , 44 ].
3. Peace as the capacity to handle conflict
As much as possible, messages should be communicated directly to the local population rather than through political leaders or another entity, as the messages may be tainted or obscured by differing agendas. For example, in the Thai border refugee camps epidemiological data were interpreted and then translated into health messages that were communicated by program staff via megaphones while travelling around the community PB. In the US military personnel and reservists in Iraq were responsible for providing humanitarian aid and direct interactions with civil authorities; a role for which they had no training EJN.
In addition, because of the military association, the information gathered was considered inherently biased and dismissed. During conflict, health and information services that were once unified under a single health ministry can become fragmented with parts falling under the aegis of government, those resisting the government, or nongovernmental organizations [ 23 , 31 ].
Access to health care and humanitarian resources can be important in political battles at the local level [ 26 ]. Each party in a conflict wants control of hospitals, health workers, food, and medications so as to be able to offer them to the community, thus enhancing their credibility, and to aid its military efforts SMM.
Epidemiologists there described attempts to ameliorate animosities by involving local constituencies in health activities: the Church, NGOs, elected officials, and other leading organizations or personalities in the community Personal communication Jorge Jara Local rather than national health authorities chose priorities, from outbreak investigations and interventions to data analysis to surveillance of violence and influenza. Through this process trust was built between the Colombia National applied epidemiology program and the local health authorities, thereby assuring access to the population that transcended partisanship.
Many workgroup members felt that negotiation skills were essential when working with multiple aid groups or the main parties in the armed conflict.
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For example, consensus building is useful when the health problems are not well defined and diverse groups must collectively identify and solve them. At the simplest level this includes the skill of running meetings and enhancing a group's utility and the understanding that disagreement might not necessarily represent failure. The goal is to help all parties understand that improving health meets the interests of all groups and to develop complimentary strategies. Too often decisions are rushed and participants pushed aside, leading to unsuccessful outcomes and future difficulties working together [ 44 ].
When disagreements are so deep that one or both sides will not accept any solution that benefits the other side, negotiation will be fruitless. To facilitate the coordination of health services, the epidemiologist needs to be familiar with the many agencies working in the target area, including governmental, nongovernmental, and United Nations agencies. The diversity of groups may make it difficult to establish a shared view of the situation, much less a collaborative plan of action. Additional obstacles to coordination may stem from competition for resources, lack of information or true differences in their philosophy about humanitarian aid and their ability to deliver it.
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Donors in particular can create a powerful force for coordination if they agree on priorities and processes. International donors can influence policy-makers by providing resources and technical support conditional on their commitment to the resolution of violent conflict [ 4 ]. It is the job of the applied epidemiologist to supply compelling credible information for these decisions. By providing credible information and establishing it as the foundation for action the epidemiologist can greatly assist coordination. Numerous workgroup members mentioned that being able to provide published medical and public health literature to government officials, donors and NGOs facilitated their efforts to coordinate agencies and to build consensus by providing an impartial standard based on scientific data [ 32 ].
One implication is that the epidemiologist needs rapid access to international literature, possibly via the Internet, even in war zones. Applied epidemiologists can use their skills and position to promote positive population health policies and programs to address inequities that exacerbate conflict and violence [ 1 , 2 , 4 ].
In addition, credible on-site information can reduce the waste and harm of poorly planned humanitarian assistance [ 9 , 10 , 23 — 25 ]. Epidemiologists' work among policy-makers and the public uniquely positions them to communicate the effects of war, advocate for the population and assist in the reconstruction of health systems [ 9 , 15 , 23 ]. As impartial agents, epidemiologists can promote dialogue between conflicting parties, influence public opinion, facilitate projects that require cooperation, and coordinate multilateral responses to health and humanitarian needs [ 13 , 22 , 23 ].
Banning landmines, creating days of tranquillity for immunization, and surveillance of homicide resulting in limiting firearms in Colombia are examples of these ideas at work [ 38 — 40 , 44 , 45 ].
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Providing health resources, including epidemiological support, should be part of a much larger diplomatic and humanitarian strategy. In fact, when a larger framework and commitment are missing, the health activities are unlikely to result in lasting changes and only increase the risks to the entire population. Epidemiologists are not diplomats nor should they be gratuitously sent into conflict situations as humanitarian band-aids.
In addition, there are real risks that scientific information, meant to improve health, might be usurped for political aims rather than humanitarian purposes [ 14 , 27 ]. For example, in Colombia the data from health surveys undertaken with the best of intentions were used to locate populations for military action Personal communication G. Suarez, Epidemiologists need to advocate for focused field research on conflict resolution and violence prevention, and to evaluate the success of health programs in conflict [ 2 , 25 , 36 ].
It is no longer practical to conceptualize complex humanitarian emergencies like war into distinct phases [ 2 ].
In reality the settings for disasters, refugees, active conflict, and anxious peace are in constant transition.