Complex humanitarian emergencies: a major global health challenge

Impact of COVID-19 pandemic on the circadian rhythm of cesarean section deliveries

Circadian rhythms synchronize all biological functions, enabling humans to foresee and respond better to periodic environmental changes. The coronavirus disease (COVID-19) lockdown regulations significantly changed the lighting conditions in pregnant women, leading to chronological disruption. This study aimed to investigate the impact of the COVID-19 on the circadian rhythm of cesarean deliveries. We investigated whether the circadian rhythm of cesarean section deliveries changed during the first year of the COVID-19 pandemic at a tertiary hospital in Van Province, eastern Turkey. We analyzed the distribution of birth times for 1476 cesarean deliveries performed between March 01, 2020 and January 20, 2021 (1st year of the COVID-19 pandemic) and compared this information with data from 1194 cesarean deliveries performed during a similar period in the previous year. The primary outcome was the change in the circadian rhythm of cesarean deliveries. Secondary outcomes included cesarean section (CS) delivery rates, indications for CS, 1st and 5th minutes Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration scores, and anesthesia technique use rates. Regarding the time distribution of CS deliveries in the first year of the COVID-19 pandemic, the maximum number of cesarean deliveries (n = 234, 16%) occurred between 14:00 and 16:00 (P = .112). Cesarean deliveries in pre-COVID-19 group were most frequently performed between 10:00 and 12:00, at a rate of 18% (n = 216) (P = .001). In both groups, the time point at which CS deliveries were the least performed was 04:00 to 06:00, and the rates were different (n = 35, 2% and n = 14, 1%, respectively) (P = .022). A 4-hour phase shift was detected at the peak of the birth time in the first year of the COVID-19 pandemic compared to the previous year. These results suggest that the circadian rhythm of cesarean deliveries is affected by the pandemic.

The epidemiological profile of incidence and mortality from epidemics in complex humanitarian emergencies from 1990 to 2022 - A scoping review

AIM

This study aimed to investigate the impact of communicable diseases with epidemic potential in complex emergency (CE) situations, focusing on the epidemiological profile of incidence and mortality and exploring underlying factors contributing to increased epidemic risks.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Review (PRISMA-ScR) guidelines, we conducted a scoping review of articles published between 1990 and 2022. The search included terms related to complex emergencies, communicable diseases, outbreaks, and epidemics. We identified 92 epidemics related to CE occurring in 32 different countries.

RESULTS

Communicable diseases like Shigellosis, Cholera, Measles, Meningococcal meningitis, Yellow Fever, and Malaria caused significant morbidity and mortality. Diarrhoeal diseases, particularly Cholera and Shigellosis, had the highest incidence rates. Shigella specifically had an incidence of 241.0 per 1000 (people at risk), with a mortality rate of 11.7 per 1000, while Cholera's incidence was 13.0 per 1000, with a mortality rate of 0.22 per 1000. Measles followed, with an incidence of 25.0 per 1000 and a mortality rate of 0.76 per 1000. Meningococcal Meningitis had an incidence rate of 1.3 per 1000 and a mortality rate of 0.13 per 1000. Despite their lower incidences, yellow fever at 0.8 per 1000 and malaria at 0.4 per 1000, their high case fatality rates of 20.1% and 0.4% remained concerning in CE. The qualitative synthesis reveals that factors such as water, sanitation, and hygiene, shelter and settlements, food and nutrition, and public health and healthcare in complex emergencies affect the risk of epidemics.

CONCLUSION

Epidemics during complex emergencies could potentially lead to a public health crisis. Between 1990 and 2022, there have been no statistically significant changes in the trend of incidence, mortality, or fatality rates of epidemic diseases in CE. It is crucial to understand that all epidemics identified in CE are fundamentally preventable.

Control, elimination, and eradication efforts for neglected tropical diseases in the World Health Organization African region over the last 30 years: A scoping review

OBJECTIVES

NTDs historically receive less attention than other diseases in the same regions. Recent gap analyses revealed notable shortcomings despite NTD elimination progress. This systematic scoping review was conducted to understand NTD control, elimination, and eradication efforts in the WHO African region over the last 30 years.

METHODS

Peer-reviewed publications from PubMed, Web of Science, and Cochrane databases related to NTD control, elimination, and eradication in the WHO African Region from 1990 to 2022 were reviewed. Included articles were categorized based on NTD; study location, type, and period; and topic areas. Technical and guidance documents from WHO, UN, partner, and academic/research institutions were reviewed. Country-specific multi-year NTD master plans were documented.

RESULTS

Four hundred eighty peer-reviewed articles, six Cochrane reviews, and 134 technical reports were included. MDA and non-interventional/survey-related studies were common topics. Lymphatic filariasis, trachoma, schistosomiasis, and onchocerciasis were the most frequently studied NTDs. Tanzania, Ethiopia, and Nigeria were the most represented countries; multi-country studies were limited.

CONCLUSION

The review highlights progress made in NTD control, elimination, and eradication efforts in the WHO African Region and can inform national/regional strategies. Disease and geographical disparities were evident, warranting focus and research in certain countries. A standardized approach to NTD control programs is needed for sustained progress.

FUNDING

There was no funding source for this study.

Climate change and human health in the Eastern Mediterranean and Middle East: Literature review, research priorities and policy suggestions

Human health is linked to climatic factors in complex ways, and climate change can have profound direct and indirect impacts on the health status of any given region. Susceptibility to climate change is modulated by biological, ecological and socio-political factors such as age, gender, geographic location, socio-economic status, occupation, health status and housing conditions, among other. In the Eastern Mediterranean and Middle East (EMME), climatic factors known to affect human health include extreme heat, water shortages and air pollution. Furthermore, the epidemiology of vector-borne diseases (VBDs) and the health consequences of population displacement are also influenced by climate change in this region. To inform future policies for adaptation and mitigation measures, and based on an extensive review of the available knowledge, we recommend several research priorities for the region. These include the generation of more empirical evidence on exposure-response functions involving climate change and specific health outcomes, the development of appropriate methodologies to evaluate the physical and psychological effects of climate change on vulnerable populations, determining how climate change alters the ecological determinants of human health, improving our understanding of the effects of long-term exposure to heat stress and air pollution, and evaluating the interactions between adaptation and mitigation strategies. Because national boundaries do not limit most climate-related factors expected to impact human health, we propose that adaptation/mitigation policies must have a regional scope, and therefore require collaborative efforts among EMME nations. Policy suggestions include a decisive region-wide decarbonisation, the integration of environmentally driven morbidity and mortality data throughout the region, advancing the development and widespread use of affordable technologies for the production and management of drinking water by non-traditional means, the development of comprehensive strategies to improve the health status of displaced populations, and fostering regional networks for monitoring and controlling the spread of infectious diseases and disease vectors.

