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


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

Recent Submissions

  • Ethical considerations for children’s participation in data collection activities during humanitarian emergencies: A Delphi review

    Cyril Bennouna; Hani Mansourian; Lindsay Stark (BioMed Central, 2017-03-01)
    Abstract Background Children’s right to participate in data collection during emergencies has been widely recognized by humanitarian actors. However, participation in such activities can expose children to risk. Tensions have been noted between the right to participate and other principles, such as the imperative to ‘do no harm.’ With little evidence to inform guidance on addressing this tension, our study sought to identify expert consensus on whether and how children participate in emergency-related data collection activities. Methods We employed a three-round Delphi technique with a purposive sample of 52 child protection specialists. Respondents answered two open-ended questions in round one. A thematic analysis of responses generated a set of unique statements addressing the study questions. In the second round, respondents rated each statement on a five-point scale. In the final round, respondents reviewed the group’s average ratings for each statement with the option to revise their own ratings. A statement was said to have reached clear consensus when at least 90% of respondents agreed or strongly agreed with the statement. Results A total of 124 statements and 14 themes emerged from the thematic analysis, with 46.0% of statements reaching clear consensus in the third round. Respondents strongly supported children’s right to participate in data collection in humanitarian settings, while also recognizing that protecting children from harm may “over-ride” the participation principle in some contexts. Respondents identified capacity and contextual considerations as important factors influencing participation decisions, though they sometimes disagreed about how these factors should determine participation. Respondents also considered the role of individual child factors and the presence of caregivers in selecting child participants, and proposed best practice approaches for securing children’s safe and meaningful participation. Conclusions With almost half of statements reaching clear consensus, these findings reflect broad agreement within the sector about engaging children in data collection in emergencies. At the same time, points of ongoing debate around how to factor different risks into child participation decisions may indicate discordant practice. Further reflection is needed around how factors such as the phase of emergency, the existence of basic services, and cultural beliefs should influence whether and how children participate.
  • Providing HIV care in the aftermath of Kenya's post-election violence Medecins Sans Frontieres' lessons learned January – March 2008

    Manzi Marcel; Reid Tony; van Engelgem Ian; Telfer Barbara (BioMed Central, 2008)
    <p>Abstract</p> <p>Kenya's post-election violence in early 2008 created considerable problems for health services, and in particular, those providing HIV care. It was feared that the disruptions in services would lead to widespread treatment interruption. MSF had been working in the Kibera slum for 10 years and was providing antiretroviral therapy to 1800 patients when the violence broke out. MSF responded to the crisis in a number of ways and managed to keep HIV services going. Treatment interruption was less than expected, and MSF profited from a number of "lessons learned" that could be applied to similar contexts where a stable situation suddenly deteriorates.</p>
  • Conflict-affected displaced persons need to benefit more from HIV and malaria national strategic plans and Global Fund grants

    Hering Heiko; Schilperoord Marian; Paik Eugene; Spiegel Paul (BioMed Central, 2010)
    <p>Abstract</p> <p>Background</p> <p>Access to HIV and malaria control programmes for refugees and internally displaced persons (IDPs) is not only a human rights issue but a public health priority for affected populations and host populations. The primary source of funding for malaria and HIV programmes for many countries is the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). This article analyses the current HIV and malaria National Strategic Plans (NSPs) and Global Fund approved proposals from rounds 1-8 for countries in Africa hosting populations with refugees and/or IDPs to document their inclusion.</p> <p>Methods</p> <p>The review was limited to countries in Africa as they constitute the highest caseload of refugees and IDPs affected by HIV and malaria. Only countries with a refugee and/or IDP population of &#8805; 10,000 persons were included. NSPs were retrieved from primary and secondary sources while approved Global Fund proposals were obtained from the organisation's website. Refugee figures were obtained from the United Nations High Commissioner for Refugees' database and IDP figures from the Internal Displacement Monitoring Centre. The inclusion of refugees and IDPs was classified into three categories: 1) no reference; 2) referenced; and 3) referenced with specific activities.</p> <p>Findings</p> <p>A majority of countries did not mention IDPs (57%) compared with 48% for refugees in their HIV NSPs. For malaria, refugees were not included in 47% of NSPs compared with 44% for IDPs. A minority (21-29%) of HIV and malaria NSPs referenced and included activities for refugees and IDPs. There were more approved Global Fund proposals for HIV than malaria for countries with both refugees and IDPs, respectively. The majority of countries with &#8805;10,000 refugees and IDPs did not include these groups in their approved proposals (61%-83%) with malaria having a higher rate of exclusion than HIV.</p> <p>Interpretation</p> <p>Countries that have signed the 1951 refugee convention have an obligation to care for refugees and this includes provision of health care. IDPs are citizens of their own country but like refugees may also not be a priority for Governments' NSPs and funding proposals. Besides legal obligations, Governments have a public health imperative to include these groups in NSPs and funding proposals. Governments may wish to add a component for refugees that is additional to the needs for their own citizens. The inclusion of forcibly displaced persons in funding proposals may have positive direct effects for host populations as international and United Nations agencies often have strong logistical capabilities that could benefit both populations. For NSPs, strong and concerted advocacy at global, regional and country levels needs to occur to successfully ensure that affected populations are included in their plans. It is essential for their inclusion to occur if we are to reach the stated goal of universal access and the Millennium Development Goals.</p>
  • Impact of the Kenya post-election crisis on clinic attendance and medication adherence for HIV-infected children in western Kenya

