Publications

Background

CAR is one of the poorest countries in the world. While UN statistics suggest that there is no health emergency in the country, two recently published mortality surveys contradict this. Moreover, recent accusations of massive scale human rights abuses by mercenaries suggested the need for a nationwide mortality survey.

Methods

Two stage cluster surveys were conducted in two different strata: one in the roughly half of the country within the Government’s control, and one in the areas mostly outside of the Government’s control. We randomly selected 40 clusters of 10 households in each stratum. The survey included questions on vital events with open-ended questions about health and household challenges at the beginning and end of each interview.

Results

70 of 80 selected clusters were successfully visited. We interviewed 699 households, containing 5070 people. 11 households (1.6%) refused to be interviewed and approximately 18.3% of households were absent at the time of visitation, mainly in the safer Government controlled areas. Interviewed households had a birth rate of 42.6 /1000 / year (95%CI 35.4–59.7) and a crude mortality rate (CMR) of 1.57 /10,000/day (95%CI: 1.36–1.78). The birth rate was lower and the death rate markedly higher in the strata outside of Government control. Families described malaria or fever, and diarrhea as the primary reported causes of death with violence accounting for 6% of all deaths

1 year has passed since the unprovoked war by Russia on Ukraine began on Feb 24, 2022. The horrendous suffering and deaths among Ukrainian civilians and the massive loss of life in the military on both sides are tragic. The UN estimates there have been 7155 conflict-related civilian deaths with 11 662 people injured, which are probably gross underestimates. There are about 5·4 million internally displaced persons (IDPs) in Ukraine, and more than 8 million refugees, most of whom have temporary protection status and reside throughout Europe. 

In the past two decades, despite ongoing war, international development assistance and funding, channelled through Afghanistan's Ministry of Public Health, expanded access to primary care, improved government hospitals, and trained thousands of health-care providers in Afghanistan, especially women. Accompanying technical assistance strengthened the capacity of Afghanistan's Ministry of Public Health to develop policy, design requirements for and oversee services provided by international and national non-governmental organisations (NGOs), and initiate surveillance, monitoring, and evaluation systems. Although progress was uneven, expanded access to higher quality care saved many lives. 

In some areas, primary health care became well enough established that in the years before the 2021 fall of Afghanistan's previous government the Taliban appointed liaisons to provincial health programmes in areas they controlled. Despite the clinics' affiliation with the former government, the Taliban engaged with managers on such issues as who was hired, which geographical areas were covered, and what health services were offered; although the Taliban used threats and coercion to influence decisions, their violent attacks on clinics and hospitals decreased. 
Afghanistan's health system remained fragile, however, and was largely reliant on donor funding and NGO implementation.

The United States of America (US) detains more migrants than any other nation. Customs and Border Patrol (CBP) and Immigration and Customs Enforcement (ICE) detain adults and families under the Department of Homeland Security, while unaccompanied minors are housed under the Office of Refugee Resettlement (ORR) within the Department of Health and Human Services. Migrants are subject to the standards and oversight of each individual agency and facility where they are detained. This paper presents an analysis of whether the current US migrant detention system upholds the standards of each agency to maintain the health of migrants. A review of peer and grey literature, along with interviews with key informants (KI) who had worked in or visited ICE, CBP, or ORR facilities since January 2018 were undertaken. Analysis of the literature review and KI interviews covered five thematic areas: health, protection of vulnerable populations, shelter, food and nutrition, and hygiene. Thirty-nine peer-reviewed publications and 28 US Office of Inspector General reports from 2010 to 2020 were reviewed. Seventeen KI interviews were conducted. Though all three detention agencies had significant areas of concern, CBP's inability to abide by its health standards was particularly alarming. The persistence of low compliance with standards stemmed from weak accountability mechanisms, minimal transparency, and inadequate capacity to provide essential services. We have five recommendations: (1) expand independent monitoring and evaluation mechanisms; (2) standardize health standards across the three agencies; (3) develop a systematic evaluation tool to help external visitors, including members of Congress, assess the degree of implementation of standards; (4) enforce consequences for private contractors who violate standards; and (5) restrict the use of waivers that allow detention facilities to circumvent compliance with standards. Ultimately, the US federal government should explore and implement alternatives to detention to maintain the health and dignity of the individuals under its care.

Background

The COVID-19 pandemic has been characterized by multiple waves with varying rates of transmission affecting countries at different times and magnitudes. Forced displacement settings were considered particularly at risk due to pre-existing vulnerabilities. Yet, the effects of COVID-19 in refugee settings are not well understood. In this study, we report on the epidemiology of COVID-19 cases in Uganda’s refugee settlement regions of West Nile, Center and South, and evaluate how health service utilization changed during the first year of the pandemic.

