Conflict and Health is an open access, peer-reviewed journal published by BioMed Central.

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The Globethics library contains articles of Conflict and Health as of vol. 1(2007) to current.

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  • Rebuilding the health sector in Gaza: alternative humanitarian voices

    Karl Blanchet; Martine Najem; Lina Shadid; Rouba Ali Fehmi; Fawzi Al Hammouri; Ghassan Saed; Khalid Saleh; Mosab Nasser; Nidal Moukaddam; Jonathan Polonsky (BMC, 2024-05-01)
    Abstract In November 2023, a variety of disparate health organizations formed an international coalition to consolidate efforts and develop collaborative strategies in response to the increasing critical healthcare challenges caused by the recent war in Gaza. The coalition includes medical and public health experts, humanitarian practitioners, academics, and health policy-makers from across the world. Their membership has not much to do with mainstream humanitarian organisations. It is lead by the diaspora from the region. Their vision is the long-term reconstruction of the health system in Gaza while responding the most urgent needs. This collective effort will require explicit efforts to speak with one voice and avoid duplication. This collective movement may be an orginal initiative that may be able to beat the expected international donor fatigue.
  • Integrating Syrian refugees into Lebanon’s healthcare system 2011–2022: a mixed-method study

    Gladys Honein-AbouHaidar; Lama Bou-Karroum; Sarah E. Parkinson; Rima Majed; Sabine Salameh; Najla Daher; Nour Hemadi; Fouad M. Fouad; Fadi El-Jardali (BMC, 2024-05-01)
    Abstract Introduction The Lebanese government estimates the number of Syrian refugees to be 1.5 million, representing 25% of the population. Refugee healthcare services have been integrated into the existing Lebanese health system. This study aims to describe the integration of Syrian refugee health services into the Lebanese national health system from 2011 to 2022, amid an ongoing economic crisis since 2019 and the COVID-19 pandemic. Methods This paper employs a mixed-methods approach drawing upon different data sources including: 1- document review (policies, legislation, laws, etc.); 2- semi-structured interviews with policymakers, stakeholders, and health workers; 3- focus group discussions with patients from both host and refugee populations; and 4- health systems and care seeking indicators. Results Although the demand for primary health care increased due to the Syrian refugee crisis, the provision of primary health care services was maintained. The infusion of international funding over time allowed primary health care centers to expand their resources to accommodate increased demand. The oversupply of physicians in Lebanon allowed the system to maintain a relatively high density of physicians even after the massive influx of refugees. The highly privatized, fragmented and expensive healthcare system has impeded Syrian refugees’ access to secondary and tertiary healthcare services. The economic crisis further exacerbated limits on access for both the host and refugee populations and caused tension between the two populations. Our findings showed that the funds are not channeled through the government, fragmentation across multiple financing sources and reliance on international funding. Common medications and vaccines were available in the public system for both refugee and host communities and were reported to be affordable. The economic crisis hindered both communities’ access to medications due to shortages and dramatic price increases. Conclusion Integrating refugees in national health systems is essential to achieve sustainable development goals, in particular universal health coverage. Although it can strengthen the capacity of national health systems, the integration of refugees in low-resource settings can be challenging due to existing health system arrangements (e.g., heavily privatized care, curative-oriented, high out-of-pocket, fragmentation across multiple financing sources, and system vulnerability to economic shocks).
  • Five recommendations to advance implementation science for humanitarian settings: the next frontier of humanitarian research

    Kathryn Falb; Sheree Kullenberg; Christina T Yuan; Alexandra Blackwell (BMC, 2024-05-01)
    Abstract Challenges in delivering evidence-based programming in humanitarian crises require new strategies to enhance implementation science for better decision-making. A recent scoping review highlights the scarcity of peer-reviewed studies on implementation in conflict zones. In this commentary, we build on this scoping review and make five recommendations for advancing implementation science for humanitarian settings. These include (1) expanding existing frameworks and tailoring them to humanitarian dynamics, (2) utilizing hybrid study designs for effectiveness-implementation studies, (3) testing implementation strategies, (4) leveraging recent methodological advancements in social and data science, and (5) enhancing training and community engagement. These approaches aim to address gaps in understanding intervention effectiveness, scale, sustainability, and equity in humanitarian settings. Integrating implementation science into humanitarian research is essential for informed decision-making and improving outcomes for affected populations.
  • The impact of armed conflicts on HIV treatment outcomes in Sub-Saharan Africa: a systematic review and meta-analysis