    Braitstein Paula; Nyandiko Winstone; Wiehe Sarah; Sang Edwin; Musick Beverly; Vreeman Rachel (BioMed Central, 2009)
    <p>Abstract</p> <p>Background</p> <p>Kenya experienced a political and humanitarian crisis following presidential elections on 27 December 2007. Over 1,200 people were killed and 300,000 displaced, with disproportionate violence in western Kenya. We sought to describe the immediate impact of this conflict on return to clinic and medication adherence for HIV-infected children cared for within the USAID-Academic Model Providing Access to Healthcare (AMPATH) in western Kenya.</p> <p>Methods</p> <p>We conducted a mixed methods analysis that included a retrospective cohort analysis, as well as key informant interviews with pediatric healthcare providers. Eligible patients were HIV-infected children, less than 14 years of age, seen in the AMPATH HIV clinic system between 26 October 2007 and 25 December 2007. We extracted demographic and clinical data, generating descriptive statistics for pre- and post-conflict antiretroviral therapy (ART) adherence and post-election return to clinic for this cohort. ART adherence was derived from caregiver-report of taking all ART doses in past 7 days. We used multivariable logistic regression to assess factors associated with not returning to clinic. Interview dialogue from was analyzed using constant comparison, progressive coding and triangulation.</p> <p>Results</p> <p>Between 26 October 2007 and 25 December 2007, 2,585 HIV-infected children (including 1,642 on ART) were seen. During 26 December 2007 to 15 April 2008, 93% (N = 2,398) returned to care. At their first visit after the election, 95% of children on ART (N = 1,408) reported perfect ART adherence, a significant drop from 98% pre-election (p &lt; 0.001). Children on ART were significantly more likely to return to clinic than those not on ART. Members of tribes targeted by violence and members of minority tribes were less likely to return. In qualitative analysis of 9 key informant interviews, prominent barriers to return to clinic and adherence included concerns for personal safety, shortages of resources, hanging priorities, and hopelessness.</p> <p>Conclusion</p> <p>During a period of humanitarian crisis, the vulnerable, HIV-infected pediatric population had disruptions in clinical care and in medication adherence, putting children at risk for viral resistance and increased morbidity. However, unique program strengths may have minimized these disruptions.</p>
  • Use of facility assessment data to improve reproductive health service delivery in the Democratic Republic of the Congo

    Casey Sara; Amisi Immacul&#233;e; Mitchell Kathleen; Haliza Martin; Austin Judy; Aveledi Blandine; Kalenga Prince (BioMed Central, 2009)
    <p>Abstract</p> <p>Background</p> <p>Prolonged exposure to war has severely impacted the provision of health services in the Democratic Republic of the Congo (DRC). Health infrastructure has been destroyed, health workers have fled and government support to health care services has been made difficult by ongoing conflict. Poor reproductive health (RH) indicators illustrate the effect that the prolonged crisis in DRC has had on the on the reproductive health (RH) of Congolese women. In 2007, with support from the RAISE Initiative, the International Rescue Committee (IRC) and CARE conducted baseline assessments of public hospitals to evaluate their capacities to meet the RH needs of the local populations and to determine availability, utilization and quality of RH services including emergency obstetric care (EmOC) and family planning (FP).</p> <p>Methods</p> <p>Data were collected from facility assessments at nine general referral hospitals in five provinces in the DRC during March, April and November 2007. Interviews, observation and clinical record review were used to assess the general infrastructure, EmOC and FP services provided, and the infection prevention environment in each of the facilities.</p> <p>Results</p> <p>None of the nine hospitals met the criteria for classification as an EmOC facility (either basic or comprehensive). Most facilities lacked any FP services. Shortage of trained staff, essential supplies and medicines and poor infection prevention practices were consistently documented. All facilities had poor systems for routine monitoring of RH services, especially with regard to EmOC.</p> <p>Conclusions</p> <p>Women's lives can be saved and their well-being improved with functioning RH services. As the DRC stabilizes, IRC and CARE in partnership with the local Ministry of Health and other service provision partners are improving RH services by: 1) providing necessary equipment and renovations to health facilities; 2) improving supply management systems; 3) providing comprehensive competency-based training for health providers in RH and infection prevention; 4) improving referral systems to the hospitals; 5) advocating for changes in national RH policies and protocols; and 6) providing technical assistance for monitoring and evaluation of key RH indicators. Together, these initiatives will improve the quality and accessibility of RH services in the DRC - services which are urgently needed and to which Congolese women are entitled by international human rights law.</p>
  • Reproductive health and quality of life of young Burmese refugees in Thailand

