• Health care in Bosnia and Herzegovina before, during, and after 1992–1995 war: a personal testimony

      Šimunović Vladimir (BioMed Central, 2007)
      <p>Abstract</p> <p>Market-based health care reform during democratic transition in Bosnia and Herzegovina was complicated by the 1992&#8211;1995 war, that devastated the country and greater part of its health care infrastructure. The course of the transition and consequences of war for the health system and health professionals are presented here from the perspective of the author. The description of real-life situations and their context is used to illustrate the problems physicians, as well as international community, were faced with and how they tried to cope with them during and after the war. Speaking openly about the mistakes that were made in those times is the first step in preventing them from happening again and an invitation for exchange of opinions and open academic discussion.</p>
    • Association between expatriation and HIV awareness and knowledge among injecting drug users in Kabul, Afghanistan: A cross-sectional comparison of former refugees to those remaining during conflict

      Todd Catherine; Safi Naqibullah; Strathdee Steffanie; Earhart Kenneth; Scott Paul; Botros Boulos; Abed Abdullah (BioMed Central, 2007)
      <p>Abstract</p> <p>Background</p> <p>Little is known about human immunodeficiency virus (HIV) awareness among Afghan injecting drug users (IDUs), many of whom initiated injecting as refugees. We explored whether differences in HIV awareness and knowledge exist between Afghan IDUs who were refugees compared to those never having left Afghanistan.</p> <p>Methods</p> <p>A convenience sample of IDUs in Kabul, Afghanistan was recruited into a cross-sectional study through street outreach over a one year period beginning in 2005. Participants completed an interviewer-administered questionnaire and underwent voluntary counseling and testing for HIV, syphilis, hepatitis B surface antigen, and hepatitis C antibody. Differences in HIV awareness and specific HIV knowledge between IDU who lived outside the country in the last decade versus those who had not were assessed with logistic regression.</p> <p>Results</p> <p>Of 464 IDUs, 463 (99%) were male; median age and age at first injection were 29 and 25 years, respectively. Most (86.4%) had lived or worked outside the country in the past ten years. Awareness of HIV was reported by 46.1%; those having been outside the country in the last decade were significantly more likely to have heard of HIV (48.3% vs. 31.7%; OR = 2.00, 95% CI: 1.14 &#8211; 3.53). However, of those aware of HIV, only 38.3% could name three correct transmission routes; specific HIV knowledge was not significantly associated with residence outside the country.</p> <p>Conclusion</p> <p>Accurate HIV knowledge among Afghan IDUs is low, though former refugees had greater HIV awareness. Reported high-risk injecting behavior was not significantly different between IDU that were refugees and those that did not leave the country, indicating that all Afghan IDU should receive targeted prevention programming.</p>
    • Delays in childhood immunization in a conflict area: a study from Sierra Leone during civil war

      von Elm Erik; Senessie Charles; Gage George (BioMed Central, 2007)
      <p>Abstract</p> <p>Background</p> <p>Sierra Leone has undergone a decade of civil war from 1991 to 2001. From this period few data on immunization coverage are available, and conflict-related delays in immunization according to the Expanded Programme on Immunization (EPI) schedule have not been investigated. We aimed to study delays in childhood immunization in the context of civil war in a Sierra Leonean community.</p> <p>Methods</p> <p>We conducted an immunization survey in Kissy Mess-Mess in the Greater Freetown area in 1998/99 using a two-stage sampling method. Based on immunization cards and verbal history we collected data on immunization for tuberculosis, diphtheria, tetanus, pertussis, polio, and measles by age group (0&#8211;8/9&#8211;11/12&#8211;23/24&#8211;35 months). We studied differences between age groups and explored temporal associations with war-related hostilities taking place in the community.</p> <p>Results</p> <p>We included 286 children who received 1690 vaccine doses; card retention was 87%. In 243 children (85%, 95% confidence interval (CI): 80&#8211;89%) immunization was up-to-date. In 161 of these children (56%, 95%CI: 50&#8211;62%) full age-appropriate immunization was achieved; in 82 (29%, 95%CI: 24&#8211;34%) immunization was not appropriate for age. In the remaining 43 children immunization was partial in 37 (13%, 95%CI: 9&#8211;17) and absent in 6 (2%, 95%CI: 1&#8211;5). Immunization status varied across age groups. In children aged 9&#8211;11 months the proportion with age-inappropriate (delayed) immunization was higher than in other age groups suggesting an association with war-related hostilities in the community.</p> <p>Conclusion</p> <p>Only about half of children under three years received full age-appropriate immunization. In children born during a period of increased hostilities, immunization was mostly inappropriate for age, but recommended immunizations were not completely abandoned. Missing or delayed immunization represents an additional threat to the health of children living in conflict areas.</p>
    • The trauma of ongoing conflict and displacement in Chechnya: quantitative assessment of living conditions, and psychosocial and general health status among war displaced in Chechnya and Ingushetia

