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Seven Ü. Humanitarianism as a tool of statecraft: contested authority, sovereign violence, and humanity in the Syrian civil war. DISASTERS 2024:e12659. [PMID: 39344300 DOI: 10.1111/disa.12659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 08/18/2024] [Indexed: 10/01/2024]
Abstract
This research explores the dynamics of interaction between the sovereign state and international humanitarian organisations in alleviating human suffering in the Syrian civil war. Considering civil wars as a rupture in sovereignty, its focus is on the practices of the sovereign state within its social context and the resulting implications for aid organisations. I argue that the Syrian regime has employed state violence, in tandem with administrative and bureaucratic impediments, to reassert its sovereign authority in humanitarian decision-making processes. This exercise of sovereign power is intertwined with the actions of aid organisations, thereby reshaping power dynamics among the state, aid organisations, and vulnerable populations. Through a qualitative method, I show that the deployment of state violence concomitantly pushes aid organisations, specifically the United Nations, towards enforcing the state sovereignty defined by the regime. As an effect of assertive sovereignty, interpretations of humanitarian principles and practices are continuously negotiated and constructed differently by aid organisations, even though they share a common overarching goal.
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Affiliation(s)
- Ümit Seven
- Graduate School of Social Sciences, Middle East Technical University, Türkiye
- Center for Security Studies, ETH Zürich, Switzerland
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Baatz RK, Ekzayez A, Najib Y, Alkhalil M, Salem M, Alshiekh MA, Patel P. Vaccination governance in protracted conflict settings: the case of northwest Syria. BMC Health Serv Res 2024; 24:1056. [PMID: 39267075 PMCID: PMC11396824 DOI: 10.1186/s12913-024-11413-1] [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: 01/16/2024] [Accepted: 08/07/2024] [Indexed: 09/14/2024] Open
Abstract
BACKGROUND Effective vaccination governance in conflict-affected regions poses unique challenges. This study evaluates the governance of vaccination programs in northwest Syria, focusing on effectiveness, efficiency, inclusiveness, data availability, vision, transparency, accountability, and sustainability. METHODS Using a mixed-methods approach, and adapting Siddiqi's framework for health governance, data were collected through 14 key informant interviews (KIIs), a validating workshop, and ethnographic observations. Findings were triangulated to provide a comprehensive understanding of vaccination governance. RESULTS The study highlights innovative approaches used to navigate the complex health governance landscape to deliver vaccination interventions, which strengthened sub-national vaccination structures such as The Syria Immunisation Group (SIG). The analysis revealed several key themes. Effectiveness and efficiency were demonstrated through cold-chain reliability and extensive outreach activities, though formal reports lacked detailed analysis of vaccine losses and linkage between disease outbreak data and coverage statistics. Key informants and workshop participants rated the vaccination strategy positively but identified inefficiencies due to irregular funding and bureaucracy. Inclusiveness and data availability were prioritised, with outreach activities targeting vulnerable groups. However, significant gaps in demographic data and reliance on paper-based systems hindered comprehensive coverage analysis. Digitalisation efforts were noted but require further support. The SIG demonstrated a clear strategic vision supported by international organizations such as the World Health Organization, yet limited partner participation in strategic planning raised concerns about broader ownership and engagement. While the SIG was perceived as approachable, the lack of public documentation and financial disclosure limited transparency. Internal information sharing was prevalent, but public communication strategies were insufficient. Accountability and sustainability faced challenges due to a decentralized structure and reliance on diverse donors. Despite stabilizing factors such as decentralization and financial continuity, fragmented oversight and reliance on donor funding remained significant concerns. DISCUSSION The study highlights the complexities of vaccination governance in conflict-affected areas. Comparisons with other conflict zones underscore the importance of local organisations and international support. The SIG's role is pivotal, but its legitimacy, transparency, and inclusivity require improvement. The potential transition to early recovery in Syria poses additional challenges to SIG's sustainability and integration into national programs. CONCLUSION The governance of vaccination in northwest Syria is multifaceted, involving multiple stakeholders and lacking a legitimate government. Enhancing transparency, local ownership, and participatory decision-making are crucial for improving governance. The role of international bodies is essential, emphasising the need for structured feedback mechanisms and transparent monitoring processes to ensure the program's success and sustainability.
