Free Media as the Social Determinants of Health: The Case of Oromia Regional State in Ethiopia ()
Received 13 January 2016; accepted 1 February 2016; published 4 February 2016
1. Introduction
Whoever controls the media controls the mind.
Jim Morrison, Famous American Singer and songwriter
The media’s the most powerful entity on earth. They have the power to make the innocent guilty and to make the guilty innocent, and that’s power. Because they control the minds of the masses. Malcolm X, African American Activist
The above quotes speak of the power that the media wields. Media disseminates knowledge and facilitates knowledge construction. Knowledge is intertwined with power [1] and [2] . Because power and knowledge are so intertwined, the knowledge created by the media can consequently be used to colonize, control or liberate. At the community level, the media can be used to help societies to understand the conditions that put them at risk and to solve their social and environmental problems. It gives a framework of thinking and can shift the lenses through which we see the world around us.
The quotations mentioned above are consistent with the views of [1] and [2] , who theorized that knowledge and power are intertwined. These views remind us to reflect, ask questions and critically analyze whether or not contemporary media produces knowledge and delivers information that enables us or controls or manipulates us.
In the Western world, many citizens are concerned about the influence that media exerts over their young people [3] . They view the media as an oppressive tool used to dominate and marginalize, and people who are critical of the dominant media want to develop their own. Indeed, attempts to control media are part of a struggle for knowledge and power. As a valued social organization, the media shapes people’s choices, values, and perspectives, and consequently has a significant influence on people’s daily lives. Thus influence also extends to population health. The Oromo, and others who are denied the right to develop their own media, need to critically analyze the objectives of the colonial powers in denying them their own media and the implications of such denial. It is in this complex context that I explore the role of free media in the development of public health conditions.
Health is a complex phenomenon, and it can be seen from the biomedical and/or socio-cultural models [4] . Although the relationship between education and health has been widely studied, little research has been conducted to assess the link between media and health. Today, education is widely accepted as a social determinant of health [5] , and plenty of resources have been devoted to identifying the pathways through which education influences health. Through research, it has been demonstrated that education plays a key role in modifying health behaviors, improving health literacy levels, increasing productivity, self-esteem, self-efficacy, social capital, healthy lifestyle, increasing awareness of health risks, service (preventive, responsive and management), social relations, resiliency, modifying the environment and developing problem solving skills [5] . Most of these studies have focused on formal education. However, even though media is closely related to education and is an essential tool for mass education, little research has examined the relationships between mass media and public health.
Knowledge contributes to the development of public health [6] . Since its inception, public health has focused on the delivery of health information, health education and information analyses. Information is routinely collected and used to monitor, analyze emerging diseases or for surveillance. Public health institutions collect information, analyze data and inform the public, thereby raising awareness about events or phenomenon. To successfully increase awareness about social policies, programs, and services, information must be clear, relevant, easy to understand and useful so that the public can quickly grasp and respond to it. To ensure clarity and consistency of information, plain language must be used in all communications with the public.
It seems that the relationships between the presence of free media and public health developments have been ignored by health researchers and policy makers. The media is an essential tool to disseminate knowledge and facilitate knowledge construction, and the development of an independent media is critical to the social transformation of a society and the improvement of public health conditions. Analyzing social conditions in understanding health helps to explain that community health problems are not necessarily the result of a single event [7] . It is for this reason that knowledge is strongly linked to health. Inequalities in the distribution of access to information and knowledge are directly related to inequality in health matters. Although this connection is well known, the Ethiopian government has long denied the Oromo people the opportunity to develop their own mass media [8] . When analyzing the public health impacts this denial has in Oromia, there are two important questions to consider: first, what are the objectives of the Ethiopian government in denying the Oromo people the right to develop their own free media? The second question is what are the social impacts of violating the people’s rights to develop their own media?
One of the issues that have not received enough attention by public health researchers and policy makers is the impact of free media on public health. The problem is not analyzing the relationships between the presence of free media and the developments of public health. Media as I scud before is an essential tool to disseminate knowledge and facilitate knowledge construction. This makes the development of an independent media critical to the social transformation of a society and to the betterment of public health conditions. The idea of analyzing social conditions as a way to understand health explains that community health problems are not necessarily the result of a single event [7] .
This paper consists of four major parts. In the first part, I introduce the background of the topic under investigation. In the second part, I cover the objective of the research and define the concept of media and public health. I explore those areas where the objectives of media and public health intersect and converge. In the third part, I explore if free media (restoring information flow, education, providing entertainment, molding opinion, recording events and establishing connecting with people) can contribute to the betterment of public health conditions in Oromia. In the last section, I cover the discussions and conclusion.
2. Background Information: Understanding the Regional Context
2.1. Language in Ethiopia
Ethiopia is a multi-ethnic-national empire [9] . Although the word Ethiopia has existed in the Greek vocabulary for over three thousand years [10] , as a state it was formed when Abyssinia, supported by European empire builders, colonized several independent states in the Horn of Africa [9] and [11] . The Oromo people constitute the single largest ethnic group in the Ethiopian empire; however, for over a century they were denied the use of their language in school, court, business and health education. They are denied developing their own literature and media. After a century, in 1992 the Oromo people achieved a partial victory and started to use their own language in school, court and public health educations [12] . However, despite this success, the Oromo people are still being denied the right to develop their own independent media, and the Ethiopian Federal Government’s working or official language remains Amharic.
A free media in Oromia in the past 130 years has been essentially non-existent. From the period of conquest in the 1880s to1970s, the Ethiopian government told the Oromo people that the Oromo language “destroys or simply break radio”. However, to defuse the influence of Somalian broadcasts in the Oromo language, the Ethiopian government started broadcasting in Afaan Oromo in the 1970s. Intended to defuse the Somali government’s propaganda, the Ethiopian state radio broadcasts in Afaan Oromo was limited to the area where the Somali radio covered. From 1974 to1992, the Ethiopian state Oromo-language radio broadcasts were expanded and covered the entire Oromia region. During this time, a newspaper was also started [13] . From 1974 to 1992, state media were used to promote class struggle and condemn national movements.
