Publications

Background: Adolescence is a critical period of human development, however, limited research on programs to improve health and well-being among younger adolescents living in conflict-affected and humanitarian settings exists. The purpose of this study was to assess the comparative effectiveness of an economic empowerment program on young adolescent outcomes in a complex humanitarian setting. 

Methods: This longitudinal, mixed-methods study examined the relative effectiveness of an integrated parent (Pigs for Peace, PFP) and young adolescent (Rabbits for Resilience, RFR) animal microfinance/asset transfer program (RFR + PFP) on adolescent outcomes of asset building, school attendance, mental health, experienced stigma, and food security compared to RFR only and PFP only over 24 months. A sub-sample of young adolescents completed in-depth qualitative interviews on the benefits and challenges of participating in RFR.

Results: Five hundred forty-two young adolescents (10–15 years) participated in three groups: RFR + PFP (N = 178), RFR only (N = 187), PFP only (N = 177). 501 (92.4%) completed baseline surveys, with 81.7% (n = 442) retention at endline. The group by time interaction (24 months) was significant for adolescent asset building (X2 = 16.54, p = .002), school attendance (X2 = 12.33, p = .015), and prosocial behavior (X2 = 10.56, p = .032). RFR + PFP (ES = 0.31, ES = 0.38) and RFR only (ES-0.39, ES = 0.14) adolescents had greater improvement in asset building and prosocial behavior compared to PFP only, respectively. The odds of missing two or more days of school in the past month were 78.4% lower in RFR only and 45.1% lower in RFR + PFP compared to PFP only. No differences between groups in change over time were found for internalizing behaviors, experienced stigma, or food security. Differences by age and gender were observed
in asset building, prosocial behavior, school attendance, experienced stigma, and food security. The voices of young adolescents identified the benefits of the RFR program through their ability to pay for school fees, help their families meet basic needs, and the respect they gained from family and community. Challenges included the death of rabbits and potential conflict within the household on how to use the rabbit asset.

Conclusion: These findings underscore the potential for integrating economic empowerment programs with both parents and young adolescents to improve economic, educational, and health outcomes for young adolescents growing up in rural and complex humanitarian settings. Trial registration: NCT02008695. Retrospectively registered 11 December 2013.

Abstract

Background: Trauma systems have been shown to save lives in military and civilian settings, but their use by humanitarians in conflict settings has been more limited. During the Battle of Mosul (October 2016–July 2017), trauma care for injured civilians was provided through a novel approach in which humanitarian actors were organized into a trauma pathway involving echelons of care, a key component of military trauma systems. A better understanding of this approach may help inform trauma care delivery in future humanitarian responses in conflicts.

Methodology: A qualitative study design was used to examine the Mosul civilian trauma response. From August– December 2017, in-depth semi-structured interviews were conducted with stakeholders (n = 54) representing nearly two dozen organizations that directly participated in or had first-hand knowledge of the response. Source document reviews were also conducted. Responses were analyzed in accordance with a published framework on civilian battlefield trauma systems, focusing on whether the response functioned as an integrated trauma system. Opportunities for improvement were identified.

Results: The Mosul civilian trauma pathway was implemented as a chain of care for civilian casualties with three successive echelons (trauma stabilization points, field hospitals, and referral hospitals). Coordinated by the World Health Organization, it comprised a variety of actors, including non-governmental organizations, civilian institutions, and at least one private medical company. Stakeholders generally felt that this approach improved access to trauma care for civilians injured near the frontlines compared to what would have been available. Several trauma systems elements such as transportation, data collection, field coordination, and post-operative rehabilitative care might have been further developed to support a more integrated system.

Conclusions: The Mosul trauma pathway evolved to address critical gaps in trauma care during the Battle of Mosul. It adapted the concept of echelons of care from western military practice to push humanitarian actors closer to the frontlines and improve access to care for injured civilians. Although efforts were made to incorporate some of the integrative components (e.g. evidence-based pre-hospital care, transportation, and data collection) that have enabled recent achievements by military trauma systems, many of these proved difficult to implement in the Mosul context. Further discussion and research are needed to determine how trauma systems insights can be adapted in future humanitarian responses given resource, logistical, and security constraints, as well as to clarify the responsibilities of various actors.

