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Onvlee O, Kok M, Buchan J, Dieleman M, Hamza M, Herbst C. Human Resources for Health in Conflict Affected Settings: A Scoping Review of Primary Peer Reviewed Publications 2016-2022. Int J Health Policy Manag 2023; 12:7306. [PMID: 38618826 PMCID: PMC10590254 DOI: 10.34172/ijhpm.2023.7306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/20/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Conflict has devastating effects on health systems, especially on healthcare workers (HCWs) working in under-resourced and hostile environments. However, little evidence is available on how policy-makers, often together with development partners, can optimize the organization of the health workforce and support HCWs to deliver accessible and trustworthy health services in conflict-affected settings (CAS). METHODS A scoping review was conducted to review recent evidence (2016-2022) on human resources for health (HRH) in CAS, and critically discuss HRH challenges in these settings. Thirty-six studies were included in the review and results were presented using an adapted version of the health labour market (HLM) framework. RESULTS Evidence from CAS highlights that conflict causes specific constraints in both the education sector and in the HLM, and deepens any existing disconnect between those sectors. Parallel and inadequate education and performance management systems, attacks on health facilities, and increased workload and stress, amongst other factors, affect HCW motivation, performance, distribution, and attrition. Short-term, narrowly focused policy-making undermines the long-term sustainability and resilience of the health workforce in CAS, and also contributes to the limited and narrow available research base. CONCLUSION While HRH and workforce issues in CAS include those found in many other low- and middle-income countries (LMICs), an additional set of challenges for HCWs, governance dynamics and institutional constraints in CAS 'multiply' negative effects on the health workforce. HRH policies, programmes and interventions must be aligned with the political and broader societal context, including the stage, severity and other dynamics of conflict. During conflict, it is important to try to monitor in- and outflow of HCWs and provide HCWs the support they need at local level or through remote measures. The post-conflict situation may present opportunities for improvement in HRH, but a clear understanding of political economy dynamics is required to better act on any such a window of opportunity.
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Affiliation(s)
- Olivier Onvlee
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Maryse Kok
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - James Buchan
- Faculty of Health, WHO Collaborating Centre, University of Technology, Sydney, NSW, Australia
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Lerosier T, Touré L, Diabaté S, Diarra Y, Ridde V. Minimal resilience and insurgent conflict: qualitative analysis of the resilience process in six primary health centres in central Mali. BMJ Glob Health 2023; 7:e010683. [PMID: 37185362 PMCID: PMC10580275 DOI: 10.1136/bmjgh-2022-010683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 04/03/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND In the context of universal health coverage in the Sahel, the study focuses on primary health centres and the difficulties of their implementation in the context of insurgency conflicts in central Mali. METHODS This is qualitative research through a multiple case study. We selected six health centres according to a reasoned choice to bring together contrasting situations. We conducted 96 semistructured interviews and consulted secondary quantitative data on attendance. By focusing on community health centres, the conceptual approach focuses on the process of resilience that unfolds in a dual context of chronic health system dysfunctions and armed conflict. RESULTS The resilience strategies deployed by health professionals were relatively basic and uncoordinated. In the end, it was the individuals who showed absorption. However, their room for manoeuvre was limited. In the most isolated health centres, resilience was based on subordinate, poorly trained staff, often from the locality. Degraded working conditions and fear caused a form of resignation among health workers. CONCLUSION The strategies and resources used showed a form of minimal resilience. This form is unfolding in a context marked by two structuring features. On the one hand, the Malian health system was relatively dysfunctional before the crisis, and on the other hand, the type of conflict was relatively low intensity that allowed health centres to remain open.
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Affiliation(s)
| | | | | | | | - Valery Ridde
- Université Paris Cité, IRD, Inserm, Ceped, F-75006, Paris, France
- Institut de Santé et Développement, Université Cheikh Anta Diop, Dakar, Senegal
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Singh NS, Redman B, Broussard G, DeCamp M, Rayes D, Ho LS, Robinson WC, Sankari A, Maziak W, Rubenstein L. 'We will never give up': a qualitative study of ethical challenges Syrian health workers face in situations of extreme violence. DISASTERS 2022; 46:301-328. [PMID: 34309056 PMCID: PMC9987559 DOI: 10.1111/disa.12503] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Active conflict settings constitute challenging operating environments for humanitarian health organisations and workers. An emerging feature of some conflicts is direct violence against health workers, facilities, and patients. Since the start of the war in 2011, Syria has endured extreme and deliberate violent attacks on health facilities and workers. This paper reports on the findings from a qualitative study that examined the lived experiences of Syrian humanitarian health workers facing extreme ethical challenges and coping with moral distress. In-depth interviews were carried out with 58 front-line health workers in north-western and southern Syria. Participants described a number of ethical and operational challenges experienced while providing services in extreme conditions, as well as strategies used to deal with them. The complex intersection of personal and organisational challenges is considered and findings are linked to key ethical and humanitarian principles. Both practical recommendations and action steps are provided to guide humanitarian health organisations.