      Andrault Elodie; Ford Nathan; Hargreaves Sally; Cunningham Debbie; van Oosten Richard; van der Kam Saskia; Boots Gerry; Kleber Rolf; de Jong Kaz (BioMed Central, 2007)
      <p>Abstract</p> <p>Background</p> <p>Conflict in Chechnya has resulted in over a decade of violence, human rights abuses, criminality and poverty, and a steady flow of displaced seeking refuge throughout the region. At the beginning of 2004 MSF undertook quantitative surveys among the displaced populations in Chechnya and neighbouring Ingushetia.</p> <p>Methods</p> <p>Surveys were carried out in Ingushetia (January 2004) and Chechnya (February 2004) through systematic sampling. Various conflict-related factors contributing to ill health were researched to obtain information on displacement history, living conditions, and psychosocial and general health status.</p> <p>Results</p> <p>The average length of displacement was five years. Conditions in both locations were poor, and people in both locations indicated food shortages (Chechnya (<it>C</it>): 13.3%, Ingushetia (<it>I</it>): 11.3%), and there was a high degree of dependency on outside help (<it>C</it>: 95.4%, <it>I</it>: 94.3%). Most people (<it>C</it>: 94%, <it>I</it>: 98%) were confronted with violence in the past. Many respondents had witnessed the killing of people (<it>C</it>: 22.7%, <it>I</it>: 24.1%) and nearly half of people interviewed witnessed arrests (<it>C</it>: 53.1%, <it>I</it>: 48.4%) and maltreatment (<it>C</it>: 56.2%, <it>I</it>: 44.5%). Approximately one third of those interviewed had directly experienced war-related violence. A substantial number of people interviewed &#8211; one third in Ingushetia (37.5%) and two-thirds in Chechnya (66.8%) &#8211; rarely felt safe. The violence was ongoing, with respondents reporting violence in the month before the survey (<it>C</it>: 12.5%, <it>I</it>: 4.6%). Results of the general health questionnaire (GHQ 28) showed that nearly all internally displaced persons interviewed were suffering from health complaints such as somatic complaints, anxiety/insomnia, depressive feelings or social dysfunction (<it>C</it>: 201, 78.5%, CI: 73.0% &#8211; 83.4%; <it>I</it>: 230, 81.3%, CI: 76.2% &#8211; 85.6%). Poor health status was reflected in other survey questions, but health services were difficult to access for around half the population (<it>C</it>: 54.3%, <it>I</it>: 46.6%).</p> <p>Discussion</p> <p>The study demonstrates that the health needs of internally displaced in both locations are similarly high and equally unaddressed. The high levels of past confrontation with violence and ongoing exposure in both locations is likely to contribute to a further deterioration of the health status of internally displaced. As of March 2007, concerns remain about how the return process is being managed by the authorities.</p>
    • HIV-1 prevalence and factors associated with infection in the conflict-affected region of North Uganda

