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Kramer C, Song M, Sufrin CB, Eber GB, Rubenstein LS, Saloner B. Release, Reentry, and Reintegration During COVID-19: Perspectives of Individuals Recently Released from the Federal Bureau of Prisons. Health Equity 2023; 7:384-394. [PMID: 37476707 PMCID: PMC10354726 DOI: 10.1089/heq.2022.0172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 07/22/2023] Open
Abstract
Introduction The COVID-19 pandemic had a large negative impact on people in U.S. prisons. Expedited releases from prison were one strategy used to decrease morbidity and mortality from COVID-19. However, little is known about the reentry experiences of those being rapidly released from custody early in the pandemic. Methods We aimed to examine the perspectives of former residents in the Federal Bureau of Prisons (BOP) regarding release, reentry, and reintegration into their respective communities. We conducted semistructured interviews with 21 recently released individuals primarily recruited through legal aid organizations between September and October 2021. Subjects were incarcerated before and during the early surge in the COVID-19 pandemic. We coded transcripts thematically with domains developed a priori in which we revised iteratively and inductively based on the data. Results Several major themes emerged. Participants reported that they needed to advocate for themselves to take advantage of the early release process. Compared with normal circumstances, they reported a lack of reentry planning and preparation before participants were released. Finally, experiences with reintegration varied but were often more challenging due to COVID-19. Discussion Residents released during COVID-19 reported many challenges with reentry that could have been mitigated by support and guidance from the BOP. Reentry is a process that should begin prelease and continues postrelease to ensure individuals have adequate structural and social supports. Health Equity Implications Inadequate reentry support has significant impacts on the health and well-being of recently released individuals and contributes to the broader context of achieving health equity for minitorized groups who are disproportionately overrepresented in prisons. Policy and practice reform is needed to address the time-sensitive, life-threatening challenges individuals face when transitioning from prison to community.
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Affiliation(s)
- Camille Kramer
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Minna Song
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Carolyn B. Sufrin
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health, Behavior and Society, and Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Gabriel B. Eber
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Leonard S. Rubenstein
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Saloner B, Kramer C, Song M, Doan B, Eber GB, Rubenstein LS, Sufrin C. COVID-19 Restrictions In Jails And Prisons: Perspectives From Carceral Leaders. Health Aff (Millwood) 2023; 42:841-848. [PMID: 37276483 DOI: 10.1377/hlthaff.2022.01473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
COVID-19 has been an unprecedented challenge in carceral facilities. As COVID-19 outbreaks spread in the US in early 2020, many jails, prisons, juvenile detention centers, and other carceral facilities undertook infection control measures such as increased quarantine and reduced outside visitation. However, the implementation of these decisions varied widely across facilities and jurisdictions. We explored how carceral decision makers grappled with ethically fraught public health challenges during the pandemic. We conducted semistructured interviews during May-October 2021 with thirty-two medical and security leaders from a diverse array of US jails and prisons. Although some facilities had existing detailed outbreak plans, most plans were inadequate for a rapidly evolving pandemic such as COVID-19. Frequently, this caused facilities to enact improvised containment plans. Quarantine and isolation were rapidly adopted across facilities in response to COVID-19, but in an inconsistent manner. Decision makers generally approached quarantine and isolation protocols as a logistical challenge, rather than an ethical one. Although they recognized the hardships imposed on incarcerated people, they generally saw the measures as justified. Comprehensive outbreak control guidelines for pandemic diseases in carceral facilities are urgently needed to ensure that future responses are more equitable and effective.
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Affiliation(s)
- Brendan Saloner
- Brendan Saloner , Johns Hopkins University, Baltimore, Maryland
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Song M, Kramer CT, Sufrin CB, Eber GB, Rubenstein LS, Beyrer C, Saloner B. "It was like you were being literally punished for getting sick": formerly incarcerated people's perspectives on liberty restrictions during COVID-19. AJOB Empir Bioeth 2023; 14:155-166. [PMID: 36811402 DOI: 10.1080/23294515.2023.2180105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND COVID-19 has greatly impacted the health of incarcerated individuals in the US. The goal of this study was to examine perspectives of recently incarcerated individuals on greater restrictions on liberty to mitigate COVID-19 transmission. METHODS We conducted semi-structured phone interviews from August through October 2021 with 21 people who had been incarcerated in Bureau of Prisons (BOP) facilities during the pandemic. Transcripts were coded and analyzed, using a thematic analysis approach. RESULTS Many facilities implemented universal "lockdowns," with time out of the cell often limited to one hour per day, with participants reporting not being able to meet all essential needs such as showers and calling loved ones. Several study participants reported that repurposed spaces and tents created for quarantine and isolation provided "unlivable conditions." Participants reported receiving no medical attention while in isolation, and staff using spaces designated for disciplinary purposes (e.g., solitary housing units) for public health isolation purposes. This resulted in the conflation of isolation and discipline, which discouraged symptom reporting. Some participants felt guilty over potentially causing another lockdown by not reporting their symptoms. Programming was frequently stopped or curtailed and communication with the outside was limited. Some participants relayed that staff threatened to punish noncompliance with masking and testing. Liberty restrictions were purportedly rationalized by staff with the idea that incarcerated people should not expect freedoms, while those incarcerated blamed staff for bringing COVID-19 into the facility. CONCLUSIONS Our results highlighted how actions by staff and administrators decreased the legitimacy of the facilities' COVID-19 response and were sometimes counterproductive. Legitimacy is key in building trust and obtaining cooperation with otherwise unpleasant but necessary restrictive measures. To prepare for future outbreaks facilities must consider the impact of liberty-restricting decisions on residents and build legitimacy for these decisions by communicating justifications to the extent possible.