Since 1992, the Ethiopian government led by the Tigray People Liberation Front (TPLF) has expanded the Oromo language media to TV and entertainment. Although in principle the government-led by the TPLF added ideas of democracy, federalism and free market economies to their constitution, in practice the regime was not much different from previous dictatorial regimes. The TPLF government continued to control all spheres of the Oromo’s people lives through their “visible and invisible hands”. In addition to this control, the media has been used to justify the injustices committed against the Oromo people. The TPLF denied the Oromo people the right to develop their own media; Oromo journalists who work for the state media are censured or conditioned to self- censure. This has created inequalities in the distribution of information and knowledge.
Language is accumulated knowledge through which societal norms and wisdom are transmitted [10] . The struggle for language and knowledge is inevitability linked to the struggle for power [14] . The linguistic dominance of certain languages is the manifestation of military conquests, political subjugations, cultural assimilation and economic exploitation. The widespread use of languages like English, French, Spanish, Portuguese, Arabic and Russian are the result of colonial conquests and language impositions [15] .
Language is the key to delivering information and the media is an important tool through which that information can be conveyed. The presence of a free media bridges the communication gap between the people and policy makers. A free media allows us to take accurate, health-related information and deliver it to the people in need. In a world where our social and natural environments determine our health [4] , rapid environmental changes put marginalized people at greater health risks than affluent people. To reduce those risks, natural and social conditions need to be renewed. To foster renovation we need to convey accurate information to the people about the circumstances in which they live and work and deliver the best possible services to people in need. A free media can contribute to the fair distribution of information (i.e. opportunities and risks) and bridge the communication gap between the people and policy makers and foster transparency.
2.2. Racism and Discrimination against the Oromo
Racism and discrimination affect people’s ability to improve their health. Racism stems from the belief that one group of people should be treated differently simply because of phenotypic differences [16] and/or real or assumed cultural differences. There is considerable evidence that successive Ethiopian regimes have covertly and overtly developed racist policies that have denied the Oromo people educational opportunities, evicted them from their homes, hindered the development of their leadership and kept them in poverty and ill-health [17] . Emmanuel Abraham, an Oromo who served as a Director General in the Ministry of Education from 1944 to 1947, exposed the regime’s discriminatory objectives. According to Abraham [18] he was accused of educating “only the Gallas [Oromo]”. The Emperor Haile Selassie was annoyed about this allegation and without Abraham’s knowledge directed the principal at the school with the largest enrollment to make a list of the pupils and the ethnic groups they represented. They found that out of 991 pupils, 701 (70.74%) were Amharas. The rest came from various other ethnic groups. Then the Emperor commanded Abraham to get a count of the students attending schools in Addis Ababa and to list them by ethnic groups. A total of 4795 students attended schools in Addis Ababa; of those, 3055 (63.71%) were Amharas and the remaining 1740 (36.29%) were from the other ethnic groups. Of these, only 583 (12.16%) were Oromo. The allegation against Emmanuel that he was enrolling more Oromos in schools was not only fallacious, but it also shows that the Abyssinian elites wanted Abraham out from the position he held and that they did not want even a handful of Oromo students attending school.
Zoga [19] also revealed the racist policy of Haile Selassie’s regime and the reactions of Oromo elites in writing about the history of the Metcha and Tulama Self-Help Association. During Haile Selassie’s regime, General Taddessee Birru worked as the chairman of the National Literacy Program. Birru had an Abyssinian first and last name. When he became chairman of the Literacy Program, he was eager to teach his Oromo people and others, even though the language of instruction was only Amharic. His enthusiasm for a literacy program among the Oromo people worried the Abyssinian elites [19] . The Prime Minster, Akililu Habte Wold, had assumed that General Birru was an Abyssinian and, in the address below, he reminded him of Haile Selassie’s educational policy:
Taddesse! After you have started leading the literacy campaign, you talk a lot about learning. It is good to say learn. However, you must know whom you have to teach. We are leading the country by leaving behind the Oromo at least by a century. If you think you can educate them, they are like an ocean, whose wave can engulf you (Cited in [20] ).
These words clearly demonstrate that the intent of the Ethiopian government policies were overtly and covertly deny the Oromo people educational opportunities. The policies were carried out in a number of ways that worked together to create barriers to accessing education. First, the Ethiopian government’s language policy prevented the Oromo people from using their language as a language of instruction. Secondly, schools were built in towns and cities and military garrisons, or in places from which the Oromo people were evicted and they are inaccessible. Third, educational curricula were framed from the dominant Abyssinian perspectives, which made education programs and their objectives foreign to the Oromo people [21] . These types of policies and actions have fostered racist ideologies, and have created an unequal distribution of access to information and knowledge. They have also affected the health of the Oromo people. For example, as I have discussed in my previous work the Ethiopian language policy denied the Oromo people the right to know about health risks and this had implications on the HIV/AIDS epidemic in Oromia [22] .
2.3. Racist Assumptions and Language in Policymaking
A number of philosophers and thinkers convincingly argue that theory informs practice and in its turn practice guides theory. Ancient Egyptians deeply believed in an afterlife. From their perspective, death occurred when the “ka” left the body. The Egyptians believed that the “ka” had to have a body to return to, and because of this they mummified their dead and built pyramids [23] . In Judeo/Christian/Islam teachings, life after death will be either in heaven or hell―unknown, far away spaces and places of no return. These teachings also give authority to human beings over the natural world. Altogether, these teachings were used as the guiding theory that people used to dismantle and pollute the natural environments and/or to be indifferent to them. According to Weber [24] the protestant work ethic fostered the accumulation of wealth and capitalism. We all do what we think it is important. Because theory informs practice, understanding the social theories helps us understand the policies that followed.
There are logical connections between our convictions and our actions. Foucault [1] , researching the history of ideas, the history of science, the history of philosophy, the history of thought, and the history of literature, came up with the concept of the “archeology of knowledge”. His work highlights the need for researchers to give their full attention to the historical origin of a concept. This means in this case that exploring the underlying reasons that informed the Ethiopian government’s decision to deny the Oromo people the right to develop their own media is helpful in understanding the magnitude of the problem.