      Musinguzi Joshua; Fabiani Massimo; Opio Alex; Ayella Emintone; Nattabi Barbara; Ciantia Filippo; Pierotti Chiara; Declich Silvia (BioMed Central, 2007)
      <p>Abstract</p> <p>Background</p> <p>Since 1986, northern Uganda has been severely affected by civil strife with most of its population currently living internally displaced in protected camps. This study aims at estimating the HIV-1 prevalence among this population and the factors associated with infection.</p> <p>Methods</p> <p>In June-December 2005, a total of 3051 antenatal clinics attendees in Gulu, Kitgum and Pader districts were anonymously tested for HIV-1 infection as part of routine sentinel surveillance. Factors associated with the infection were evaluated using logistic regression models.</p> <p>Results</p> <p>The age-standardised HIV-1 prevalence was 10.3%, 9.1% and 4.3% in the Gulu, Kitgum and Pader district, respectively. The overall prevalence in the area comprised of these districts was 8.2% when data was weighted according to the districts' population size. Data from all sites combined show that, besides older women [20&#8211;24 years: adjusted odds ratio (AOR) = 1.96, 95% confidence interval (CI): 1.29&#8211;2.97; 25&#8211;29 years: AOR = 2.01, 95% CI: 1.30&#8211;3.11; &#8805; 30 years: AOR = 1.91, 95% CI: 1.23&#8211;2.97], unmarried women (AOR = 1.47, 95% CI: 1.06&#8211;2.04), and those with a partner with a non-traditional occupation (AOR = 1.62, 95% CI: 1.18&#8211;2.21), women living outside of protected camps for internally displaced persons have a higher risk of being HIV-1 infected than internally displaced women (AOR = 1.55, 95% CI: 1.15&#8211;2.08).</p> <p>Conclusion</p> <p>Although published data from Gulu district show a declining HIV-1 prevalence trend that is consistent with that observed at the national level since 1993, the prevalence in North Uganda is still high. Internally displaced women have a lower risk of being infected probably because of their reduced mobility and accessibility, and increased access to health prevention services.</p>
    • Geographical information system and access to HIV testing, treatment and prevention of mother-to-child transmission in conflict affected Northern Uganda

      George Melville; Mukooyo Eddie; Olu Olushayo; Okware Sam; Wanyana Jennifer; Alisalad Abdikamal; Natseri Nasan; Chamla Dick (BioMed Central, 2007)
      <p>Abstract</p> <p>Objectives</p> <p>Using Geographical Information System (GIS) as a tool to determine access to and gaps in providing HIV counselling and testing (VCT), treatment (ART) and mother-to-child transmission (PMTCT) services in conflict affected northern Uganda.</p> <p>Methods</p> <p>Cross-sectional data on availability and utilization, and geo-coordinates of health facilities providing VCT, PMTCT, and ART were collected in order to determine access. ArcView software produced maps showing locations of facilities and Internally Displaced Population(IDP) camps.</p> <p>Findings</p> <p>There were 167 health facilities located inside and outside 132 IDP camps with VCT, PMTCT and ART services provided in 32 (19.2%), 15 (9%) and 10 (6%) facilities respectively. There was uneven availability and utilization of services and resources among districts, camps and health facilities. Inadequate staff and stock-out of essential commodities were found in lower health facility levels. Provision of VCT was 100% of the HSSP II target at health centres IV and hospitals but 28% at HC III. For PMTCT and ART, only 42.9% and 20% of the respective targets were reached at the health centres IV.</p> <p>Conclusion</p> <p>Access to VCT, PMTCT and ART services was geographically limited due to inadequacy and heterogeneous dispersion of these services among districts and camps. GIS mapping can be effective in identifying service delivery gaps and presenting complex data into simplistic results hence can be recommended in need assessments in conflict settings.</p>
    • Screening for Posttraumatic Stress Disorder among Somali ex-combatants: A validation study