Migration, a defining issue of our time, is essential to growing economies and is an integral part of the social and cultural fabric of our societies. The positive impacts of migration are apparent globally, with more than 164 million international labour workers contributing to economies worldwide, and hundreds of millions more moving for work within their own countries. The numbers of forcibly displaced people, such as refugees and internally displaced persons, worldwide are much smaller but rose to a record 70·8 million in 2018. The World Bank predicts that nearly half of the world’s poor will live in fragile and conflict-affected states by 2030.

However, despite the fact that migration will always be part of our global reality, people who migrate often face restrictive migration policies, unsafe working conditions, discrimination, and health policies and systems that exclude them at many stages of their journeys: within countries of origin, in transit settings, and destination countries alike. Adverse policies and conditions increasingly deny migrants their basic human rights, including the right to health. These, have resulted in preventable deaths and morbidity due to mental and physical health complications among migrants arising from inadequate access to basic health care and conditions that do not meet even basic humanitarian standards. It is not only restrictive migration policies that harm migrant health but also lack of policies within countries to enable access to services or reduce exposure to work or migration-related illness and injury.

Abstract Background: Humanitarian health care organizations and health workers working in contexts of armed or violent conflict experience challenges in fulfilling ethical obligations and humanitarian principles. To better understand the types of challenges experienced in these contexts, we conducted a systematic literature review.

Methods: A broad search strategy was developed for English language publications available in PubMed, Ovid/ EMBASE, and Scopus. The search relied upon three key concept blocks: conflict settings, humanitarian or relief organizations, and non-clinical or non-military ethics. To be included, publications had to (1) refer implicitly or explicitly to ethics and/or humanitarian principle(s), (2) relate to non-military relief work in active conflict or conflictaffected settings, (3) relate to organizational mission and/or delivery of services, and (4) relate to events after 1900. Records were qualitatively analyzed using an emergent thematic analysis approach that mapped challenges onto recognized ethical obligations and humanitarian principles.

Results: A total of 66 out of a possible 2077 retrieved records met inclusion criteria. The most frequently noted ethical challenges for organizations working in conflict settings were (1) providing the highest attainable quality of care, (2) protecting workers, and (3) minimizing unintended harms. The humanitarian principle most frequently noted as challenging to uphold was neutrality (the duty that humanitarian actors must not take sides in a conflict). Ethical challenges and humanitarian principles were commonly co-coded. For example, the challenge of providing the highest attainable quality of care frequently intersected with the humanitarian principle of humanity.

Conclusions: By categorizing the types of ethical challenges experienced by humanitarian care organizations, this review can help organizations anticipate issues that might arise in conflict settings. The identified relationships between ethical challenges and humanitarian principles suggests that frameworks and guidance for ethical decision-making, if adapted for conflict settings, could support organizational capacity to fulfill ethical and humanitarian commitments.

Background: The majority of deaths during conflict and displacement are due to indirect causes, specifically infectious diseases. Although the control of communicable diseases and epidemics is one of the top priorities during humanitarian crises, little has been published about epidemics in refugee camps. In this article we analyze data from the health information system managed by the United Nations High Commissioner for Refugees (UNHCR) capturing key public health information from camps. We provide insights into the epidemiological profile and overall burden of epidemics in these settings in order to inform decisions on priority interventions.

Methods: We used data from UNHCR Health Information System and conducted a descriptive analysis of outbreaks between January 2009 to July 2017 in terms of frequency, geographical distribution, duration, size, case fatality, attack rate, and type of outbreaks.

Results: A total of 364 outbreaks occurred in 21 countries, affecting 108 refugee camps. Seventy-five percent of epidemics were due to measles, cholera, meningitis; 70% of them occurred in three countries (Kenya, Chad, Thailand). Fifty percent of the camps recorded <1 outbreak/year, while 90% of camps experienced one or two types of diseases. Half of the outbreaks lasted less than one month and had fewer than 10 cases.