    Hafte Kahsay Kebede; Hailay Abrha Gesesew; Amanuel Tesfay Gebremedhin; Paul Ward (BMC, 2024-05-01)
    Abstract Background Despite the fact that Sub-Saharan Africa bears a disproportionate burden of armed conflicts and HIV infection, there has been inadequate synthesis of the impact of armed conflict on HIV treatment outcomes. We summarized the available evidence on the impact of armed conflicts on HIV treatment outcomes in Sub-Saharan Africa from 2002 to 2022. Methods We searched four databases; MEDLINE, PubMed, CINHAL, and Scopus. We also explored grey literature sources and reviewed the bibliographies of all articles to identify any additional relevant studies. We included quantitative studies published in English from January 1, 2002 to December 30, 2022 that reported on HIV treatment outcomes for patients receiving antiretroviral therapy (ART) in conflict and post-conflict areas, IDP centers, or refugee camps, and reported on their treatment outcomes from sub-Saharan Africa. Studies published in languages other than English, reporting on non-ART patients and reporting on current or former military populations were excluded. We used EndNote X9 and Covidence to remove duplicates, extracted data using JBI-MAStARI, assessed risk of bias using AHRQ criteria, reported results using PRISMA checklist, and determined Statistical heterogeneity using Cochran Q test and Higgins I2, R- and RevMan-5 software were used for meta-analysis. Results The review included 16 studies with participant numbers ranging from 102 to 2572. Lost To Follow-Up (LTFU) percentages varied between 5.4% and 43.5%, virologic non-suppression rates ranged from 25 to 33%, adherence rates were over 88%, and mortality rates were between 4.2% and 13%. A pooled meta-analysis of virologic non-suppression rates from active conflict settings revealed a non-suppression rate of 30% (0.30 (0.26–0.33), I2 = 0.00%, p = 0.000). In contrast, a pooled meta-analysis of predictors of loss to follow-up (LTFU) from post-conflict settings identified a higher odds ratio for females compared to males (1.51 (1.05, 2.17), I2 = 0%, p = 0.03). Conclusion The review highlights a lack of research on the relationship between armed conflicts and HIV care outcomes in SSA. The available documents lack quality of designs and data sources, and the depth and diversity of subjects covered.
  • Strengthening event-based surveillance (EBS): a case study from Afghanistan

    Mohamed Mostafa Tahoun; Mohammad Nadir Sahak; Muzhgan Habibi; Mohamad Jamaluddin Ahadi; Bahara Rasoly; Sabrina Shivji; Ahmed Taha Aboushady; Pierre Nabeth; Mahmoud Sadek; Alaa Abouzeid (BMC, 2024-04-01)
    Summary The sustained instability in Afghanistan, along with ongoing disease outbreaks and the impact of the COVID-19 pandemic, has significantly affected the country. During the COVID-19 pandemic, the country’s detection and response capacities faced challenges. Case identification was done in all health facilities from primary to tertiary levels but neglected cases at the community level, resulting in undetected and uncontrolled transmission from communities. This emphasizes a missed opportunity for early detection that Event-Based Surveillance (EBS) could have facilitated. Therefore, Afghanistan planned to strengthen the EBS component of the national public health surveillance system to enhance the capacity for the rapid detection and response to infectious disease outbreaks, including COVID-19 and other emerging diseases. This effort was undertaken to promptly mitigate the impact of such outbreaks. We conducted a landscape assessment of Afghanistan’s public health surveillance system to identify the best way to enhance EBS, and then we crafted an implementation work plan. The work plan included the following steps: establishing an EBS multisectoral coordination and working group, identifying EBS information sources, prioritizing public health events of importance, defining signals, establishing reporting mechanisms, and developing standard operating procedures and training guides. EBS is currently being piloted in seven provinces in Afghanistan. The lessons learned from the pilot phase will support its overall expansion throughout the country.
  • The effect of COVID-19 on the non-COVID health outcomes of crisis-affected peoples: a systematic review

    N. Thompson; K. W. Y. Kyaw; L. Singh; J. C. Cikomola; N. S. Singh; Bayard Roberts (BMC, 2024-04-01)
    Abstract Background The COVID-19 pandemic posed considerable risks to populations affected by humanitarian crises in low- and middle-income countries (LMICs). However, there is limited understanding of how the pandemic may have affected non-COVID health outcomes among crisis-affected populations. Our aim was to examine the evidence on the impact of the COVID-19 pandemic on non-COVID-19 health outcomes for crisis-affected populations in LMICs. Methods A systematic review methodology was applied following PRISMA guidelines. Eligibility criteria were: crisis-affected populations in LMICS; COVID-19; and all health topics, except for sexual and reproductive health which was covered in a linked review. Five bibliographic databases and additional grey literature sources were searched. The search period was from 2019 to 31 July 2022. Eligible papers were extracted and analysed using a narrative synthesis approach based on the study objectives and relevant health access and systems frameworks. A quality appraisal was also conducted. Findings 4320 articles were screened, and 15 eligible studies were identified and included in this review. Ten studies collected health outcomes data. Eight related to mental health, which generally showed worse mental health outcomes because of the pandemic, and pandemic-related stressors were identified. Two studies assessed physical health outcomes in children, while none addressed physical health outcomes among adults. Nine studies reported on access to healthcare, revealing worse access levels due to the pandemic and noting key barriers to care. Seven studies reported on the impact on health systems, with key challenges including reduced and distorted health care funding, reduced staff capacity, interrupted medicines and supplies, weak information and mixed-messaging, and weak leadership. All fifteen studies on the social determinants of health, particularly highlighting the effect of increasing poverty, the role of gender, and food insecurity on health outcomes. The quality of papers was limited overall. Conclusion This review found some limited evidence indicating negative mental health effects, increased barriers to accessing care, damage to health systems and magnified impacts on the social determinants of health for crisis-affected people during the COVID-19 pandemic. However, the small number and limited quality of the studies make the overall strength of evidence quite weak.
  • Access to care in Afghanistan after august 2021: a cross-sectional study exploring Afghans’ perspectives in 10 provinces