Prehospital emergency care in a humanitarian environment: an overview of the ethical considerations

Recent history has demonstrated that UK Defence personnel can be used, potentially with little notice, in humanitarian disaster zones. The provision of prehospital emergency care (PHEC) in a humanitarian environment requires an innovative approach to overcome the technical challenges of a resource-limited setting. In addition to technical challenges, prehospital practitioners working in a humanitarian environment can expect to be faced with ethically testing situations that they are not familiar with in their usual practice. The organisational and individual ethical decision-making burden can result in significant harms. Therefore, the aim of this paper is to discuss the ethical considerations relevant to providing PHEC during a humanitarian disaster in order that personnel can be more prepared to optimally deliver care. This is a paper commissioned as a part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

Feasibility of establishing a core set of sexual, reproductive, maternal, newborn, child, and adolescent health indicators in humanitarian settings: results from a multi-methods assessment in Bangladesh

BACKGROUND

Reliable and rigorously collected sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) data in humanitarian settings is often sparse and varies in quality across different humanitarian settings. To address this gap in quality data, the World Health Organization (WHO) developed a core set of indicators for monitoring and evaluating SRMNCAH services and outcomes, and assessed their feasibility in Bangladesh, Afghanistan, Jordan, and the Democratic Republic of Congo.

METHODS

The feasibility assessments aggregated information from global consultations and field-level assessments to reach a consensus on a set of core SRMNCAH indicators among WHO partners. The feasibility assessment in Bangladesh focused on the following constructs: relevance/usefulness of the core set of indicators, the feasibility of measurement, availability of systems and resources, and ethical issues during data collection and management. The field-level multi-methods assessment included five components; a desk review, key informant interviews, focus group discussions, and facility assessments including observations of facility-level data management.

RESULTS

The findings suggest that there is widespread support among stakeholders for developing a standardized core set of SRMNCAH indicators to be collected among all humanitarian actors in Bangladesh. There are numerous resources and data collection systems that could be leveraged, built upon, and improved to ensure the feasibility of collecting this proposed set of indicators. However, the data collection load requested from donors, the national government, international and UN agencies, coordination/cluster systems must be better harmonized, standardized, and less burdensome.

CONCLUSION

This core set of indicators would only be useful if it has the buy-in from the international community that results in harmonizing and coordinating data collection efforts and relevant indicators' reporting requirements.

The Impact of the Coronavirus Pandemic Curfew on the Psychosocial Lives of Pregnant Women in Jordan

Objectives

Worldwide the COVID-19 pandemic has negatively affected the health and psychosocial lives of people. International guidelines recommend special attention to pregnant women during pandemics and national emergencies. This study aimed to report the impact of the COVID-19 pandemic curfew on the psychosocial lives of pregnant women in Jordan.

Design

A cross-sectional study was conducted and included women who were pregnant during the COVID-19 curfew in Jordan, which took place between mid-March and mid-June of 2020.

Settings

A web-based survey that was posted on various social media platforms.

Participants

Women who at the time of the study were 18 years of age or more, were living in Jordan, and were pregnant during the curfew.

Measurements and findings

Data collected included women's characteristics, the impact of the curfew on the pregnancy, physical activity, and psychosocial lives and the barriers to seeking healthcare, in addition to pregnancy and delivery details, and changes in nutrition and supplements intake.

A total of 877 women responded to the survey. The results showed that 21.1% of the respondents did not receive any antenatal care (ANC) during the curfew. The respondents also reported that the main barriers for seeking ANC included healthcare facilities being closed (85.2%), the need for travel permits (76.8%), financial difficulties (63.9%), and fear of catching the COVID-19 virus (60.1%). Furthermore, 93.3% reported that they had psychological stress, and 29.9% reported that they had at least one form of domestic violence. Statistically significant associations existed between various women's characteristics, obstetric, psychosocial factors, and the level of psychological stress.

Key conclusions

The COVID-19 pandemic curfew, which was applied in Jordan, resulted in a negative impact on the psychosocial lives of pregnant women. As a result, pregnant women did not receive optimal antenatal care and experienced higher degrees of psychological stress and domestic violence.

Implications for practice

The findings of our study may encourage national healthcare policymakers to ensure the provision of appropriate psychosocial support of pregnant women during large scale emergencies.

Care delivery among refugees and internally displaced persons affected by complex emergencies: a systematic review of the literature

Aim

This study reviews the empirical evidence on care delivery in complex emergencies (CEs) to better understand ways of improving care delivery and mitigating inequity in care among refugees and internally displaced persons (IDPs) in CEs.

Subject and methods

A systematic search was conducted in Web of Science, MEDLINE, PubMed and Embase. A manual search was conducted in the WHO Global Index Medicus and Google Scholar. Peer-reviewed English-language publications that reported results on care delivery in CEs were included for review. There was no limitation on the year or the geographical location of the studies. The content of the publications was qualitatively analysed, and the results are thematically presented in tabular form.

Results

Thirty publications were identified. Information regarding coverage, accessibility, quality, continuity and comprehensiveness of care service delivery was extracted and synthesized. Findings showed that constant insecurity, funding, language barriers and gender differences were factors impeding access to and coverage and comprehensiveness of care delivery in CEs. The review also showed a preference for traditional treatment among some refugees and IDPs.

Conclusion

Evidence from this systematic review revealed a high level of unmet healthcare need among refugees and IDPs and the need for a paradigm shift in the approach to care delivery in CEs. We recommend further research aimed at a more critical evaluation of care delivery in CEs with a view to providing a more innovative and context-specific care service delivery in these settings.

Scoping Review on the Impact of Outbreaks on Sexual and Reproductive Health Services: Proposed Frameworks for Pre-, Intra-, and Postoutbreak Situations

Introduction

Recent experiences from global outbreaks have highlighted the severe disruptions in sexual and reproductive health services that expose women and girls to preventable health risks. Yet, to date, there is no review studying the possible impact of outbreaks on sexual and reproductive health (SRH). Methodology. Studies reporting outbreaks impacting sexual and reproductive health and pregnancy outcomes were identified using MEDLINE, Embase, and ISI-WoS. Reported impacts were reviewed at systems, community, and legislative levels.

Results

The initial run listed 4423 studies; the 37 studies that met all inclusion criteria were mainly from Latin America and Africa. Studies on outbreaks of diseases like Zika and Ebola have documented declines in facility-based deliveries, contraceptive use, and antenatal and institutional care due to burdened healthcare system. Service usage was also impacted by a lack of trust in the healthcare system and system shocks, including workforce capacity and availability. At the community level, poverty and lack of awareness were critical contributors to poor access to SRH services. Assessing the target population's knowledge, attitude, beliefs, and behavior and using health literacy principles for communication were fundamental for designing service delivery. Online resources for SRH services were an acceptable medium of information among young adults. In outbreak situations, SRH and pregnancy outcomes were improved by implementing laboratory surveillance, free-of-cost contraceptive services, improved screening through professional training, and quality of care. In addition, mobile health clinics were reported to be effective in remote areas. Knowledge Contribution. In outbreaks, the interventions are categorized into preoutbreak, during, and postoutbreak periods. The proposed steps can help to improve and do course correction in emergencies. Though conducted before the COVID-19 crisis, the authors believe that lessons can be drawn from the paper to understand and mitigate the impact of the pandemic on sexual and reproductive health services.