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Affiliation(s)
- Namrita S Singh
- PhD, MSc is Owner/Founder and Principal Advisor of Health Research Toolbox, LLC, and a Faculty Associate at the Department of International Health and Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, United States
| | - Brittany Redman
- MA, LPC is a Research Associate at Health Research Toolbox, LLC, and a Research Associate with the Humanitarian Assistance Applied Research Group, International Disaster Psychology Program, University of Denver, United States
| | - Grant Broussard
- MSPH is a Research Assistant at the Department of International Health and Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, United States
| | - Matthew DeCamp
- MD, PhD is an Associate Professor at the Center for Bioethics and Humanities and Division of General Internal Medicine, University of Colorado School of Medicine, United States
| | - Diana Rayes
- MHS is a Doctoral Student at the Department of International Health, Johns Hopkins Bloomberg School of Public Health, United States
| | - Lara S Ho
- PhD, RN is Director of Strategic Initiatives at the Health Unit, International Rescue Committee, and a Faculty Associate at the Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, United States
| | - W Courtland Robinson
- PhD is an Associate Professor at the Department of International Health and Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, United States
| | - Abdulghani Sankari
- MD, PhD is a Professor and Assistant Dean at the Department of Internal Medicine, Wayne State University-School of Medicine, and Director of the Department of Medical Education, Ascension Providence Hospital, United States
| | - Wasim Maziak
- MD, PhD is a Professor at the Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, United States
| | - Leonard Rubenstein
- JD is Professor of the Practice at the Center for Public Health and Human Rights and Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, and core faculty at Johns Hopkins Berman Institute of Bioethics, United States
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Rahmat ZS, Aamar H, Siddiqui JA, Mirha HT, Hassan M, Essar MY, Bchara J, Hashim HT. Mental health impacts of humanitarian crisis on HCWs in Syria amidst COVID-19. Med Confl Surviv 2022; 38:23-30. [PMID: 35172659 DOI: 10.1080/13623699.2022.2040091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Zainab Syyeda Rahmat
- Faculty of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Humna Aamar
- Faculty of Medicine, Sindh Medical College, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Javeria Arif Siddiqui
- Faculty of Medicine, Sindh Medical College, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Hania-Tul Mirha
- Faculty of Medicine, CMH Medical College Lahore, Lahore, Pakistan
| | - Marium Hassan
- Faculty of Medicine, Sindh Medical College, Jinnah Sindh Medical University, Karachi, Pakistan
| | | | - John Bchara
- Faculty of Medicine, Tishreen University, Latakia, Syria
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Kallström A, Al-Abdulla O, Parkki J, Häkkinen M, Juusola H, Kauhanen J. I don't leave my people; They need me: Qualitative research of local health care professionals' working motivations in Syria. Confl Health 2022; 16:1. [PMID: 34980205 PMCID: PMC8721480 DOI: 10.1186/s13031-021-00432-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/08/2021] [Indexed: 11/30/2022] Open
Abstract
Background The Syrian conflict has endured for a decade, causing one of the most significant humanitarian crises since World War II. The conflict has inflicted massive damage to civil infrastructure, and not even the health care sector has been spared. On the contrary, health care has been targeted, and as a result, many health professionals have left the country. Despite the life-threatening condition, many health professionals continued to work inside Syria even in the middle of the acute crisis. This qualitative study aims to determine the factors that have motivated Syrian health professionals to work in a conflict-affected country. Methods The research is based on 20 semi-structured interviews of Syrian health care workers. Interviews were conducted in 2016–2017 in Gaziantep, Turkey. A thematic inductive content analysis examined the motivational factors Syrian health care workers expressed for their work in the conflict area. Results Motivating factors for health care workers were intrinsic and extrinsic. Intrinsic reasons included humanitarian principles and medical ethics. Also, different ideological reasons, patriotic, political and religious, were mentioned. Economic and professional reasons were named as extrinsic reasons for continuing work in the war-torn country. Conclusions The study adds information on the effects of the Syrian crisis on health care—from healthcare workers' perspective. It provides a unique insight on motivations why health care workers are continuing their work in Syria. This research underlines that the health care system would collapse totally without local professionals and leave the population without adequate health care.