Conclusions: UNHCR and partners appear to be successfully containing infectious disease epidemics in refugee camps. Preventive measures addressing water, sanitation, hygiene and shelter conditions could nevertheless reduce the risk for water and air-borne diseases. Vaccination remains a key preventive strategy that needs to be enhanced and adapted to such mobile populations.

The modern successor to the Hippocratic oath, called the Declaration of Geneva, was updated and approved by the World Medical Association in 2017. The pledge states that “The health and well-being of my patient will be my first consideration” and “I will not use my medical knowledge to violate human rights and civil liberties, even under threat.” Can a physician work in US immigration detention facilities while upholding this pledge? There is a humanitarian emergency at theUS-Mexico border where migrants, including families, adults, or unaccompanied children, are detained and processed by the Department of Homeland Security’s (DHS) Customs and Border Patrol and are held in over crowded and unsanitary conditions with insufficient medical care.2 Children (persons <18 years), without their parents or guardians, are often being detained in these detention facilities beyond the 72 hours allowed under federal law.

This year's Global Nutrition Cluster meeting in July, 2019, offered a platform on which to discuss all nutrition-related humanitarian emergencies. Ebola virus disease (EVD) and breastfeeding in DR Congo was an obvious topic. More than 2800 cases have been confirmed in the ongoing outbreak in DR Congo; most cases are adults, and 56% of cases are women. Ample information is available on the presence of Ebola virus in bodily fluids such as blood, urine, and semen, and on the prevention of transmission from these fluids. However, information on EVD and breastmilk is limited.

Venezuela’s economic crisis has triggered mass migration; more than 3.4 million Venezuelans have fled to other countries in the region and beyond. An assessment mission to Cúcuta, in the Colombian border state of North Santander, was undertaken from July 26 to August 1, 2018, and to Bôa Vista and Pacaraima, in the state of Roraima, Brazil, between August 24 and 28, 2018. Interviews were conducted with key informants, including health providers and organizations engaged in the humanitarian response. Secondary analysis of gray literature and data shared by key informants was also undertaken. Surveillance data demonstrate increases in infectious diseases, as well as adverse maternal and neonatal health outcomes, among Venezuelans in North Santander and Roraima.

Background: Large epidemics frequently emerge in conflict-affected states. We examined the cholera response during the humanitarian crisis in Yemen to inform control strategies.

Methods: We conducted interviews with practitioners and advisors on preparedness; surveillance; laboratory; case management; malnutrition; water, sanitation and hygiene (WASH); vaccination; coordination and insecurity. We undertook a literature review of global and Yemen-specific cholera guidance, examined surveillance data from the first and second waves (28 September 2016–12 March 2018) and reviewed reports on airstrikes on water systems and health facilities (April 2015–December 2017). We used the Global Task Force on Cholera Control’s framework to examine intervention strategies and thematic analysis to understand decision making.

Results: Yemen is water scarce, and repeated airstrikes damaged water systems, risking widespread infection. Since a cholera preparedness and response plan was absent, on detection, the humanitarian cluster system rapidly developed response plans. The initial plans did not prioritise key actions including community-directed WASH to reduce transmission, epidemiological analysis and laboratory monitoring. Coordination was not harmonised across the crisis-focused clusters and epidemic-focused incident management system. The health strategy was crisis focused and was centralised on functional health facilities, underemphasising less accessible areas. As vaccination was not incorporated into preparedness, consensus on its use remained slow. At the second wave peak, key actions including data management, community-directed WASH and oral rehydration and vaccination were scaled-up.

Since the fall of former Sudan President Omar al-Bashir's regime in April, 2019, the political and security situation in Sudan has been in flux. The Sudanese Transitional Military Council (TMC) and opposition groups signed a 3-year power-sharing agreement on July 4, 2019. Protesters have since voiced a mix of cautious optimism and scepticism, particularly about the role of the military in the transitional period. This is because until June 30, 2019, the TMC had violently responded to peaceful mass protests organised by the Forces for Freedom and Change (FFC), an umbrella organisation of opposition groups, prominently spearheaded by multiple medical professional bodies. According to various reports, this response has led to at least 100 civilian deaths, 70 cases of rape, and attacks on medical staff and facilities. The Rapid Support Forces (RSF) implicated in recent violence are comprised of the Janjaweed militia with a documented history of human rights abuses in Darfur and elsewhere. With the TMC and its RSF still clinging to power as part of the new power-sharing agreement, even the short term in Sudan remains unpredictable.