The impact of humanitarian assistance on post-disaster social vulnerabilities: some early reflections on the Nepal earthquake in 2015

Every year, thousands of people around the world who face unequal access to political and social power and resources lose their lives and/or livelihoods in natural hazard events. As a result, the reduction of vulnerability has become a central concern of humanitarian actors. This paper analyses the impact of humanitarian assistance on vulnerabilities in Nepal following the Gorkha earthquake on 25 April 2015. The causes and manifestations of vulnerability before and after the disaster are determined through the application of the Pressure and Release model and the adoption of a mixed-methods research approach. The findings of the study reveal that 20 months after the earthquake, humanitarian assistance had not had any long-term positive influences on the root causes of the phenomenon, and that vulnerabilities at the micro level could be resolved in part. To diminish the extent of disasters in the future, however, the fundamental reasons for the vulnerability have to be addressed better.

Conceptualizing Ethical Issues of Humanitarian Work: Results From a Critical Literature Review

This article presents results of a critical review of the literature discussing the ethical issues arising in humanitarian work, following the method proposed by McCullough, Coverdale and Chervenak. Our aim was primarily to focus on how the ethical issues arising in humanitarian work are conceptualized within the literature we reviewed. We think that properly conceptualizing the ethical issues which humanitarian workers may face can provide avenues to better respond to them. We analysed 61 documents, as part of a literature review, which revealed that there truly is a need, amongst the authors and in humanitarian work, to discuss ethics. Indeed, even if only a small number of authors define explicitly the words they use to discuss ethics, the great quantity that we have uncovered in the documents seem to suggest vast and rich grounds upon which to address ethical issues. We believe it to be important that the ethical issues of humanitarian work are increasingly addressed in the literature and argue that it would be helpful for the vocabulary used by authors to be employed and developed even more rigorously, so that their discussions show more precision, coherence, relevance, exhaustiveness, and sufficiency. The review of the literature, as well as the resulting analysis in this article, is part of a broader project to suggest a way to conceptualize the ethical issues of humanitarian work based on the strengths and innovations of this and other studies.

Complex emergencies and the control and elimination of neglected tropical diseases in Africa: developing a practical approach for implementing safe and effective mapping and intervention strategies

Background

Complex emergencies resulting from conflict and political instability are a major challenge for national neglected tropical diseases (NTDs) control and elimination programmes, especially in sub-Saharan Africa. Currently, there are no formal guidelines for national programmes to use and plan activities in these humanitarian situations, therefore the aim of this study was to develop a new methodological approach for making decisions about the implementation of safe and effective mapping and mass drug administration (MDA) intervention strategies.

Methods

The study focussed on the 47 World Health Organization’s African Region (AFR) countries. NTD data were based on five diseases controlled by preventive chemotherapy (PC; i.e. lymphatic filariasis, onchocerciasis, schistosomiasis, soil transmitted helminths, trachoma), obtained from the WHO data portals and The Global Trachoma Atlas for 2018. Data on complex emergencies were obtained from the Armed Conflict Location and Event Data Project for 2018–2019.

NTD and conflict data were summarised and mapped. A decision tree was developed using NTD mapping, endemicity, MDA and implementing partners data, together with conflict status information at district level. South Sudan was used as a case study, given its current nexus of high NTD prevalence, incidences of conflict, and the presence of a national NTD programme and supporting partners.

Results

For the five NTDs, between 26 and 41 countries required PC, 69.2–212.7 million people were treated with coverage between 54.8–71.4%. In total 15,273 conflict events were reported including high rates of violence against civilians (29.4%), protests (28.8%), and battles (18.1%). The decision tree process included four main steps including i) information gathering ii) determine a disease mapping strategy iii) determine an MDA implementation strategy and iv) create a disease and conflict database. Based on these steps, risk maps were created. The South Sudan case study on onchocerciasis found the majority of the districts requiring mapping or MDA had a conflict event, and required specialised methods adapted to context and risk, with support from implementation partners in selected areas.

Conclusions

The paper presents a new methodological approach for implementing safe and effective mapping and intervention strategies in NTD endemic countries with ongoing complex emergencies, which will help to address challenges and make progress toward the NTD Roadmap targets of 2030.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00356-7.

Structure, function and performance of Early Warning Alert and Response Network (EWARN) in emergencies in the Eastern Mediterranean Region

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The outbreak detection function was undermined by inclusion of non-epidemic diseases.

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Adoption of electronic platforms expanded coverage of hard-to-reach areas.

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Conflict emergencies limited coverage, despite progress due to electronic solutions.

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The EWARN is being retained far longer than expected in protracted emergencies.

Introduction

The Eastern Mediterranean Region (EMR) has experienced several protracted humanitarian crises. The affected population are served by eight Early Warning Alert and Response Network (EWARN) systems for outbreak detection and response. This study aimed to compare structure, function and performance of the systems’ adherence to current guidance, and noted emerging lessons.

Methods

This study included a review of published and unpublished literature, a structured survey and interviews.

Results

Findings showed that all systems adhered to basic EWARN structure. Four of eight systems had electronic platforms, while one was implementing one. Regarding key EWARN function of outbreak detection: of the 35 health conditions, 26 were communicable diseases and nine were non-communicable; two systems focused on epidemic-prone diseases. Half the systems achieved ≥60% population coverage, five achieved ≥80% reporting timeliness, six achieved ≥80% reporting completeness, and seven achieved verification of ≥80% of alerts of suspected outbreaks.

Conclusion

The findings showed that the systems followed the EWARN structure, while increasing adoption of electronic platforms. Performance, including timeliness and completeness of reporting, and timely verification of alerts were optimal for most of the systems. However, population coverage was low for most of the systems, and the EWARN’s primary focus of outbreak detection was undermined by the increasing number of non-epidemic diseases.

The associated factors of cesarean section during COVID-19 pandemic: a cross-sectional study in nine cities of China

Background

Improving and maintaining the health of mothers and newborns is indisputably a global priority, especially during a pandemic. This study intends to examine the factors associated with cesarean section (CS) during lockdown time.

Methods

A total of 678 women who just gave birth within 7 days were enrolled from maternal and children hospitals in nine cities of China from April to May 2020. The delivery modes and potential influencing factors were investigated. The subgroup analysis and sensitivity analysis were used to examine the association of CS and risk factors among populations with different characteristics and to control for possible confounding, respectively.

Results

The overall rate of cesarean delivery was 37.3%. In multi-variant model, maternal age > 30 years (OR, 95% CI = 1.71, 1.21–2.41), higher pre-gestational BMI (OR, 95% CI = 1.16, 1.10–1.23), living in regions with confirmed COVID-19 cases > 500 (OR, 95% CI = 2.45, 1.74–3.45), and excess gestational weight gain (OR, 95% CI = 1.73, 1.17–2.55) were associated with cesarean delivery. These trends of associations were not changes in sensitivity analysis and subgroup analysis. Cesarean delivery occurred more in women who got more nutrition instruction during the pandemic period in the univariant model; however, this association showed insignificance in the multiple-variant analysis.

Conclusion

A high cesarean delivery rate was found in uninfected women who experienced lockdown in their third trimester. During the COVID-19 pandemic, more medical support should be provided in severely affected regions to ensure and promote health in pregnancy.

COVID-19 in the Pediatric Population-Review and Current Evidence

Purpose of Review

Coronavirus disease 2019 (COVID-19) pandemic has major health and economic impacts. We review disease characteristics in children.