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Affiliation(s)
- Agneta Kallström
- Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, The University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland.
| | - Orwa Al-Abdulla
- Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, The University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland
| | - Jan Parkki
- Independent Researcher, Helsinki, Finland
| | | | - Hannu Juusola
- Department of Cultures, The University of Helsinki, Helsinki, Finland
| | - Jussi Kauhanen
- Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, The University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland
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Abouzeid M, Elzalabany MK, Nuwayhid I, Jabbour S. Conflict-related health research in Syria, 2011-2019: a scoping review for The Lancet - AUB Commission on Syria. Confl Health 2021; 15:92. [PMID: 34906178 PMCID: PMC8672497 DOI: 10.1186/s13031-021-00384-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 04/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The volume of health-related publications on Syria has increased considerably over the course of the conflict compared with the pre-war period. This increase is largely attributed to commentaries, news reports and editorials rather than research publications. This paper seeks to characterise the conflict-related population and humanitarian health and health systems research focused inside Syria and published over the course of the Syrian conflict. METHODS As part of a broader scoping review covering English, Arabic and French literature on health and Syria published from 01 January 2011 to 31 December 2019 and indexed in seven citation databases (PubMed, Medline (OVID), CINAHL Complete, Global Health, EMBASE, Web of Science, Scopus), we analyzed conflict-related research papers focused on health issues inside Syria and on Syrians or residents of Syria. We classified research articles based on the major thematic areas studied. We abstracted bibliometric information, study characteristics, research focus, funding statements and key limitations and challenges of conducting research as described by the study authors. To gain additional insights, we examined, separately, non-research publications reporting field and operational activities as well as personal reflections and narrative accounts of first-hand experiences inside Syria. RESULTS Of 2073 papers identified in the scoping review, 710 (34%) exclusively focus on health issues of Syrians or residents inside Syria, of which 350 (49%) are conflict-related, including 89 (25%) research papers. Annual volume of research increased over time, from one publication in 2013 to 26 publications in 2018 and 29 in 2019. Damascus was the most frequently studied governorate (n = 33), followed by Aleppo (n = 25). Papers used a wide range of research methodologies, predominantly quantitative (n = 68). The country of institutional affiliation(s) of first and last authors are predominantly Syria (n = 30, 21 respectively), the United States (n = 25, 19 respectively) or the United Kingdom (n = 12, 10 respectively). The majority of authors had academic institutional affiliations. The most frequently examined themes were health status, the health system and humanitarian assistance, response or needs (n = 38, 34, 26 respectively). Authors described a range of contextual, methodological and administrative challenges in conducting research on health inside Syria. Thirty-one publications presented field and operational activities and eight publications were reflections or first-hand personal accounts of experiences inside Syria. CONCLUSIONS Despite a growing volume of research publications examining population and humanitarian health and health systems issues inside conflict-ravaged Syria, there are considerable geographic and thematic gaps, including limited research on several key pillars of the health system such as governance, financing and medical products; issues such as injury epidemiology and non-communicable disease burden; the situation in the north-east and south of Syria; and besieged areas and populations. Recognising the myriad of complexities of researching active conflict settings, it is essential that research in/on Syria continues, in order to build the evidence base, understand critical health issues, identify knowledge gaps and inform the research agenda to address the needs of the people of Syria following a decade of conflict.
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Affiliation(s)
- Marian Abouzeid
- The Lancet-American University of Beirut Commission on Syria, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.,Alfred Deakin Institute for Citizenship and Globalisation and Centre for Humanitarian Leadership, Deakin University, Burwood, Australia.,Faculty of Health Sciences, American University of Beirut, P.O.Box: 11-0236, Riad El Solh, Beirut, 1107 2020, Lebanon
| | - Manal K Elzalabany
- The Lancet-American University of Beirut Commission on Syria, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Iman Nuwayhid
- The Lancet-American University of Beirut Commission on Syria, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.,Faculty of Health Sciences, American University of Beirut, P.O.Box: 11-0236, Riad El Solh, Beirut, 1107 2020, Lebanon
| | - Samer Jabbour
- The Lancet-American University of Beirut Commission on Syria, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon. .,Faculty of Health Sciences, American University of Beirut, P.O.Box: 11-0236, Riad El Solh, Beirut, 1107 2020, Lebanon.
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Do Health-Care Students Know About Chemical Biological Radioactive Nuclear Weapons? Disaster Med Public Health Prep 2021; 17:e54. [PMID: 34732269 DOI: 10.1017/dmp.2021.307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to determine the level of knowledge of students receiving different levels of health-care education (doctors, nurses, paramedics) on chemical, biological, radioactive, and nuclear weapons (CBRNW). METHODS This study was designed as a qualitative, descriptive, and cross-sectional research. The study reached 87.68% of the population. A survey form was created by the researcher in line with the literature. Ethical permission and verbal consents were obtained. The data were collected by face-to-face interviews. RESULTS It was observed that there was no difference between the enrolled departments, that the participants had very low levels of knowledge on the subject despite considering it a likely threat for Turkey, and that they thought the public and the health-care professionals in this field had insufficient knowledge. Sex, age, and field education were the variables that created a difference. CONCLUSION Training regarding CBRNW should be further questioned and individuals should receive ongoing training to increase and update their knowledge and skills.