    Sondorp Egbert; Carrara Verena; Naranichakul Nantarat; Benner Marie; Townsend Joy; Kaloi Wiphan; Hunnangkul Saowalak; Htwe Kyi (BioMed Central, 2010)
    <p>Abstract</p> <p>Background</p> <p>Of the 140 000 Burmese* refugees living in camps in Thailand, 30% are youths aged 15-24. Health services in these camps do not specifically target young people and their problems and needs are poorly understood. This study aimed to assess their reproductive health issues and quality of life, and identifies appropriate service needs.</p> <p>Methods</p> <p>We used a stratified two-stage random sample questionnaire survey of 397 young people 15-24 years from 5,183 households, and 19 semi-structured qualitative interviews to assess and explore health and quality of life issues.</p> <p>Results</p> <p>The young people in the camps had very limited knowledge of reproductive health issues; only about one in five correctly answered at least one question on reproductive health. They were clear that they wanted more reproductive health education and services, to be provided by health workers rather than parents or teachers who were not able to give them the information they needed. Marital status was associated with sexual health knowledge; having relevant knowledge of reproductive health was up to six times higher in married compared to unmarried youth, after adjusting for socio-economic and demographic factors. Although condom use was considered important, in practice a large proportion of respondents felt too embarrassed to use them. There was a contradiction between moral views and actual behaviour; more than half believed they should remain virgins until marriage, while over half of the youth experienced sex before marriage. Two thirds of women were married before the age of 18, but two third felt they did not marry at the right age. Forced sex was considered acceptable by one in three youth. The youth considered their quality of life to be poor and limited due to confinement in the camps, the limited work opportunities, the aid dependency, the unclear future and the boredom and unhappiness they face.</p> <p>Conclusions</p> <p>The long conflict in Myanmar and the resultant long stay in refugee camps over decades affect the wellbeing of these young people. Lack of sexual health education and relevant services, and their concerns for their future are particular problems, which need to be addressed. Issues of education, vocational training and job possibilities also need to be considered.</p> <p>*Burmese is used for all ethnic groups</p>
  • Ethics of conducting research in conflict settings

    Ford Nathan; Mills Edward; Upshur Ross; Zachariah Rony (BioMed Central, 2009)
    <p>Abstract</p> <p>Humanitarian agencies are increasingly engaged in research in conflict and post-conflict settings. This is justified by the need to improve the quality of assistance provided in these settings and to collect evidence of the highest standard to inform advocacy and policy change. The instability of conflict-affected areas, and the heightened vulnerability of populations caught in conflict, calls for careful consideration of the research methods employed, the levels of evidence sought, and ethical requirements. Special attention needs to be placed on the feasibility and necessity of doing research in conflict-settings, and the harm-benefit ratio for potential research participants.</p>
  • Reproductive health for refugees by refugees in Guinea II: sexually transmitted infections