Recent Findings

Children comprise 1–2% of the diagnosed cases, and typically suffer mild disease. The median age of infected children is 3.3–11 years, and male/female ratio is 1.15–1.55. Common symptoms in children include upper respiratory symptoms (26–54%), cough (44–54%), fever (32–65%), and gastrointestinal (15–30%) symptoms. Substantial proportion (4–23%) are asymptomatic. Death rates are up to 0.7%. Risk factors associated with severe disease are neonatal age group, male gender, lower respiratory tract disease, and pre-existing medical conditions. Vertical transmission was reported. Multisystem inflammatory syndrome (MIS), characterized by fever, multisystem organ involvement, and laboratory markers of inflammation, causes critical illness in > 50% of cases and is increasingly reported from endemic countries. Indirect effects of the coronavirus epidemic include higher rates of psychiatric morbidities, education loss, unhealthy lifestyle changes, and increased child neglect. Vaccines are in clinical trials and immunogenicity has not yet been shown in children.

Summary

Overall, COVID-19 has lower incidence and causes milder disease in children compared with adult patients. MIS is a rare severe complication more common in children. More data on the efficacy and safety of antivirals in children are needed.

Study protocol: building an evidence base for epidemiology emergency response, a mixed-methods study

INTRODUCTION

Determinants and drivers for emergencies, such as political instability, weak health systems, climate change and forcibly displaced populations, are increasing the severity, complexity and frequency of public health emergencies. As emergencies become more complex, it is increasingly important that the required skillset of the emergency response workforce is clearly defined. To enable essential epidemiological activities to be implemented and managed during an emergency, a workforce is required with the right mix of skills, knowledge, experience and local context awareness. This study aims to provide local and international responders with an opportunity to actively contribute to the development of new thinking around emergency response roles and required competencies. In this study, we will develop recommendations using a broad range of evidence to address identified lessons and challenges so that future major emergency responses are culturally and contextually appropriate, and less reliant on long-term international deployments.

METHOD AND ANALYSIS

We will conduct a mixed-methods study using an exploratory sequential study design. The integration of four data sources, including key informant interviews, a scoping literature review, survey and semistructured interviews will allow the research questions to be examined in a flexible, semistructured way, from a range of perspectives. The study is unequally weighted, with a qualitative emphasis. We will analyse all activities as individual components, and then together in an integrated analysis. Thematic analysis will be conducted in NVivo V.11 and quantitative analysis will be conducted in Stata V.15.

ETHICS AND DISSEMINATION

All activities have been approved by the Science and Medical Delegated Ethics Review Committee at the Australian National University (protocol numbers 2018-521, 2018-641, 2019-068). Findings will be disseminated through international and local deployment partners, peer-reviewed publication, presentation at international conferences and through social media such as Twitter and Facebook.

An urgent call to address the nutritional status of women and children in Nepal during COVID-19 crises

Due to the ongoing nationwide lockdown in Nepal, women and children face a greater risk of malnutrition and eventually leading to mortality and morbidity. To harness the progress made so far in improving the nutritional status of women and children, a focus on nutrition should be a part of the COVID-19 response plan.

"Making Patients" in Postwar and Resource-scarce Settings. Diagnosing and Treating Mental Illness in Postwar Kosovo

Postwar development contexts are increasingly sites of mental health and psychosocial interventions in which local health providers are trained by foreign experts in evidence-based diagnostic and treatment strategies. Underlying this course of action is a well-accepted biomedical logic that assumes symptoms can be identified and translated into mental disorders, and disorders into forms of treatment. I question this logic by investigating how patients are actually "made" in postwar and resource-scarce settings. Specifically, I focus on the tensions and ethical dilemmas with which practitioners in Kosovo grapple as they navigate requirements of international standards, their own perception of good care, and the limited resources at their disposal. The resultant practice of "making patients" to fit diagnostic repertoires is a product of health practitioners' structural power, but also an ethical response to the materially untenable conditions that practitioners and their patients are confronting.

(Re-) conceptualising vulnerability as a part of risk in global health emergency response: updating the pressure and release model for global health emergencies

Vulnerability has become a key concept in emergency response research and is being critically discussed across several disciplines. While the concept has been adopted into global health, its conceptualisation and especially its role in the conceptualisation of risk and therefore in risk assessments is still lacking. This paper uses the risk concept pioneered in hazard research that assumes that risk is a function of the interaction between hazard and vulnerability rather than the neo-liberal conceptualisation of vulnerability and vulnerable groups and communities. By seeking to modify the original pressure and release model, the paper unpacks the representation or lack of representation of vulnerability in risk assessments in global health emergency response and discusses what benefits can be gained from making the underlying assumptions about vulnerability, which are present whether vulnerability is sufficiently conceptualised and consciously included or not, explicit. The paper argues that discussions about risk in global health emergencies should be better grounded in a theoretical understanding of the concept of vulnerability and that this theoretical understanding needs to inform risk assessments which implicitly used the concept of vulnerability. By using the hazard research approach to vulnerability, it offers an alternative narrative with new perspectives on the value and limits of vulnerability as a concept and a tool.

Health Consequences of an Armed Conflict in Zamboanga, Philippines Using a Syndromic Surveillance Database

The Zamboanga armed conflict was a 19-day long encounter in the Philippines in 2013 that displaced 119,000 people from their homes. This study describes the health consequences of this complex emergency in different age groups, time periods, and health facilities using data from Surveillance in Post Extreme Emergencies and Disasters (SPEED). This is a descriptive study of the SPEED database spanning 196 days of observation post-disaster and 1065 SPEED reports from 49 health facilities. Evacuation centers and village health centers, both primary care facilities, had the highest number of consults. Common infections and noncommunicable diseases were the most common reasons for consultations, namely, acute respiratory infections, fever, watery diarrhea, skin disease, and hypertension. Infections can be associated with environmental conditions in displaced populations, while hypertension has a high prevalence in the country and implies long-term care. Conflict-related injuries and deaths were not frequently observed due to the volatile situation that influenced health-seeking behavior as well as possible reporting gaps. In conclusion, in complex emergencies, as in natural disasters, wherein early alert and warning for potential outbreaks is crucial, SPEED can assist decision makers on response and recovery interventions. Linkages between SPEED and other surveillance and reporting systems need to be explored.

Is palliative care cost-effective in low-income and middle-income countries? A mixed-methods systematic review

Introduction

Of the 40 million people globally in need of palliative care (PC), just 14% receive it, predominantly in high-income countries. Within fragile health systems that lack PC, incurable illness is often marked by pain and suffering, as well as burdensome costs. In high-income settings, PC decreases healthcare utilisation, thus enhancing value. Similar cost-effectiveness models are lacking in low-income and middle-income countries and with them, the impetus and funding to expand PC delivery.

Methods

We conducted a systematic search of seven databases to gather evidence of the cost-effectiveness of PC in low-income and middle-income countries. We extracted and synthesised palliative outcomes and economic data from original research studies occurring in low-income and middle-income countries. This review adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and includes a quality appraisal.

Results

Our search identified 10 eligible papers that included palliative and economic outcomes in low-income and middle-income countries. Four provided true cost-effectiveness analyses in comparing the costs of PC versus alternative care, with PC offering cost savings, favourable palliative outcomes and positive patient-reported and family-reported outcomes.