Methods

We calculate descriptive statistics, testing rates, and incidence rates of COVID-19 cases in UNHCR’s line list and adjusted odds ratios for selected outcomes. We evaluate the changes in health services using monthly routine data from UNHCR’s health information system (January 2017 to March 2021) and apply interrupted time series analysis with a generalized additive model and negative binomial distribution, accounting for long-term trends and seasonality, reporting results as incidence rate ratios.

Findings

The first COVID-19 case was registered in Uganda on March 20, 2020, and among refugees two months later on May 22, 2020 in Adjumani settlement. Incidence rates were higher at national level for the general population compared to refugees by region and overall. Testing capacity in the settlements was lower compared to the national level. Characteristics of COVID-19 cases among refugees in Uganda seem to align with the global epidemiology of COVID-19. Only hospitalization rate was higher than globally reported. The indirect effects of COVID-19 on routine health services and outcomes appear quite consistent across regions. Maternal and child routine and preventative health services seem to have been less affected by COVID-19 than consultations for acute conditions. All regions reported a decrease in consultations for respiratory tract infections.

Humanitarian crises represent a significant public health risk factor for affected populations exacerbating mortality, morbidity, disabilities, and reducing access to and quality of health care. Reliable and timely information on the health status of and services provided to crisis-affected populations is crucial to establish public health priorities, mobilize funds, and monitor the performance of humanitarian action. Numerous efforts have contributed to standardizing and presenting timely public health information in humanitarian settings over the last two decades. While the prominence of process and output (rather than outcome and impact) indicators in monitoring frameworks leads to adequate information on resources and activities, health outcomes are rarely measured due to the challenges of measuring them using gold-standard methods that are difficult to implement in humanitarian settings.

We argue that challenges in collecting the gold-standard performance measures should not be a rationale for neglecting outcome measures for critical health and nutrition programs in humanitarian emergencies. Alternative indicators or measurement methods that are robust, practical, and feasible in varying contexts should be used in the interim while acknowledging limitations or interpretation constraints. In this paper, we draw from existing literature, expert judgment, and operational experience to propose an approach to adapt public health indicators for measuring performance of the humanitarian response across varied contexts.

The war in Ukraine and its direct and indirect consequences have reverberated throughout the world. The media report on the horrific consequences that are occurring daily, mostly through personal stories that attempt to encapsulate the horrors of this unprovoked war by Russia. Until this issue in The Lancet Healthy Longevity, to my knowledge there have been no peer-reviewed articles with large-scale quantitative data that analyse the health situation for Ukrainian refugees and their potential effects on health systems. When I was the Emergency Coordinator for the Ukraine refugee response for WHO in March and April of this year, I noted that this absence of available health data from EU hosting countries made planning and response extremely difficult for the multitude of actors involved in the Ukrainian refugee crisis. Until now, the data collected and shared on Ukrainian refugees by the EU-refugee hosting governments remain inadequate for an effective response and for future planning.

Objective 

To assess the health cost (or benefit) of crisis-driven migration by focusing on the infant mortality rate (IMR) of the Colombian diaspora in Venezuela and the Venezuelan diaspora in Colombia.

Methods 

We compare national to diaspora IMRs over the period 1980-2018. National IMRs are death-to-birth ratios reported by the official vital statistics, whereas diaspora IMRs are calculated by using a semiparametric regression model on the summary birth histories collected in the population censuses. We analyize the diaspora IMRs according to whether their arrival corresponds to precrisis or crisis-driven migration.

Results 

During crises, diaspora IMRs show better health outcomes than those of non-migrants. The Colombian diaspora had an average annual IMR of −1.8 (95% CI −3.3 to 0.28) per year and the Venezuelan diaspora had −4.5 (95% CI −5.8 to −3.3). However, the protective role of migration is neither guaranteed nor consistent, as a crisis in the country of destination exposes immigrants to worse health outcomes than the non-migrant population.

Conclusion 

Migration is a survival strategy that allows people to reduce the negative effects they face during a crisis in their country of origin. The distinction between crisis-driven and precrisis migration provides a framework for assessing the cross-border effects on health outcomes due to diaspora composition, particularly when populations face adverse conditions.