    Ekirapa Akaco; Borchert Matthias; von Roenne Franz; Chen Mark; Howard Natasha; Souare Yaya; von Roenne Anna (BioMed Central, 2008)
    <p>Abstract</p> <p>Background</p> <p>Providing reproductive and sexual health services is an important and challenging aspect of caring for displaced populations, and preventive and curative sexual health services may play a role in reducing HIV transmission in complex emergencies. From 1995, the non-governmental "Reproductive Health Group" (RHG) worked amongst refugees displaced by conflicts in Sierra Leone and Liberia (1989&#8211;2004). RHG recruited refugee nurses and midwives to provide reproductive and sexual health services for refugees in the Forest Region of Guinea, and trained refugee women as lay health workers. A cross-sectional survey was conducted in 1999 to assess sexual health needs, knowledge and practices among refugees, and the potential impact of RHG's work.</p> <p>Methods</p> <p>Trained interviewers administered a questionnaire on self-reported STI symptoms, and sexual health knowledge, attitudes and practices to 445 men and 444 women selected through multistage stratified cluster sampling. Chi-squared tests were used where appropriate. Multivariable logistic regression with robust standard errors (to adjust for the cluster sampling design) was used to assess if factors such as source of information about sexually transmitted infections (STIs) was associated with better knowledge.</p> <p>Results</p> <p>30% of women and 24% of men reported at least one episode of genital discharge and/or genital ulceration within the past 12 months. Only 25% correctly named all key symptoms of STIs in both sexes. Inappropriate beliefs (e.g. that swallowing tablets before sex, avoiding public toilets, and/or washing their genitals after sex protected against STIs) were prevalent. Respondents citing RHG facilitators as their information source were more likely to respond correctly about STIs; RHG facilitators were more frequently cited than non-healthcare information sources in men who correctly named the key STI symptoms (odds ratio (OR) = 5.2, 95% confidence interval (CI) 1.9&#8211;13.9), and in men and women who correctly identified effective STI protection methods (OR = 2.9, 95% CI 1.5&#8211;5.8 and OR = 4.6, 95% CI 1.6&#8211;13.2 respectively).</p> <p>Conclusion</p> <p>Our study revealed a high prevalence of STI symptoms, and gaps in sexual health knowledge in this displaced population. Learning about STIs from RHG health facilitators was associated with better knowledge. RHG's model could be considered in other complex emergency settings.</p>
  • Conflict in the Indian Kashmir Valley II: psychosocial impact

    van Galen Renate; Ford Nathan; Kleber Rolf; Fromm Silke; Kam Saskia; Reilley Brigg; Lokuge Kamalini; de Jong Kaz (BioMed Central, 2008)
    <p>Abstract</p> <p>Background</p> <p>India and Pakistan have disputed ownership of the Kashmir Valley region for many years, resulting in high levels of exposure to violence among the civilian population of Kashmir (India). A survey was done as part of routine programme evaluation to assess confrontation with violence and its consequences on mental health, health service usage, and socio-economic functioning.</p> <p>Methods</p> <p>We undertook a two-stage cluster household survey in two districts of Kashmir (India) using questionnaires adapted from other conflict areas. Analysis was stratified for gender.</p> <p>Results</p> <p>Over one-third of respondents (n = 510) were found to have symptoms of psychological distress (33.3%, CI: 28.3&#8211;38.4); women scoring significantly higher (OR 2.5; CI: 1.7&#8211;3.6). A third of respondents had contemplated suicide (33.3%, CI: 28.3&#8211;38.4). Feelings of insecurity were associated with higher levels of psychological distress for both genders (males: OR 2.4, CI: 1.3&#8211;4.4; females: OR 1.9, CI: 1.1&#8211;3.3). Among males, violation of modesty, (OR 3.3, CI: 1.6&#8211;6.8), forced displacement, (OR 3.5, CI: 1.7&#8211;7.1), and physical disability resulting from violence (OR 2.7, CI: 1.2&#8211;5.9) were associated with greater levels of psychological distress; for women, risk factors for psychological distress included dependency on others for daily living (OR 2.4, CI: 1.3&#8211;4.8), the witnessing of killing (OR 1.9, CI: 1.1&#8211;3.4), and torture (OR 2.1, CI: 1.2&#8211;3.7). Self-rated poor health (male: OR 4.4, CI: 2.4&#8211;8.1; female: OR 3.4, CI: 2.0&#8211;5.8) and being unable to work (male: OR 6.7, CI: 3.5&#8211;13.0; female: OR 2.6, CI: 1.5&#8211;4.4) were associated with mental distress.</p> <p>Conclusion</p> <p>The ongoing conflict exacts a huge toll on the communities' mental well-being. We found high levels of psychological distress that impacts on daily life and places a burden on the health system. Ongoing feelings of personal vulnerability (not feeling safe) was associated with high levels of psychological distress. Community mental health programmes should be considered as a way reduce the pressure on the health system and improve socio-economic functioning of those suffering from mental health problems.</p>
  • Conflict in the Indian Kashmir Valley I: exposure to violence