      Odenwald Michael; Lingenfelder Birke; Hinkel Harald; Rockstroh Brigitte; Schauer Maggie; Elbert Thomas; Neuner Frank (BioMed Central, 2007)
      <p>Abstract</p> <p>Background</p> <p>In Somalia, a large number of active and former combatants are affected by psychological problems such as Posttraumatic Stress Disorder (PTSD). This disorder impairs their ability to re-integrate into civilian life. However, many screening instruments for Posttraumatic Stress Disorder used in post-conflict settings have limited validity. Here we report on development and validation of a screening tool for PTSD in Somali language with a sample of ex-combatants.</p> <p>Methods</p> <p>We adapted the Posttraumatic Diagnostic Scale (PDS) to reflect linguistic and cultural differences within the Somali community so that local interviewers could be trained to administer the scale. For validation purposes, a randomly selected group of 135 Somali ex-combatants was screened by trained local interviewers; 64 of them were then re-assessed by trained clinical psychologists using the Composite International Diagnostic Interview (CIDI) and the Self-Report Questionnaire (SRQ-20).</p> <p>Results</p> <p>The screening instrument showed good internal consistency (Cronbach's &#945; = .86), convergent validity with the CIDI (sensitivity = .90; specificity = .90) as well as concurrent validity: positive cases showed higher SRQ-20 scores, higher prevalence of psychotic symptoms, and higher levels of intake of the local stimulant drug khat. Compared to a single cut-off score, the multi-criteria scoring, in keeping with the DSM-IV, produced more diagnostic specificity.</p> <p>Conclusion</p> <p>The results provide evidence that our screening instrument is a reliable and valid method to detect PTSD among Somali ex-combatants. A future Disarmament, Demobilization and Reintegration Program in Somalia is recommended to screen for PTSD in order to identify ex-combatants with special psycho-social needs.</p>
    • Public health, conflict and human rights: toward a collaborative research agenda

      Ron James; Thoms Oskar (BioMed Central, 2007)
      <p>Abstract</p> <p>Although epidemiology is increasingly contributing to policy debates on issues of conflict and human rights, its potential is still underutilized. As a result, this article calls for greater collaboration between public health researchers, conflict analysts and human rights monitors, with special emphasis on retrospective, population-based surveys. The article surveys relevant recent public health research, explains why collaboration is useful, and outlines possible future research scenarios, including those pertaining to the indirect and long-term consequences of conflict; human rights and security in conflict prone areas; and the link between human rights, conflict, and International Humanitarian Law.</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>
    • Occurrence and overlap of natural disasters, complex emergencies and epidemics during the past decade (1995&#8211;2004)

      Salama Peter; Le Phuoc; Ververs Mija-Tesse; Spiegel Paul (BioMed Central, 2007)
      <p>Abstract</p> <p>Background</p> <p>The fields of expertise of natural disasters and complex emergencies (CEs) are quite distinct, with different tools for mitigation and response as well as different types of competent organizations and qualified professionals who respond. However, natural disasters and CEs can occur concurrently in the same geographic location, and epidemics can occur during or following either event. The occurrence and overlap of these three types of events have not been well studied.</p> <p>Methods</p> <p>All natural disasters, CEs and epidemics occurring within the past decade (1995&#8211;2004) that met the inclusion criteria were included. The largest 30 events in each category were based on the total number of deaths recorded. The main databases used were the Emergency Events Database for natural disasters, the Uppsala Conflict Database Program for CEs and the World Health Organization outbreaks archive for epidemics.</p> <p>Analysis</p> <p>During the past decade, 63% of the largest CEs had &#8805;1 epidemic compared with 23% of the largest natural disasters. Twenty-seven percent of the largest natural disasters occurred in areas with &#8805;1 ongoing CE while 87% of the largest CEs had &#8805;1 natural disaster.</p> <p>Conclusion</p> <p>Epidemics commonly occur during CEs. The data presented in this article do not support the often-repeated assertion that epidemics, especially large-scale epidemics, commonly occur following large-scale natural disasters. This observation has important policy and programmatic implications when preparing and responding to epidemics. There is an important and previously unrecognized overlap between natural disasters and CEs. Training and tools are needed to help bridge the gap between the different type of organizations and professionals who respond to natural disasters and CEs to ensure an integrated and coordinated response.</p>
    • Building cooperation through health initiatives: an Arab and Israeli case study