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Affiliation(s)
- Minna Song
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Camille T Kramer
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Carolyn B Sufrin
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gabriel B Eber
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Leonard S Rubenstein
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Chris Beyrer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Kramer C, Song M, Sufrin CB, Eber GB, Rubenstein LS, Saloner B. COVID-19 vaccination hesitancy and uptake: Perspectives from people released from the Federal Bureau of Prisons. Vaccine 2023; 41:1408-1417. [PMID: 36690558 PMCID: PMC9866228 DOI: 10.1016/j.vaccine.2023.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
People in United States (US) prisons and jails have been disproportionately impacted by the COVID-19 pandemic. This is due to challenges containing outbreaks in facilities and the high rates of health conditions that increase the risk of adverse outcomes. Vaccination is one strategy to disrupt COVID-19 transmission, but there are many factors impeding vaccination while in custody. We aimed to examine the perspectives of former residents in the Federal Bureau of Prisons (BOP) regarding COVID-19 vaccine hesitancy and acceptance. Between September-October 2021, we conducted semi-structured interviews with 21 recently released individuals who were incarcerated before and during COVID-19 and coded transcripts thematically. We assessed perceptions of the vaccine rollout and factors shaping vaccination uptake in custody and after release. The vaccine was available to seven participants in custody, of whom three were vaccinated. Interviewees had mixed attitudes about how vaccines were distributed, particularly with priority given to staff. Most were reluctant to get vaccinated in custody for varying reasons including observing staff declining to be vaccinated, lack of counseling to address specific questions about safety, and general lack of trust in the carceral system. By contrast, twelve got vaccinated post-release because of greater trust in community health care and stated they would not have done so while incarcerated. For residents in the BOP, COVID-19 vaccination was not simply a binary decision, instead they weighed the costs and benefits with most deciding against getting vaccinated. Institutions of incarceration must address these concerns to increase vaccine uptake as the pandemic continues.
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Affiliation(s)
- Camille Kramer
- Johns Hopkins University School of Medicine, Department of Gynecology and Obstetrics, 4940 Eastern Ave., A101 Baltimore, MD 21224, USA.
| | - Minna Song
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, USA
| | - Carolyn B Sufrin
- Johns Hopkins University School of Medicine, Department of Gynecology and Obstetrics, 4940 Eastern Ave., A101 Baltimore, MD 21224, USA; Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, 624 N Broadway, Baltimore, MD 21205, USA
| | - Gabriel B Eber
- Johns Hopkins University Bloomberg School of Public Health, Department of Epidemiology, 624 N Broadway, Baltimore, MD 21205, USA
| | - Leonard S Rubenstein
- Johns Hopkins University Bloomberg School of Public Health, Department of Epidemiology, 624 N Broadway, Baltimore, MD 21205, USA
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, USA
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Pancheshnikov A, Boddu R, Rubenstein LS, Cuneo CN. Unstable gynaecological patient with an ankle monitor: implications of US Immigration and Customs Enforcement's Alternatives to Detention programme in the healthcare setting. BMJ Case Rep 2022; 15:15/6/e246515. [PMID: 35764334 PMCID: PMC9240831 DOI: 10.1136/bcr-2021-246515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We review the case of an unstable gynaecological patient in the USA who presented with profuse vaginal bleeding after spontaneous miscarriage and was ultimately diagnosed with a uterine arteriovenous malformation managed with interventional radiology embolisation of her uterine artery. Her case was complicated by the presence of an ankle monitoring device which had been placed by US Immigration and Customs Enforcement as part of the Alternatives to Detention programme in which she was enrolled during her immigration proceedings. The device prompted important considerations regarding the potential use of cautery, MRI compatibility and device-related trauma, in addition to causing significant anxiety for the patient, who was concerned about how the team's actions could affect her immigration case. Discussion of her course and shared perspective highlights the unique clinical and medicolegal considerations presented by the expanded use of ankle monitoring devices for electronic surveillance (or 'e-carceration') of non-violent immigrants and others.