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Affiliation(s)
| | - Abdulkarim Ekzayez
- Research for Health System Strengthening in northern Syria (R4HSSS), The Centre for Conflict & Health Research (CCHR), King's College London, Strand, WC2R 2LS, London, UK.
- Syria Development Centre (SyriaDev), London, UK.
| | - Yasser Najib
- Syria Immunisation Group (SIG), Gaziantep, Turkey
| | - Munzer Alkhalil
- Syria Public Health Network, London, UK
- Research for Health System Strengthening in Northern Syria (R4HSSS), UOSSM, Gaziantep, Turkey
| | | | | | - Preeti Patel
- Research for Health System Strengthening in northern Syria (R4HSSS), The Centre for Conflict & Health Research (CCHR), King's College London, Strand, WC2R 2LS, London, UK
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The Influence of War and Conflict on Infectious Disease: A Rapid Review of Historical Lessons We Have Yet to Learn. SUSTAINABILITY 2021. [DOI: 10.3390/su131910783] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Armed conflicts degrade established healthcare systems, which typically manifests as a resurgence of preventable infectious diseases. While 70% of deaths globally are now from non-communicable disease; in low-income countries, respiratory infections, diarrheal illness, malaria, tuberculosis, and HIV/AIDs are all in the top 10 causes of death. The burden of these infectious diseases is exacerbated by armed conflict, translating into even more dramatic long-term consequences. This rapid evidence review searched electronic databases in PubMed, Scopus, and Web of Science. Of 381 identified publications, 73 were included in this review. Several authors indicate that the impact of infectious diseases increases in wars and armed conflicts due to disruption to surveillance and response systems that were often poorly developed to begin with. Although the true impact of conflict on infectious disease spread is not known and requires further research, the link between them is indisputable. Current decision-making management systems are insufficient and only pass the baton to the next unwary generation.
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Alhaffar MHDBA, Janos S. Public health consequences after ten years of the Syrian crisis: a literature review. Global Health 2021; 17:111. [PMID: 34538248 PMCID: PMC8449996 DOI: 10.1186/s12992-021-00762-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/26/2021] [Indexed: 01/25/2023] Open
Abstract
Ten years of the Syrian war had a devastating effect on Syrian lives, including millions of refugees and displaced people, enormous destruction in the infrastructure, and the worst economic crisis Syria has ever faced. The health sector was hit hard by this war, up to 50% of the health facilities have been destroyed and up to 70% of the healthcare providers fled the country seeking safety, which increased the workload and mental pressure for the remaining medical staff. Five databases were searched and 438 articles were included according to the inclusion criteria, the articles were divided into categories according to the topic of the article. Through this review, the current health status of the Syrian population living inside Syria, whether under governmental or opposition control, was reviewed, and also, the health status of the Syrian refugees was examined according to each host country. Public health indicators were used to summarize and categorize the information. This research reviewed mental health, children and maternal health, oral health, non-communicable diseases, infectious diseases, occupational health, and the effect of the COVID − 19 pandemic on the Syrian healthcare system. The results of the review are irritating, as still after ten years of war and millions of refugees there is an enormous need for healthcare services, and international organization has failed to respond to those needs. The review ended with the current and future challenges facing the healthcare system, and suggestions about rebuilding the healthcare system. Through this review, the major consequences of the Syrian war on the health of the Syrian population have been reviewed and highlighted. Considerable challenges will face the future of health in Syria which require the collaboration of the health authorities to respond to the growing needs of the Syrian population. This article draws an overview about how the Syrian war affected health sector for Syrian population inside and outside Syria after ten years of war which makes it an important reference for future researchers to get the main highlight of the health sector during the Syrian crisis.