    Kleber Rolf; Fromm Silke; Ford Nathan; Reilley Brigg; Lokuge Kamalini; de Jong Kaz; van Galen Renate; Kam Saskia (BioMed Central, 2008)
    <p>Abstract</p> <p>Background</p> <p>India and Pakistan have disputed ownership of the Kashmir Valley region for many years, resulting in several conflicts since the end of partition in 1947. Very little is known about the prevalence of violence and insecurity in this population.</p> <p>Methods</p> <p>We undertook a two-stage cluster household survey in two districts (30 villages) of the Indian part of Kashmir to assess experiences with violence and mental health status among the conflict-affected Kashmiri population. The article presents our findings for confrontations with violence. Data were collected for recent events (last 3 months) and those occurring since the start of the conflict. Informed consent was obtained for all interviews.</p> <p>Results</p> <p>510 interviews were completed. Respondents reported frequent direct confrontations with violence since the start of conflict, including exposure to crossfire (85.7%), round up raids (82.7%), the witnessing of torture (66.9%), rape (13.3%), and self-experience of forced labour (33.7%), arrests/kidnapping (16.9%), torture (12.9%), and sexual violence (11.6%). Males reported more confrontations with violence than females, and had an increased likelihood of having directly experienced physical/mental maltreatment (OR 3.9, CI: 2.7&#8211;5.7), violation of their modesty (OR 3.6, CI: 1.9&#8211;6.8) and injury (OR 3.5, CI: 1.4&#8211;8.7). Males also had high odds of self-being arrested/kidnapped (OR 8.0, CI: 4.1&#8211;15.5).</p> <p>Conclusion</p> <p>The civilian population in Kashmir is exposed to high levels of violence, as demonstrated by the high frequency of deliberate events as detention, hostage, and torture. The reported violence may result in substantial health, including mental health problems. Males reported significantly more confrontations with almost all violent events; this can be explained by higher participation in outdoor activities.</p>
  • Reproductive health services for refugees by refugees in Guinea I: family planning

    Borchert Matthias; Blankhart David; Kollie Sarah; Newey Claire; Souare Yaya; Chen Mark; von Roenne Anna; Howard Natasha (BioMed Central, 2008)
    <p>Abstract</p> <p>Background</p> <p>Comprehensive studies of family planning (FP) in refugee camps are relatively uncommon. This paper examines gender and age differences in family planning knowledge, attitudes, and practices among Sierra Leonean and Liberian refugees living in Guinea.</p> <p>Methods</p> <p>In 1999, a cross-sectional survey was conducted of 889 reproductive-age men and women refugees from 48 camps served by the refugee-organised <it>Reproductive Health Group </it>(<it>RHG</it>). Sampling was multi-stage with data collected for socio-demographics, family planning, sexual health, and antenatal care. Statistics were calculated for selected indicators.</p> <p>Results</p> <p>Women knew more about FP, although men's education reduced this difference. RHG facilitators were the primary source of reproductive health information for all respondents. However, more men then women obtained information from non-health sources, such as friends and media. Approval of FP was high, significantly higher in women than in men (90% vs. 70%). However, more than 40% reported not having discussed FP with their partner. Perceived service quality was an important determinant in choosing where to get contraceptives. Contraceptive use in the camps served by RHG was much higher than typical for either refugees' country of origin or the host country (17% vs. 3.9 and 4.1% respectively), but the risk of unwanted pregnancy remained considerable (69%).</p> <p>Conclusion</p> <p>This refugee self-help model appeared largely effective and could be considered for reproductive health needs in similar settings. Having any formal education appeared a major determinant of FP knowledge for men, while this was less noticeable for women. Thus, FP communication strategies for refugees should consider gender-specific messages and channels.</p>
  • Mortality, violence and access to care in two districts of Port-au-Prince, Haiti

    Bachy Catherine; Ford Nathan; Mancini Silvia; Ponsar Fr&#233;d&#233;rique; Van Herp Michel (BioMed Central, 2009)
    <p>Abstract</p> <p>Background</p> <p>Towards the end of 2006 open conflict broke out between United Nations forces and armed militia in Port-au-Prince, Haiti. Fighting was most intense in the district of Cit&#233; Soleil.</p> <p>Methods</p> <p>A cross-sectional, random-sample survey among the conflict-affected populations living in Cit&#233; Soleil and Martissant was carried out over a 4-week period in 2006 using a semi-structured questionnaire to assess exposure to violence and access to health care. Household heads from 945 households (corresponding to 4,763 people) in Cit&#233; Soleil and 1,800 household (9,539 people) in Martissant provided information on household members. The average recall period was 579 days for Cit&#233; Soleil and 601 days for Martissant.</p> <p>Results</p> <p>In Cit&#233; Soleil 120 deaths (21 children) were reported (CMR 0.4 deaths/10,000 people/day; &lt;5 MR 0.5 deaths/10,000/day) while in Martissant 165 deaths (8 children) were reported (CMR 0.3/10,000 people/day; &lt;5 MR 0.2/10,000 people/day). Violence was reported as the main cause of adult mortality in both locations (mainly gunshot wounds) accounting for 29.2% of deaths in Cit&#233; Soleil and 23% of deaths in Martissant. 22.9% of families in Cit&#233; Soleil and 18.6% in Martissant reported at least one victim of violence. Destruction of property and belongings was common in both Cit&#233; Soleil (52.4% of families) and Martissant (14.9%). Access to health services was limited, with 11% (22/196) of victims of violence in Cit&#233; Soleil and 23% (49/212) in Martissant unable to access care due to insecurity or lack of money.</p> <p>Discussion</p> <p>Extrapolating to the total population of these two districts some 2,000 violent deaths occurred over the recall period. Among the survivors, violence had lasting effects in terms of physical and mental health and loss of property and possessions.</p>
  • Sexual violence in the protracted conflict of DRC programming for rape survivors in South Kivu