      Sriharan Abi; Skinner Harvey (BioMed Central, 2007)
      <p>Abstract</p> <p>Background</p> <p>Ongoing conflict in the Middle East poses a major threat to health and security. A project screening Arab and Israeli newborns for hearing loss provided an opportunity to evaluate ways for building cooperation. The aims of this study were to: a) examine what attracted Israeli, Jordanian and Palestinian participants to the project, b) describe challenges they faced, and c) draw lessons learned for guiding cross-border health initiatives.</p> <p>Methods</p> <p>A case study method was used involving 12 key informants stratified by country (3 Israeli, 3 Jordanian, 3 Palestinian, 3 Canadian). In-depth interviews were tape-recorded, transcribed and analyzed using an inductive qualitative approach to derive key themes.</p> <p>Results</p> <p>Major reasons for getting involved included: concern over an important health problem, curiosity about neighbors and opportunities for professional advancement. Participants were attracted to prospects for opening the dialogue, building relationships and facilitating cooperation in the region. The political situation was a major challenge that delayed implementation of the project and placed participants under social pressure. Among lessons learned, fostering personal relationships was viewed as critical for success of this initiative.</p> <p>Conclusion</p> <p>Arab and Israeli health professionals were prepared to get involved for two types of reasons: a) Project Level: opportunity to address a significant health issue (e.g. congenital hearing loss) while enhancing their professional careers, and b) Meta Level: concern about taking positive steps for building cooperation in the region. We invite discussion about roles that health professionals can play in building "cooperation networks" for underpinning health security, conflict resolution and global health promotion.</p>
    • Correlates of current cigarette smoking among in-school adolescents in the Kurdistan region of Iraq

      Siziya Seter; Muula Adamson; Rudatsikira Emmanuel (BioMed Central, 2007)
      <p>Abstract</p> <p>Background</p> <p>Many adult cigarette smokers initiated the habit as adolescents. Adolescent tobacco use may be a marker of other unhealthy behaviours. There are limited data on the prevalence and correlates of cigarette smoking among in-school adolescents in Iraq. We aimed to estimate the prevalence of, and assess the socio-demographic correlates of current cigarette smoking among in-school adolescents in Kurdistan region of Iraq.</p> <p>Methods</p> <p>Secondary data analysis of the Global Youth Tobacco Survey, conducted in the region of Kurdistan, Iraq in 2006. Logistic regression analysis was conducted to assess the association between current cigarette smoking and explanatory variables.</p> <p>Results</p> <p>One thousand nine hundred eighty-nine adolescents participated in the Kurdistan-Iraq Global Youth Tobacco Survey. Of these, 58.1% and 41.9% were boys and girls respectively. The overall prevalence of current cigarette smoking was 15.3%; 25.1% and 2.7% in boys and girls respectively. The factors associated with adolescent smoking were: parents' smoking, smoking in closest friends, male gender, having pocket money and perceptions that boys or girls who smoked were attractive.</p> <p>Conclusion</p> <p>We suggest that public health interventions aimed to curb adolescent cigarette smoking should be designed, implemented and evaluated with due recognition to the factors that are associated with the habit.</p>
    • Occurrence and overlap of natural disasters, complex emergencies and epidemics during the past decade (1995–2004)

      Ververs Mija-Tesse; Le Phuoc; Spiegel Paul B; Salama Peter (BioMed Central, 2007-03-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Background&lt;/p&gt; &lt;p&gt;The fields of expertise of natural disasters and complex emergencies (CEs) are quite distinct, with different tools for mitigation and response as well as different types of competent organizations and qualified professionals who respond. However, natural disasters and CEs can occur concurrently in the same geographic location, and epidemics can occur during or following either event. The occurrence and overlap of these three types of events have not been well studied.&lt;/p&gt; &lt;p&gt;Methods&lt;/p&gt; &lt;p&gt;All natural disasters, CEs and epidemics occurring within the past decade (1995–2004) that met the inclusion criteria were included. The largest 30 events in each category were based on the total number of deaths recorded. The main databases used were the Emergency Events Database for natural disasters, the Uppsala Conflict Database Program for CEs and the World Health Organization outbreaks archive for epidemics.&lt;/p&gt; &lt;p&gt;Analysis&lt;/p&gt; &lt;p&gt;During the past decade, 63% of the largest CEs had ≥1 epidemic compared with 23% of the largest natural disasters. Twenty-seven percent of the largest natural disasters occurred in areas with ≥1 ongoing CE while 87% of the largest CEs had ≥1 natural disaster.&lt;/p&gt; &lt;p&gt;Conclusion&lt;/p&gt; &lt;p&gt;Epidemics commonly occur during CEs. The data presented in this article do not support the often-repeated assertion that epidemics, especially large-scale epidemics, commonly occur following large-scale natural disasters. This observation has important policy and programmatic implications when preparing and responding to epidemics. There is an important and previously unrecognized overlap between natural disasters and CEs. Training and tools are needed to help bridge the gap between the different type of organizations and professionals who respond to natural disasters and CEs to ensure an integrated and coordinated response.&lt;/p&gt;
    • Civil conflict and sleeping sickness in Africa in general and Uganda in particular