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Affiliation(s)
| | - Sandor Janos
- Head of the Department of Public Health and Epidemiology, University of Debrecen, School of Health Sciences, Debrecen, Hungary
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Mbaeyi C, Moran T, Wadood Z, Ather F, Sykes E, Nikulin J, Al Safadi M, Stehling-Ariza T, Zomahoun L, Ismaili A, Abourshaid N, Asghar H, Korukluoglu G, Duizer E, Ehrhardt D, Burns CC, Sharaf M. Stopping a polio outbreak in the midst of war: Lessons from Syria. Vaccine 2021; 39:3717-3723. [PMID: 34053791 DOI: 10.1016/j.vaccine.2021.05.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/05/2021] [Accepted: 05/17/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Outbreaks of circulating vaccine-derived polioviruses (cVDPVs) pose a threat to the eventual eradication of all polioviruses. In 2017, an outbreak of cVDPV type 2 (cVDPV2) occurred in the midst of a war in Syria. We describe vaccination-based risk factors for and the successful response to the outbreak. METHODS We performed a descriptive analysis of cVDPV2 cases and key indicators of poliovirus surveillance and vaccination activities during 2016-2018. In the absence of reliable subnational coverage data, we used the caregiver-reported vaccination status of children with non-polio acute flaccid paralysis (AFP) as a proxy for vaccination coverage. We then estimated the relative odds of being unvaccinated against polio, comparing children in areas affected by the outbreak to children in other parts of Syria in order to establish the presence of poliovirus immunity gaps in outbreak affected areas. FINDINGS A total of 74 cVDPV2 cases were reported, with paralysis onset ranging from 3 March to 21 September 2017. All but three cases were reported from Deir-ez-Zor governorate and 84% had received < 3 doses of oral poliovirus vaccine (OPV). After adjusting for age and sex, non-polio AFP case-patients aged 6-59 months in outbreak-affected areas had 2.5 (95% CI: 1.1-5.7) increased odds of being unvaccinated with OPV compared with non-polio AFP case-patients in the same age group in other parts of Syria. Three outbreak response rounds of monovalent OPV type 2 (mOPV2) vaccination were conducted, with governorate-level coverage mostly exceeding 80%. INTERPRETATION Significant declines in both national and subnational polio vaccination coverage, precipitated by war and a humanitarian crisis, led to a cVDPV2 outbreak in Syria that was successfully contained following three rounds of mOPV2 vaccination.
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Affiliation(s)
- Chukwuma Mbaeyi
- United States Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Atlanta, GA 30329, USA.
| | - Thomas Moran
- World Health Organization Headquarters, Avenue Appia 20, 1202 Geneva, Switzerland
| | - Zubair Wadood
- World Health Organization Headquarters, Avenue Appia 20, 1202 Geneva, Switzerland
| | - Fazal Ather
- Middle East and North Africa Office, United Nations Children's Fund, Abdulqader Al-Abed Street, Building No. 15, Tla'a Al-Ali, Amman, Jordan
| | - Emma Sykes
- World Health Organization, Regional Office for the Eastern Mediterranean, Mohammad Jamjoum Street, Ministry of Interior Circle Building No. 5, P.O. Box 811547, Amman 11181, Jordan
| | - Joanna Nikulin
- World Health Organization, Regional Office for the Eastern Mediterranean, Mohammad Jamjoum Street, Ministry of Interior Circle Building No. 5, P.O. Box 811547, Amman 11181, Jordan
| | - Mohammad Al Safadi
- World Health Organization Headquarters, Avenue Appia 20, 1202 Geneva, Switzerland
| | - Tasha Stehling-Ariza
- United States Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Atlanta, GA 30329, USA
| | - Laurel Zomahoun
- World Health Organization Headquarters, Avenue Appia 20, 1202 Geneva, Switzerland
| | - Abdelkarim Ismaili
- World Health Organization, Regional Office for the Eastern Mediterranean, Mohammad Jamjoum Street, Ministry of Interior Circle Building No. 5, P.O. Box 811547, Amman 11181, Jordan
| | - Nidal Abourshaid
- Syria Country Office, United Nations Children's Fund, East Mazzeh, Al Shafiee St., Damascus, Syria
| | - Humayun Asghar
- World Health Organization, Regional Office for the Eastern Mediterranean, Mohammad Jamjoum Street, Ministry of Interior Circle Building No. 5, P.O. Box 811547, Amman 11181, Jordan
| | - Gulay Korukluoglu
- Public Health Institutions of Turkey, Adnan Saygun Cad. No. 55, F Blok 06100 Sihhiye, Ankara, Turkey
| | - Erwin Duizer
- National Polio Laboratory, Centre for Infectious Disease Control, National Institute for Public Health and the Environment, P.O. Box 1, 3720 BA, Bilthoven, the Netherlands
| | - Derek Ehrhardt
- United States Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Atlanta, GA 30329, USA
| | - Cara C Burns
- United States Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Atlanta, GA 30329, USA
| | - Magdi Sharaf
- World Health Organization, Regional Office for the Eastern Mediterranean, Mohammad Jamjoum Street, Ministry of Interior Circle Building No. 5, P.O. Box 811547, Amman 11181, Jordan