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Kallström A, Al-Abdulla O, Parkki J, Häkkinen M, Juusola H, Kauhanen J. I had to leave. I had to leave my clinic, my city, leave everything behind in Syria. Qualitative research of Syrian healthcare workers migrating from the war-torn country. BMJ Open 2021; 11:e049941. [PMID: 34732480 PMCID: PMC8572379 DOI: 10.1136/bmjopen-2021-049941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To explore the reasons why healthcare workers migrate from Syria, a country where conflict has been raging for over a decade. DESIGN A qualitative study was performed using semistructured interviews. Semistructured questions guided in-depth interviews. Content analysis was used. SETTING Participants were Syrian healthcare workers who had worked in the country after the conflict started in 2011, but at some point left Syria and settled abroad. The interviews took place in Turkey and Europe in 2016 and 2017. PARTICIPANTS We collected data from 20 participants (18 males and 2 females) through snowball sampling method. RESULTS Healthcare workers migrated from Syria only because of security reasons. In most cases, the decision to leave resulted from the generalised violence against civilians by different warring parties, mainly the Government of Syria and the Islamic State. Intentional attacks against healthcare workers were also one of the main reasons for leaving. Some participants had a specific notable trigger event before leaving, such as colleagues being detained or killed. Many participants simply grew tired of living under constant fear, with their families also at risk. CONCLUSIONS This research adds to the body of literature on violence against healthcare workers in Syria. It helps to understand the reasons why healthcare workers leave the country. The study also indicates that the international community has failed to protect Syrian healthcare workers. The intensity of the conflict has left many healthcare workers with no other option than to leave. Understanding this migration will enable the discovery of new solutions for protecting healthcare workers in current and future conflicts.
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Affiliation(s)
- Agneta Kallström
- Faculty of Health Sciences, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Orwa Al-Abdulla
- Faculty of Health Sciences, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | | | | | - Hannu Juusola
- Department of Cultures, University of Helsinki, Helsinki, Finland
| | - Jussi Kauhanen
- Faculty of Health Sciences, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
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Muzzall E, Perlman B, Rubenstein LS, Haar RJ. Overview of attacks against civilian infrastructure during the Syrian civil war, 2012-2018. BMJ Glob Health 2021; 6:bmjgh-2021-006384. [PMID: 34598977 PMCID: PMC8488748 DOI: 10.1136/bmjgh-2021-006384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/01/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Hundreds of thousands of people have been killed during the Syrian civil war and millions more displaced along with an unconscionable amount of destroyed civilian infrastructure. METHODS We aggregate attack data from Airwars, Physicians for Human Rights and the Safeguarding Health in Conflict Coalition/Insecurity Insight to provide a summary of attacks against civilian infrastructure during the years 2012-2018. Specifically, we explore relationships between date of attack, governorate, perpetrator and weapon for 2689 attacks against five civilian infrastructure classes: healthcare, private, public, school and unknown. Multiple correspondence analysis (MCA) via squared cosine distance, k-means clustering of the MCA row coordinates, binomial lasso classification and Cramer's V coefficients are used to produce and investigate these correlations. RESULTS Frequencies and proportions of attacks against the civilian infrastructure classes by year, governorate, perpetrator and weapon are presented. MCA results identify variation along the first two dimensions for the variables year, governorate, perpetrator and healthcare infrastructure in four topics of interest: (1) Syrian government attacks against healthcare infrastructure, (2) US-led Coalition offensives in Raqqa in 2017, (3) Russian violence in Aleppo in 2016 and (4) airstrikes on non-healthcare infrastructure. These topics of interest are supported by results of the k-means clustering, binomial lasso classification and Cramer's V coefficients. DISCUSSION Findings suggest that violence against healthcare infrastructure correlates strongly with specific perpetrators. We hope that the results of this study provide researchers with valuable data and insights that can be used in future analyses to better understand the Syrian conflict.