The 9-year conflict in Syria has resulted in one of the worst humanitarian crises of our generation, with more than 11·7 million people in need of humanitarian assistance in Syria, 11·3 million in need of health assistance, and 6·2 million internally displaced within Syria.
 In one of the worst onslaughts of the conflict to date, Syrian Government and Russian forces have intensified their ground shelling and airstrikes in northwest Syria since early April, 2019. This area contains an estimated 3 million people of whom 1·3 million are internally displaced people, who have already been displaced from other parts of Syria such as Aleppo and Eastern Ghouta by previous government offensives; the most severely affected area is in the southernmost part of the demilitarised zone of Idlib province. To date, 380 casualties, including 91 children, have been reported in Idlib; with 27 deaths, including 11 children, in just 1 day on June 10, 2019. These attacks echo prior campaigns by government forces to retake territory through inflicting a heavy civilian price.

However, this offensive is even more catastrophic as civilians are trapped between the closed Turkish border and are unable to return to other parts of Syria with guarantees of their safety. On June 27, 2019, 11 humanitarian organisations warned of the worsening humanitarian catastrophe in Idlib, with 3 million lives in danger, including 1 million children.

Armed conflicts are widespread in sub-Saharan Africa and considered to be an important factor in slowing down national progress in reproductive, maternal, newborn and child health (RMNCH). The measurement of the impact of conflicts on national levels and trends in RMNCH is difficult. National surveys conducted before and sometimes during and after conflicts are a major source of information on the national and local effects of conflicts on RMNCH. We examined data from national surveys in 13 countries in sub-Saharan Africa with major conflicts during 1990–2016 to assess the levels and trends in RMNCH intervention coverage, nutritional status and mortality in children under 5 years in comparison with subregional trends. The surveys provide substantive evidence of a negative association between levels and trends in national indicators of RMNCH service coverage, child growth and under-5 mortality with armed conflict, with some notable exceptions. National surveys are an important source of data to assess the longer term national consequences of conflicts for RMNCH in most countries, despite limitations due to sampling and timing of the surveys.

Prospective, community-based surveillance systems for measuring birth, death, and population movement rates may have advantages over the ‘gold-standard’ retrospective household survey in humanitarian contexts. A community-based, monthly surveillance system was established in South Kivu, Democratic Republic of the Congo, in partnership with a local implementing partner and the national ministry of health. Data were collected on the occurrence of births, deaths, arrivals, and departures over the course of one year, and a retrospective survey was conducted at the end of the period to validate the information. Discrepancies between the two approaches were resolved by a third visit to the households with discordant records. The study found that the surveillance system was superior in terms of its specificity and sensitivity in measuring crude mortality and birth rates as compared to the survey, demonstrating the method's potential to measure accurately important population-level health metrics in an insecure setting in a timely, community-acceptable manner.

Background: In June 2017, the U.S.-backed Syrian Democratic Forces (SDF) launched a military operation to retake the city of Raqqa, Syria, from the so-called Islamic State. The city population incurred mass numbers of wounded. In the post-offensive period, the population returned to a city (Raqqa) contaminated with improvised explosive devices (IEDs) and explosive remnants of war (ERWs), resulting in a second wave of wounded patients. Médecins Sans Frontières (MSF) supported a hospital in Tal-Abyad (north of Raqqa) and scaled up operations in response to this crisis. We describe the cohort of blast-wounded cases admitted to this hospital in order help prepare future humanitarian responses.

Methods: We retrospectively extracted data from clinical charts in the MSF-supported hospital. We included all new admissions for blast-wounded patients with key data elements documented. We performed comparative analyses from the offensive period (June 6, 2017 to October 17, 2017) and the post-offensive period (October 18, 2017 to March 17, 2018).