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Sekkarie M, Murad L, Al-Makki A, Al-Saghir F, Rifai O, Isreb M. End-Stage Kidney Disease in Areas of Armed Conflicts: Challenges and Solutions. Semin Nephrol 2020; 40:354-362. [PMID: 32800286 DOI: 10.1016/j.semnephrol.2020.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Violent and protracted conflicts are disastrous to civilian populations and their health care systems. The complex requirements of caring for end-stage kidney disease (ESKD) dialysis patients in such contexts pose unique challenges. Dialysis is procedurally complex and resource-intensive. Delivering ESKD care in man-made conflict settings presents added challenges beyond what is required in natural disasters and resource-limited situations. In this article, we review the medical literature on, and document experience with, managing dialysis ESKD patients in conflict zones. We discuss the impact of war on patient outcomes, dialysis system infrastructure, operational funding, and risks to providers and organizations. This article provides recommendations to health care providers, educators, and policymakers on how to mitigate associated challenges.
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Affiliation(s)
- Mohamed Sekkarie
- Nephrology and Hypertension Associates, Bluefield, WV; The Syrian National Kidney Foundation, Bloomfield Hills, MI; Address reprint requests to Mohamed Sekkarie, MD, MPH, Nephrology and Hypertension Associates, PLLC, 188 Brookwood Dr, Charlottesville, VA 22902..
| | - Lina Murad
- Metropolitan Access Center, Washington, DC
| | - Akram Al-Makki
- The Syrian National Kidney Foundation, Bloomfield Hills, MI; Nephrology, Indiana University of Health-Arnett, Lafayette, IN
| | - Fahd Al-Saghir
- The Syrian National Kidney Foundation, Bloomfield Hills, MI; Michigan Kidney Consultants, Pontiac, MI
| | - Oussama Rifai
- The Syrian National Kidney Foundation, Bloomfield Hills, MI; The Virtual Nephrologist, Lynn Haven, FL
| | - Majd Isreb
- The Syrian National Kidney Foundation, Bloomfield Hills, MI; Internal Medicine/Nephrology, PeaceHealth Medical Group Nephrology, Washington State University Elson S Floyd College of Medicine, Vancouver, WA
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Tappis H, Elaraby S, Elnakib S, AlShawafi NAA, BaSaleem H, Al-Gawfi IAS, Othman F, Shafique F, Al-Kubati E, Rafique N, Spiegel P. Reproductive, maternal, newborn and child health service delivery during conflict in Yemen: a case study. Confl Health 2020; 14:30. [PMID: 32514295 PMCID: PMC7254736 DOI: 10.1186/s13031-020-00269-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 03/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Armed conflict, food insecurity, epidemic cholera, economic decline and deterioration of essential public services present overwhelming challenges to population health and well-being in Yemen. Although the majority of the population is in need of humanitarian assistance and civil servants in many areas have not received salaries since 2016, many healthcare providers continue to work, and families continue to need and seek care. METHODS This case study examines how reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH+N) services have been delivered since 2015, and identifies factors influencing implementation of these services in three governorates of Yemen. Content analysis methods were used to analyze publicly available documents and datasets published since 2000 as well as 94 semi-structured individual and group interviews conducted with government officials, humanitarian agency staff and facility-based healthcare providers and six focus group discussions conducted with community health midwives and volunteers in September-October 2018. RESULTS Humanitarian response efforts focus on maintaining basic services at functioning facilities, and deploying mobile clinics, outreach teams and community health volunteer networks to address urgent needs where access is possible. Attention to specific aspects of RMNCAH+N varies slightly by location, with differences driven by priorities of government authorities, levels of violence, humanitarian access and availability of qualified human resources. Health services for women and children are generally considered to be a priority; however, cholera control and treatment of acute malnutrition are given precedence over other services along the continuum of care. Although health workers display notable resilience working in difficult conditions, challenges resulting from insecurity, limited functionality of health facilities, and challenges in importation and distribution of supplies limit the availability and quality of services. CONCLUSIONS Challenges to providing quality RMNCAH+N services in Yemen are formidable, given the nature and scale of humanitarian needs, lack of access due to insecurity, politicization of aid, weak health system capacity, costs of care seeking, and an ongoing cholera epidemic. Greater attention to availability, quality and coordination of RMNCAH services, coupled with investments in health workforce development and supply management are needed to maintain access to life-saving services and mitigate longer term impacts on maternal and child health and development. Lessons learned from Yemen on how to address ongoing primary health care needs during massive epidemics in conflict settings, particularly for women and children, will be important to support other countries faced with similar crises in the future.