    Schmitz K Peter; Steiner Birthe; Rosenberger Sandrine; Sondorp Egbert; Mesmer Ursula; Benner Marie (BioMed Central, 2009)
    <p>Abstract</p> <p>Background</p> <p>Despite international acknowledgement of the linkages between sexual violence and conflict, reliable data on its prevalence, the circumstances, characteristics of perpetrators, and physical or mental health impacts is rare. Among the conflicts that have been associated with widespread sexual violence has been the one in the Democratic Republic of the Congo (DRC).</p> <p>Methods</p> <p>From 2003 till to date Malteser International has run a medico-social support programme for rape survivors in South Kivu province, DRC. In the context of this programme, a host of data was collected. We present these data and discuss the findings within the frame of available literature.</p> <p>Results</p> <p>Malteser International registered 20,517 female rape survivors in the three year period 2005&#8211;2007. Women of all ages have been targeted by sexual violence and only few of those &#8211; and many of them only after several years &#8211; sought medical care and psychological help. Sexual violence in the DRC frequently led to social, especially familial, exclusion. Members of military and paramilitary groups were identified as the main perpetrators of sexual violence.</p> <p>Conclusion</p> <p>We have documented that in the DRC conflict sexual violence has been &#8211; and continues to be &#8211; highly prevalent in a wide area in the East of the country. Humanitarian programming in this field is challenging due to the multiple needs of rape survivors. The easily accessible, integrated medical and psycho-social care that the programme offered apparently responded to the needs of many rape survivors in this area.</p>
  • Universal access: the benefits and challenges in bringing integrated HIV care to isolated and conflict affected populations in the Republic of Congo

    Hamel Catherine; Ford Nathan; O'Brien Daniel; Pottie Kevin; Mills Clair (BioMed Central, 2009)
    <p/> <p>The Pool region of the Republic of Congo is an isolated, conflict-affected area with under-resourced and poorly functioning health care services. Despite significant AIDS-related mortality and morbidity in this area, and a national level commitment to universal HIV care, HIV has been largely neglected. In 2005 M&#233;decins Sans Fronti&#232;res decided to introduce HIV care activities. However, in this setting of high basic health care needs, limited medical resources and competing medical priorities, a vertical HIV programme was not suitable. This paper describes the process of integrating HIV care and treatment into basic health services, the clinical outcomes of 222 patients started on antiretroviral treatment (ART), and the benefits to communities and health care systems. Key lessons learned include the use of multi-skilled human resources, the step-wise implementation of HIV activities, the initial engagement of an HIV experienced staff member, the use of simplified and adapted testing, clinical and monitoring protocols and drug regimens, the introduction of more complex monitoring tools to simplify clinical management decisions and intensive staff education regarding the benefits of HIV integration. This project in a rural and remote conflict-affected setting demonstrates that integrated HIV programs can save lives and play a key role in helping to achieve universal access to ART in Africa.</p>
  • Users' guides to the medical literature: how to use an article about mortality in a humanitarian emergency

    Garfield Richard; Cooper Curtis; Schull Michael; Mills Edward; Guyatt Gordon; Singh Sonal; Beyrer Chris; Orbinski James; Woodruff Bradley; Hardy Colleen; et al. (BioMed Central, 2008)
    <p>Abstract</p> <p>The accurate interpretation of mortality surveys in humanitarian crises is useful for both public health responses and security responses. Recent examples suggest that few medical personnel and researchers can accurately interpret the validity of a mortality survey in these settings. Using an example of a mortality survey from the Democratic Republic of Congo (DRC), we demonstrate important methodological considerations that readers should keep in mind when reading a mortality survey to determine the validity of the study and the applicability of the findings to their settings.</p>
  • Coming together to document mortality in conflict situations: proceedings of a symposium

    Degomme Olivier; Ratnayake Ruwan; Guha-Sapir Debarati (BioMed Central, 2009)
    <p>Abstract</p> <p>The use of epidemiology in documenting the mortality experience in complex emergencies has become pervasive in humanitarian practice. Recent assessments in Iraq and Darfur have provoked much discussion on the assessment of mortality in scientific and policy spheres. In this context, the Centre for Research on the Epidemiology of Disasters and the Harvard Humanitarian Initiative held an inter-disciplinary symposium to examine the topic among epidemiologists, demographers, forensic scientists and legal and human rights investigators.</p> <p>We aimed to strengthen the scientific understanding of mortality estimation by reviewing progress across fields and building inter-disciplinary bridges. We report on the presentations and discussions here.</p>
  • Prevalence of <it>plasmodium falciparum </it>in active conflict areas of eastern Burma: a summary of cross-sectional data