Results: We included 322 blast related injuries. There were more than twice the number of cases with blast injuries in the post-offensive period as the offensive period (225 vs. 97, p = <.001). The offensive period saw a significantly higher proportion of female patients (32.0%, n = 31 vs. 11.1%, n = 25, p < 0.001) and paediatric patients (42.3%, n = 41 vs 24.9%, n = 56, p = 0.002). Blast-injured patients in the post-offensive period included more cases with multiple traumatic injuries (65.8%, n = 148 vs. 39.2%, n = 38, p < 0.001). The treatment of the blast-injured cases in the post-offensive period was more labor intensive with those patients having a higher median number of interventions (2 vs 1, p = <0.001) and higher median number of days in hospital (7 vs 4, p = < 0.001).

Conclusions: In the wake of the Raqqa offensive, the MSF-supported district hospital received an unpredicted second, larger and more complex wave of blast-wounded cases as the population returned to a city strewn with IEDs and ERWs. These findings indicate the high risk of traumatic injury to the population even after warring factions have vacated conflict zones. Medical humanitarian actors should be prepared for a continued and scaled up response in areas known to be highly contaminated with explosive ordnance.

We describe human rights violations against migrant workers at the Thailand-Myanmar border, and evaluate differences by gender and industry. This mixed methods study pairs key informant interviews ( n = 40) with a cross-sectional quantitative survey of migrant workers from Myanmar ( n = 589) recruited via respondent-driven sampling. Key informants described significant hazards during migration, including deception, theft, and physical and sexual abuse, the latter primarily for women. Quantitative results confirmed prevalent mistreatment and abuse, with significant gender differences, most notably women's disproportionate burden of sexual abuse. Current evidence on the nature of experiences, and significant differences by gender, can position prevention and response programming.

Background: Integrated community case management (iCCM) is a strategy to train community health workers (relais communautaires or RECOs in French) in low-resource settings to provide treatment for uncomplicated ma- laria, pneumonia, and diarrhea for children 2-59 months of age. The package of Ministry of Public Health tools for RECOs in the Democratic Republic of Congo that was being used in 2013 included seven data collection tools and job aids which were redundant and difficult to use. As part of the WHO-sup- ported iCCM program, the International Rescue Committee developed and evaluated a simplified set of pictorial tools and curriculum adapted for low-lit- erate RECOs.

Methods: The revised training curriculum and tools were tested in a quasi-experimental study, with 74 RECOs enrolled in the control group and 78 RECOs in the intervention group. Three outcomes were assessed during the study period from Sept. 2015-July 2016: 1) quality of care, measured by direct observation and reexamination; 2) workload, measured as the time required for each assessment – including documentation; and 3) costs of rolling out each package. Logistic regression was used to calculate odds ratios for correct treat- ment by the intervention group compared to the control group, controlling for characteristics of the RECOs, the child, and the catchment area.

Results: Children seen by the RECOs in the intervention group had nearly three times higher odds of receiving correct treatment (adjusted odds ratioaOR = 2.9, 95% confidence interval CI = 1.3-6.3, P = 0.010). On average, the time spent by the intervention group was 10.6 minutes less (95% CI=6.6- 14.7, P < 0.001), representing 6.2 hours of time saved per month for a RECO seeing 35 children. The estimated cost savings amounts to over US$ 300 000 for a four-year program supporting 1500 RECOs.

Conclusion: This study demonstrates that, at scale, simplified tools and a training package adapted for low-literate RECOs could substantially improve health outcomes for under-five children while reducing implementation costs and decreasing their workload. The training curriculum and simplified tools have been adopted nationally based on the results from this study.

No discipline has been impacted more by war and armed conflict than health care has. Health systems and health care providers are often the first victims, suffering increasingly heinous acts that cripple the essential health delivery and public health infrastructure necessary for the protection of civilian and military victims of the state at war. This commentary argues that current instructional opportunities to prepare health care providers fall short in both content and preparation, especially in those operational skill sets necessary to manage multiple challenges, threats, and violations under international humanitarian law and to perform triage management in a resource-poor medical setting. Utilizing a historical framework, the commentary addresses the transformation of the education and training of humanitarian health professionals from the Cold War to today followed by recommendations for the future.