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Affiliation(s)
- Anna Pancheshnikov
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rohini Boddu
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Leonard S Rubenstein
- Program on Human Rights, Health and Conflict, Center for Public Health and Human Rights; Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - C Nicholas Cuneo
- Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA .,Program on Migrant Health and Human Rights, Center for Public Health and Human Rights; Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Saloner B, Eber GB, Sufrin CB, Beyrer C, Rubenstein LS. A Human Rights Framework for Advancing the Standard of Medical Care for Incarcerated People in the United States in the Time of COVID-19. Health Hum Rights 2022; 24:59-75. [PMID: 35747287 PMCID: PMC9212822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The COVID-19 pandemic has underscored the lack of resources and oversight that hinders medical care for incarcerated people in the United States. The US Supreme Court has held that "deliberate indifference" to "serious medical needs" violates the Constitution. But this legal standard does not assure the consistent provision of health care services. This leads the United States to fall behind European nations that define universal standards of care grounded in principles of human rights and the ideal of equivalence that incarcerated and non-incarcerated people are entitled to the same health care. In this paper, we review a diverse legal and policy literature and undertake a conceptual analysis of policy issues related to the standard of care in correctional health; we then describe a framework for moving incrementally closer toward a universal standard. The expansion of Medicaid funding and benefits to corrections facilities, alongside a system of comprehensive and enforceable external oversight, would meaningfully raise the standard of care. Although these changes on their own will not resolve all of the thorny health problems posed by mass incarceration, they present a tangible opportunity to move closer to the human rights ideal.
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Affiliation(s)
- Brendan Saloner
- Associate professor in the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health and core faculty in the Berman Institute of Bioethics at Johns Hopkins University, Baltimore, USA.,Please address correspondence to Brendan Saloner. .
| | - Gabriel B. Eber
- Senior associate in the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Carolyn B. Sufrin
- Associate professor in the Department of Gynecology and Obstetrics at Johns Hopkins School of Medicine and Department of Health, Behavior, and Society at Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Chris Beyrer
- Professor of epidemiology in the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Leonard S. Rubenstein
- Professor of the practice in the Berman Institute of Bioethics at Johns Hopkins University and Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Affiliation(s)
- Lawrence O Gostin
- O'Neill Institute for National and Global Health Law, Georgetown University, Washington, DC
| | - Leonard S Rubenstein
- Center for Public Health and Human Rights, Johns Hopkins University, Baltimore, Maryland
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Rubenstein LS, Amon JJ. Global health, human rights, and the law. Lancet 2019; 394:1987-1988. [PMID: 31789211 DOI: 10.1016/s0140-6736(19)32468-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/28/2019] [Indexed: 11/17/2022]
Affiliation(s)
| | - Joseph J Amon
- Drexel Dornsife School of Public Health, Philadelphia, PA, USA
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Footer KHA, Clouse E, Rayes D, Sahloul Z, Rubenstein LS. Qualitative accounts from Syrian health professionals regarding violations of the right to health, including the use of chemical weapons, in opposition-held Syria. BMJ Open 2018; 8:e021096. [PMID: 30082351 PMCID: PMC6078235 DOI: 10.1136/bmjopen-2017-021096] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To explore the impact of the conflict, including the use of chemical weapons, in Syria on healthcare through the experiences of health providers using a public health and human rights lens. DESIGN A qualitative study using semi-structured interviews conducted in-person or over Skype using a thematic analysis approach. SETTING Interviews were conducted with Syrian health workers operating in opposition-held Syria in cooperation with a medical relief organisation in Gaziantep, Turkey. PARTICIPANTS We examined data from 29 semi-structured in-depth interviews with a sample of health professionals with current or recent work-related experience in opposition-controlled areas of Syria, including respondents to chemical attacks. RESULTS Findings highlight the health worker experience of attacks on health infrastructure and services in Syria and consequences in terms of access and scarcity in availability of essential medicines and equipment. Quality of services is explored through physicians' accounts of the knock-on effect of shortages of equipment, supplies and personnel on the right to health and its ethical implications. Health workers themselves were found to be operating under extreme conditions, in particular responding to the most recent chemical attacks that occurred in 2017, with implications for their own health and mental well-being. CONCLUSIONS The study provides unique insight into the impact war has had on Syrian's right to health through the accounts of a sample of Syrian health professionals, with continuing relevance to the current conflict and professional issues facing health workers in conflict settings.