    Martina Valente; Alessandro Lamberti-Castronuovo; Francesca Bocchini; Yasir Shafiq; Monica Trentin; Michela Paschetto; Ghulam Ali Bahdori; Jan Agha Khadem; Mirza Sayed Nadeem; Mohammand Hanif Patmal (BMC, 2024-04-01)
    Abstract Background The Taliban takeover in August 2021 ended a decades-long conflict in Afghanistan. Yet, along with improved security, there have been collateral changes, such as the exacerbation of the economic crisis and brain drain. Although these changes have altered the lives of Afghans in many ways, it is unclear whether they have affected access to care. This study aimed to analyse Afghans’ access to care and how this access has changed after August 2021. Methods The study relied on the collaboration with the non-governmental organisation EMERGENCY, running a network of three hospitals and 41 First Aid Posts in 10 Afghan provinces. A 67-item questionnaire about access to care changes after August 2021 was developed and disseminated at EMERGENCY facilities. Ordinal logistic regression was used to evaluate whether access to care changes were associated with participants’ characteristics. Results In total, 1807 valid responses were returned. Most respondents (54.34%) reported improved security when visiting healthcare facilities, while the ability to reach facilities has remained stable for the majority of them (50.28%). Care is less affordable for the majority of respondents (45.82%). Female respondents, those who are unmarried and not engaged, and patients in the Panjshir province were less likely to perceive improvements in access to care. Conclusions Findings outline which dimensions of access to care need resource allocation. The inability to pay for care is the most relevant barrier to access care after August 2021 and must therefore be prioritised. Women and people from the Panjshir province may require ad hoc interventions to improve their access to care.
  • The integration of ortho-plastic limb salvage teams in the humanitarian response to violence-related open tibial fractures: evaluating outcomes in the Gaza Strip

    Theresa Farhat; Krystel Moussally; Hasan Nahouli; Shahd Abu Hamad; Khulood Abul Qaraya; Zahi Abdul-Sater; Walaa G. El Sheikh; Nadine Jawad; Khouloud Al Sedawi; Mohammed Obaid (BMC, 2024-04-01)
    Abstract Background Limb salvage by ortho-plastic teams is the standard protocol for treating open tibial fractures in high-income countries, but there’s limited research on this in conflict settings like the Gaza Strip. This study assessed the clinical impact of gunshot-related open tibial fractures, compared patient management by orthopedic and ortho-plastic teams, and identified the risk factors for bone non-union in this context. Methods A retrospective review of medical records was conducted on Gaza Strip patients with gunshot-induced-open tibial fractures from March 2018 to October 2020. Data included patient demographics, treatments, and outcomes, with at least one year of follow-up. Primary outcomes were union, non-union, infection, and amputation. Results The study included 244 injured individuals, predominantly young adult males (99.2%) with nearly half (48.9%) having Gustilo-Anderson type IIIB fractures and more than half (66.8%) with over 1 cm of bone loss. Most patients required surgery, including rotational flaps and bone grafts with a median of 3 admissions and 9 surgeries. Ortho-plastic teams managed more severe muscle and skin injuries, cases with bone loss > 1 cm, and performed less debridement compared to other groups, though these differences were not statistically significant. Non-union occurred in 53% of the cases, with the ortho-plastic team having the highest rate at 63.6%. Infection rates were high (92.5%), but no significant differences in bone or infection outcomes were observed among the different groups. Logistic regression analysis identified bone loss > 1 cm, vascular injury, and the use of a definitive fixator at the first application as predictors of non-union. Conclusions This study highlights the severity and complexity of such injuries, emphasizing their significant impact on patients and the healthcare system. Ortho-plastic teams appeared to play a crucial role in managing severe cases. However, further research is still needed to enhance our understanding of how to effectively manage these injuries.
  • Did aid to the Ebola crisis divert aid for reproductive, maternal, and newborn health? An analysis of donor-reported data in Sierra Leone