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Affiliation(s)
- Hannah Tappis
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
| | - Sarah Elaraby
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
| | - Shatha Elnakib
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
| | | | | | | | | | | | | | | | - Paul Spiegel
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
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Grundy J, Biggs BA. The Impact of Conflict on Immunisation Coverage in 16 Countries. Int J Health Policy Manag 2019; 8:211-221. [PMID: 31050966 PMCID: PMC6499911 DOI: 10.15171/ijhpm.2018.127] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 12/10/2018] [Indexed: 11/18/2022] Open
Abstract
Background: Military conflict has been an ongoing determinant of inequitable immunisation coverage in many low- and middle-income countries, yet the impact of conflict on the attainment of global health goals has not been fully addressed. This review will describe and analyse the association between conflict, immunisation coverage and vaccine-preventable disease (VPD) outbreaks, along with country specific strategies to mitigate the impact in 16 countries.
Methods: We cross-matched immunisation coverage and VPD data in 2014 for displaced and refugee populations. Data on refugee or displaced persons was sourced from the United Nations High Commissioner for Refugees (UNHCR) database, and immunisation coverage and disease incidence data from World Health Organization (WHO) databases. Demographic and Health Survey (DHS) databases provided additional data on national and sub-national coverage. The 16 countries were selected because they had the largest numbers of registered UNHCR "persons of interest" and received new vaccine support from Global Alliance for Vaccine and Immunisation (GAVI), the Vaccine Alliance. We used national planning and reporting documentation including immunisation multiyear plans, health system strengthening strategies and GAVI annual progress reports (APRs) to assess the impact of conflict on immunisation access and coverage rates, and reviewed strategies developed to address immunisation program shortfalls in conflict settings. We also searched the peer-reviewed literature for evidence that linked immunisation coverage and VPD outbreaks with evidence of conflict.
Results: We found that these 16 countries, representing just 12% of the global population, were responsible for 67% of global polio cases and 39% of global measles cases between 2010 and 2015. Fourteen out of the 16 countries were below the global average of 85% coverage for diphtheria, pertussis, and tetanus (DPT3) in 2014. We present data from countries where the onset of conflict has been associated with sudden drops in national and sub-national immunisation coverage. Tense security conditions, along with damaged health infrastructure and depleted human resources have contributed to infrequent outreach services, and delays in new vaccine introductions and immunisation campaigns. These factors have in turn contributed to pockets of low coverage and disease outbreaks in sub-national areas affected by conflict. Despite these impacts, there was limited reference to the health needs of conflict affected populations in immunisation planning and reporting documents in all 16 countries. Development partner investments were heavily skewed towards vaccine provision and working with partner governments, with comparatively low levels of health systems support or civil partnerships.
Conclusion: Global and national policy and planning focus is required on the service delivery needs of conflict affected populations, with increased investment in health system support and civil partnerships, if persistent immunisation inequities in conflict affected areas are to be addressed.