Critical analyses in the history of Abyssinian and Oromo relations reveal that longstanding Abyssinian racist assumptions about the Oromo people informed Ethiopian government policy makers. For example, according to Asma Giyorgis the influential authors in the Royal family of King Menelik the Oromo people came into being after an Abyssinian starving lady went to Lalo (an Oromo man) in search of milk. The document suggests that Lalo married the woman and she produced seven children: four boys named Karrayu, Tulama, Meeca, Wallo and three girls named Alko, Duratti and Ayantu. The document says that these children grew up and became thieves, outlaws and robbers. At one point the Abyssinian chief Azmach Endreyas led an expedition against Lalo. Lalo was defeated and forced to flee with his cattle and children to a forest known as “Galla”. In the forest, Lalo and his children nourished themselves with khat, coffee and milk and worshipped the devil. The devil they worshipped taught them a new language and caused them not to understand the Christian language i.e. Amharic. As the document clearly puts it, “Lalo learned Gallegna [Oromo language] from the devil” [25] . This story represents deeply rooted racist assumptions about the Oromo people. The story provides a theoretical reason for the negation of the Oromo language and culture.
Consistent with this racist theory, soon after the Oromo people were colonized the Oromo language was transformed from being the “lingua franca” in the Horn of Africa to the language banned by the colonial state and cursed by their religious institutions―the Ethiopian Orthodox church and Islam. Consequently, in 1944, the Oromo language was officially banned by decree [26] . The Abyssinian elites theorized that the use of the Oromo language put radio out of service or simply break radio. By that they made an effort to convince the Oromo people not to think about having media.
In the same way that slaves were denied education in the USA, because reading brings ideas and writing transmits information which brought discontent many states passed laws that forbid the education of slaves, so the Ethiopian government denied the Oromo people schooling and developing their own media. Like American slaves who were discovered to have learned to read were subjected to beatings and amputations, so Oromos found listening to independent media face prosecution. For example, in 2008 the Ethiopian government adopted laws―namely the Mass Media and Freedom of Information Proclamation and the Anti-Terrorism Proclamation―that restricted free expression [27] . However, they faced enormous difficulties implementing them, because they did not have the tools to monitor the users of social media. To acquire the tools needed to control social media, the Ethiopian government bought very expensive computer software from Chinese, Germany and Italian companies. Not only that, according to Human Rights Watch [28] and [29] the Ethiopian government spied on opposition party members and individuals of Ethiopian origin who resided in the Western world.
During slavery, in the USA slave masters knew that knowledge was power and feared educated slaves. The slave masters feared that educated slaves would apply their knowledge to inform and educate others that the relationships between them were not just and instigate uprisings. Because of this, on all plantations slaves were denied the right to be educated [30] . As Frederick Douglass, a civil right activist, rightfully stated, “knowledge makes a man unfit to be a slave” [31] , knowledge gives people the tools needed to de-legitimize racist theories and practices. If there are many educated men and women, racist theories and practices abruptly lose their legitimacy and the dominant groups would have enormous difficulty keeping people subordinate. Marginalized people allowed to learn will soon understand that being kept subordinate is unjustifiable and they would pro- mptly begin to demand equal treatment. This is why the Oromo people struggle to develop their own free media and the Ethiopian government tirelessly works to stop them.
3. What Are the Social Determinants of Health?
Initially, improvements in public health were achieved through understanding the nature of the biological, che- mical and physical agents that contribute to mortality and morbidity. Until recently, the social conditions that increased or reduced the risk factors to these agents and other unhealthy social conditions had not been taken into consideration [4] and [7] . Now social conditions are being evaluated because it has become clear that a population’s health depends on both socially-constructed and naturally-determined conditions. Socially constructed conditions come from the interactions between people and society, which include educational attainment, employment, and housing. These conditions are collectively referred to as “the social determinants of health”.
Our health is dependent on the ways we take care of our bodies―the quality and quantity of foods we consume, whether we live active lifestyles or live and work in healthy conditions, and the presence of social justice [32] . Having enough resources, reasonable housing, clean water, supportive families and friends, safe work environments and access to higher education are important to our health [7] . Although naturally-determined conditions like genetics are impossible to change, improving social conditions is doable and mitigating and managing health risks becomes possible. Since the socially constructed determinants of health are fundamental to a population’s health, health promotion strategies work to reduce or prevent the social conditions that put people at risk. Fairly distributing the social determinants of health can help avert socially created problems [32] .
Although in all cases the population’s health status represents the social conditions in which they live and work, social determinants affecting health can have different effects in different locales. Indeed, even one social condition can positively affect the health of a population in one setting and negatively affect it in another. For example, Sen argues that free presses facilitate free flow of ideas and by that it helps a society decide which policies to pursue [33] . This makes media is one of the social determinants of health. Where free media outlets exist in abundance, they can be used to raise awareness about illnesses and diseases and poor-health behaviors. However, in Oromia, where there are no free media, their absence makes it difficult to inform and educate people about emerging health risks and opportunities. This hinders people’s abilities to construct and obtain knowledge, understand social realities and develop problem-solving skills, thereby limiting their choices in life.
4. Research Objectives
In writing this paper I am motivated by a sense of social justice, a desire for emancipation and a desire to create supportive, healthy environments in Oromia. The objective of this paper is to explore whether the absence of free media hinders the development of better public health conditions. In this paper I explore the mechanisms through which mass media can support the development of healthy public policy and facilitate the improvement of public health conditions.
Framework of Thinking and Methodology
Research as a voyage of innovation and social transformation; research it inculcates critical thinking and is instrumental in solving social problems. In public health, disease prevention and health promotion strategies are founded on the understanding that human capability is the most comprehensive framework within which community health in general and human well-being in particular can be conceptualized [7] and [34] . For example, Burkitt [35] noted, “if people are falling over the edge of a cliff and are sustaining injuries, the problem could be dealt with by stationing an ambulance at the bottom, or erecting a fence at the top”. Indeed, framing health problems in terms of the social determinants of health aims at giving attention to nonmedical strategies, promoting healthy social policies and improving population’s health. Hence, using the framework of “the upstream” public health metaphor of disease prevention and health promotion, this paper asks several questions and makes effort to connect all the dots and answer them. These questions include: “what is media and public health, what are the conditions of free media and public health in Oromia, why does the Ethiopian government deny the rights of Oromo people developing a free media, what are the relationships between media and public health, what are the impacts of the denial of the rights to develop media on public health conditions in Oromia, what can we do about it in the future?
5. The Media and Its Function
According to Merriam-Webster’s Dictionary [36] , the word media comes from the word medium and it means cultivation, conveyance, expression or communication to a large number of people. It is also associated with the transmission of power and authority. Media is seen as the means by which modern social orders are created and sustained [37] . This makes media a form of communication that dispenses information, social norms and power. The means of dispensing information include print, recording, cinema, radio, television, Internet, phone and social media.