      Berrang Ford Lea (BMC, 2007-03-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Conflict and war have long been recognized as determinants of infectious disease risk. Re-emergence of epidemic sleeping sickness in sub-Saharan Africa since the 1970s has coincided with extensive civil conflict in affected regions. Sleeping sickness incidence has placed increasing pressure on the health resources of countries already burdened by malaria, HIV/AIDS, and tuberculosis. In areas of Sudan, the Democratic Republic of the Congo, and Angola, sleeping sickness occurs in epidemic proportions, and is the first or second greatest cause of mortality in some areas, ahead of HIV/AIDS. In Uganda, there is evidence of increasing spread and establishment of new foci in central districts. Conflict is an important determinant of sleeping sickness outbreaks, and has contributed to disease resurgence. This paper presents a review and characterization of the processes by which conflict has contributed to the occurrence of sleeping sickness in Africa. Conflict contributes to disease risk by affecting the transmission potential of sleeping sickness via economic impacts, degradation of health systems and services, internal displacement of populations, regional insecurity, and reduced access for humanitarian support. Particular focus is given to the case of sleeping sickness in south-eastern Uganda, where incidence increase is expected to continue. Disease intervention is constrained in regions with high insecurity; in these areas, political stabilization, localized deployment of health resources, increased administrative integration and national capacity are required to mitigate incidence. Conflict-related variables should be explicitly integrated into risk mapping and prioritization of targeted sleeping sickness research and mitigation initiatives.&lt;/p&gt;
    • Conflict and health: a paradigm shift in global health and human rights

      Singh Sonal; Orbinski James J; Mills Edward J (BioMed Central, 2007-03-01)
    • The trauma of ongoing conflict and displacement in Chechnya: quantitative assessment of living conditions, and psychosocial and general health status among war displaced in Chechnya and Ingushetia

      Boots Gerry; Cunningham Debbie; van Oosten Richard; Hargreaves Sally; Ford Nathan; van der Kam Saskia; de Jong Kaz; Andrault Elodie; Kleber Rolf (BioMed Central, 2007-03-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Background&lt;/p&gt; &lt;p&gt;Conflict in Chechnya has resulted in over a decade of violence, human rights abuses, criminality and poverty, and a steady flow of displaced seeking refuge throughout the region. At the beginning of 2004 MSF undertook quantitative surveys among the displaced populations in Chechnya and neighbouring Ingushetia.&lt;/p&gt; &lt;p&gt;Methods&lt;/p&gt; &lt;p&gt;Surveys were carried out in Ingushetia (January 2004) and Chechnya (February 2004) through systematic sampling. Various conflict-related factors contributing to ill health were researched to obtain information on displacement history, living conditions, and psychosocial and general health status.&lt;/p&gt; &lt;p&gt;Results&lt;/p&gt; &lt;p&gt;The average length of displacement was five years. Conditions in both locations were poor, and people in both locations indicated food shortages (Chechnya (&lt;it&gt;C&lt;/it&gt;): 13.3%, Ingushetia (&lt;it&gt;I&lt;/it&gt;): 11.3%), and there was a high degree of dependency on outside help (&lt;it&gt;C&lt;/it&gt;: 95.4%, &lt;it&gt;I&lt;/it&gt;: 94.3%). Most people (&lt;it&gt;C&lt;/it&gt;: 94%, &lt;it&gt;I&lt;/it&gt;: 98%) were confronted with violence in the past. Many respondents had witnessed the killing of people (&lt;it&gt;C&lt;/it&gt;: 22.7%, &lt;it&gt;I&lt;/it&gt;: 24.1%) and nearly half of people interviewed witnessed arrests (&lt;it&gt;C&lt;/it&gt;: 53.1%, &lt;it&gt;I&lt;/it&gt;: 48.4%) and maltreatment (&lt;it&gt;C&lt;/it&gt;: 56.2%, &lt;it&gt;I&lt;/it&gt;: 44.5%). Approximately one third of those interviewed had directly experienced war-related violence. A substantial number of people interviewed – one third in Ingushetia (37.5%) and two-thirds in Chechnya (66.8%) – rarely felt safe. The violence was ongoing, with respondents reporting violence in the month before the survey (&lt;it&gt;C&lt;/it&gt;: 12.5%, &lt;it&gt;I&lt;/it&gt;: 4.6%). Results of the general health questionnaire (GHQ 28) showed that nearly all internally displaced persons interviewed were suffering from health complaints such as somatic complaints, anxiety/insomnia, depressive feelings or social dysfunction (&lt;it&gt;C&lt;/it&gt;: 201, 78.5%, CI: 73.0% – 83.4%; &lt;it&gt;I&lt;/it&gt;: 230, 81.3%, CI: 76.2% – 85.6%). Poor health status was reflected in other survey questions, but health services were difficult to access for around half the population (&lt;it&gt;C&lt;/it&gt;: 54.3%, &lt;it&gt;I&lt;/it&gt;: 46.6%).&lt;/p&gt; &lt;p&gt;Discussion&lt;/p&gt; &lt;p&gt;The study demonstrates that the health needs of internally displaced in both locations are similarly high and equally unaddressed. The high levels of past confrontation with violence and ongoing exposure in both locations is likely to contribute to a further deterioration of the health status of internally displaced. As of March 2007, concerns remain about how the return process is being managed by the authorities.&lt;/p&gt;
    • HIV-1 prevalence and factors associated with infection in the conflict-affected region of North Uganda