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Affiliation(s)
- Katherine H A Footer
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Emily Clouse
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Diana Rayes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Zaher Sahloul
- Christ Advocate Medical Center, Oak Lawn, Illinois, USA
| | - Leonard S Rubenstein
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Haar RJ, Risko CB, Singh S, Rayes D, Albaik A, Alnajar M, Kewara M, Clouse E, Baker E, Rubenstein LS. Determining the scope of attacks on health in four governorates of Syria in 2016: Results of a field surveillance program. PLoS Med 2018; 15:e1002559. [PMID: 29689085 PMCID: PMC5915680 DOI: 10.1371/journal.pmed.1002559] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 03/23/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Violent attacks on and interferences with hospitals, ambulances, health workers, and patients during conflict destroy vital health services during a time when they are most needed and undermine the long-term capacity of the health system. In Syria, such attacks have been frequent and intense and represent grave violations of the Geneva Conventions, but the number reported has varied considerably. A systematic mechanism to document these attacks could assist in designing more protection strategies and play a critical role in influencing policy, promoting justice, and addressing the health needs of the population. METHODS AND FINDINGS We developed a mobile data collection questionnaire to collect data on incidents of attacks on healthcare directly from the field. Data collectors from the Syrian American Medical Society (SAMS), using the tool or a text messaging system, recorded information on incidents across four of Syria's northern governorates (Aleppo, Idleb, Hama, and Homs) from January 1, 2016, to December 31, 2016. SAMS recorded a total of 200 attacks on healthcare in 2016, 102 of them using the mobile data collection tool. Direct attacks on health facilities comprised the majority of attacks recorded (88.0%; n = 176). One hundred and twelve healthcare staff and 185 patients were killed in these incidents. Thirty-five percent of the facilities were attacked more than once over the data collection period; hospitals were significantly more likely to be attacked more than once compared to clinics and other types of healthcare facilities. Aerial bombs were used in the overwhelming majority of cases (91.5%). We also compared the SAMS data to a separate database developed by Physicians for Human Rights (PHR) based on media reports and matched the incidents to compare the results from the two methods (this analysis was limited to incidents at health facilities). Among 90 relevant incidents verified by PHR and 177 by SAMS, there were 60 that could be matched to each other, highlighting the differences in results from the two methods. This study is limited by the complexities of data collection in a conflict setting, only partial use of the standardized reporting tool, and the fact that limited accessibility of some health facilities and workers and may be biased towards the reporting of attacks on larger or more visible health facilities. CONCLUSIONS The use of field data collectors and use of consistent definitions can play an important role in the tracking incidents of attacks on health services. A mobile systematic data collection tool can complement other methods for tracking incidents of attacks on healthcare and ensure the collection of detailed information about each attack that may assist in better advocacy, programs, and accountability but can be practically challenging. Comparing attacks between SAMS and PHR suggests that there may have been significantly more attacks than previously captured by any one methodology. This scale of attacks suggests that targeting of healthcare in Syria is systematic and highlights the failure of condemnation by the international community and medical groups working in Syria of such attacks to stop them.
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Affiliation(s)
- Rohini J. Haar
- School of Public Health, University of California, Berkeley, California, United States of America
- * E-mail:
| | - Casey B. Risko
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Sonal Singh
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Diana Rayes
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Ahmad Albaik
- Syrian American Medical Society, Gaziantep, Turkey
| | | | - Mazen Kewara
- Syrian American Medical Society, Gaziantep, Turkey
| | - Emily Clouse
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Elise Baker
- Physicians for Human Rights, New York, New York, United States of America
| | - Leonard S. Rubenstein
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Jabbour S, Fouad FM, Leaning J, McKay D, Nasser R, Rubenstein LS, Sparrow A, Spiegel P, Tarakji A, Waldman R, Hallam R, Mukwege D, Tayara G. Death and suffering in Eastern Ghouta, Syria: a call for action to protect civilians and health care. Lancet 2018; 391:815-817. [PMID: 29496277 DOI: 10.1016/s0140-6736(18)30527-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Samer Jabbour
- Faculty of Health Sciences, American University of Beirut, Beirut 1107 2020, Lebanon.