Media has seven interconnected functions: to inform, educate, entertain, mold opinion, provide a framework of thinking, make or establish connections between people, events, places and ideas and record events [38] . The information disseminated during educational programs, on news and/or news analyses and entertainment, helps to shape the opinions of people. When media inform the public, this provides data for people to analyze. This helps them construct knowledge and helps them ask themselves and others critical questions and this allows them to enlarge their choices in life. When media educates, it transmits proven knowledge and valid logic or best practices. Information delivered in the form of entertainment helps people to relax and manage their stress, heal faster and overcome depression. Also, information delivered in the form of entertainment can educate people.
Another function of media is to mold people’s opinions or provide them a framework of thinking. As information is presented, people start to process and analyze the information by using their own experience or using the framework of thinking provided by the media. By using their own framework of thinking, individuals can construct their own knowledge and change their views and better understand their social condition. The knowledge constructed can be used to critically analyze and understand the social conditions in which they live and work. Knowledge is used to identify existing or newly emerging health risks and opportunities. Identifying health risks helps people to modify their health behavior or change the social conditions that put them at risk. If necessary, the informed groups can self-evaluate, seek more information and clarification or help. On the other hand, foreseeing emerging opportunities helps widen their choices in life. In addition, knowledge can be used to challenge the social power that put them at risk and to resist unjust power relations.
The fifth function of the media is to provide a framework of thinking. By providing a framework of thinking the media helps people to critically observe and understand their social conditions. The other function is connecting or establishing connections between people, events, places and ideas. Connecting people facilitates dialogue and exchange of ideas and experiences. Connecting events and ideas of the past and the present helps societies to envision for the better future. The last important function of media is to record events and keep records for the next generation.
Information seeking and receiving is one of the essential tools people need to survive, transform their society and flourish. The right to seek, receive and impart information and ideas of all kinds has been recognized in the UN human rights charter. The International Covenant on Civil and Political Rights (ICCPR) recognizes that everyone has the right to hold opinions, seek and receive information as article 19 of ICCPR [39] states:
Everyone shall have the right to freedom of expression; this right shall include freedom to seek, receive and impart information and ideas of all kinds, regardless of frontiers, either orally, in writing or in print, in the form of art, or through any other media of his choice.
Although the Ethiopian government signed this and other UN covenants, it violates the rights of the Oromo people to develop their own media. For example, the TPLF regime’s the Anti-Terrorism Proclamation, which was created to contain the “the Arab-Spring”, defined terrorism broadly and brands as terrorists many independent individuals and groups who oppose their social-political-economic policies [40] . Under the cover of fighting terrorism, the Ethiopian government forbids a free media, terrorizes innocent people, Jalata [41] referred for this “terrorism from above”.
5.1. What Is Public Health?
Public health is defined as “the science and art of promoting health, preventing disease, and prolonging life through the organized efforts of society” [42] . The definition makes clear that the focuses of public health interventions are to prevent and manage diseases, injuries and promote health through surveillance of disease or health risk cases. The arts of promoting health and preventing diseases through collective action is referring to as promoting healthy social policy, creating enabling social conditions, disseminating information and widening informed choices. This includes the formulation of healthy public policies, healthy social conditions, healthy behaviors and livable social and natural environments as well as widening choices in life in general and informed choices in particular. If our health is determined by the social conditions in which people live and work, which is ultimately linked to power and choices in life, providing information about restoring the missing links between events can be a powerful intervention and helps identifying the “visible and invisible hand”, i.e. colonial and other forms of oppression.
Population health focuses on the interconnected social conditions and environmental factors that influence the health of populations over time, that identify systematic variations in the prevalence and incidence of disease and illness, and that apply the resulting knowledge to the development and implementation of healthy policies and processes to reduce risks and improve the health and well-being of those populations.
Public health works to achieve these goals by enabling people to understand their social problems, building public health capacity, and creating supportive environments for health. A major component of this strategy includes improving the health literacy level. In Canada, the average lifespan has increased by more than 30 years since the early 1900s. Twenty-five of these 30 years are attributed to advances in public health [43] . In the last century, the twelve great public health achievements in Canada have been: a) safer and healthier foods; b) control of infectious diseases; c) healthier environments; d) vaccination; e) recognizing tobacco use as a health hazard; f) motor-vehicle safety; g) healthier mothers and babies; h) acting on the social determinants of health; i) universal policies; j) safer workplaces; k) family planning and l) decline in deaths from coronary heart disease and stroke [43] . The secret of success is changing the world for the better and turning public health knowledge into practice.
5.2. Public Health and the Oromo People
When we speak about public health in Oromia, some might ask whether it is a foreign idea or an indigenous concept. Did the Oromo people develop public health ideas and principles before contact with the Europeans? If the answer is yes, were the ideas and principles on which they were founded similar to our modern-day understanding of public health? If we carefully analyze the Oromo oral history, traditional theories and indigenous practices surrounding health and disease, we can clearly see that they had developed sophisticated knowledge. Although they had not fully developed an extensive scientific understanding of microbiology, they had applied many of the principles of microbiology. For example, they practiced disease prevention by quarantining infected humans and animals. The carcasses of animals infected with contagious infections were either burnt or buried. If an infected person survived, they kept him/her in isolation for three weeks and then shaved the hair, cut the nails, washed the clothes of the person and caregivers before allowing them into the community.
The Oromo people also have well developed herbal remedies and other remedial care. If a domestic animal infected with rabies bites a person, they kill the infected animal, cook its liver and feed it the person. However, it is not fully understood how feeding the infected liver is scientifically effective. Oromo people also have a deep understanding of the relationships between social status, food security and health. For example, when individuals who live in malaria free zones plan to visit malaria affected regions, as a prevention strategy they will incorporate garlic into their diet for two week prior to their visit.