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Affiliation(s)
- Evan Muzzall
- Stanford University Libraries, Stanford University, Stanford, California, USA
| | - Brian Perlman
- Human Rights Center, School of Law, University of California Berkeley, Berkeley, California, USA
| | - Leonard S Rubenstein
- Center for Humanitarian Health, Department of Epidemiology, School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rohini J Haar
- Division of Epidemiology and Biostatistics, School of Public Health, University of California Berkeley, Berkeley, California, USA
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Cratsley K, Brooks MA, Mackey TK. Refugee Mental Health, Global Health Policy, and the Syrian Crisis. Front Public Health 2021; 9:676000. [PMID: 34414156 PMCID: PMC8369241 DOI: 10.3389/fpubh.2021.676000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/23/2021] [Indexed: 11/13/2022] Open
Abstract
The most recent global refugee figures are staggering, with over 82.4 million people forcibly displaced and 26.4 million registered refugees. The ongoing conflict in Syria is a major contributor. After a decade of violence and destabilization, over 13.4 million Syrians have been displaced, including 6.7 million internally displaced persons and 6.7 million refugees registered in other countries. Beyond the immediate political and economic challenges, an essential component of any response to this humanitarian crisis must be health-related, including policies and interventions specific to mental health. This policy and practice review addresses refugee mental health in the context of the Syrian crisis, providing an update and overview of the current situation while exploring new initiatives in mental health research and global health policy that can help strengthen and expand services. Relevant global health policy frameworks are first briefly introduced, followed by a short summary of recent research on refugee mental health. We then provide an update on the current status of research, service provision, and health policy in the leading destinations for Syrians who have been forcibly displaced. This starts within Syria and then turns to Turkey, Lebanon, Jordan, and Germany. Finally, several general recommendations are discussed, including the pressing need for more data at each phase of migration, the expansion of integrated mental health services, and the explicit inclusion and prioritization of refugee mental health in national and global health policy.
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Affiliation(s)
- Kelso Cratsley
- Department of Philosophy & Religion, American University, Washington, DC, United States
| | | | - Tim K. Mackey
- Global Health Program, Department of Anthropology, University of California, San Diego, La Jolla, CA, United States
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Haar RJ, Read R, Fast L, Blanchet K, Rinaldi S, Taithe B, Wille C, Rubenstein LS. Violence against healthcare in conflict: a systematic review of the literature and agenda for future research. Confl Health 2021; 15:37. [PMID: 33962623 PMCID: PMC8103060 DOI: 10.1186/s13031-021-00372-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Attacks on health care in armed conflict, including those on health workers, facilities, patients and transports, represent serious violations of human rights and international humanitarian law. Information about these incidents and their characteristics are available in myriad forms: as published research or commentary, investigative reports, and within online data collection initiatives. We review the research on attacks on health to understand what data they rely on, what subjects they cover and what gaps exist in order to develop a research agenda going forward. METHODS AND FINDINGS This study utilizes a systematic review of peer-reviewed to identify and understand relevant data about attacks on health in situations of conflict. We identified 1479 papers published before January 1, 2020 using systematic and hand-searching and chose 45 articles for review that matched our inclusion criteria. We extracted data on geographical and conflict foci, methodology, objectives and major themes. Among the included articles, 26 focused on assessment of evidence of attacks, 15 on analyzing their impacts, three on the legal and human rights principles and one on the methods of documentation. We analyzed article data to answer questions about where and when attacks occur and are investigated, what types of attacks occur, who is perpetrating them, and how and why they are studied. We synthesized cross-cutting themes on the impacts of these attacks, mitigation efforts, and gaps in existing data. CONCLUSION Recognizing limitations in the review, we find there have been comparatively few studies over the past four decades but the literature is growing. To deepen the discussions of the scope of attacks and to enable cross-context comparisons, documentation of attacks on health must be enhanced to make the data more consistent, more thorough, more accessible, include diverse perspectives, and clarify taxonomy. As the research on attacks on health expands, practical questions on how the data is utilized for advocacy, protection and accountability must be prioritized.
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Affiliation(s)
- Rohini J Haar
- Division of Epidemiology, University of California, Berkeley, School of Public Health, Berkeley, CA, USA.