Conclusions

Despite the small number of included studies, wide variety of study types and lack of high-quality studies, several patterns emerged: (1) low-cost PC delivery in low-income and middle-income countries is possible, (2) patient-reported outcomes are favourable and (3) PC is less costly than the alternative. This review highlights the extraordinary need for robust cost-effectiveness analysis of PC in low-income and middle-income countries in order to develop health economic models for the delivery of PC, direct resource allocation and guide healthcare policy for PC delivery in low-income and middle-income countries.

Risk factors and risk factor cascades for communicable disease outbreaks in complex humanitarian emergencies: a qualitative systematic review

Background

Communicable diseases are a major concern during complex humanitarian emergencies (CHEs). Descriptions of risk factors for outbreaks are often non-specific and not easily generalisable to similar situations. This review attempts to capture relevant evidence and explore whether it is possible to better generalise the role of risk factors and risk factor cascades these factors may form.

Methods

A systematic search of the key databases and websites was conducted. Search terms included terms for CHEs (United Nations Office for the Coordination of Humanitarian Affairs definition) and terms for communicable diseases. Due to the types of evidence found, a thematic synthesis was conducted.

Results

26 articles met inclusion criteria. Key risk factors include crowded conditions, forced displacement, poor quality shelter, poor water, sanitation and hygiene, lack of healthcare facilities and lack of adequate surveillance. Most identified risk factors do not relate to specific diseases, or are specific to a group of diseases such as diarrhoeal diseases and not to a particular disease within that group. Risk factors are often listed in general terms but are poorly evidenced, not contextualised and not considered with respect to interaction effects in individual publications. The high level of the inter-relatedness of risk factors became evident, demonstrating risk factor cascades that are triggered by individual risk factors or clusters of risk factors.

Conclusions

CHEs pose a significant threat to public health. More rigorous research on the risk of disease outbreaks in CHEs is needed, from a practitioner and from an academic point of view.

US Centers for Disease Control and Prevention and Its Partners' Contributions to Global Health Security

To achieve compliance with the revised World Health Organization International Health Regulations (IHR 2005), countries must be able to rapidly prevent, detect, and respond to public health threats. Most nations, however, remain unprepared to manage and control complex health emergencies, whether due to natural disasters, emerging infectious disease outbreaks, or the inadvertent or intentional release of highly pathogenic organisms. The US Centers for Disease Control and Prevention (CDC) works with countries and partners to build and strengthen global health security preparedness so they can quickly respond to public health crises. This report highlights selected CDC global health protection platform accomplishments that help mitigate global health threats and build core, cross-cutting capacity to identify and contain disease outbreaks at their source. CDC contributions support country efforts to achieve IHR 2005 compliance, contribute to the international framework for countering infectious disease crises, and enhance health security for Americans and populations around the world.

Centers for Disease Control and Prevention Public Health Response to Humanitarian Emergencies, 2007-2016

Humanitarian emergencies, including complex emergencies associated with fragile states or areas of conflict, affect millions of persons worldwide. Such emergencies threaten global health security and have complicated but predictable effects on public health. The Centers for Disease Control and Prevention (CDC) Emergency Response and Recovery Branch (ERRB) (Division of Global Health Protection, Center for Global Health) contributes to public health emergency responses by providing epidemiologic support for humanitarian health interventions. To capture the extent of this emergency response work for the past decade, we conducted a retrospective review of ERRB's responses during 2007-2016. Responses were conducted across the world and in collaboration with national and international partners. Lessons from this work include the need to develop epidemiologic tools for use in resource-limited contexts, build local capacity for response and health systems recovery, and adapt responses to changing public health threats in fragile states. Through ERRB's multisector expertise and ability to respond quickly, CDC guides humanitarian response to protect emergency-affected populations.

Triage and the Lost Art of Decoding Vital Signs: Restoring Physiologically Based Triage Skills in Complex Humanitarian Emergencies

Triage management remains a major challenge, especially in resource-poor settings such as war, complex humanitarian emergencies, and public health emergencies in developing countries. In triage it is often the disruption of physiology, not anatomy, that is critical, supporting triage methodology based on clinician-assessed physiological parameters as well as anatomy and mechanism of injury. In recent times, too many clinicians from developed countries have deployed to humanitarian emergencies without the physical exam skills needed to assess patients without the benefit of remotely fed electronic monitoring, laboratory, and imaging studies. In triage, inclusion of the once-widely accepted and collectively taught “art of decoding vital signs” with attention to their character and meaning may provide clues to a patient’s physiological state, improving triage sensitivity. Attention to decoding vital signs is not a triage methodology of its own or a scoring system, but rather a skill set that supports existing triage methodologies. With unique triage management challenges being raised by an ever-changing variety of humanitarian crises, these once useful skill sets need to be revisited, understood, taught, and utilized by triage planners, triage officers, and teams as a necessary adjunct to physiologically based triage decision-making. (Disaster Med Public Health Preparedness. 2018;12:76–85)

Pre-travel health advice guidelines for humanitarian workers: A systematic review

BACKGROUND

In the last decades, there have been several natural disasters and global catastrophies with a steady increase in humanitarian relief work. This has resulted in increased research in the field of humanitarian aid, however the focus is mostly on the victims of the disasters and not on the individuals and organisations providing aid.

OBJECTIVES

The intent of this research is to review the information available on pre-deployment interventions and recommendations such as vaccinations and other health preserving measures in volunteers and professionals deploying abroad in humanitarian relief missions.

METHODS

We performed a systematic literature review of papers written in English, French, Italian or German. We searched the following databases: Cochrane, PubMed, CINAHL, EMBASE and also hand searched reference lists. The cut-off date for the publication search was November 20th, 2014. In addition to the literature search we also sent a questionnaire to 30 organisations to detail their approach to preparing relief workers.

RESULTS

We identified 163 papers of possible relevance and finally included 35 papers in the systematic review. Six organisations provided information on pre-deployment preparation of aid workers. Identified papers show that pre-deployment physical and mental fitness are paramount for success in humanitarian missions. However, in many settings, pre-travel medical and psychological assessments and/or training/education sessions are not mandatory. We identified high-risk hazards for aid workers (often location specific), these included: travellers׳ diarrhoea, vector-borne infections, accidents, violence, tuberculosis, HIV, hepatitis A, leptospirosis, typhoid fever, seasonal and H1N1 influenza.

CONCLUSIONS

The medical evaluation can identify problems or risk factors, such as psychological frailty, that can be exacerbated by the stressful settings of humanitarian missions. In this pre-travel setting, the status of routine vaccinations can be controlled and completed, medication dispensed and targeted preventive advice provided. A mission specific first-aid kit can be recommended. There is a lack of evidence-based literature on the theme of pre-travel advice guidelines for humanitarian workers. We propose a shared database of literature on this topic as a resource and suggest that some standardization of guidelines would be useful for future planning.

Burden of malaria is higher among children in an internal displacement camp compared to a neighbouring village in the Democratic Republic of the Congo

BACKGROUND

In the Democratic Republic of the Congo (DRC), violent conflict has caused the displacement of millions of people into camps where they are exposed to poor living conditions and high rates of infectious diseases. Malaria, in particular, is a major cause of mortality in children under five; however, the burden of disease in displacement camps has not previously been described.