The history of public health tells us that one of the first written records in the field is linked to Greek mythology. Two thousand years ago, Greek mythology had drawn a distinction between curative medicine and prevention or health promotion. This myth suggests that the Greek god of health had two daughters: Hygiea―the god of prevention and wellness and Panacea, the goddess of treatment. Indeed the term hygiene came from the name Hygiea―the goddess of health, cleanliness and sanitation. Likewise the idea of public health is deeply ingrained in Oromo social and cultural norms. Oromo myth emphasizes the mother Goddess (Ayyo Ummee) and father God (Abba Ummaa) and their role in the prevention of epidemics, diseases, famine and war, as well as in the promotion of peace and rain. The Oromo people value individuals’ rights and health, and they emphasize principles associated with collective rights, public health, and the greater good. For example, in their daily prayers the Oromo people say, “keep us from extreme famine, avert us from extreme war, preclude us from epidemic diseases, give us no stormy weather and provide us a peaceful rain” [44] and [13] . The accumulated knowledge in public health sciences clearly suggests that the Oromo prayers for good health, peace and prosperity i.e. public good, are achievable. Since societies do what they think is important, if the Oromo people were empowered they would be quite capable of fostering the development of public health.
5.3. Public Health Stories
What makes the media salient to population health? Public health ideas and principles are intertwined with peace and social justice. Given that social justice is the foundation of public health, understanding social and political forces that negatively impact public health and addressing them are critical to advancing public health [45] and [7] and [34] . Mass media is a powerful tool we use to tell stories. When the media narrate stories, these influence societies and foster debate between policy makers and the general public. They can provide valuable services to the public by telling the story from the public health perspective. Telling a story from the public health perspective helps people to see the upstream causes of health problems.
Media and public health can complement each other and function in mutually supportive ways. Promoting the development of media can positively contribute to the advancement of public health [46] . Let us take a close look at the story below and see how storytelling and analyzing narratives can make a difference in understanding a series of events or in connecting separate issues. The story retells the experience of a young Oromo girl who died of a leg infection while in Addis Ababa (Finfinne). By critically examining the story, we can better understand the social policies created by the Ethiopian government and the consequential social policies (in this case poverty and disease) which Czyzewski calls the “invisible hand or colonial oppression” [47]
“Why did Bultu (12 year old girl) die?
Because she had a bad infection in her leg.
But why did she have this infection?
Because she had a cut on her leg that got infected.
But why did she have a cut on her leg?
Because she was collecting leftover food in the Addis Ababa (Finfinne) city junk, and there was some sharp broken glass, that she fell on.
But why was she collecting leftover food in the junk?
Because her family is poor and they could not provide her with food.
But why couldn’t the family provide her food?
Because they had lost their farmland and moved to the city of (Addis Ababa).
But why they could not find a job in the city?
Because they do not speak Amharic and they are illiterate.
But why weren’t they educated?
Because schools were in the Amharic language, and were only available in cities and towns.
But why wasn’t the language of instruction in Afaan Oromo?
Because the Ethiopian government does not recognize the Oromos as their own citizens.
But why didn’t the Oromo people exercise their rights to decide on their affairs?
Because they did not know that they had the right to decide on their affairs.
But why don’t they know about the 1948, the 1966 and others UN declaration of Human Rights?
Because no one had told them.
Who is responsible for the death of this young girl―Bultu?
But why...?”
6. Media and Public Health: Making the Connection
What are the relationships between public health and the free media? Research on the denial of free media as a harmful determinant of population health is in its infancy. Despite that, we know that the relationships between public health and media are multidimensional. As presented in Table 1, although the social functions of media and public health may seem unrelated, there are areas where they clearly overlap. To explore and sort out these complex relationships, we must closely examine the functions of the media and public health and investigate their connections. The need to explore the overlapping functions of these social institutions comes from the fact that the major determinants of health are socially created and social transformation is a method by which to effect changes. In addition to this, the accumulated empirical evidence in public health suggests that improvement in health requires innovation, and in its turn innovation requires transmission of knowledge and information [6] . In the next section, I will look at those specific functions from the public health perspective.
6.1. Major Functions of Media
The review of literature on the functions of the media reveals that the media has eight major intermingled functions. These include providing data or disseminating information, educating, advocating, entertaining the public,
molding opinion, providing a framework of thinking, connecting people with events or people and keeping records and transmitting them to the next generation.
6.2. Providing Data or Dissemination of Information
The first vital function of media is providing data and information to the masses. To inform means to give essential or formative principles or to tell someone facts or make them aware of something [48] . Telling a story is providing data and information to people [49] . But, people are not simply passive recipients of information. Providing data helps consumers to analyze it in parallel to their culture, episteme, previous experience or prior knowledge and construct logic. When information is delivered in the form of news or news analyses, the recipients analyze it and try to make sense from the story. If the story is disheartening, they will envision ways to prevent the occurrence of such events. If the information is desirable, they will start to embrace the idea or principle. Such a process helps people to self-evaluate and identify their strengths and their weaknesses. Though, people are able to construct knowledge or synthesize knowledge. When media delivers data, people gather the pieces, make connections and then put the pieces together to formulate the whole. Through this process, they construct knowledge. For example, presenting history in an anticolonial framework of thinking is telling the past events so that the present can be understood accordingly and the future is reordered and controlled [50] . Know- ledge is power and it enables people to effectively develop informed policies, deliver, evaluate and improve their skills [6] [51] and [52] . This helps to prevent diseases or reduce risks and create healthy social conditions.
As presented in Figure 1, knowledge is constructed when data or information is captured, categorized, systematically organized, analysed, verified, comprehended and then used. Once information is comprehended and verified, it becomes wisdom. It is for this reason that knowledge is seen as information in context [53] and [49] . According to ASTHO [49] , knowledge is created when the following intermingled conditions occur: a) information is evaluated for accuracy and relevance; b) information is transformed to meet current or potential needs; c) information is structured and organized for retrieval; d) information is analysed and the results are evaluated; e) information is routinely delivered or made accessible when and where needed for decisions. It is this transition from data to knowledge that significantly enhances the ability of communities to understand and address their health needs [49] and [53] .
Providing information to the masses creates favorable conditions for people to empower themselves. Empowerment is a multidimensional social process through which individuals and communities gain better understanding and control over their lives. As a consequence, they are enabled to change their social and political environments, life circumstances and improve their choices in life. Delivering information has the capacity to unleash domination and help to modify or change society [46] . By evaluating health and disease from a social determinants perspective, we see that a community’s health problems are the result of past and present interacting events.