      Musinguzi Joshua; Opio Alex A; Ciantia Filippo; Pierotti Chiara; Nattabi Barbara; Fabiani Massimo; Ayella Emintone O; Declich Silvia (BioMed Central, 2007-03-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Background&lt;/p&gt; &lt;p&gt;Since 1986, northern Uganda has been severely affected by civil strife with most of its population currently living internally displaced in protected camps. This study aims at estimating the HIV-1 prevalence among this population and the factors associated with infection.&lt;/p&gt; &lt;p&gt;Methods&lt;/p&gt; &lt;p&gt;In June-December 2005, a total of 3051 antenatal clinics attendees in Gulu, Kitgum and Pader districts were anonymously tested for HIV-1 infection as part of routine sentinel surveillance. Factors associated with the infection were evaluated using logistic regression models.&lt;/p&gt; &lt;p&gt;Results&lt;/p&gt; &lt;p&gt;The age-standardised HIV-1 prevalence was 10.3%, 9.1% and 4.3% in the Gulu, Kitgum and Pader district, respectively. The overall prevalence in the area comprised of these districts was 8.2% when data was weighted according to the districts' population size. Data from all sites combined show that, besides older women [20–24 years: adjusted odds ratio (AOR) = 1.96, 95% confidence interval (CI): 1.29–2.97; 25–29 years: AOR = 2.01, 95% CI: 1.30–3.11; ≥ 30 years: AOR = 1.91, 95% CI: 1.23–2.97], unmarried women (AOR = 1.47, 95% CI: 1.06–2.04), and those with a partner with a non-traditional occupation (AOR = 1.62, 95% CI: 1.18–2.21), women living outside of protected camps for internally displaced persons have a higher risk of being HIV-1 infected than internally displaced women (AOR = 1.55, 95% CI: 1.15–2.08).&lt;/p&gt; &lt;p&gt;Conclusion&lt;/p&gt; &lt;p&gt;Although published data from Gulu district show a declining HIV-1 prevalence trend that is consistent with that observed at the national level since 1993, the prevalence in North Uganda is still high. Internally displaced women have a lower risk of being infected probably because of their reduced mobility and accessibility, and increased access to health prevention services.&lt;/p&gt;
    • Association between expatriation and HIV awareness and knowledge among injecting drug users in Kabul, Afghanistan: A cross-sectional comparison of former refugees to those remaining during conflict