    Susannah H. Mayhew; Kirkley Doyle; Lawrence S. Babawo; Esther Mokuwa; Hana Rohan; Melisa Martinez-Alverez; Josephine Borghi; Ebola Gbalo Research Team; Catherine Pitt (BMC, 2024-04-01)
    Abstract Background Infectious disease outbreaks like Ebola and Covid-19 are increasing in frequency. They may harm reproductive, maternal and newborn health (RMNH) directly and indirectly. Sierra Leone experienced a sharp deterioration of RMNH during the 2014–16 Ebola epidemic. One possible explanation is that donor funding may have been diverted away from RMNH to the Ebola response. Methods We analysed donor-reported data from the Organisation for Economic Cooperation and Development (OECD)’s Creditor Reported System (CRS) data for Sierra Leone before, during and after the 2014–16 Ebola epidemic to understand whether aid flows for Ebola displaced aid for RMNH. We estimated aid for Ebola using key term searches and manual review of CRS records. We estimated aid for RMNH by applying the Muskoka-2 algorithm to the CRS and analysing CRS purpose codes. Results We find substantial increases in aid to Sierra Leone (from $484 million in 2013 to $1 billion at the height of the epidemic in 2015), most of which was earmarked for the Ebola response. Overall, Ebola aid was additional to RMNH funding. RMNH aid was sustained during the epidemic (at $42 m per year) and peaked immediately after (at $77 m in 2016). There is some evidence of a small displacement of RMNH aid from the UK during the period when its Ebola funding increased. Conclusions Modest changes to RMNH donor aid patterns are insufficient to explain the severe decline in RMNH indicators recorded during the outbreak. Our findings therefore suggest the need for substantial increases in routine aid to ensure that basic RMNH services and infrastructure are strong before an epidemic occurs, as well as increased aid for RMNH during epidemics like Ebola and Covid-19, if reproductive, maternal and newborn healthcare is to be maintained at pre-epidemic levels.
  • Exploring barriers to access to care following the 2021 socio-political changes in Afghanistan: a qualitative study

    Alessandro Lamberti-Castronuovo; Martina Valente; Francesca Bocchini; Monica Trentin; Michela Paschetto; Ghulam Ali Bahdori; Jan Agha Khadem; Mirza Sayed Nadeem; Mohammad Hanif Patmal; Mohammad Tawoos Alizai (BMC, 2024-04-01)
    Abstract Background Following the change of government in August 2021, the social and economic landscape of Afghanistan deteriorated into an economic and humanitarian crisis. Afghans continue to struggle to access basic healthcare services, making Universal Health Coverage (UHC) in the country a major challenge. The aim of this study was to perform a qualitative investigation into the main access to care challenges in Afghanistan and whether these challenges have been influenced by the recent socio-political developments, by examining the perspectives of health professionals and hospital directors working in the country. Methods Health professionals working in facilities run by an international non-government organisation, which has maintained continuous operations since 1999 and has become a key health reference point for the population, alongside the public health system, and hospital directors working in government hospitals were recruited to participate in an in-depth qualitative study using semi-structured interviews. Results A total of 43 participants from ten provinces were interviewed in this study. Four issues were identified as critical barriers to achieving UHC in Afghanistan: (1) the lack of quality human resources; (2) the suboptimal management of chronic diseases and trauma; (3) the inaccessibility of necessary health services due to financial hardship; (4) the unequal accessibility of care for different demographic groups. Conclusions Health professionals and hospital directors shed light on weaknesses in the Afghan health system highlighting chronic issues and issues that have deteriorated as a result of the 2021 socio-political changes. In order to improve access to care, future healthcare system reforms should consider the perspectives of Afghan professionals working in the country, who are in close contact with Afghan patients and communities.
  • Prevalence, comorbidities, and factors associated with prolonged grief disorder, posttraumatic stress disorder and complex posttraumatic stress disorder in refugees: a systematic review