Let me put things in context. In August 2010, I visited my home village in the Western Oromia region of Ethiopia. While I was there anthrax infection emerged and killed many cattle and wild animals. The Oromo farmers were desperate to understand the nature of the infection but they were not equipped to manage it. No media covered the emergence of this deadly contagious disease. No public health education was provided about the infection. There were fertile social conditions for the infection to spread quickly to the nearby districts. The favorable social conditions I observed included: a) the butchers killed the animals with no veterinary inspections; b) in towns, the butchers advertised their products by hanging the lung of the newly killed cow in front of their shops. This allowed for flies to carry the bacteria and spread it to animals and humans. Had a media campaign
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Figure 1. Schematic representation of knowledge construction.
been in place, the situation could have been better managed and extent of the outbreak could have been better controlled or perhaps not have happened at all.
6.3. Educating
The second vital function of media is educating the masses. Educating is not simply the transmission of knowledge and helping people to read but it is transformative. It is fostering reading about the social and natural world [2] . According to Guthrie [54] , education is “a form of learning in which the knowledge, skills, and habits of a group of people are transferred from one generation to the next”. This means educating is giving intellectual, moral, and social instruction to the learner. Educating the masses is disseminating knowledge and facilitating knowledge construction. Education is also important for disseminating proven knowledge and best practices. When media deliver mass education, it shares valid, proven or best practices. This helps individuals and communities to develop problem-solving skills and helps to change or maintain health behavior and cultural norms [55] and [56] . This means that teaching, learning and researching are not neutral actions. Knowledge is a socially constructed phenomena and its validity depends on the knower [57] and [2] . What constitutes valid knowledge to the colonizers is not necessarily valid for the colonized people. By the same token, what is true for the Ethiopian elites is not true for the Oromo people. This makes the Oromo people’s effort to develop their own media a struggle about transforming their own society, socially and culturally and flourishing as a group in the world.
6.4. Advocating
The third important function of media is advocating [58] , which includes promoting for healthy social policies. When the media advocates, it helps to shift the focus from the old unjust world to a new democratic and equitable world. Advocacy supports the need for fair distribution of power, privileges and risks. It educates people about healthy social policies, alternative solutions, shapes the opinions of the public and policy makers and advances health education and promotion. The media can provide legitimacy and support for a just world; it can effectively reach opinion leaders and advance social policy initiatives. It also facilitates community participation and structural changes as well as helping to identify “upstream” causes of social ills. In turn, this creates a new agenda and perspective, and generates pressure on policymakers [46] . In doing that, it fosters finding socially- culturally acceptable and financially feasible solutions.
The concept of health promotion is consistent with the term emancipation or liberation, which is the act of setting someone, or a group, free from all oppression. When it comes to media, when we are referring to liberation, we are referring to liberation of the mind. As I have discussed above, media ideally provides information, education, and advocates, entertains, gives a framework of thinking, records events and connects events. When I say media has the capacity to liberate, I am implying that it can produce critical & knowledgeable citizens, who can deeply understand their social problems, develop problem-solving skills and who are able to initiate changes. However, if media is used to colonize the mind, it can produce docile or submissive citizens.
Let me take a specific example of the latter. In the 1960’s, when many African countries liberated and became the masters of their destinies, if the Oromo people had had their own media and had been informed about the events, their status would have been quite different today. For example, Kenya a neighboring country to Oromia, was liberated after fierce resistance to British colonial forces. In that struggle, Jomo Kenyata the first Kenyan president spoke his famous words “when the missionaries arrived, the Africans had the land and the missionaries had the Bible. They taught us how to pray with our eyes closed. When we opened them, they had the land and we had the Bible” [59] . Kenyata’s words resonate with the Oromo people if the information has reached the Oromo people, it would have had deep meaning.
Another example that I want to highlight is the way handy information helps to save money. It is an observation made about electric meters in Dutch housing (in the 1970s) during the oil embargo. Some of the electric meters were installed in front halls, which are easily visible and some of them were installed in the basement― hardly visible to the family. At the end of the year, houses where the electric meters were installed in the front hall paid 30% less. This proves that information is a powerful tool that can be used to take timely and appropriate actions [60] .
6.5. Entertaining
Another function of media is entertaining. Entertainment is a form of activity that holds the attention and interest of the audience, or gives pleasure and delight. Information delivered in the form of entertainment helps people to relax and manage their stress, heal faster and overcome their depression. Health education and disease prevention can be delivered through entertainment. For example, 88% of Americans learn about health issues from television [61] . Through mass media, we can make people observe and imitate the acts of the actors or role models in performing a particular behavior. In many countries, HIV/AIDS awareness programs and healthy sexual behaviors are delivered via entertainment [62] . Television programs are highly visible mediums that can reach a wide range of audiences through stories that show the importance of specific messages. If television shows the image of a person dying from HIV/AIDS, it helps viewers to better understand the seriousness of the problem.
6.6. Molding Opinion
The other important functions of media are changing attitudes or molding the opinions of people and providing a framework of thinking [37] . The term mold means to construct rules of reason or to work into a required shape, form an opinion or behavior. This means that molding opinion is shaping or forming reason. Media present news and news analyses in a specific frame of reference. Molding opinion is one of the areas where the power of media is exercised and where competing ideas clash. Given that media molds opinions and it provides a framework of thinking, it helps to focus on some issues rather than others [63] (WHO, 2007). To illustrate the ways that the media gives a framework of thinking and explore the impacts, let me take you back to an event I observed when I was a teenager. The event occurred during the 1977/1978 Ethio-Somali war. At that time, the Ethiopian government media presented the Somali army and people as “ugly creatures”. Many people believed this description and took for granted that their sons had been conscripted to the Ethiopian militia and taken to Eastern Ethiopia to fight the “ugly creature”. One of the conscripted militias lost his arm and returned back to the village.
Individuals who suspected the Ethiopian government propaganda wanted to verify if the Somalis were truly “ugly creatures”. When one of the conscripted militias lost his arm and returned back to the village one of the first questions he was asked was “what do the Somalis look like”. The answer he gave was “they look like us”. When they asked him, how they would differentiate the enemy from friends, he answered, “they are dressed marxoo”. When they asked him if they speak a different language, he surprisingly said “they speak Oromo language with an accent” [64] .
The importance of this narrative is to demonstrate how the propaganda that was spread by the Ethiopian government created a false image of Somalians that shaped the beliefs and guided the expectations of the people. The conscripted soldier initially believed what the Ethiopian government authority presented. However, his observation was contrary to what they had led him to believe. The differences were that the people presented to him as “the enemy” or “the Somalis” were like him except for the dress code and accent, and they spoke Oromo language. This means the Ethiopian state media gave a specific framework of thinking and made the Oromo people in Eastern Oromia who are brothers and sisters with the Oromo people in Western Oromia think of them “as the enemy―as the Somali”. At that time, if the Oromo people had had their own media, the damage done against the Oromo people in Eastern Oromia would have been less severe because that image of “evil” could have been challenged.