Since the beginning of the COVID-19 pandemic, much research has been conducted globally, but relatively few studies have been carried out in complex emergency settings that pose numerous operational challenges. We conducted a qualitative study to explore the barriers and enablers of a COVID-19 cohort study conducted in South Sudan and Eastern Democratic Republic of the Congo, to inform future research on COVID-19 and infectious diseases in humanitarian settings. We used a case study design embedded within the original prospective cohort study. Qualitative data was collected through four health facility assessments, 28 key informant interviews, and a focus group discussion. Data were analyzed using a manual thematic analysis approach and summarized against four primary themes: testing challenges and enablers, perceptions and attitudes towards COVID-19, national health system considerations, and study management considerations. Findings suggest most of the challenges affecting the cohort study were not specific to COVID-19 research but have been a feature of previous infectious disease research carried out in complex emergencies. However, the pandemic has exacerbated certain problems. The high proportion of travellers enrolled due to testing mandates, stigmatization of infected individuals linked to the heavy global focus on COVID-19, strained resources during waves of increasing infections, and remote management requirements all negatively impacted the cohort study. Factors that facilitated the research included proactive management, data quality oversight procedures, and strong collaboration with national health stakeholders. The global impact of COVID-19, its high public profile, and specific pandemic policies pose further operational challenges for research in already complex humanitarian settings. Future studies could plan mitigation measures that include flexibility in staffing and budgets, strategies to expand testing, and early partnerships with local organizations and health authorities.

La República de Colombia es Estado parte de instrumentos internacionales e interamericanos de derechos humanos y humanitarios, y es garante del derecho a la salud de todas las personas, sin discriminación. No obstante, los inmigrantes enfrentan obstáculos de accesibilidad y aceptabilidad de servicios de salud. En este marco, el objetivo de la presente investigación es doble. El primero es examinar la legislación y la jurisprudencia colombiana que dan garantía a la salud de los migrantes internacionales. Segundo, se pretende identificar perfiles de inmigrantes venezolanos que han tenido o no acceso a la salud. Estos perfiles se construyen a partir de los datos recogidos por la primera Encuesta de Calidad de Vida e Integración de los Migrantes Venezolanos en Colombia. La finalidad es caracterizar a la población migrante que es excluida, lo que podría contribuir a su inclusión e integración en Colombia. Por un lado, se constata que la aplicación efectiva de los principios constitucionales de igualdad depende del estatus migratorio de la persona y de la afiliación al Sistema General de Seguridad Social en Salud. Dicho estatus está vinculado con la posesión de documentos de identidad venezolanos, el tiempo de residencia, y el momento de llegada al mencionado país. Por otro lado, se observa que los inmigrantes irregulares solo pueden acceder al servicio de urgencias. La pobreza individual y la vulnerabilidad colectiva caracterizan a los inmigrantes que no han tenido acceso al sistema de salud cuando lo han necesitado.

Objectives 

Our study described demographic characteristics, exposures and symptoms, and comorbidities to evaluate risk factors of hospitalisation and mortality among cases in Juba, South Sudan (SSD) and North and South Kivu in eastern Democratic Republic of the Congo (DRC).

This study examines mental, neurological, and substance use (MNS) service usage within refugee camp primary health care facilities in low- and middle-income countries (LMICs) by analyzing surveillance data from the United Nations High Commissioner for Refugees Health Information System (HIS). Such information is crucial for efforts to strengthen MNS services in primary health care settings for refugees in LMICs.

Background

The effects of the Coronavirus Disease 2019 (COVID-19) pandemic in humanitarian contexts are not well understood. Specific vulnerabilities in such settings raised concerns about the ability to respond and maintain essential health services. This study describes the epidemiology of COVID-19 in Azraq and Zaatari refugee camps in Jordan (population: 37,932 and 79,034, respectively) and evaluates changes in routine health services during the COVID-19 pandemic.

The worsening military invasion of Ukraine by Russia since Feb 24, 2022 has massive geopolitical consequences. Up to May 4, 2022, more than 5·7 million refugees have fled into surrounding host countries in Europe. In late April, 2022, I returned from 6·5 weeks as the Emergency Coordinator for the WHO refugee health response at the Refugee Health Extension, a small hub created to support strategies, guidance, systems, and interagency and intercountry coordination for the Ukrainian refugee health response based in Poland. This humanitarian response is different from my previous humanitarian experiences.

On 1 April 2022, the US Centers for Disease Control and Prevention (CDC) moved to close a sorry chapter in the organization’s history by terminating the inhumane immigration policy known colloquially as Title 421. The original order, issued on 20 March 2020, invoked a rarely used provision of US health law — section 265 of US Code Title 42 — allowing the US federal government, on the grounds of public health, to immediately turn away and expel people arriving at the border seeking asylum protection2. The order was then revised and renewed multiple times over two years by the CDC under both the Trump and Biden administrations. The public health justification for Title 42 was spurious at its inception and at odds with the science on SARS-CoV-2 transmission and infection. In allowing public health to be weaponized and used as a means to subvert the internationally recognized right to seek asylum, the CDC established a disturbing global precedent that undermined trust in public health institutions at precisely the moment when the world needed that trust most.