METHODS

Two cross-sectional surveys were performed. First, prevalence of Plasmodium falciparum antigenemia was measured in a random sample of 200 children living in a displacement camp and 200 children from a nearby village (control group). Second, the proportion of febrile illness attributable to malaria was measured in a study of 100 children from the displacement camp and 100 children from the control village presenting to the same health clinic with fever. All participants were tested for P. falciparum with a rapid diagnostic test and additional demographic data, clinical characteristics, and malaria risk factors were determined using a parental questionnaire.

RESULTS

In the community survey, children living in the displacement camp had a higher prevalence of P. falciparum infection (17 %) than controls (7.5 %) (OR 2.6; 95 % CI 1.3-4.1; P = 0.0095). In the clinic-based survey, the proportion of febrile illness attributable to malaria was higher among children from the displacement camp (78 %) than controls (39 %) (OR 5.5; 95 % CI 3.0-10.3; P < 0.001). Household bed net ownership and use was significantly lower in the displacement camp than control village in both surveys. Statistically significant differences in household wealth, maternal education, and exposure to community violence were also found.

CONCLUSIONS

Population displacement due to violent conflict appears to be a risk factor for malaria, a major cause of child mortality. Children living in displacement camps are a relatively understudied population, but have a high burden of malaria, despite control programmes focused on bed net distribution.

Vaccine-preventable disease and the under-utilization of immunizations in complex humanitarian emergencies

Complex humanitarian emergencies affect 40-60 million people annually and are a growing public health concern worldwide. Despite efforts to provide medical and public health services to populations affected by complex emergencies, significant morbidity and mortality persist. Measles is a major communicable disease threat, but through vaccination of broader target age groups beyond the traditional immunization schedule, measles-related mortality has been significantly reduced during crises. Yet, a limited number of vaccine-preventable diseases continue to contribute disproportionately to morbidity and mortality in complex emergencies. The literature suggests that Streptococcus pneumoniae, Rotavirus, and Haemophilus influenzae type-b should be key targets for vaccination programs. Because of the significant contribution of these three pathogens to complex humanitarian emergencies in low and middle-income countries regardless of disaster type, geography, or population, their vaccines should be considered essential components of the standard emergency response effort. We discuss the barriers to vaccine distribution and provide evidence for strategies to improve distribution, including expanded target age-range and reduced dose schedules. Our review includes specific recommendations for the expanded use of these three vaccines in complex emergencies in low and middle-income countries as a way to guide future policy discussions.

A retrospective analysis of oral cholera vaccine use, disease severity and deaths during an outbreak in South Sudan

Objective

To determine whether pre-emptive oral cholera vaccination reduces disease severity and mortality in people who develop cholera disease during an outbreak.

Methods

The study involved a retrospective analysis of demographic and clinical data from 41 cholera treatment facilities in South Sudan on patients who developed cholera disease between 23 April and 20 July 2014 during a large outbreak, a few months after a pre-emptive oral vaccination campaign. Patients who developed severe dehydration were regarded as having a severe cholera infection. Vaccinated and unvaccinated patients were compared and multivariate logistic regression analysis was used to identify factors associated with developing severe disease or death.

Findings

In total, 4115 cholera patients were treated at the 41 facilities: 1946 (47.3%) had severe disease and 62 (1.5%) deaths occurred. Multivariate analysis showed that patients who received two doses of oral cholera vaccine were 4.5-fold less likely to develop severe disease than unvaccinated patients (adjusted odds ratio, aOR: 0.22; 95% confidence interval, CI: 0.11–0.44). Moreover, those with severe cholera were significantly more likely to die than those without (aOR: 4.76; 95% CI: 2.33–9.77).

Conclusion

Pre-emptive vaccination with two doses of oral cholera vaccine was associated with a significant reduction in the likelihood of developing severe cholera disease during an outbreak in South Sudan. Moreover, severe disease was the strongest predictor of death. Two doses of oral cholera vaccine should be used in emergencies to reduce the disease burden.

Professionalization of anesthesiologists and critical care specialists in humanitarian action: a nationwide poll among italian residents

BACKGROUND

Over the last decades, humanitarian crises have seen a sharp upward trend. Regrettably, physicians involved in humanitarian action have often demonstrated incomplete preparation for these compelling events which have proved to be quite different from their daily work. Responders to these crises have included an unpredictable mix of beginner-level, mid-level, and expert-level providers. The quality of care has varied considerably. The international humanitarian community, in responding to international calls for improved accountability, transparency, coordination, and a registry of professionalized international responders, has recently launched a call for further professionalization within the humanitarian assistance sector, especially among academic-affiliated education and training programs. As anesthetists have been involved traditionally in medical relief operations, and recent disasters have seen a massive engagement of young physicians, the authors conducted, as a first step, a poll among residents in Anesthesia and Critical Care Medicine in Italy to evaluate their interest in participating in competency-based humanitarian assistance education and in training incorporated early in residencies.

METHODS

The Directors of all the 39 accredited anesthesia/critical care training programs in Italy were contacted and asked to submit a questionnaire to their residents regarding the objectives of the poll study. After acceptance to participate, residents were enrolled and asked to complete a web-based poll.

RESULTS

A total of 29 (74%) of the initial training programs participated in the poll. Out of the 1,362 questionnaires mailed to residents, 924 (68%) were fully completed and returned. Only 63(6.8%) of the respondents voiced prior participation in humanitarian missions, but up to 690 (74.7%) stated they were interested in participating in future humanitarian deployments during their residency that carried over into their professional careers. Countrywide, 896 (97%) favored prior preparation for residents before participating in humanitarian missions, while the need for a specific, formal, professionalization process of the entire humanitarian aid sector was supported by 889 (96.2%).

CONCLUSIONS

In Italy, the majority of anesthesia/critical care residents, through a formal poll study, affirmed interest in participating in humanitarian assistance missions and believe that further professionalization within the humanitarian aid sector is required. These results have implications for residency training programs worldwide.

Clinical characteristics of the inhabitants of an internally displaced persons camp in Brazzaville, Republic of Congo after the arms dump blast on March 4, 2012

BACKGROUND

On March 4, 2012, an arms dump exploded in a densely populated area in Brazzaville, Republic of the Congo. At least 250 people were killed, 2,500 wounded, and 13,800 left homeless, of which 5,000 were relocated to a newly constructed internally displaced person (IDP) camp.

AIM

To describe the medical complaints of persons presenting to the IDP camp for medical evaluation.

PATIENTS AND METHODS

All patients seen and treated by the Belgian First Aid and Support Team (B-FAST) in the IDP camp on March 10 and 11, 2012 were included. A unique number, age, gender, and inventory of complaints were registered on standard World Health Organization (WHO) forms.

RESULTS

Out of 245 presenting patients, 242 files were processed. One in two patients were minors (<18 years-old), the male/female ratio was 50/50 in minors and 28/72 in adults; median (range) age in minors was three years (0-17) and for adults was 32.5 years (18-68). Twenty percent of the children were determined to be malnourished. Signs and symptoms related to infectious diseases were present in 75% of minors and 53% of adults. Trauma was present in 12% of minors and 21% of adults.

