Publications

On the morning of May 26, a Russian missile destroyed Dnipropetrovsk City Hospital No 14 in Dnipro, Ukraine, killing at least two people and injuring more than 30. Later that same day, the BBC reported that attacks on medical facilities and staff in Sudan might constitute war crimes. As described in a World Report, such attacks continue in Sudan, including most recently the looting and occupation of centres run by Médecins Sans Frontières, denying Sudanese civilians much needed medical care. From the deliberate targeting of hospitals in Syria and the destruction of the health system in Yemen, to the arrest and abduction of doctors in Myanmar and the persecution of health workers and violations of medical neutrality in Iran, the sanctity of the Red Cross and Red Crescent appears to be at a new low. The uncomfortable truth is that attacks against health facilities and staff in conflicts can be committed largely with legal impunity.

Background

Despite increasing evidence on COVID-19, few studies have been conducted in humanitarian settings and none have investigated the direct and indirect effects of the pandemic in the Central African Republic. We studied the COVID-19 epidemiology, health service utilization, and health care seeking behavior in the first year of the pandemic in Bangui and surrounding areas.

Methods

This mixed-methods study encompasses four components: descriptive epidemiological analysis of reported COVID-19 cases data; interrupted time series analysis of health service utilization using routine health service data; qualitative analysis of health care workers’ perceptions of how health services were affected; and health care seeking behavior of community members with a household survey and focus group discussions.

Background

Approximately 25% of facility births take place in private health facilities. Recent national studies of maternal and newborn health (MNH) service availability and quality have focused solely on the status of public sector facilities, leaving a striking gap in information on the quality of maternal and newborn care services.

Methods

A rapid cross-sectional assessment was conducted in November 2022 to assess the quality of MNH services at private hospitals in Iraq. Multi-stage sampling was used to select 15% of the country’s 164 private hospitals. Assessment tools included a facility assessment checklist, a structured health worker interview tool, and a structured client exit interview tool. Data collection was conducted using KoboToolbox software on Android tablets, and analysis was conducted using SPSS v28.

Results

All hospitals visited provided MNH services and had skilled personnel present or on-call 24 h/day, 7 days/week. Most births (88%) documented between January and June 2022 were cesarean births. Findings indicate that nearly all hospitals have the human resources, equipment, medicines, and supplies necessary for quality antenatal, intrapartum, and early essential newborn care, and many are also equipped with special units and resources needed to care for small and sick babies. However, while resources are in place for basic and advanced care, there are gaps in knowledge and practice of high-impact interventions that require few or no resources to perform, including skin-to-skin thermal care and support for early initiation of breastfeeding. Person-centered maternity care scores suggest that private hospitals offer a positive experience of care for all clients, ho

Until recently, little attention from humanitarian agencies has been given to management of noncommunicable diseases in emergencies. Chronic kidney disease (CKD) is a common non-communicable disease, and despite its increasing prevalence, management of CKD, including kidney failure (KF) and kidney transplantation, receives little support in health emergencies. Management of patients with end-stage kidney failure on maintenance dialysis requires a complex infrastructure consisting of a built environment, electricity, water delivery, dialysis equipment, secure dialysis supplies chain, skilled medical staff, and leadership, which may not be available in many situations. Where these requirements do exist, they are easily disrupted in humanitarian emergencies. Protracted conflicts, such as those in the Democratic Republic of the Congo, Iraq, Libya, Syria, Somalia, Yemen, and Ukraine, have produced a new urgency for the planning and management of persons with KF and other non-communicable diseases.

Cholera outbreaks primarily occur in areas lacking adequate water, sanitation, and hygiene (WASH), and infection can cause severe dehydration and death. As individuals living near cholera cases are more likely to contract cholera, case-area targeted interventions (CATI), where a response team visits case and neighbor households and conducts WASH and/or epidemiological interventions, are increasingly implemented to interrupt cholera transmission. As part of a multi-pronged evaluation on whether CATIs reduce cholera transmission, we compared two organizations' standard operating procedures (SOPs) with information from key informant interviews with 26 staff at national/headquarters and field levels who implemented CATIs in Nigeria in 2021. While organizations generally adhered to SOPs during implementation, deviations related to accessing case household and neighbor household selection were made due to incomplete line lists, high population density, and insufficient staffing and materials. We recommend reducing the CATI radius, providing more explicit context-specific guidance in SOPs, adopting more measures to ensure sufficient staffing and supplies, improving surveillance and data management, and strengthening risk communication and community engagement. The qualitative results herein will inform future quantitative analysis to provide recommendations for overall CATI implementation in future cholera responses in fragile contexts.

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.