    Franziska Lechner-Meichsner; Hannah Comtesse; Marie Olk (BMC, 2024-04-01)
    Abstract Background The number of refugees worldwide is at an all-time high with many being exposed to potentially traumatic events and the loss of loved ones. The 11th revision of the International Statistical Classification of Diseases and Related Health Problems now includes prolonged grief disorder and complex posttraumatic stress disorder and revised criteria for posttraumatic stress disorder. An overview of these stress-related disorders among people who have become refugees is therefore needed. Consequently, we conducted a systematic review to determine prevalence rates, comorbidities, and associated factors for each of the disorders. Method We systematically searched PubMed, Web of Science, and PsycArticles to identify studies that reported prevalence rates, predictors or associated factors, and/or comorbid mental disorders for either (1) prolonged grief disorder, (2) posttraumatic stress disorder, or (3) complex posttraumatic stress disorder among refugees. The selection process followed the PRISMA guidelines. Results A total of 36 studies met the inclusion criteria. Most of the studies were of high quality. There was substantial variation in prevalence rates by disorder, with prolonged grief ranging from 6 to 54%, posttraumatic stress disorder ranging from 0.4 to 80%, and complex posttraumatic stress disorder ranging from 3 to 74.6%. Pooled prevalence for posttraumatic stress disorder was estimated at 29.8% in treatment seeking samples and 9.92% in population samples. For complex posttraumatic stress disorder, it was estimated at 57.4% in treatment seeking samples and 7.8% in population samples. Posttraumatic stress disorder was among the most frequent comorbidities for prolonged grief disorder while depressive symptoms were the most frequently occurring co-morbidity across all three disorders. Sociodemographic variables, trauma exposure, and loss characteristics were associated with higher symptom severity. Postmigration living difficulties played an important role in prolonged grief and complex posttraumatic stress disorder. Conclusion The review revealed substantial differences in prevalence rates between the three studied disorders but underscored a very high prevalence of ICD-11 stress-related disorders among refugees. The identified associated factors point to subgroups that may be particularly at risk and establishes a foundational basis for targeted interventions and potential policy changes. Future research should incorporate longitudinal investigations and emphasize culturally sensitive assessments.
  • War related disruption of clinical tuberculosis services in Tigray, Ethiopia during the recent regional conflict: a mixed sequential method study

    Kibrom Gebreselasie Gebrehiwot; Gebremedhin Berhe Gebregergis; Measho Gebreslasie Gebregziabher; Teklay Gebrecherkos; Wegen Beyene Tesfamariam; Hailay Gebretnsae; Gebregziabher Berihu; Letebrhan Weldemhret; Goyitom Gebremedhn; Tsegay Wellay (BMC, 2024-04-01)
    Abstract Background More than 70% of the health facilities in Tigray, northern Ethiopia, have been totally or partially destroyed by the recent war in the region. Diagnosis and management of tuberculosis were among many health services that suffered. In this study we assess the status of tuberculosis care in health facilities of Tigray during the recent war and compare it with the immediate pre-war state. Methods Using sequential mixed method, we analyzed and compared the availability of diagnostic services in 69 health facilities and the utilization of tuberculosis care in 50 of them immediately before the war (September-October 2020) and during the war (November-July 2021). TB focal persons in each selected health facility were interviewed to evaluate the status of diagnostic services. Patient service utilization was assessed using health facility registrations. We also compared the average monthly case detection rate of multidrug resistant tuberculosis in the region before and during the war. We computed summary statistics and performed comparisons using t-tests. Finally, existing challenges related to tuberculosis care in the region were explored via in-depth interviews. Two investigators openly coded and analyzed the qualitative data independently via thematic analysis. Results Among the 69 health facilities randomly selected, the registers of 19 facilities were destroyed by the war; data from the remaining 50 facilities were included in the TB service utilization analysis. In the first month of the war (November 2021) the number of tuberculosis patients visiting health facilities fell 34%. Subsequently the visitation rate improved steadily, but not to pre-war rates. This reduction was significant in northwest, central and eastern zones. Tuberculosis care in rural areas was hit hardest. Prior to the war 60% of tuberculosis patients were served in rural clinics; this number dropped to an average of 17% during the war. Health facilities were systematically looted. Of the 69 institutions assessed, over 69% of the microscopes in health centers, 87.5% of the microscopes in primary hospitals, and 68% of the microscopes in general hospitals were stolen or damaged. Two GeneXpert nucleic acid amplification machines were also taken from general hospitals. Regarding drug resistant TB, the average number of multidrug resistant tuberculosis (MDR TB) cases detected per month was reduced by 41% during the war with p-value < 0.001. In-depth interviews with eight health care workers indicated that the main factors affecting tuberculosis care in the area were lack of security, health facility destruction, theft of essential equipment, and drug supply disruption. Conclusion and recommendation Many tuberculosis patients failed to visit health facilities during the war. There was substantial physical damage to health care facilities and systematic looting of diagnostic equipment. Restoring basic public services and revitalizing clinical care for tuberculosis need urgent consideration.
  • The Red Cross Red Crescent Health Information System (RCHIS): an electronic medical records and health information management system for the red cross red crescent emergency response units