CONCLUSIONS

One week following the disaster event, after people had relocated to IDP camps, infectious diseases became the predominate reason for seeking medical evaluation. Less than one in five people presenting to the medical post had injuries directly related to the event. Demographic data showed that around 50% of people in the IDP camp presenting for medical care were children, of which one in five was malnourished.

The role of academic research and teaching in addressing health in situations of conflict and instability

The key roles of academic research and teaching in addressing health in situations of conflict and instability are to better inform and better equip actors with the knowledge and skills to address health problems. The four key contributions of research are: quantifying the health problem, examining the contextual circumstances, investigating the epidemiology of health problems and evaluation of health care and humanitarian interventions. The role of teaching can complement research by distributing its' findings in addition to teaching skill sets to apply this knowledge and conduct further research. Academic research and teaching both play imperative roles in enabling more successful approaches in addressing health in situations of conflict and instability.

Funding based on needs? A study on the use of needs assessment data by a major humanitarian health assistance donor in its decisions to allocate funds

Background: International humanitarian assistance is essential for disaster-affected populations, particularly in resource scarce settings. To target such assistance, needs assessments are required. According to internationally endorsed principles, donor governments should provide funding for humanitarian assistance based on need. Aim: The aim of this study is to explore a major donor’s use of needs assessment data in decision-making for allocations of funds for health-related humanitarian assistance contributions. Setting: This is a case study of the Swedish International Development Cooperation Agency (Sida), a major and respected international donor of humanitarian assistance. Methods: To explore Sida’s use of needs assessment data in practice for needs-based allocations, we reviewed all decision documents and assessment memoranda for humanitarian assistance contributions for 2012 using content analysis; this was followed by interviews with key personnel at Sida. Results: Our document analysis found that needs assessment data was not systematically included in Sida’s assessment memoranda and decision documents. In the interviews, we observed various descriptions of the concept of needs assessments, the importance of contextual influences as well as previous collaborations with implementing humanitarian assistance organizations. Our findings indicate that policies guiding funding decisions on humanitarian assistance need to be matched with available needs assessment data and that terminologies and concepts have to be clearly defined. Conclusion: Based on the document analysis and the interviews, it is unclear how well Sida used needs assessment data for decisions to allocate funds. However, although our observations show that needs assessments are seldom used in decision making, Sida’s use of needs assessments has improved compared to a previous study. To improve project funds allocations based on needs assessment data, it will be critical to develop distinct frameworks for allocation distributions based on needs assessment and clear definitions, measurements and interpretations of needs. Key words: Needs assessment, humanitarian assistance, disasters, donor decision-making

Deadly professions: violent attacks against aid-workers and the health implications for local populations

War has devastating implications for families, communities, cultures, economies, and state infrastructure. Similarly, the last decade has seen an increase in the number of attacks against health workers in conflict zones and unstable environments. Unfortunately, these attacks have grave consequences for local populations which often rely on foreign aid programs for their health and well-being. As such, this paper will examine why aid-workers have increasingly been targeted for abductions, ambushes, assassinations, and various forms of intimidation. Furthermore, examples of terminated health programs, as well as populations served by current medical and humanitarian interventions, will be provided to impart a sense of magnitude and importance of health programs to the reader. Lastly, suggestions will be presented which could serve to minimize aid-workers' risk and exposure to acts of violence in the field.

Implementation of Evidence-based Humanitarian Programs in Military-led Missions: Part I. Qualitative Gap Analysis of Current Military and International Aid Programs

Background: A recent Department of Defense instruction mandates country-specific assessments, identification of interventions, and development of guidance for Department of Defense to plan, train, and prepare for the provision of humanitarian assistance in stability operations. It also directs the use of outcome-based measures of effectiveness and the establishment of processes facilitating transparency of information. Whereas this would align military-led projects closer to the standards of the international aid community, how this process will be developed and implemented within the military has not yet been determined.

Methods: To begin developing an evidence-based program for military-led humanitarian aid, we conducted a qualitative gap analysis comparing information from a Web search of Department of Defense medical after-action reports, lessons learned, and expert interviews with the internationally accepted standards in humanitarian assistance impact assessment.

Results: There is a major gap in the ability of the Department of Defense to assess the impact of humanitarian assistance in stability operations compared with international development standards. Of the 1000 Department of Defense after-action reports and lessons learned reviewed, only 7 (0.7%) reports refer to, but do not discuss, impact assessment or outcome-based measures of effectiveness.

Conclusions: This investigation shows that the Department of Defense humanitarian assistance operations are, historically, recorded without documentation using quantifiable health data identifying which aid activities contributed directly to desired outcomes or favorable public opinion, and rarely are analyzed for effectiveness. As humanitarian assistance operations assume an ever greater role in US military strategy, it is imperative that we investigate useful impact assessment models to meet mission directives and, more important, to maximize coordination in a necessarily integrated and cooperative development environment. These findings provide baseline knowledge for the implementation of an evidence-based impact assessment process to validate future Department of Defense humanitarian assistance operations. (Disaster Med Public Health Preparedness. 2008;2:230–236)

Strange but common bedfellows: the relationship between humanitarians and the military in developing psychosocial interventions for civilian populations affected by armed conflict

This essay analyses how the relationships between Cold War and post-Cold War politics, military psychiatry, humanitarian aid and mental health interventions in war and post-war contexts have transformed over time. It focuses on the restrictions imposed on humanitarian interventions and aid during the Cold War; the politics leading to the transfer of the PTSD diagnosis and its treatment from the military to civilian populations; humanitarian intervention campaigns in the post-Cold War era; and the development of psychosocial intervention programs and standards of care for civilian populations affected by armed conflict. Viewing these developments in their broader historical, political and social contexts reveals the politics behind mental health interventions conducted in countries and populations affected by warfare. In such militarized contexts, the work of NGOs providing assistance to people suffering from trauma-related health problems is far from neutral as it depends on the support of the military and plays an important role in the shaping of international politics and humanitarian aid programs.

Human resources issues and Australian Disaster Medical Assistance Teams: results of a national survey of team members

BACKGROUND

Calls for disaster medical assistance teams (DMATs) are likely to continue in response to international disasters. As part of a national survey, this study was designed to evaluate Australian DMAT experience in relation to the human resources issues associated with deployment.

METHODS

Data was collected via an anonymous mailed survey distributed via State and Territory representatives on the Australian Health Protection Committee, who identified team members associated with Australian DMAT deployments from the 2004 South East Asian Tsunami disaster.

RESULTS

The response rate for this survey was 50% (59/118). Most personnel had deployed to the Asian Tsunami affected areas with DMAT members having significant clinical and international experience. While all except one respondent stated they received a full orientation prior to deployment, only 34% of respondents (20/59) felt their role was clearly defined pre deployment. Approximately 56% (33/59) felt their actual role matched their intended role and that their clinical background was well suited to their tasks. Most respondents were prepared to be available for deployment for 1 month (34%, 20/59). The most common period of notice needed to deploy was 6-12 hours for 29% (17/59) followed by 12-24 hours for 24% (14/59). The preferred period of overseas deployment was 14-21 days (46%, 27/59) followed by 1 month (25%, 15/59) and the optimum shift period was felt to be 12 hours by 66% (39/59). The majority felt that there was both adequate pay (71%, 42/59) and adequate indemnity (66%, 39/59). Almost half (49%, 29/59) stated it was better to work with people from the same hospital and, while most felt their deployment could be easily covered by staff from their workplace (56%, 33/59) and caused an inconvenience to their colleagues (51%, 30/59), it was less likely to interrupt service delivery in their workplace (10%, 6/59) or cause an inconvenience to patients (9%, 5/59). Deployment was felt to benefit the affected community by nearly all (95%, 56/59) while less (42%, 25/59) felt that there was a benefit for their own local community. Nearly all felt their role was recognised on return (93%, 55/59) and an identical number (93%, 55/59) enjoyed the experience. All stated they would volunteer again, with 88% strongly agreeing with this statement.