Hundreds of Russian and Assad-regime hospital bombings in Syria; Saudi Arabia-led coalition airstrikes on hospitals in Yemen—assisted by United States and United Kingdom weapons and military aid; Ethiopian and Eritrean military forces' destruction of the health system in Tigray and the Ethiopian government's block of desperately needed humanitarian aid to millions; Israel's repeated breaches of obligations to protect hospitals, ambulances, and emergency responders in wars in Gaza; dozens of health workers killed and hundreds arrested following the 2021 coup in Myanmar. These are only some of depredations against health care in war during the past decade.

Active conflict settings present challenging operating environments for humanitarian health organizations and workers. An emerging feature of some conflicts is direct violence against health workers, facilities, and patients. Since the start of the war in 2011, Syria has endured extreme and deliberate violent attacks on health facilities and workers. This paper reports findings from a qualitative study that examined the lived experiences of Syrian humanitarian health workers facing extreme ethical challenges and coping with moral distress. In-depth interviews were carried out with 58 front-line health workers in northern and southern Syria. Participants described a number of ethical and operational challenges they experienced while providing services in extreme conditions, as well as strategies used to cope with them. The complex intersection of personal and organizational challenges is considered, and findings are linked to key ethical and humanitarian principles. Practical recommendations and action steps are provided to guide humanitarian health organizations. This article is protected by copyright. All rights reserved.

The worsening humanitarian catastrophe and conflict in Ukraine has led to the largest refugee crisis in Europe since World War 2. Millions of people are expected to flee Ukraine, with more than a million individuals having fled the country in the first week of the conflict alone. The consequences of war, trauma, and devastation must be tackled swiftly. The resultant mid-term and long-term needs must propel all sectors, including health, into rapid action. The UCL–Lancet Commission on Migration and Health report highlighted evidence-based approaches to address the health needs of forcibly displaced individuals.

Although the initial response of the EU agreeing to a uniform policy of settlement, work, and welfare rights for those forcibly displaced is welcomed, implementation of these policies, without restrictions, red tape, or xenophobia and racism is by no means assured. The COVID-19 pandemic illuminated the need to strengthen health systems and reduce disparities in access to and quality of care for migrant groups. As the crisis in Ukraine becomes protracted, access to health care could be at further risk because nations have varying levels of preparedness and reception, and variable health systems, particularly in neighbouring countries such as Poland, Slovakia, Bulgaria, and the Czech Republic (Czechia), which will be strained by the large numbers of people arriving from Ukraine. These countries will need increased support, including financial support, from other countries. The Ukrainian crisis will test political solidarity, health system planning and capacity, and the global community's ability to keep the commitment to universal health coverage.

Introduction 

Non-pharmaceutical interventions (NPIs) are a crucial suite of measures to prevent and control infectious disease outbreaks. They are particularly important for crisis-affected populations that typically reside in settings characterised by overcrowding, inadequate access to healthcare and resource limitations. To describe the landscape of research and identify evidence gaps concerning the acceptability, feasibility, and effectiveness of NPIs among crisis-affected populations and informal settings, we conducted a systematic scoping review of the published evidence.

Methods

We systematically reviewed peer-reviewed articles published between 1970 and 2020 to collate available evidence on the feasibility, acceptability, and effectiveness of NPIs in crisis-affected populations and informal settlements. We performed quality assessments of each study using a standardised questionnaire.

Results

 Our review included 158 studies published in 85 peer-reviewed articles. Most research used low quality study designs. The acceptability, feasibility, and effectiveness of NPIs was highly context dependent. In general, simple and cost-effective interventions such as community-level environmental cleaning and provision of water, sanitation and hygiene services, and distribution of items for personal protection such as insecticide-treated nets, were both highly feasible and acceptable. Logistical, financial, and human resource constraints affected both the implementation and sustainability of measures. Community engagement emerged as a strong factor contributing to the effectiveness of NPIs. Conversely, measures that involve potential restriction on personal liberty such as case isolation were found to be less acceptable to the community.

As of March 31, 2022, the World Health Organization’s Surveillance System for Attacks on Health Care (SSA) reported at least 82 attacks on health care in Ukraine, resulting in 72 deaths and 43 injuries. Most attacks involved the use of heavy weapons against health care facilities, personnel, patients, and medical supplies. In Mariupol, a direct Russian airstrike on a hospital complex reportedly injured at least 17 health workers and patients; an expectant mother later died. Russian forces reportedly took 100 patients and health workers and 400 civilians as hostages inside an intensive care hospital. These are part of a larger global pattern of attacks on health care in conflict zones. In the period 2016-2020, more than 4000 incidents of violence against health care in conflict areas were reported.