      Safi Naqibullah; Botros Boulos A; Scott Paul T; Strathdee Steffanie A; Abed Abdullah MS; Todd Catherine S; Earhart Kenneth C (BMC, 2007-03-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Background&lt;/p&gt; &lt;p&gt;Little is known about human immunodeficiency virus (HIV) awareness among Afghan injecting drug users (IDUs), many of whom initiated injecting as refugees. We explored whether differences in HIV awareness and knowledge exist between Afghan IDUs who were refugees compared to those never having left Afghanistan.&lt;/p&gt; &lt;p&gt;Methods&lt;/p&gt; &lt;p&gt;A convenience sample of IDUs in Kabul, Afghanistan was recruited into a cross-sectional study through street outreach over a one year period beginning in 2005. Participants completed an interviewer-administered questionnaire and underwent voluntary counseling and testing for HIV, syphilis, hepatitis B surface antigen, and hepatitis C antibody. Differences in HIV awareness and specific HIV knowledge between IDU who lived outside the country in the last decade versus those who had not were assessed with logistic regression.&lt;/p&gt; &lt;p&gt;Results&lt;/p&gt; &lt;p&gt;Of 464 IDUs, 463 (99%) were male; median age and age at first injection were 29 and 25 years, respectively. Most (86.4%) had lived or worked outside the country in the past ten years. Awareness of HIV was reported by 46.1%; those having been outside the country in the last decade were significantly more likely to have heard of HIV (48.3% vs. 31.7%; OR = 2.00, 95% CI: 1.14 – 3.53). However, of those aware of HIV, only 38.3% could name three correct transmission routes; specific HIV knowledge was not significantly associated with residence outside the country.&lt;/p&gt; &lt;p&gt;Conclusion&lt;/p&gt; &lt;p&gt;Accurate HIV knowledge among Afghan IDUs is low, though former refugees had greater HIV awareness. Reported high-risk injecting behavior was not significantly different between IDU that were refugees and those that did not leave the country, indicating that all Afghan IDU should receive targeted prevention programming.&lt;/p&gt;
    • Health care in Bosnia and Herzegovina before, during, and after 1992–1995 war: a personal testimony

      Šimunović Vladimir J (BioMed Central, 2007-05-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Market-based health care reform during democratic transition in Bosnia and Herzegovina was complicated by the 1992–1995 war, that devastated the country and greater part of its health care infrastructure. The course of the transition and consequences of war for the health system and health professionals are presented here from the perspective of the author. The description of real-life situations and their context is used to illustrate the problems physicians, as well as international community, were faced with and how they tried to cope with them during and after the war. Speaking openly about the mistakes that were made in those times is the first step in preventing them from happening again and an invitation for exchange of opinions and open academic discussion.&lt;/p&gt;
    • Building cooperation through health initiatives: an Arab and Israeli case study

      Skinner Harvey A; Sriharan Abi (BMC, 2007-07-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Background&lt;/p&gt; &lt;p&gt;Ongoing conflict in the Middle East poses a major threat to health and security. A project screening Arab and Israeli newborns for hearing loss provided an opportunity to evaluate ways for building cooperation. The aims of this study were to: a) examine what attracted Israeli, Jordanian and Palestinian participants to the project, b) describe challenges they faced, and c) draw lessons learned for guiding cross-border health initiatives.&lt;/p&gt; &lt;p&gt;Methods&lt;/p&gt; &lt;p&gt;A case study method was used involving 12 key informants stratified by country (3 Israeli, 3 Jordanian, 3 Palestinian, 3 Canadian). In-depth interviews were tape-recorded, transcribed and analyzed using an inductive qualitative approach to derive key themes.&lt;/p&gt; &lt;p&gt;Results&lt;/p&gt; &lt;p&gt;Major reasons for getting involved included: concern over an important health problem, curiosity about neighbors and opportunities for professional advancement. Participants were attracted to prospects for opening the dialogue, building relationships and facilitating cooperation in the region. The political situation was a major challenge that delayed implementation of the project and placed participants under social pressure. Among lessons learned, fostering personal relationships was viewed as critical for success of this initiative.&lt;/p&gt; &lt;p&gt;Conclusion&lt;/p&gt; &lt;p&gt;Arab and Israeli health professionals were prepared to get involved for two types of reasons: a) Project Level: opportunity to address a significant health issue (e.g. congenital hearing loss) while enhancing their professional careers, and b) Meta Level: concern about taking positive steps for building cooperation in the region. We invite discussion about roles that health professionals can play in building "cooperation networks" for underpinning health security, conflict resolution and global health promotion.&lt;/p&gt;