| | - Róisín Read
- University of Manchester, School of Arts, Languages and Cultures, Humanitarian and Conflict Response Institute, Manchester, UK
| | - Larissa Fast
- University of Manchester, School of Arts, Languages and Cultures, Humanitarian and Conflict Response Institute, Manchester, UK
| | - Karl Blanchet
- Geneva Centre of Humanitarian Studies, University of Geneva, The Graduate Institute of International and Development Studies, Geneva, Switzerland
| | - Stephanie Rinaldi
- University of Manchester, School of Arts, Languages and Cultures, Humanitarian and Conflict Response Institute, Manchester, UK
| | - Bertrand Taithe
- University of Manchester, School of Arts, Languages and Cultures, Humanitarian and Conflict Response Institute, Manchester, UK
| | | | - Leonard S Rubenstein
- Program on Human Rights, Health and Conflict, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Kallström A, Häkkinen M, Al-Abdulla O, Juusola H, Kauhanen J. Caught in crossfire: health care workers' experiences of violence in Syria. Med Confl Surviv 2021; 37:34-54. [PMID: 33641561 DOI: 10.1080/13623699.2021.1889654] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Health care is attacked in many contemporary conflicts despite the Geneva Conventions. The war in Syria has become notorious for targeted violence against health care. This qualitative study describes health care workers' experiences of violence using semi-structured interviews (n = 25) with professionals who have been working in Syria. The participants were selected using a snowball sampling method and interviewed in Turkey and Europe between 2016-2017. Analysis was conducted using content analysis. Results revealed that the most destructive and horrific forms of violence health care workers have experienced were committed mostly by the Government of Syria and the Islamic State. Non-state armed groups and Kurdish Forces have also committed acts of violence against health care, though their scope and scale were considered to have a lower mortality. The nature of violence has evolved during the conflict: starting from verbal threats and eventually leading to hospital bombings. Health care workers were not only providers of health care to injured demonstrators, they also participated in non- violent anti-government actions. The international community has not taken action to protect health care in Syria. For health workers finding safe environments in which to deliver health care has been impossible.
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Affiliation(s)
- Agneta Kallström
- Laurea University of Applied Sciences, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | | | - Orwa Al-Abdulla
- Laurea University of Applied Sciences, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Hannu Juusola
- Department of Cultures, Faculty of Arts, Helsinki University, Helsinki, Finland
| | - Jussi Kauhanen
- Laurea University of Applied Sciences, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
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Elnakib S, Elaraby S, Othman F, BaSaleem H, Abdulghani AlShawafi NA, Saleh Al-Gawfi IA, Shafique F, Al-Kubati E, Rafique N, Tappis H. Providing care under extreme adversity: The impact of the Yemen conflict on the personal and professional lives of health workers. Soc Sci Med 2021; 272:113751. [PMID: 33588206 PMCID: PMC7938221 DOI: 10.1016/j.socscimed.2021.113751] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/24/2020] [Accepted: 02/03/2021] [Indexed: 11/28/2022]
Abstract
The war in Yemen, described as the world's 'worst humanitarian crisis,' has seen numerous attacks against health care. While global attention to attacks on health workers has increased significantly over the past decade, gaps in research on the lived experiences of frontline staff persist. This study draws on perspectives of frontline health workers in Yemen to understand the impact of the ongoing conflict on their personal and professional lives. Forty-three facility-based health worker interviews, and 6 focus group discussions with community-based health workers and midwives were conducted in Sana'a, Aden and Taiz governorates at the peak of the Yemen conflict. Data were analysed using content analysis methods. Findings highlight the extent and range of violence confronting health workers in Yemen as well as the coping strategies they use to attenuate the impact of acute and chronic stressors resulting from conflict. We find that the complex security situation - characterized by multiple parties to the conflict, politicization of humanitarian aid and constraints in humanitarian access - was coupled with everyday stressors that prevented health workers from carrying out their work. Participants reported sporadic attacks by armed civilians, tensions with patients, and harassment at checkpoints. Working conditions were dire, and participants reported chronic suspension of salaries as well as serious shortages of essential supplies and medicines. Themes specific to coping centered around fatalism and religious motivation, resourcefulness and innovation, and sense of duty and patriotism. Our findings demonstrate that health workers experience substantial stress and face various pressures while delivering lifesaving services in Yemen. While they exhibit considerable resilience and coping, they have needs that remain largely unaddressed. Accordingly, the humanitarian community should direct more attention to responding to the mental health and psychosocial needs of health workers, while actively working to ameliorate the conditions in which they work.