Abstract: Little is known about effective strategies to reduce rates of suicide among refugees and other displaced populations. This review aims to synthesise and assess the evidence base for suicide prevention and response programmes in refugee settings. We conducted a systematic review from peer-reviewed literature databases (five databases) and grey literature sources of literature published prior to November 27, 2017. We identified eight records (six peer-reviewed articles and two grey literature reports) that met our inclusion criteria. None of the eight records provided conclusive evidence of effectiveness. Five records had an unclear level of evidence and three records were potentially promising or promising. Most of the studies reviewed utilised multiple synergistic strategies. The most rigorous study showed the effectiveness of Brief Intervention and Contact and Safety planning. There is limited evidence of the effectiveness of other suicide prevention strategies for these groups. Future studies should attempt to better understand the impact of suicide prevention strategies, and explicitly unpack the individual and synergistic effects of multiple-strategies on suicide-related outcomes. Evidence from this review supports the use of Brief Intervention and Contact type interventions, but more research is needed to replicate findings particularly among populations in displacement.

Background: In June 2014, an estimated 1500 fighters of the Islamic State of Iraq and Syria (ISIS) seized control of Mosul, Iraq’s second city. Although many residents fled, others stayed behind, enduring the restrictive civil and social policies of ISIS. In December 2016, the military activity, known as the liberation campaign, began in east Mosul, concluding in west Mosul in June 2017. Methods: To assess life in Mosul under ISIS, and the consequences of the military campaign to retake Mosul we conducted a 40 cluster-30 household survey in Mosul, starting in March 2017. All households included were present in Mosul throughout the entire time of ISIS control and military action.

Results: In June 2014, 915 of 1139 school-age children (80.3%) had been in school, but only 28 (2.2%) attended at least some school after ISIS seized control. This represented a decision of families. Injuries to women resulting from intimate partner violence were reported in 415 (34.5%) households. In the surveyed households, 819 marriages had occurred; 688 (84.0%) among women. Of these women, 89 (12.9%) were aged 15 years and less, and 253 (49.7%) were aged under 18 at the time of marriage. With Mosul economically damaged by ISIS control and physically during the Iraqi military action, there was little employment at the time of the survey, and few persons were bringing cash into households. The liberation of Mosul in 2017 caused extensive damage to dwellings. Overall only a quarter of dwellings had not sustained some damage. In west Mosul, only 21.7% of houses had little or no damage from the conflict, with 98 (21.7%) households reporting their house had been destroyed, forcing its occupants to move. No houses had regular electricity and there was limited piped water. Inadequate fuel for cooking was reported by 996 (82.9%) households.

Conclusion: The physical, and social damage occurring during ISIS occupation of Mosul and during the subsequent military action (liberation) was substantial and its impact is unlikely to be erased soon.

Objectives: ISIS seized Mosul in June 2014. This survey was conducted to assess health status, health needs, and health-seeking behavior during ISIS control and the subsequent Iraqi military campaign. Methods: Forty clusters were chosen: 25 from east Mosul and 15 from west Mosul. In each, 30  households were interviewed, representing 7559 persons. The start house for each cluster was selected using satellite maps. The survey in east Mosul was conducted from March 13–31, 2017, and in west Mosul from July 18–31, 2017.

Results: In the preceding 2 weeks, 265 (5.4%) adults reported being ill. Some 67 (25.3%) complaints were for emotional or behavioral issues, and 59 (22.3%) for noncommunicable diseases. There were 349 (13.2%) children under age 15 reportedly ill during this time. Diarrhea, respiratory complaints, and emotional and behavioral problems were most common. Care seeking among both children and adults was low, especially in west Mosul. During ISIS occupation, 640 (39.0%) women of childbearing age reported deliveries. Of these, 431 (67.3%) had received some antenatal care, and 582 (90.9%) delivered in a hospital. Complications were reported by 417 (65.2%).

Conclusions: Communicable and noncommunicable diseases were reported for both children and adults, with a high prevalence of emotional and behavioral problems, particularly in west Mosul. Care-seeking was low, treatment compliance for noncommunicable diseases was poor, and treatment options for patients were limited. (Disaster Med Public Health Preparedness. 2019;page 1 of 9) Key Words: health-seeking behavior, Iraq, ISIS, Mosul