| | - Fouad M Fouad
- Faculty of Health Sciences, American University of Beirut, Beirut 1107 2020, Lebanon
| | - Jennifer Leaning
- FXB Center for Health and Human Rights, Harvard University, Cambridge, MA, USA
| | - Donna McKay
- Physicians for Human Rights, New York, NY, USA
| | - Rabie Nasser
- Syrian Center for Policy Studies, Beirut, Lebanon
| | - Leonard S Rubenstein
- Safeguarding Health in Conflict Coalition and Program on Human Rights, Health and Conflict, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Annie Sparrow
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul Spiegel
- Johns Hopkins Center for Humanitarian Health and Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ahmad Tarakji
- Syrian American Medical Society, Washington, DC, USA
| | - Ronald Waldman
- Milken Institute School of Public Health, George Washington University and Doctors of the World, Washington, DC, USA
| | - Rola Hallam
- CanDo, London, UK; Royal Free Hospital, London, UK
| | - Denis Mukwege
- Panzi Hospital, Bukavu, Democratic Republic of Congo
| | - Ghanem Tayara
- Union of Medical Care and Relief Organizations International, Birmingham, UK
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Berger Z, Rubenstein LS, DeCamp M. Clinical care and complicity with torture. BMJ 2018; 360:k449. [PMID: 29420187 DOI: 10.1136/bmj.k449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Zackary Berger
- Johns Hopkins School of Medicine, Division of General Internal Medicine, Baltimore, MA, USA
- Johns Hopkins Berman Institute of Bioethics
| | - Leonard S Rubenstein
- Johns Hopkins Berman Institute of Bioethics
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health
- Johns Hopkins Berman Institute of Bioethics
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health
| | - Matthew DeCamp
- Johns Hopkins School of Medicine, Division of General Internal Medicine, Baltimore, MA, USA
- Johns Hopkins Berman Institute of Bioethics
- Johns Hopkins School of Medicine, Division of General Internal Medicine, Baltimore, MA, USA
- Johns Hopkins Berman Institute of Bioethics
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Abstract
Worldwide, a disproportionate burden of HIV, tuberculosis, and hepatitis is present among current and former prisoners. This problem results from laws, policies, and policing practices that unjustly and discriminatorily detain individuals and fail to ensure continuity of prevention, care, and treatment upon detention, throughout imprisonment, and upon release. These government actions, and the failure to ensure humane prison conditions, constitute violations of human rights to be free of discrimination and cruel and inhuman treatment, to due process of law, and to health. Although interventions to prevent and treat HIV, tuberculosis, hepatitis, and drug dependence have proven successful in prisons and are required by international law, they commonly are not available. Prison health services are often not governed by ministries responsible for national public health programmes, and prison officials are often unwilling to implement effective prevention measures such as needle exchange, condom distribution, and opioid substitution therapy in custodial settings, often based on mistaken ideas about their incompatibility with prison security. In nearly all countries, prisoners face stigma and social marginalisation upon release and frequently are unable to access health and social support services. Reforms in criminal law, policing practices, and justice systems to reduce imprisonment, reforms in the organisation and management of prisons and their health services, and greater investment of resources are needed.
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Affiliation(s)
- Leonard S Rubenstein
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA.
| | - Joseph J Amon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Health and Human Rights Division, Human Rights Watch, New York, NY, USA
| | - Megan McLemore
- Health and Human Rights Division, Human Rights Watch, New York, NY, USA
| | - Patrick Eba
- UNAIDS, Geneva, Switzerland; College of Law and Management Studies, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Kate Dolan
- National Drug and Alcohol Research Centre, Sydney, NSW, Australia
| | - Rick Lines
- Harm Reduction International, London, UK
| | - Chris Beyrer
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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16
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Wirtz AL, Glass N, Pham K, Perrin N, Rubenstein LS, Singh S, Vu A. Comprehensive development and testing of the ASIST-GBV, a screening tool for responding to gender-based violence among women in humanitarian settings. Confl Health 2016; 10:7. [PMID: 27099617 PMCID: PMC4837612 DOI: 10.1186/s13031-016-0071-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 02/08/2016] [Indexed: 11/10/2022] Open
Abstract
Background Conflict affected refugees and internally displaced persons (IDPs) are at increased vulnerability to gender-based violence (GBV). Health, psychosocial, and protection services have been implemented in humanitarian settings, but GBV remains under-reported and available services under-utilized. To improve access to existing GBV services and facilitate reporting, the ASIST-GBV screening tool was developed and tested for use in humanitarian settings. This process was completed in four phases: 1) systematic literature review, 2) qualitative research that included individual interviews and focus groups with GBV survivors and service providers, respectively, 3) pilot testing of the developed screening tool, and 4) 3-month implementation testing of the screening tool. Research was conducted among female refugees, aged ≥15 years in Ethiopia, and female IDPs, aged ≥18 years in Colombia. Results The systematic review and meta-analysis identified a range of GBV experiences and estimated a 21.4 % prevalence of sexual violence (95 % CI:14.9-28.7) among conflict-affected populations. No existing screening tools for GBV in humanitarian settings were identified. Qualitative research with GBV survivors in Ethiopia and Colombia found multiple forms of GBV experienced by refugees and IDPs that occurred during conflict, in transit, and in displaced settings. Identified forms of violence were combined into seven key items on the screening tool: threats of violence, physical violence, forced sex, sexual exploitation, forced pregnancy, forced abortion, and early or forced marriage. Cognitive testing further refined the tool. Pilot testing in both sites demonstrated preliminary feasibility where 64.8 % of participants in Ethiopia and 44.9 % of participants in Colombia were identified with recent (last 12 months) cases of GBV. Implementation testing of the screening tool, conducted as a routine service in camp/district hospitals, allowed for identification of GBV cases and referrals to services. In this phase, 50.6 % of participants in Ethiopia and 63.4 % in Colombia screened positive for recent experiences of GBV. Psychometric testing demonstrated appropriate internal consistency of the tool (Cronbach’s α = 0.77) and item response theory demonstrated appropriate discrimination and difficulty of the tool. Conclusion The ASIST-GBV screening tool has demonstrated utility and validity for use in confidential identification and referral of refugees and IDPs who experience GBV.