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Affiliation(s)
- Shatha Elnakib
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sarah Elaraby
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Alexandria University, Alexandria, Egypt
| | | | | | | | | | | | | | | | - Hannah Tappis
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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14
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Five Decades of Global Chemical Terror Attacks: Data Analysis to Inform Training and Preparedness. Disaster Med Public Health Prep 2020; 15:750-761. [PMID: 32703327 DOI: 10.1017/dmp.2020.176] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Chemical weapons attacks during the recent conflict in Syria and Iraq highlight the need to better understand the changing epidemiology of chemical weapons use, especially among non-state actors. Public health professionals and policy-makers require this data to prioritize funding, training, chemical weapons preparedness, disaster response, and recovery. The purpose of this investigation is to provide descriptive data that can be used by policy-makers and public safety officials to better prepare for these potential attacks. METHODS A five-decade descriptive retrospective review of The Global Terrorism Database, maintained by the National Consortium for the Study of Terrorism and Responses to Terrorism, was conducted to understand trends in chemical agents, targets, and routes of exposure. We reviewed and analyzed data specific to these documented chemical attacks between 1970 and 2017. RESULTS 383 terror attacks involved chemical weapons over the study period. A specific agent was named in 154 incidents, while 124 incidents could be classified into traditional chemical weapons categories (eg, vesicant, choking agents). A route of exposure was identified in 242 attacks, with the most common routes of exposure being dermal-mucosal and inhalational. Caustic agents were used in the highest portion of attacks (25%) where the route of exposure was known. Explosive devices were used in 21% of attacks to deliver these chemical agents. Of particular note, private citizens and educational facilities were targeted in 25% and 12% of attacks, respectively. The average number of attacks increased from 6 per year between 1970 and 2011 to 24.9 per year between 2011 and 2017 (coinciding with the start of the Syria conflict). The most commonly utilized chemicals were chlorine (26.0%), tear gas (20.8%), and cyanide (15.6%). Blood agent incidents declined from 32.6% before the September 11, 2001 attacks to 13.6% after 2001, while nerve agent attacks fell from 9.3% to 1.2%. In contrast, choking (namely chlorine) and vesicant (mustard) agent use increased from 7% to 48.1% and from 2.3% to 6.2% of attacks, respectively. CONCLUSIONS Chemical weapon use in global terrorism remains an increasingly common occurrence that requires better characterization. The average number of chemical terrorist attacks per year is increasing, with a large proportion resulting from the conflicts in Iraq and Syria. Choking (chlorine) and vesicant (mustard) agents have become the predominant chemical terror agent since 2001, with a decreased incidence of blood (cyanogenic) and nerve (sarin) agents. Future preparedness initiatives should focus on vulnerable targets such as private citizens and educational institutions. Improving blast injury response is essential, along with prioritizing disaster training focused on choking agents, vesicants, and caustics.
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15
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Bdaiwi Y, Rayes D, Sabouni A, Murad L, Fouad F, Zakaria W, Hariri M, Ekzayez A, Tarakji A, Abbara A. Challenges of providing healthcare worker education and training in protracted conflict: a focus on non-government controlled areas in north west Syria. Confl Health 2020; 14:42. [PMID: 32665784 PMCID: PMC7341478 DOI: 10.1186/s13031-020-00287-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 06/11/2020] [Indexed: 12/21/2022] Open
Abstract
Without healthcare workers (HCWs), health and humanitarian provision in Syria cannot be sustained either now or in the post-conflict phase. The protracted conflict has led to the exodus of more than 70% of the healthcare workforce. Those remaining work in dangerous conditions with insufficient resources and a healthcare system that has been decimated by protracted conflict. For many HCWs, particularly those in non-government-controlled areas (NGCAs) of Syria, undergraduate education and postgraduate training has been interrupted with few opportunities to continue. In this manuscript, we explore initiatives present in north west Syria at both undergraduate and postgraduate level for physician and non-physician HCWs. Conclusion: Challenges to HCW education in north west Syria can be broadly divided into 1. Organisational (local healthcare leadership and governance, coordination and collaboration between stakeholders, competition between stakeholders and insufficient funding.) 2. Programmatic (lack of accreditation or recognition of qualifications, insufficient physical space for teaching, exodus of faculty affecting teaching and training, prioritisation of physicians over non-physicians, informally trained healthcare workers.) 3. Healthcare system related (politicisation of healthcare system, changing healthcare needs of the population, ongoing attacks on healthcare.) Locally implementable strategies including dedicated funding are key to supporting retention of HCWs and return during post-conflict reconstruction.
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Affiliation(s)
| | - Diana Rayes
- Syria Public Health Network, London, UK.,School of Public Health, University of California, Berkeley, CA USA
| | - Ammar Sabouni
- Academic Primary Care, Hull York Medical School, Hull, UK
| | - Lina Murad
- Syrian American Medical Society, Washington DC, USA
| | - Fouad Fouad
- American University of Beirut, Beirut, Lebanon
| | | | | | | | | | - Aula Abbara
- Syria Public Health Network, London, UK.,Syrian American Medical Society, Washington DC, USA.,Department of Infection, Imperial College, London, UK
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16
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Hamid A, Scior K, Williams ACDC. Qualitative accounts from Syrian mental health professionals: shared realities in the context of conflict and forced displacement. BMJ Open 2020; 10:e034291. [PMID: 32430449 PMCID: PMC7239525 DOI: 10.1136/bmjopen-2019-034291] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 04/22/2020] [Accepted: 04/29/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To explore the impact of the provision of care of forcibly displaced Syrian mental health professionals (MHPs) to Syrian clients in the community given shared experiences and backgrounds with clients. DESIGN A qualitative study using thematic analysis of in-depth semistructured interviews to explore shared realities, self-disclosure and the impact of providing therapy. SETTING Syrian MHPs operating in Gaziantep and Istanbul, Turkey, were interviewed. PARTICIPANTS Sixteen forcibly displaced Syrian MHPs (eight male, eight female) aged between 24 and 54 years (M=35, SD=8.3) who provided care to the displaced Syrian community in Turkey. RESULTS All workers described having a shared reality with their clients as helpful in therapy and a smaller proportion described it as a vulnerability. All described their work with Syrian clients as fulfilling and most described it as distressing. Participants referred to self-care,supervision, peer-support and personal therapy as a means to cope. CONCLUSIONS This study provides the first insight into the shared experiences of the ongoing trauma, loss and violations resulting from the ongoing Syrian conflict from the perspective of Syrian MHPs, adding to the literature of the professional issues and ethical duty to protect health workers in conflict settings.