    Whichard Emily; Smith Linda; Mullany Luke; Lee Catherine; Mahn Mahn; Lee Thomas; Richards Adam; Shwe Oo Eh Kalu; Banek Kristin (BioMed Central, 2007)
    <p>Abstract</p> <p>Background</p> <p>Burma records the highest number of malaria deaths in southeast Asia and may represent a reservoir of infection for its neighbors, but the burden of disease and magnitude of transmission among border populations of Burma remains unknown.</p> <p>Methods</p> <p><it>Plasmodium falciparum </it>(<it>Pf</it>) parasitemia was detected using a HRP-II antigen based rapid test (Paracheck-Pf<sup>&#174;</sup>). <it>Pf </it>prevalence was estimated from screenings conducted in 49 villages participating in a malaria control program, and four retrospective mortality cluster surveys encompassing a sampling frame of more than 220,000. Crude odds ratios were calculated to evaluate <it>Pf </it>prevalence by age, sex, and dry vs. rainy season.</p> <p>Results</p> <p>9,796 rapid tests were performed among 28,410 villagers in malaria program areas through four years (2003: 8.4%, 95% CI: 8.3 &#8211; 8.6; 2004: 7.1%, 95% CI: 6.9 &#8211; 7.3; 2005:10.5%, 95% CI: 9.3 &#8211; 11.8 and 2006: 9.3%, 95% CI: 8.2 &#8211; 10.6). Children under 5 (OR = 1.99; 95% CI: 1.93 &#8211; 2.06) and those 5 to 14 years (OR = 2.24, 95% CI: 2.18 &#8211; 2.29) were more likely to be positive than adults. Prevalence was slightly higher among females (OR = 1.04, 95% CI: 1.02 &#8211; 1.06) and in the rainy season (OR = 1.48, 95% CI: 1.16 &#8211; 1.88). Among 5,538 rapid tests conducted in four cluster surveys, 10.2% were positive (range 6.3%, 95% CI: 3.9 &#8211; 8.8; to 12.4%, 95% CI: 9.4 &#8211; 15.4).</p> <p>Conclusion</p> <p>Prevalence of <it>plasmodium falciparum </it>in conflict areas of eastern Burma is higher than rates reported among populations in neighboring Thailand, particularly among children. This population serves as a large reservoir of infection that contributes to a high disease burden within Burma and likely constitutes a source of infection for neighboring regions.</p>
  • An assessment of vulnerability to HIV infection of boatmen in Teknaf, Bangladesh

    Saha Nirod; Mercer Alec; Azim Tasnim; Wansom Tanyaporn; Kabir Humayun; Gazi Rukhsana (BioMed Central, 2008)
    <p>Abstract</p> <p>Background</p> <p>Mobile population groups are at high risk for contracting HIV infection. Many factors contribute to this risk including high prevalence of risky behavior and increased risk of violence due to conflict and war. The Naf River serves as the primary border crossing point between Teknaf, Bangladesh and Mynamar [Burma] for both official and unofficial travel of people and goods. Little is known about the risk behavior of boatmen who travel back and forth between Teknaf and Myanmar. However, we hypothesize that boatmen may act as a bridging population for HIV/AIDS between the high-prevalence country of Myanmar and the low-prevalence country of Bangladesh.</p> <p>Methods</p> <p>Methods included initial rapport building with community members, mapping of boatmen communities, and in-depth qualitative interviews with key informants and members from other vulnerable groups such as spouses of boatmen, commercial female sex workers, and injecting drug users. Information from the first three stages was used to create a cross-sectional survey that was administered to 433 boatmen.</p> <p>Results</p> <p>Over 40% of the boatmen had visited Myanmar during the course of their work. 17% of these boatmen had sex with CSW while abroad. There was a significant correlation found between the number of nights spent in Myanmar and sex with commercial sex workers.</p> <p>In the past year, 19% of all boatmen surveyed had sex with another man. 14% of boatmen had participated in group sex, with groups ranging in size from three to fourteen people. Condom use was rare {0 to 4.7% during the last month}, irrespective of types of sex partners. Regression analysis showed that boatmen who were 25 years and older were statistically less likely to have sexual intercourse with non- marital female partners in the last year compared to the boatmen aged less than 25 years. Similarly deep-sea fishing boatmen and non-fishing boatmen were statistically less likely to have sexual intercourse with non- marital female partners in the last year compared to the day long fishing boatmen adjusting for all other variables. Boatmen's knowledge regarding HIV transmission and personal risk perception for contracting HIV was low.</p> <p>Conclusion</p> <p>Boatmen in Teknaf are an integral part of a high-risk sexual behaviour network between Myanmar and Bangladesh. They are at risk of obtaining HIV infection due to cross border mobility and unsafe sexual practices. There is an urgent need for designing interventions targeting boatmen in Teknaf to combat an impending epidemic of HIV among this group. They could be included in the serological surveillance as a vulnerable group. Interventions need to address issues on both sides of the border, other vulnerable groups, and refugees. Strong political will and cross border collaboration is mandatory for such interventions.</p>
  • Increase coverage of HIV and AIDS services in Myanmar