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Affiliation(s)
- A L Wirtz
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, USA
| | - N Glass
- Johns Hopkins School of Nursing, Baltimore, USA
| | - K Pham
- Department of Emergency Medicine, Johns Hopkins Medical Institute, Baltimore, USA ; Department of International Health, Johns Hopkins School of Public Health, Baltimore, USA
| | - N Perrin
- Johns Hopkins School of Nursing, Baltimore, USA ; Center for Health Research, Kaiser Permanente Northwest, Portland, USA
| | - L S Rubenstein
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, USA
| | - S Singh
- Department of Internal Medicine, Johns Hopkins Medical Institute, Baltimore, USA
| | - A Vu
- Department of Emergency Medicine, Johns Hopkins Medical Institute, Baltimore, USA ; Department of International Health, Johns Hopkins School of Public Health, Baltimore, USA
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17
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Abstract
Leonard Rubenstein and colleagues argue that professional associations should ensure that military rules do not require health professionals to choose between service to their country and ethical practice.
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Affiliation(s)
- Leonard S. Rubenstein
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland, United States of America
- * E-mail:
| | - Scott A. Allen
- University of California at Riverside School of Medicine, Riverside, California, United States of America
| | - Phyllis A. Guze
- University of California at Riverside School of Medicine, Riverside, California, United States of America
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Devakumar D, Birch M, Rubenstein LS, Osrin D, Sondorp E, Wells JCK. Child health in Syria: recognising the lasting effects of warfare on health. Confl Health 2015; 9:34. [PMID: 26535056 PMCID: PMC4630938 DOI: 10.1186/s13031-015-0061-6] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 10/14/2015] [Indexed: 11/10/2022] Open
Abstract
The war in Syria, now in its fourth year, is one of the bloodiest in recent times. The legacy of war includes damage to the health of children that can last for decades and affect future generations. In this article we discuss the effects of the war on Syria's children, highlighting the less documented longer-term effects. In addition to their present suffering, these children, and their own children, are likely to face further challenges as a result of the current conflict. This is essential to understand both for effective interventions and for ethical reasons.
