Presentation by Michael Loevinsohn, STEPS Centre, at the First Global Symposium on Health Systems Research, 17 November 2010.

1. First Global Symposium on Health Systems
Research, Montreux
Environment-Health Research:
Challenges and Opportunities
Michael Loevinsohn
STEPS Centre
Institute of Development Studies
November 17, 2010

2. • Creating conditions favouring new health
threats – and the re-emergence of old ones
• Creating multiple health threats, linked to
the same suite of changes
• Health systems face new demands yet their
capacity may be eroded by those same
changes
• Classic environment-health research (one
environmental factor, one disease) ill-
adapted
Rapid, multi-faceted
environmental change

3. • Develop/adapt methods to understand the
dynamic, cross-sector production of risk
• Methods to identify the changes that may
be loosening structures of risk –
opportunities to advance especially primary
prevention
• Methods to clarify and support decisions:
 Locating risks and opportunities
 Valuing “prevention dividends”
 Working out the needs for collaboration
New demands on health-
environment research

4. • Important: economic and ecological drivers
are increasing food insecurity in countries
with generalized HIV epidemics
• Complex: each is cause and consequence of
the other
• Poorly elucidated by conventional methods
e.g. cross-sectional or longitudinal survey
Issue: Food insecurity and
HIV/AIDS

5. • An increasingly vulnerable rural population,
dependent on maize in one season and casual
labour
• Two poor harvests 2001-02 and poor
administrative decisions → maize price surge
• Unequally felt: by location, occupation, gender
• Accounts described people pushed by hunger
into situations of infection risk
 Survival sex – exchanged for food or work
 Distress migration to towns/cities, less affected
rural areas
Loevinsohn M. 2011. Seasonal hunger, the 2001-03 famine and the dynamics of HIV in Malawi. In Devereux S, Sabates Wheeler R,
Longhurst R (eds) Seasonality, Rural Livelihoods and Development. London: Earthscan.
Loevinsohn M. submitted. The 2001-03 famine and the dynamics of HIV in Malawi: an (un)natural experiment
The Malawi famine and HIV:
an (un)natural experiment

6. HIV prevalence at Malawi
antenatal sites 1994-2005
0
5
10
15
20
25
30
1995 1997 1999 2001 2003 2005
Prevalence(%)
Urban
Semi-
urban
Rural

7. Change in HIV vs. rural hunger
Rural antenatal sites
0
0.5
1
1.5
2
2.5
3
10 20 30 40 50
Rural population in need of food aid (%)
Relativeprevalence2003/1999

8. Change in HIV vs. rural hunger
Non-rural antenatal sites
■ cities ▲ towns
Nsanje
0.4
0.6
0.8
1
1.2
1.4
0 10 20 30 40 50
Rural population in need of food aid (%)
Relativeprevalence2003/1999

9. • Further analysis shows they were
mostly farmers, young (<25 years) and
uneducated (< primary)
• Moving in distress, they would have
been at high risk of falling into
dangerous situations
• 2004-05 survey confirms a surge of
young rural women migrating during the
famine, suggesting more than a
transient movement
Who were these migrants?

10. Conclusions
The famine had a rapid and
substantial effect on HIV prevalence
and population distribution across
the country
Structural determinants e.g. poverty
can change rapidly
Declines in urban HIV prevalence
may have other causes than
“behaviour change” esp. rural out-
migration

11. Evidence of “prevention dividends”
• In the rural areas where hunger was
least, prevalence of cassava (rugged,
high caloric yield) was greatest
• Peak market maize price was lower
where cassava was widely grown
• Not a panacea but a useful element of
diversity
• S. India: Watershed Development, by
reducing distress migration, averts
substantial HIV infections
 synergistic with condom promotion
(simulation – Loevinsohn 2006)

13. Cassava and hunger
Dec 2002 – Mar 2003
0
10
20
30
40
50
60
0 20 40 60 80 100
Households growing cassava (%)
Householdsneedingfoodaid
(%)
North
Centre
South
Peri-urban

14. Cassava and maize price
February 2002
0
10
20
30
40
50
0 10 20 30 40 50 60 70 80
Households growing cassava (%)
Maizeprice/kg
North
Centre
South
Peri-urban