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Affiliation(s)
- Aseel Hamid
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Katrina Scior
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Amanda C de C Williams
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
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17
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Fardousi N, Douedari Y, Howard N. Healthcare under siege: a qualitative study of health-worker responses to targeting and besiegement in Syria. BMJ Open 2019; 9:e029651. [PMID: 31488482 PMCID: PMC6731863 DOI: 10.1136/bmjopen-2019-029651] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To explore health-worker perspectives on security, improving safety, managing constrained resources and handling mass casualties during besiegement in Syria. DESIGN A qualitative study using semi-structured key informant interviews, conducted remotely over WhatsApp and Skype, and analysed thematically using inductive coding. SETTING Secondary and tertiary health facilities affected by besiegement in Aleppo (from July to December 2016) and Rural Damascus (from August 2013 to February 2018). PARTICIPANTS Twenty-one male Syrian health-workers and service-users who had experienced besiegement and targeting of their health facilities. RESULTS Participants described four related challenges of: (i) conflict-related responses, particularly responding to mass casualties; (ii) targeted attack responses, particularly preventing/surviving facility bombings; (iii) besiegement responses, particularly mitigating severe resource constraints; and (iv) chronic risk responses, particularly maintaining emotional resilience. Mass casualty response involved triage and training to prioritise mortality reduction and available resources, for example those with greatest need and likelihood of survival. Targeting response was largely physical, including fortification, working underground, reducing visibility and services dispersal. Besiegement response required resource conservation, for example, controlling consumption, reusing consumables, low-technology equipment, finding alternative supply routes, stockpiling and strengthening available human resources through online trainings and establishing a medical school in Ghouta. Risk responses included managing safety worries, finding value in work and maintaining hope. CONCLUSION Besieged health-workers were most affected by severe resource constraints and safety concerns while responding to overwhelming mass casualty events. Lessons for targeting/besiegement planning include training staff and preparing for: (i) mass casualties, through local/online health-worker training in triage, emergency response and resource conservation; allowing task-shifting; and providing access to low-technology equipment; (ii) attacks, through strengthened facility security, for example, protection and deterrence through fortification, working underground and reducing visibility; and (iii) besiegement, through ensuring access to internet, electricity and low-technology/reusable equipment; securely stockpiling fuel, medicines and supplies; and establishing alternative supply routes.
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Affiliation(s)
- Nasser Fardousi
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Yazan Douedari
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Natasha Howard
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
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18
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Thomson N, Littlejohn M, Strathdee SA, Southby RF, Coghlan B, Rosenfeld JV, Galvani AP. Harnessing synergies at the interface of public health and the security sector. Lancet 2019; 393:207-209. [PMID: 30663581 DOI: 10.1016/s0140-6736(18)32999-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/16/2018] [Indexed: 01/13/2023]
Affiliation(s)
- Nicholas Thomson
- Security and Health Executive Leadership Institute and the Law Enforcement and Public Health Program, Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia; Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
| | - Mason Littlejohn
- Security and Health Executive Leadership Institute and the Law Enforcement and Public Health Program, Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Steffanie A Strathdee
- Department of Medicine, University of California School of Medicine, La Jolla, CA, USA
| | - Richard F Southby
- Milken Institute School of Public Health, The George Washington University, Washington, DC, USA; Security and Health Executive Leadership Institute and the Law Enforcement and Public Health Program, Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Benjamin Coghlan
- Health-Security Program, Burnet Institute, Melbourne, VIC, Australia
| | - Jeffrey V Rosenfeld
- The Alfred Hospital, Melbourne, VIC, Australia; Monash University, Clayton, VIC, Australia; F Edward Hébert School of Medicine, Uniformed Services University of The Health Sciences, Bethesda, MD, USA
| | - Alison P Galvani
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA
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