    Petrie Charles; Williams Brian; B&#252;hler Markus; Baker Daniel (BioMed Central, 2008)
    <p>Abstract</p> <p>Myanmar is experiencing an HIV epidemic documented since the late 1980s. The National AIDS Programme national surveillance ante-natal clinics had already estimated in 1993 that 1.4% of pregnant women were HIV positive, and UNAIDS estimates that at end 2005 1.3% (range 0.7&#8211;2.0%) of the adult population was living with HIV. While a HIV surveillance system has been in place since 1992, the programmatic response to the epidemic has been slower to emerge although short- and medium-terms plans have been formulated since 1990. These early plans focused on the health sector, omitted key population groups at risk of HIV transmission and have not been adequately funded. The public health system more generally is severely under-funded.</p> <p>By the beginning of the new decade, a number of organisations had begun working on HIV and AIDS, though not yet in a formally coordinated manner. The Joint Programme on AIDS in Myanmar 2003&#8211;2005 was an attempt to deliver HIV services through a planned and agreed strategic framework. Donors established the Fund for HIV/AIDS in Myanmar (FHAM), providing a pooled mechanism for funding and significantly increasing the resources available in Myanmar. By 2006 substantial advances had been made in terms of scope and diversity of service delivery, including outreach to most at risk populations to HIV. More organisations provided more services to an increased number of people. Services ranged from the provision of HIV prevention messages via mass media and through peers from high-risk groups, to the provision of care, treatment and support for people living with HIV. However, the data also show that this scaling up has not been sufficient to reach the vast majority of people in need of HIV and AIDS services.</p> <p>The operating environment constrains activities, but does not, in general, prohibit them. The slow rate of service expansion can be attributed to the burdens imposed by administrative measures, broader constraints on research, debate and organizing, and insufficient resources. Nevertheless, evidence of recent years illustrates that increased investment leads to more services provided to people in need, helping them to obtain their right to health care. But service expansion, policy improvement and capacity building cannot occur without more resources.</p>
  • Iraq War mortality estimates: A systematic review

    Mills Edward; Takaro Tim; Tapp Christine; Guyatt Gordon; Burkle Frederick; Amad Hani; Wilson Kumanan (BioMed Central, 2008)
    <p>Abstract</p> <p>Background</p> <p>In March 2003, the United States invaded Iraq. The subsequent number, rates, and causes of mortality in Iraq resulting from the war remain unclear, despite intense international attention. Understanding mortality estimates from modern warfare, where the majority of casualties are civilian, is of critical importance for public health and protection afforded under international humanitarian law. We aimed to review the studies, reports and counts on Iraqi deaths since the start of the war and assessed their methodological quality and results.</p> <p>Methods</p> <p>We performed a systematic search of 15 electronic databases from inception to January 2008. In addition, we conducted a non-structured search of 3 other databases, reviewed study reference lists and contacted subject matter experts. We included studies that provided estimates of Iraqi deaths based on primary research over a reported period of time since the invasion. We excluded studies that summarized mortality estimates and combined non-fatal injuries and also studies of specific sub-populations, e.g. under-5 mortality. We calculated crude and cause-specific mortality rates attributable to violence and average deaths per day for each study, where not already provided.</p> <p>Results</p> <p>Thirteen studies met the eligibility criteria. The studies used a wide range of methodologies, varying from sentinel-data collection to population-based surveys. Studies assessed as the highest quality, those using population-based methods, yielded the highest estimates. Average deaths per day ranged from 48 to 759. The cause-specific mortality rates attributable to violence ranged from 0.64 to 10.25 per 1,000 per year.</p> <p>Conclusion</p> <p>Our review indicates that, despite varying estimates, the mortality burden of the war and its sequelae on Iraq is large. The use of established epidemiological methods is rare. This review illustrates the pressing need to promote sound epidemiologic approaches to determining mortality estimates and to establish guidelines for policy-makers, the media and the public on how to interpret these estimates.</p>

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