CONCLUSIONS

This study of Australian DMAT members provides significant insights into a number of human resources issues and should help guide future deployments. The preferred 'on call' arrangements, notice to deploy, period of overseas deployment and shift length are all identified. This extended period of operations needs to be supported by planning and provision of rest cycles, food, temporary accommodation and rest areas for staff. The study also suggests that more emphasis should be placed on team selection and clarification of roles. While the majority felt that there was both adequate pay and adequate indemnity, further work clarifying this, based on national conditions of service should be, and are, being explored currently by the state based teams in Australia. Importantly, the deployment was viewed positively by team members who all stated they would volunteer again, which allows the development of an experienced cohort of team members.

Leadership and Use of Standards by Australian Disaster Medical Assistance Teams: Results of a National Survey of Team Members

Introduction

It is likely that calls for disaster medical assistance teams (DMATs) will continue in response to international disasters.

Objective

As part of a national survey, the present study was designed to evaluate leadership issues and use of standards in Australian DMATs.

Methods

Data was collected via an anonymous mailed survey distributed via State and Territory representatives on the Australian Health Protection Committee, who identified team members associated with Australian DMAT deployments from the 2004 Asian Tsunami disaster.

Results

The response rate for this survey was estimated to be approximately 50% (59/118). Most of the personnel had deployed to the Asian Tsunami affected areas. The DMAT members were quite experienced, with 53% (31/59) of personnel in the 45-55 years of age group. Seventy-five percent (44/59) of the respondents were male. Fifty-eight percent (34/59) of the survey participants had significant experience in international disasters, although few felt they had previous experience in disaster management (5%, 3/59). There was unanimous support for a clear command structure (100%, 59/59), with strong support for leadership training for DMAT commanders (85%, 50/59). However only 34% (20/59) felt that their roles were clearly defined pre-deployment, and 59% (35/59) felt that team members could be identified easily. Leadership was identified by two team members as one of the biggest personal hardships faced during their deployment. While no respondents disagreed with the need for meaningful, evidence-based standards to be developed, only 51% (30/59) stated that indicators of effectiveness were used for the deployment.

Conclusions

In this study of Australian DMAT members, there was unanimous support for a clear command structure in future deployments, with clearly defined team roles and reporting structures. This should be supported by clear identification of team leaders to assist inter-agency coordination, and by leadership training for DMAT commanders. Members of Australian DMATs would also support the development and implementation of meaningful, evidence-based standards. More work is needed to identify or develop actual standards and the measures of effectiveness to be used, as well as the contents and nature of leadership training.

Aitken P, Leggat PA, Robertson AG, Harley H, Speare R, Leclercq MG. Leadership and use of standards by Australian disaster medical assistance teams: results of a national survey of team members.Prehosp Disaster Med.2012;27(2):1-6.

Education and training of Australian disaster medical assistance team members: results of a national survey

INTRODUCTION

Calls for disaster medical assistance teams (DMATs) are likely to continue in response to international disasters.

OBJECTIVE

As part of a national survey, the present study was designed to evaluate the education and training of Australian DMATs.

METHODS

Data were collected via an anonymous, mailed survey distributed via State and Territory representatives on the Australian Health Protection Committee, who identified team members associated with Australian DMAT deployments from the 2004 Southeast Asia tsunami disaster.

RESULTS

The response rate for this survey was 50% (59/118). Most of the personnel had deployed to the tsunami-affected areas. The DMAT members were quite experienced, with 53% of personnel in the 45-55-year age group (31/59). Seventy-six percent of the respondents were male (44/58). While most respondents had not participated in any specific training or educationalprogram, any kind of relevant training was regarded as important in preparing personnel for deployment. The majority of respondents had experience in disasters, ranging from hypothetical exercises (58%, 34/59) to actual military (41%, 24/49) and non-governmental organization (32%, 19/59) deployments. Only 27% of respondents felt that existing training programs had adequately prepared them for deployment. Thirty-four percent of respondents (20/59) indicated that they had not received cultural awareness training prior to deployment, and 42% (25/59) received no communication equipment training. Most respondents felt that DMAT members needed to be able to handle practical aspects of deployments, such as training as a team (68%, 40/59), use of communications equipment (93%, 55/59), ability to erect tents/shelters (90%, 53/59), and use of water purification equipment (86%, 51/59). Most respondents (85%, 50/59) felt leadership training was essential for DMAT commanders. Most (88%, 52/59) agreed that teams need to be adequately trained prior to deployment, and that a specific DMAT training program should be developed (86%, 51/59).

CONCLUSIONS

This study of Australian DMAT members suggests that more emphasis should be placed on the education and training. Prior planning is required to ensure the success of DMAT deployments and training should include practical aspects of deployment. Leadership training was seen as essential for DMAT commanders, as was team-based training. While any kind of relevant training was regarded as important for preparing personnel for deployment, Australian DMAT members, who generally are a highly experienced group of health professionals, have identified the need for specific DMAT training.

Establishing moral bearings: ethics and expatriate health care professionals in humanitarian work

Expatriate health care professionals frequently participate in international responses to natural disasters and humanitarian emergencies. This field of practice presents important clinical, logistical and ethical challenges for clinicians. This paper considers the ethics of health care practice in humanitarian contexts. It examines features that contribute to forming the moral landscape of humanitarian work, and discusses normative guidelines and approaches that are relevant for this work. These tools and frameworks provide important ethics resources for humanitarian settings. Finally, it elaborates a set of questions that can aid health care professionals as they analyse ethical issues that they experience in the field. The proposed process can assist clinicians as they seek to establish their moral bearings in situations of ethical complexity and uncertainty. Identifying and developing ethics resources and vocabulary for clinical practice in humanitarian work will help health care professionals provide ethically sound care to patients and communities.

Revisiting sphere: new standards of service delivery for new trends in protracted displacement

The proportion of people living in protracted displacement, as well as the duration of this displacement, is increasing. International humanitarian standards for services provided in protracted displacement are based on the Sphere Standards, which were formulated using evidence and experience from acute phase emergencies. However, the majority of protracted emergencies are in the post-emergency phase. This paper discusses trends in displacement, outlines reasons why using the Sphere Standards as minimum standards of service provision in protracted displacement does not adequately meet the needs of these populations, and analyses areas where greater standards of service provision are necessary. An expansion of the evidence base regarding determinants of morbidity and mortality in protracted emergencies is needed. This, followed by a joint approach to designing new, effective standards focused on proactive policies, will allow the humanitarian community more appropriately to serve and enable the millions of people currently living in protracted displacement.