Why is the framework of thinking so important for marginalized people and for public health advancements? To answer this question, I quote the words of Charles W. Mills, an American sociologist who said:
Freedom is not merely the opportunity to do as one pleases; neither is it merely the opportunity to choose between set alternatives. Freedom is, first of all, the chance to formulate the available choices, to argue over them―and then, the opportunity to choose. [65] .
The words of Professor Mills suggest that freedom is not the opportunity to do as one pleases. It is the opportunity to analyze and choose. Analysis means examining the assumptions and beliefs that lie behind theory and practice. Consuming information framed only by the Ethiopian state twisted the views of the Oromo people and limited their choices. It is essential that the Oromo people have media that deliver information from their own perspectives.
6.7. Connecting
Media is also important at connecting people, events, places and ideas [63] . Through songs and poems, electronic and written records, media connects people to the past, present and future. For example, in the form of songs the Oromo people connect the present generation to the past as well as to the future and help them to envision a better future. Media helps to connect people who are settled in different parts of the world and facilitates the exchange of ideas and experiences across boundaries and borders. Exchange of experiences creates conditions for people to see their world differently. As I have discussed above, if the Oromo people had been allowed to develop their own media, the connections between the Oromos in the East, South, North, and in the West would have been established. This would have helped them in exchanging ideas, experiences and perspectives. In turn, this would have helped them to get organized, collectively address their common interests and establish common security. Connecting people creates opportunities to dialogue, share information and construct knowledge [51] and [53] . Constructing knowledge from dialogue can help establish common security or use the emerging opportunities, and this can ultimately help reduce or even prevent emerging risks.
6.8. Recording Events
The last important function of media is recording events. Recording events is preserving the memory, knowledge or details of information about events. Record keeping involves transmitting information, experiences, wisdom and knowledge to the next generation. Transmitting information and experiences helps people learn from the past and prepare for the future. One of the challenges that oral societies like the Oromo people face is that knowledge transmitted from one generation to the next can be lost as it passes. This makes them prone to repeat the mistakes that their ancestors have made. If they developed their own media, they could record events permanently, transmit the wisdom and the achievements of the current generation to the next and learn from it and expand their perspectives. When media is used to store knowledge, the human mind need no longer be constrained by the limits of memory. This makes knowledge boundless and transferable. Recording events is critically important not only for the current generation but also for the generations to come.
As has been clearly shown above in the conceptual framework (in Figure 2), the identified functions of media are critical to knowledge construction and knowledge transmission, and these are essential to the development of better public health conditions.
There is considerable research evidence that education is one of the crucial social determinants of health. Obviously there are some logical connections between education and media. If we agree that education is meant to develop thoughtful, reflective citizens we need to recognize the importance of media and promote a free media. In the next section I explore the relationships between knowledge and public health conditions.
7. Public Health Consequences of Properly Functioning Media
Most social policies and practices tend to be continuations of past policies and practices. One of the key factors
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Figure 2. Concise illustration of the relationships between media and public health.
that foster change in social policy is a paradigm shift of thinking [66] . Human relationships are the manifestation of deep-seated assumptions and knowledge. Some of these assumptions are driven by scientific knowledge, while others are derived from lived experiences, and the rest are derived from critical knowledge i.e. social- political movement [66] . Knowledge influences social relations and the distribution of opportunities and risks. Since the beginning of public health knowledge and social relations are part of modern public health practices, the core function of media is to transmit knowledge and facilitate knowledge construction and this makes it an integral part of public health. In California, work with media is seen as one of the cores of essential public health functions [67] . The media provides a broader understanding of the social and environmental factors that shape our health. Media can set the governmental or popular agenda, moves social problems to a higher level, conveys the agenda of interest groups, discourages un-acceptable behavior, impedes government from creating social ills, and challenges government from developing bad politics, permits to ignore social ills [33] and [68] .
7.1. What Are the Relationships between Knowledge and Public Health?
Knowledge is intertwined with power [1] and [2] . Health and disease is a complex phenomenon, as it can be seen from biomedical and socio-cultural perspectives [63] . If we accept the theory that social power influences our health, this suggests that empowering marginalized people is vital to prevent diseases and promote health. Knowledge influences health and disease through the following intermingled mechanisms. First, knowledge fosters the modification of health behaviors and helps people to develop healthy lifestyles. Second, it helps communities to better identify risks, and services (preventive, responsive and management), fosters modifying the social-natural environments and increases the efficiency levels of communities and individuals. Third, knowledge raises awareness about opportunities and facilitates effective planning for the future, advances health literacy levels, improves self-esteem and self-efficiency. Fourth, knowledge fosters positive social relations and helps maintain peace and stability in the community and creates favorable conditions for social transformation. Fifth, knowledge helps individuals and community resiliency. Sixth, it helps people to develop problem-solving skills and modify their social-natural environments.
Let us look at a specific example. If we understood health from the perspective of social determinants, we could see that community health problems result from the interactions of past and recent social events. Clearly understanding these relationships is half way to finding working solutions. Indeed, many people understand that diseases can occur as a sudden phenomenon. Shifting people’s perceptions to understand where diseases come from, how they originate, what are involved in illness and health is important. If people understood that their living and working conditions are implicated to their health, they can make efforts to prevent, reduce and slow these processes. Seventh, knowledge improves performance and increases creativity and productivity and this helps to the betterment of economic well-being of people.
Knowledge also improves social capital, thereby ameliorating a person’s place in society. Social capital is important to a community’s social fabric and it helps to establish social networks within the community and amongst community members. If the person’s status in the community is good, the community members would trust him or her. This makes it easier for community members to get organized. According to (Kemenade [69] , individuals’ social capital is: a) the building blocks that generate the social capital for the larger society; b) the fostering of social interactions of the community members; c) the building and sustaining of efficient organizations and a sense of common purpose; d) the providing of opportunities for participation; e) the playing of an essential role in the functioning of any society; f) helping communities social networks, strengthening social cohesion of the members and quality of life; g) improving the participation of community members. Individuals with high social capital are usually the formal and informal leaders of society and they are important in fostering a community’s resiliency [70] .