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Affiliation(s)
- John Grundy
- College of Public Health, Medical and Veterinary Services, Cairns Campus, James Cook University, Douglas, QLD, Australia
| | - Beverley-Ann Biggs
- Department of Medicine, Doherty Institute, University of Melbourne, Melbourne, VIC, Australia.,Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, VIC, Australia
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After polio: Imagining, planning, and delivering a world beyond eradication. Health Place 2018; 54:29-36. [DOI: 10.1016/j.healthplace.2018.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/29/2018] [Accepted: 09/10/2018] [Indexed: 11/21/2022]
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Palmer JJ, Robert O, Kansiime F. Including refugees in disease elimination: challenges observed from a sleeping sickness programme in Uganda. Confl Health 2017; 11:22. [PMID: 29213301 PMCID: PMC5710113 DOI: 10.1186/s13031-017-0125-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 10/04/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Ensuring equity between forcibly-displaced and host area populations is a key challenge for global elimination programmes. We studied Uganda's response to the recent refugee influx from South Sudan to identify key governance and operational lessons for national sleeping sickness programmes working with displaced populations today. A refugee policy which favours integration of primary healthcare services for refugee and host populations and the availability of rapid diagnostic tests (RDTs) to detect sleeping sickness at this health system level makes Uganda well-placed to include refugees in sleeping sickness surveillance. METHODS Using ethnographic observations of coordination meetings, review of programme data, interviews with sleeping sickness and refugee authorities and group discussions with health staff and refugees (2013-2016), we nevertheless identified some key challenges to equitably integrating refugees into government sleeping sickness surveillance. RESULTS Despite fears that refugees were at risk of disease and posed a threat to elimination, six months into the response, programme coordinators progressed to a sentinel surveillance strategy in districts hosting the highest concentrations of refugees. This meant that RDTs, the programme's primary surveillance tool, were removed from most refugee-serving facilities, exacerbating existing inequitable access to surveillance and leading refugees to claim that their access to sleeping sickness tests had been better in South Sudan. This was not intentionally done to exclude refugees from care, rather, four key governance challenges made it difficult for the programme to recognise and correct inequities affecting refugees: (a) perceived donor pressure to reduce the sleeping sickness programme's scope without clear international elimination guidance on surveillance quality; (b) a problematic history of programme relations with refugee-hosting districts which strained supervision of surveillance quality; (c) difficulties that government health workers faced to produce good quality surveillance in a crisis; and (d) reluctant engagement between the sleeping sickness programme and humanitarian structures. CONCLUSIONS Despite progressive policy intentions, several entrenched governance norms and practices worked against integration of refugees into the national sleeping sickness surveillance system. Elimination programmes which marginalise forced migrants risk unwittingly contributing to disease spread and reinforce social inequities, so new norms urgently need to be established at local, national and international levels.
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Affiliation(s)
- Jennifer J. Palmer
- Centre of African Studies, School of Social and Political Sciences, University of Edinburgh, 15a George Square, Edinburgh, EH8 9LD UK
- Health in Humanitarian Crises Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Okello Robert
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Freddie Kansiime
- Department of Public and Community Health, Busitema University, PO Box 236, Tororo, Uganda
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Colombo S, Pavignani E. Recurrent failings of medical humanitarianism: intractable, ignored, or just exaggerated? Lancet 2017; 390:2314-2324. [PMID: 28602557 DOI: 10.1016/s0140-6736(17)31277-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/19/2017] [Accepted: 04/25/2017] [Indexed: 11/13/2022]
Abstract
Humanitarian health workers operate in dangerous and uncertain contexts, in which mistakes and failures are common, often have severe consequences, and are regularly repeated, despite being documented by many reviews. This Series paper aims to discuss the failures of medical humanitarianism. We describe why some of these recurrent failings, which are often not identified until much later, seem intractable: they are so entrenched in humanitarian action that they cannot be addressed by simple technical fixes. We argue that relief health-care interventions should be contextualised. Perhaps medical humanitarianism deserves a better reputation than the one at times tarnished by unfair criticism, resulting from inapplicable guiding principles and unrealistic expectations. The present situation is not conducive to radical reforms of humanitarian medicine; complex crises multiply and no political, diplomatic, or military solutions are in sight. Relief agencies have to compete for financial resources that do not increase at the same pace as health needs. Avoiding the repetition of failures requires recognising previous mistakes and addressing them through different policies by donors, stronger documentation and analysis of humanitarian programmes and interventions, increased professionalisation, improved, opportunistic relationships with the media, and better ways of working together with local health stakeholders and through indigenous institutions.
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Affiliation(s)
| | - Enrico Pavignani
- School of Public Health, University of Queensland, Herston, QLD, Australia
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