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Affiliation(s)
- Delan Devakumar
- Institute for Global Health, University College London, 30 Guilford St, London, WC1N 1EH UK
| | - Marion Birch
- Institute for Global Health, University College London, 30 Guilford St, London, WC1N 1EH UK
| | - Leonard S Rubenstein
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205 USA
| | - David Osrin
- Institute for Global Health, University College London, 30 Guilford St, London, WC1N 1EH UK
| | - Egbert Sondorp
- Royal Tropical Institute, Mauritskade 63, 1092AD Amsterdam, Netherlands
| | - Jonathan C K Wells
- Childhood Nutrition Research Centre, Institute of Child Health, University College London, London, WC1N 1EH UK
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20
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Haar RJ, Footer KH, Singh S, Sherman SG, Branchini C, Sclar J, Clouse E, Rubenstein LS. Measurement of attacks and interferences with health care in conflict: validation of an incident reporting tool for attacks on and interferences with health care in eastern Burma. Confl Health 2014; 8:23. [PMID: 25400693 PMCID: PMC4232629 DOI: 10.1186/1752-1505-8-23] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 08/21/2014] [Indexed: 12/01/2022] Open
Abstract
Background Attacks on health care in armed conflict and other civil disturbances, including those on health workers, health facilities, patients and health transports, represent a critical yet often overlooked violation of human rights and international humanitarian law. Reporting has been limited yet local health workers working on the frontline in conflict are often the victims of chronic abuse and interferences with their care-giving. This paper reports on the validation and revision of an instrument designed to capture incidents via a qualitative and quantitative evaluation method. Methods Based on previous research and interviews with experts, investigators developed a 33-question instrument to report on attacks on healthcare. These items would provide information about who, what, where, when, and the impact of each incident of attack on or interference with health. The questions are grouped into 4 domains: health facilities, health workers, patients, and health transports. 38 health workers who work in eastern Burma participated in detailed discussion groups in August 2013 to review the face and content validity of the instrument and then tested the instrument based on two simulated scenarios. Completed forms were graded to test the inter-rater reliability of the instrument. Results Face and content validity were confirmed with participants expressing that the instrument would assist in better reporting of attacks on health in the setting of eastern Burma where they work. Participants were able to give an accurate account of relevant incidents (86% and 82% on Scenarios 1 and 2 respectively). Item-by-item review of the instrument revealed that greater than 95% of participants completed the correct sections. Errors primarily occurred in quantifying the impact of the incident on patient care. Revisions to the translated instrument based on the results consisted primarily of design improvements and simplification of some numerical fields. Conclusion This instrument was validated for use in eastern Burma and could be used as a model for reporting violence towards health care in other conflict settings. Electronic supplementary material The online version of this article (doi:10.1186/1752-1505-8-23) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rohini J Haar
- Department of Emergency Medicine, St. Luke's-Roosevelt Hospital, 1111 Amsterdam Avenue, New York, NY 10026 USA
| | - Katherine Ha Footer
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St. E7141, Baltimore, MD 21205 USA
| | - Sonal Singh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St. E7141, Baltimore, MD 21205 USA
| | - Susan G Sherman
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E6543, Baltimore, MD 21205 USA
| | - Casey Branchini
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205 USA
| | - Joshua Sclar
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St. WB 602, Baltimore, MD 21205 USA
| | - Emily Clouse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St. E7141, Baltimore, MD 21205 USA
| | - Leonard S Rubenstein
- Johns Hopkins Bloomberg School of Public Health, Center for Public Health and Human Rights, 615 N Wolfe Street, E7148, Baltimore, MD 21205 USA
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22
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Wirtz AL, Pham K, Glass N, Loochkartt S, Kidane T, Cuspoca D, Rubenstein LS, Singh S, Vu A. Gender-based violence in conflict and displacement: qualitative findings from displaced women in Colombia. Confl Health 2014; 8:10. [PMID: 25076981 PMCID: PMC4115473 DOI: 10.1186/1752-1505-8-10] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Accepted: 07/03/2014] [Indexed: 11/10/2022] Open
Abstract
Introduction Gender-based violence (GBV) is prevalent among, though not specific to, conflict affected populations and related to multifarious levels of vulnerability of conflict and displacement. Colombia has been marked with decades of conflict, with an estimated 5.2 million internally displaced persons (IDPs) and ongoing violence. We conducted qualitative research to understand the contexts of conflict, displacement and dynamics with GBV. This as part of a multi-phase, mixed method study, in collaboration with UNHCR, to develop a screening tool to confidentially identify cases of GBV for referral among IDP women who were survivors of GBV. Methods Qualitative research was used to identify the range of GBV, perpetrators, contexts in conflict and displacement, barriers to reporting and service uptake, as well as to understand experiences of service providers. Thirty-five female IDPs, aged 18 years and older, who self-identified as survivors of GBV were enrolled for in-depth interviews in San Jose de Guaviare and Quibdo, Colombia in June 2012. Thirty-one service providers participated in six focus group discussions and four interviews across these sites. Results Survivors described a range of GBV across conflict and displacement settings. Armed actors in conflict settings perpetrated threats of violence and harm to family members, child recruitment, and, to a lesser degree, rape and forced abortion. Opportunistic violence, including abduction, rape, and few accounts of trafficking were more commonly reported to occur in the displacement setting, often perpetrated by unknown individuals. Intrafamilial violence, intimate partner violence, including physical and sexual violence and reproductive control were salient across settings and may be exacerbated by conflict and displacement. Barriers to reporting and services seeking were reported by survivors and providers alike. Conclusions Findings highlight the need for early identification of GBV cases, with emphasis on confidential approaches and active engagement of survivors in available, quality services. Such efforts may facilitate achievement of the goals of new Colombian laws, which seek to prevent and respond to GBV, including in conflict settings. Ongoing conflict and generalized GBV in displacement, as well as among the wider population, suggests a need to create sustainable solutions that are accessible to both IDPs and general populations.
