City University of New York (CUNY) CUNY Academic Works All Dissertations, Theses, and Capstone Projects Dissertations, Theses, and Capstone Projects 2-2016 The Impact of Climate Variability and Conflict on Childhood Diarrhea and Malnutrition in West Africa Gillian Dunn Graduate Center, City University of New York How does access to this work benefit ou?y Let us know! More information about this work at: https://academicworks.cuny.edu/gc_etds/765 Discover additional works at: https://academicworks.cuny.edu This work is made publicly available by the City University of New York (CUNY). Contact: [email protected] The Impact of Climate Variability and Conflict on Childhood Diarrhea and Malnutrition in West Africa by Gillian Dunn A dissertation submitted to the Graduate Faculty in Public Health in partial fulfillment of the requirements for the degree of Doctor of Public Health, The City University of New York 2016 © 2016 Gillian Dunn All Rights Reserved ii The Impact of Climate Variability and Conflict on Childhood Diarrhea and Malnutrition in West Africa by Gillian Dunn This manuscript has been read and accepted for the Graduate Faculty in Public Health to satisfy the dissertation requirement for the degree of Doctor of Public Health Deborah Balk, PhD Sponsor of Examining Committee Date Signature Denis Nash, PhD Executive Officer, Public Health Date Signature Examining Committee: Glen Johnson, PhD Grace Sembajwe, ScD Emmanuel d’Harcourt, MD THE CITY UNIVERSITY OF NEW YORK iii Dissertation Abstract Title: The Impact of Climate Variability and Conflict on Childhood Diarrhea and Malnutrition in West Africa Author: Gillian Dunn Sponsor: Deborah Balk Objectives: This dissertation aims to contribute to our understanding of how climate variability and armed conflict impacts diarrheal disease and malnutrition among young children in West Africa. Two studies examine the associations between climate and diarrheal disease across the whole study area – ten countries in West Africa during the period 2008-2013. The third study examines diarrheal disease and malnutrition in Northeast Nigeria before (2008) and after (2013) the start of the current armed conflict in the area. Methods: Outcome variables and child, caregiver, and household characteristics for these studies are from the Demographic and Health Surveys. Additional datasets include specialized products for rainfall, temperature, climate class, population density, and urban population ranking. The first two studies use geo- spatial techniques to 1) determine if there are areas of elevated risk after controlling for climatic and other covariates and 2) determine whether there is spatial variation in the associations between diarrheal disease and climatic and other covariates. The third study uses a double-difference methodology to study both diarrheal disease and malnutrition and their associations with conflict. Results: The first study found statistically significant clusters of elevated risk in 10 urban areas and 13 largely rural areas after adjusting for household and climatic factors with a relative risk range of 1.5 to 7.2. Results from the second study indicate that the associations between diarrheal disease and key household, environmental, and climatic factors vary according to location – a phenomenon which is masked by global models - and that the associations are both positive and negative (increase and decrease risk). The third study iv found that if children exposed to the conflict in Northeast Nigeria had not been exposed, their mean weight- for-height z-scores would be nearly half a standard deviation higher, the proportion of moderately and severely wasted children would be 13 percentage points lower, and the prevalence of diarrhea would be 8 percentage points lower than they are. Conclusions: The studies in this dissertation provide additional evidence for the relationships between climate variability, conflict, and child health in West Africa. Previous studies have provided mixed evidence for the role of factors such as rainfall on child health outcomes. Here, geo-spatial methods identify both areas of heightened risk and the role of specific risk factors in particular locations. For example, the first study found elevated risk of diarrheal disease in northern Cameroon and the second study indicates that two risk factors in that area are low coverage of improved sanitation facilities and low rainfall at the time of the survey. The effects of conflict on child health are conceptually inherent and have been quantified with different methods and outcomes. The research here furthers those efforts by quantifying the impact of a particular conflict – the Boko Haram insurgency - on the health and growth of young children. The findings from this research support on-going development goals which aim to improve modifiable factors including increased coverage of improved water sources and sanitation facilities, increased educational attainment, the alleviation of poverty and food insecurity, and resolving on-going conflicts around the world. The results also support adaptation measures, which are aimed at factors that are difficult to change in themselves, such as living in areas where temperatures are increasing due to climate change. Such measures include promoting income diversification and access to goods and services for farmers and pastoralists and improving infrastructure and public services in urban areas. Limitations, including spatial, temporal, and methodological issues with the data sources are discussed, as are suggestions for future research. v Acknowledgements I would like to express my deep appreciation and gratitude to my committee members - Deborah Balk (Sponsor), Glen Johnson (Chair), Grace Sembajwe (First Reader), and Emmanuel d’Harcourt (Outside Reader) – for their guidance, thought-provoking suggestions, and general collegiality throughout the doctoral experience. I would also like to thank the faculty, staff, and my fellow students at CUNY from whom I learned so much. And most of all, a heartfelt thank you to my extended family and friends near and far who have encouraged and supported me over these past years. vi Table of Contents Dissertation Abstract ........................................................................................................................................................................... iv Acknowledgements .............................................................................................................................................................................. vi List of Figures ..................................................................................................................................................................................... viii List of Tables ........................................................................................................................................................................................ ix Chapter 1. Introduction................................................................................................................................................................. 1 1.1 Childhood diarrhea and malnutrition............................................................................................................................................. 2 1.2 Climate variability and health ........................................................................................................................................................ 6 1.3 Armed conflict and health .............................................................................................................................................................. 9 1.4 Overall goal of dissertation .......................................................................................................................................................... 11 1.5 Specific aims and hypotheses ...................................................................................................................................................... 12 1.6 References .................................................................................................................................................................................... 14 Chapter 2. The Geo-spatial Distribution of Childhood Diarrheal Disease in West Africa: A Covariate-Adjusted Cluster Analysis 17 Abstract ............................................................................................................................................................................................... 17 2.1 Introduction ................................................................................................................................................................................. 17 2.2 Methods ....................................................................................................................................................................................... 21 2.3 Results .......................................................................................................................................................................................... 28 2.4 Discussion ..................................................................................................................................................................................... 35 2.5 Conclusion ...................................................................................................................................................................................