    Felix Holl; Lauren Clarke; Thomas Raffort; Elvire Serres; Laura Archer; Panu Saaristo (BMC, 2024-04-01)
    Abstract Background The Red Cross and Red Crescent Movement (RCRC) utilizes specialized Emergency Response Units (ERUs) for international disaster response. However, data collection and reporting within ERUs have been time-consuming and paper-based. The Red Cross Red Crescent Health Information System (RCHIS) was developed to improve clinical documentation and reporting, ensuring accuracy and ease of use while increasing compliance with reporting standards. Case presentation RCHIS is an Electronic Medical Record (EMR) and Health Information System (HIS) designed for RCRC ERUs. It can be accessed on Android tablets or Windows laptops, both online and offline. The system securely stores data on Microsoft Azure cloud, with synchronization facilitated through a local ERU server. The functional architecture covers all clinical functions of ERU clinics and hospitals, incorporating user-friendly features. A pilot study was conducted with the Portuguese Red Cross (PRC) during a large-scale event. Thirteen super users were trained and subsequently trained the staff. During the four-day pilot, 77 user accounts were created, and 243 patient files were documented. Feedback indicated that RCHIS was easy to use, requiring minimal training time, and had sufficient training for full utilization. Real-time reporting facilitated coordination with the civil defense authority. Conclusions The development and pilot use of RCHIS demonstrated its feasibility and efficacy within RCRC ERUs. The system addressed the need for an EMR and HIS solution, enabling comprehensive clinical documentation and supporting administrative reporting functions. The pilot study validated the training of trainers’ approach and paved the way for further domestic use of RCHIS. RCHIS has the potential to improve patient safety, quality of care, and reporting efficiency within ERUs. Automated reporting reduces the burden on ERU leadership, while electronic compilation enhances record completeness and correctness. Ongoing feedback collection and feature development continue to enhance RCHIS’s functionality. Further trainings took place in 2023 and preparations for international deployments are under way. RCHIS represents a significant step toward improved emergency medical care and coordination within the RCRC and has implications for similar systems in other Emergency Medical Teams.
  • The impact of conflict on infectious disease: a systematic literature review

    Valia Marou; Constantine I. Vardavas; Katerina Aslanoglou; Katerina Nikitara; Zinovia Plyta; Jo Leonardi-Bee; Kirsty Atkins; Orla Condell; Favelle Lamb; Jonathan E. Suk (BMC, 2024-04-01)
    Abstract Background Conflict situations, armed or not, have been associated with emergence and transmission of infectious diseases. This review aims to identify the pathways through which infectious diseases emerge within conflict situations and to outline appropriate infectious disease preparedness and response strategies. Methods A systematic review was performed representing published evidence from January 2000 to October 2023. Ovid Medline and Embase were utilised to obtain literature on infectious diseases in any conflict settings. The systematic review adhered to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis). No geographical restrictions were imposed. Findings Our review identified 51 studies covering AIDS, Hepatitis B, Tuberculosis, Cholera, Coronavirus 2, Ebola, Poliomyelitis, Malaria, Leishmaniasis, Measles, Diphtheria, Dengue and Acute Bacterial Meningitis within conflict settings in Europe, Middle East, Asia, and Africa since October 2023. Key factors contributing to disease emergence and transmission in conflict situations included population displacement, destruction of vital infrastructure, reduction in functioning healthcare systems and healthcare personnel, disruption of disease control programmes (including reduced surveillance, diagnostic delays, and interrupted vaccinations), reduced access by healthcare providers to populations within areas of active conflict, increased population vulnerability due to limited access to healthcare services, and disruptions in the supply chain of safe water, food, and medication. To mitigate these infectious disease risks reported preparedness and response strategies included both disease-specific intervention strategies as well as broader concepts such as the education of conflict-affected populations through infectious disease awareness programmes, investing in and enabling health care in locations with displaced populations, intensifying immunisation campaigns, and ensuring political commitment and intersectoral collaborations between governments and international organisations. Conclusion Conflict plays a direct and indirect role in the transmission and propagation of infectious diseases. The findings from this review can assist decision-makers in the development of evidence-based preparedness and response strategies for the timely and effective containment of infectious disease outbreaks in conflict zones and amongst conflict-driven displaced populations. Funding European Centre for Disease Prevention and Control under specific contract No. 22 ECD.13,154 within Framework contract ECDC/2019/001 Lot 1B.
  • How integration of refugees into national health systems became a global priority: a qualitative policy analysis

    Shatha Elnakib; Caitlin Jackson; Ummekulsoom Lalani; Yusra Ribhi Shawar; Sara Bennett (BMC, 2024-04-01)
    Abstract Background Despite a long history of political discourse around refugee integration, it wasn’t until 2016 that this issue emerged as a global political priority. Limited research has examined the evolution of policies of global actors around health service provision to refugees and how refugee integration into health systems came onto the global agenda. This study seeks to fill this gap. Methods Drawing on a document review of 20 peer-reviewed articles, 46 global policies and reports, and 18 semi-structured interviews with actors representing various bilateral, multilateral and non-governmental organizations involved with refugee health policy and funding, we analyze factors that have shaped the global policy priority of integration. We use the Shiffman and Smith Policy Framework on determinants of political priority to organize our findings. Results Several important factors generated global priority for refugee integration into national health systems. Employing the above-mentioned framework, actor power increased due to network expansion through collaborations between humanitarian and development actors. Ideas took hold through the framing of integration as a human rights and responsibility sharing. While political context was influenced through several global movements, it was ultimately the influx of Syrian refugees into Europe and the increasing securitization of the refugee crisis that led to key policies, and critically, global funding to support integration within refugee hosting nations. Finally, issue characteristics, namely the magnitude of the global refugee crisis, its protractedness and the increasing urbanicity of refugee inflows, led integration to emerge as a manageable solution. Conclusion The past decade has seen a substantial reframing of refugee integration, along with increased financing sources and increased collaboration, explains this shift towards their integration into health systems. However, despite the emergence of integration as a global political priority, the extent to which efforts around integration have translated into action at the national level remains uncertain.
  • The emergence and regression of political priority for refugee integration into the Jordanian health system: an analysis using the Kingdon’s multiple streams model