Although the free media have a significant role in the development of better public health conditions, they can have certain negative effects as well. In the Western world most media are organized having profit and control in mind. The attitude of profit and control compromises the true needs of the public. Media are linked to specific illnesses like anorexia nervosa, bulimia, obesity and other chronic diseases. The fashion industry uses the media to promote unhealthy physical aspirations and poor body image. Such a fear creates conditions for young people to worry about their weight and out of such fear they may develop eating disorders i.e. anorexia nervosa or bulimia. In Africa, the sufferers of anorexia nervosa and bulimia come from affluent parts of society who have access to Western media and education [71] . In line with this, the food industry uses the media to advertise junk food and it creates conditions for families to consume energy dense foods and contribute to obesity levels and adopt sedentary lifestyles [72] . Furthermore, the movie industry conditioned people to spend their spare time in front of screens. People learned to adopt a sedentary life style. Therefore, work must be done to ensure that the media is used to promote positive public health practices that continue to improve the health outcomes of the public.
7.2. What Are the Necessary Conditions for the Media to Foster Better Public Health?
The major prerequisites for health are peace, shelter, education, food, income, a stable eco-system, sustainable resources and social justice, and equity [73] and [56] . Freedom [74] and providing information to individuals and communities enhances their intellectual capital [53] . However, not all media create a compelling vision of preferred social conditions, facilitate the empowerment of people to support participation in community affairs, promote social transformation and create healthy social conditions. As I have discussed earlier, the Ethiopian media works contrary to the public health agenda. In many cases, the Ethiopian media justifies the crimes that the Ethiopian security forces perpetuate. It distorts and exaggerates information with the intent to deny the Oromo people access to relevant and important information. For example, when the Ethiopian government leases Oromo land to investors and evicts farmers from their ancestral lands with little or no compensation, the media reports the arrival of investors without mentioning a word about the impacts of the illegal transfer of land, the number of people evicted who are now homeless. For this reason, in Oromia the Ethiopian state media is seen as “the state deceptions”. To explain this, one of my informant said, “the Ethiopian state media and social realities are like water and oil or unmixable” [75] .
Clearly, from the Oromo perspective, the stories that the Ethiopian state media presents and what are social realities are incompatible. Seeing the Ethiopian government media as an institution that delivers “deceptive messages” has measurable public health implications. For example, in the 1990s when the Ethiopian media started to raise awareness about HIV/AIDS, many people conceptualized it as one of the state’s deceptive messages. People responded to HIV/AIDS education by saying; “you silenced me not to express my views and muted my voice, but now you want to tell me what I should do in my bedroom? Please, leave politics in my bedroom to me alone” [75] .
Participation of community members depends on citizens having reliable, accurate information put in a meaningful context. This means that to be effective media need to present accurate, balanced, consistent, culturally competent, evidence-based, inclusive and reliable messages. In addition, in order to promote social transformation the media should be service oriented.
8. Discussions and Conclusions
Health is a complex phenomenon, and it can be looked at from many perspectives [7] and [34] . Public health principles apply the knowledge gained from science to the improvement of the health conditions of people, through health promotion, health education and disease prevention. This suggests that the free media have a significant role to play in enlarging people’s choice in life and in the development of public health conditions.
People are not passive information receivers. When the media provide information to people, they synthesize information and construct knowledge. Disseminating knowledge, information and facilitating knowledge construction empowers the people. Power that comes from this process helps to translate knowledge into policy and action. If we agree that social power influences health, this suggests that the empowerment of the marginalized and disadvantaged people is vital to improve their health.
Understanding health and diseases in terms of social determinants of health makes public health conditions that are the result of the accumulation of both the past and recent events. Health risks can be fully prevented or reduced. It is understood that the determinants of health act synergistically rather than separately [7] and [76] . It is for this reason that inequalities in health are seen as the manifestation of inequalities in the society. When media educates the masses, it widens their scope and helps people realize that their health is determined by their social conditions. This transforms members of society into active agents that work towards acquiring better health conditions, rather than being passive players who simply hope for improvements to public health conditions. This makes the free media central to creating a meaningful and healthy social order.
Conclusions
In this paper, I have made an effort to capture and analyze the ways the media influences the development of public health conditions. From this paper, the following conclusions can be made. First, although more work is needed to widen our understanding of the role of the media in the development of public health, our current knowledge suggests their relationships are complex as summarized in Figure 2.
Secondly, the media represents cultivation, conveyance, expression or communication to a large number of people and transmits knowledge, power and authority. This makes the media a form that dispenses information, knowledge and power. Knowledge widens people’s scope and power, potentially enlarging their choices in life. This means the intent of successive Ethiopian regimes in denying the Oromo people the right to develop their own media is the equivalent of hindering them from building their capacity, understanding their social problems and enlarging their choices in life. If providing information is enhancing the intellectual capital of the society, denying the Oromo people the ability to develop their own media is suppressing such a capacity, and that is contrary to a good public health agenda.
Thirdly, two primary functions of the media are disseminating knowledge and facilitating knowledge construction. The knowledge disseminated through education programs, news and/or news analyses and entertainment provides data. By analyzing the data using their own framework of thinking, societies can effectively construct knowledge. This helps people to better understand the social conditions in which they live and work.
Fourth, knowledge is used to identify emerging health risks and opportunities. Identifying emerging health risks helps individuals and groups to modify or change the conditions that put them at risk. If necessary, the knowledgeable groups can then self-evaluate, seek more information and ask for help to clarify the information. On the other hand, foreseeing emerging opportunities helps them to make use of knowledge and widen their choices in life.
Fifth, from the beginning public health has been intertwined with peace and social justice. The presence of peace and social justice facilitates knowledge construction and develops problem-solving skills. Knowledge is instrumental to understanding social problems, transforming the society and advancing better public health conditions. If knowledge helps people to critically understand the social and political forces that contribute to health, it is vital also to promoting peace and public health development. This makes media an important tool for effectively disseminating information, facilitating analyses of information, constructing knowledge, empowering people and promoting the fair distribution of power, privileges and risks.
Sixth, there is an urgent need to recognize that denying people the right to develop their own free media is an attempt to incapacitate society. If we agree with the view that knowledge is relevant to the social transformation of a society and to the betterment of public health conditions, we need to recognize the relevance of free media and actively promote it.
NOTES
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*This paper is the work of the author―not the institution.