    Shatha Elnakib; Laila Akhu-Zaheya; Wejdan Khater; Lama Bou-Karroum; Gladys Honein-AbouHaidar; Sabine Salameh; Yusra Ribhi Shawar; Paul Spiegel (BMC, 2024-04-01)
    Abstract Background The prolonged presence of Syrian refugees in Jordan has highlighted the need for sustainable health service delivery models for refugees. In 2012, the Jordanian government adopted a policy that granted Syrian refugees access, free of charge, to the national health system. However since 2012, successive policy revisions have limited refugee access. This paper seeks to understand factors that initially put refugee integration into the health system on the policy agenda, as well as how these same factors later affected commitment to sustain the policy. Methods This paper draws on data from a document review of 197 peer-reviewed and grey literature publications, a media analysis of newspaper articles retrieved from four officially recognized newspapers in Jordan, and 33 semi-structured key informant interviews. We used Kingdon’s Multiple Streams Model – a well-established tool for analyzing policy adoption – to understand how political priority developed for integration of refugees into the health system. Results We find that several factors helped bring attention to the issue, namely concerns over infectious disease transmission to host communities, high rates of chronic conditions among the refugee population and the increasingly urban and dispersed nature of refugees. At the outset of the conflict, the national mood was receptive to refugees. Politicians and government officials quickly recognized the crisis as an opportunity to secure material and technical support from the international humanitarian community. At the same time, global pressures for integrating refugees into national health systems helped move the integration agenda forward in Jordan and the region more broadly. Since 2012, there were several modifications to the policy that signal profound changes in national views around the continued presence of Syrian refugees in the country, as well as reduced external financial support which has undermined the sustainability of the policy. Conclusion This case study underscores the dynamic nature of policymaking and the challenge of sustaining government commitment to the right to health among refugees. Our analysis has important implications for advocates seeking to advance and maintain momentum for the integration of refugees into national health systems.
  • Armed actor interventions in humanitarian and public health crises: examining perspectives of crisis-affected community members

    Samuel T. Boland; Alexandria Nylen; Madison Bates; Maria Carinnes Alejandria; Rob Grace; Zein Tayyeb; Adam C. Levine (BMC, 2024-04-01)
    Abstract Background Despite frequently providing non-military services in times of crisis, little systematic research has examined the perspectives of crisis-affected community members on the role of armed actors responding to humanitarian crises and public health emergencies. Methods To address this research gap, 175 interviews were conducted (2020–2021) amongst humanitarian and public health practitioners; armed actors; and crisis-affected community members across three country and four crisis contexts. Specifically, this effort included an Ebola outbreak in the Democratic Republic of the Congo; a refugee crisis on the Jordanian-Syrian border; and a volcanic eruption and COVID-19 outbreak in the Philippines. Data was analysed using grounded theory principles. Results Crisis-affected community members held diverse views. Non-state armed groups (NSAGs) and government armed actors were characterised as antagonists by some but supportive by others; gender issues were central to perceptions of armed actors, in ways that were both prejudicing and favourable. Overall perception was most closely linked to armed actor roles rather than the relative amount of conflict in a given area. Conclusions Findings nuance the relevant literature characterizing NSAGs as disruptive agents, and also the relevant literature that does not fully consider the nuances of gender and armed actor roles as deeply relevant to crisis-affected community perspectives on armed actors. These findings have important implications for both policy and academic discourse on militarization and localization.
  • ‘Nowhere and no one is safe’: spatial analysis of damage to critical civilian infrastructure in the Gaza Strip during the first phase of the Israeli military campaign, 7 October to 22 November 2023

    Yara Asi; David Mills; P. Gregg Greenough; Dennis Kunichoff; Saira Khan; Jamon Van Den Hoek; Corey Scher; Saleem Halabi; Sawsan Abdulrahim; Nadine Bahour (BMC, 2024-04-01)
    Abstract Background Since the Hamas attacks in Israel on 7 October 2023, the Israeli military has launched an assault in the Gaza Strip, which included over 12,000 targets struck and over 25,000 tons of incendiary munitions used by 2 November 2023. The objectives of this study include: (1) the descriptive and inferential spatial analysis of damage to critical civilian infrastructure (health, education, and water facilities) across the Gaza Strip during the first phase of the military campaign, defined as 7 October to 22 November 2023 and (2) the analysis of damage clustering around critical civilian infrastructure to explore broader questions about Israel’s adherence to International Humanitarian Law (IHL). Methods We applied multi-temporal coherent change detection on Copernicus Sentinel 1-A Synthetic Aperture Radar (SAR) imagery to detect signals indicative of damage to the built environment through 22 November 2023. Specific locations of health, education, and water facilities were delineated using open-source building footprint and cross-checked with geocoded data from OCHA, OpenStreetMap, and Humanitarian OpenStreetMap Team. We then assessed the retrieval of damage at and with close proximity to sites of health, education, and water infrastructure in addition to designated evacuation corridors and civilian protection zones. The Global Moran’s I autocorrelation inference statistic was used to determine whether health, education, and water facility infrastructure damage was spatially random or clustered. Results During the period under investigation, in the entire Gaza Strip, 60.8% (n = 59) of health, 68.2% (n = 324) of education, and 42.1% (n = 64) of water facilities sustained infrastructure damage. Furthermore, 35.1% (n = 34) of health, 40.2% (n = 191) of education, and 36.8% (n = 56) of water facilities were functionally destroyed. Applying the Global Moran’s I spatial inference statistic to facilities demonstrated a high degree of damage clustering for all three types of critical civilian infrastructure, with Z-scores indicating < 1% likelihood of cluster damage occurring by random chance. Conclusion Spatial statistical analysis suggests widespread damage to critical civilian infrastructure that should have been provided protection under IHL. These findings raise serious allegations about the violation of IHL, especially in light of Israeli officials’ statements explicitly inciting violence and displacement and multiple widely reported acts of collective punishment.
  • Impacts of attacks to female health care workers in three territories of Colombia

    María Esperanza Echeverry-López; Alejandra Marín-Uribe; Isabel C. Garcés-Palacio; Yadira Borrero-Ramírez; Dora María Hernández-Holguin; Carlos Iván Pacheco-Sánchez; Rohini J. Haar (BMC, 2024-04-01)
    Abstract Background This study explores the impacts of attacks perpetrated in the context of armed conflict, to female health workers in three Colombian territories. Methods We conducted a document review of the reports and databases of the Colombian Truth Commission, 17 in-depth semi-structured interviews with experts on the national and regional armed conflict and the medical mission, and 26 female health workers who were victims of attacks. Results Experts and female health workers reported attacks to health activities, facilities, equipment, and personnel, including attacks to traditional doctors belonging to indigenous communities. The most frequent attacks were threats and retention of health personnel; theft of supplies and medicines; damage and use of infrastructure and means of transport for purposes other than health care; and hinderance of health service provision. The attacks occurred in a framework of structural violence that intersects with poverty, racism, and gender bias. The impacts of these attacks include gender-based violence, significant disruption of the lives of health workers, and physical, emotional, psychological, social, and economic effects on the victims and their families. The government response to protect victims and populations has been absent or insufficient. Conclusions Attacks to health care were reported in all the studied territories obstructing adequate health care. Impacts of these attacks affect negatively the professional and personal life of the workers and are aggravated by structural violence and absent or little institutional response.
  • War and education: the attacks on medical schools amidst ongoing armed conflict, Sudan 2023

    Esra Abdallah Abdalwahed Mahgoub; Amna Khairy; Samar Osman; Musab Babiker Haga; Sarah Hashim Mohammed Osman; Abubker Mohammed Abbu Hassan; Hala Kamal; Ayia Babiker (BMC, 2024-03-01)
    Abstract Background War results in widespread destruction of a country’s infrastructure, healthcare facilities, and educational institutions. This study aims to assess the attacks on medical schools amidst the ongoing conflict in Sudan. Methods A descriptive cross-sectional study was conducted across 58 medical schools located in the states of Khartoum, Darfur, and Kordofan. Data on attacks between April 15, 2023, and July 15th 2023, were collected using online data collection form. Results All medical schools in conflict areas were included in the study. More than half (58.6%) of these medical schools were attacked. Private schools, constituting the majority of the study sample, were the most frequently attacked (70.6%). Of these, 52.9% were located in Khartoum city. More than one form of attack was reported in 64.7% of the affected schools. Looting occurred in 73.5% of the attacked faculties, while 67.6% of them were converted into military bases. Despite these challenges, 60.3% of the schools in the conflict zone managed to restore the educational process through online learning and collaboration with other institutions. Conclusion During a three-month period of warfare, most medical schools within conflict zones were attacked. This emphasizes the vulnerability of medical education institutions during war and highlights the urgent need of the Ministry of Higher Education interventions to provide leadership, support, and oversight for the educational process in medical schools across the country.

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