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Affiliation(s)
- Andrea L Wirtz
- Department of Emergency Medicine, Johns Hopkins Medical Institute, Baltimore, USA ; Center for Public Health and Human Rights, Department of Epidemiology, Johns School of Public Health, Baltimore, USA
| | - Kiemanh Pham
- Department of Emergency Medicine, Johns Hopkins Medical Institute, Baltimore, USA ; Department of International Health, Johns Hopkins School of Public Health, Baltimore, USA
| | - Nancy Glass
- Johns Hopkins School of Nursing, Baltimore, USA
| | | | - Teemar Kidane
- United Nations High Commissioner for Refugees, Bogota, Colombia
| | - Decssy Cuspoca
- Departamento de Antropología de la Universidad de los Andes, Bogota, Colombia
| | - Leonard S Rubenstein
- Center for Public Health and Human Rights, Department of Epidemiology, Johns School of Public Health, Baltimore, USA
| | - Sonal Singh
- Center for Public Health and Human Rights, Department of Epidemiology, Johns School of Public Health, Baltimore, USA ; Department of General Internal Medicine, Johns Hopkins Medical Institute, Baltimore, USA
| | - Alexander Vu
- Department of Emergency Medicine, Johns Hopkins Medical Institute, Baltimore, USA ; Department of International Health, Johns Hopkins School of Public Health, Baltimore, USA
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Smith TJS, Rubenstein LS, Nachman KE. Availability of information about airborne hazardous releases from animal feeding operations. PLoS One 2013; 8:e85342. [PMID: 24400039 PMCID: PMC3880374 DOI: 10.1371/journal.pone.0085342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 12/03/2013] [Indexed: 11/18/2022] Open
Abstract
Introduction Air from animal feeding operations (AFOs) has been shown to transport numerous contaminants of public health concern. While federal statutes like the Emergency Planning and Community Right-to-Know Act (EPCRA) generally require that facilities report hazardous releases, AFOs have been exempted from most of these requirements by the U.S. Environmental Protection Agency (EPA). We assessed the availability of information about AFO airborne hazardous releases following these exemptions. Methods We submitted public records requests to 7 states overlapping with or adjacent to the Chesapeake Bay watershed for reports of hazardous releases made by AFOs under EPCRA. From the records received, we calculated the proportion of AFOs in each state for which ≥1 reports were available. We also determined the availability of specific types of information required under EPCRA. The numbers of AFOs permitted under the Clean Water Act (CWA) or analogous state laws, as determined from permitting databases obtained from states, were used as denominators. Results We received both EPCRA reports and permitting databases from 4 of 7 states. Across these 4 states, the mean proportion of AFOs for which ≥1 EPCRA reports were available was 15% (range: 2-33%). The mean proportions of AFOs for which the name or identity of the substance released, ≥1 estimates of quantity released, and information about nearby population density and sensitive populations were available were 15% (range: 2-33%), 8% (range: 0-22%), and 14% (range: 2-8%), respectively. Discussion These results suggest that information about the airborne hazardous releases of a large majority of AFOs is not available under federal law in the states that we investigated. While the results cannot be attributed to specific factors by this method, attention to multiple factors, including revision of the EPA’s exemptions, may increase the availability of information relevant to the health of populations living or working near AFOs.
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Affiliation(s)
- Tyler J. S. Smith
- Johns Hopkins Center for a Livable Future, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Leonard S. Rubenstein
- Johns Hopkins Center for a Livable Future, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Keeve E. Nachman
- Johns Hopkins Center for a Livable Future, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
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Wirtz AL, Glass N, Pham K, Aberra A, Rubenstein LS, Singh S, Vu A. Development of a screening tool to identify female survivors of gender-based violence in a humanitarian setting: qualitative evidence from research among refugees in Ethiopia. Confl Health 2013; 7:13. [PMID: 23758886 PMCID: PMC3695841 DOI: 10.1186/1752-1505-7-13] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 06/03/2013] [Indexed: 12/02/2022] Open
Abstract
Background High levels of gender-based violence (GBV) persist among conflict-affected populations and within humanitarian settings and are paralleled by under-reporting and low service utilization. Novel and evidence-based approaches are necessary to change the current state of GBV amongst these populations. We present the findings of qualitative research, which were used to inform the development of a screening tool as one potential strategy to identify and respond to GBV for females in humanitarian settings. Methods Qualitative research methods were conducted from January-February 2011 to explore the range of experiences of GBV and barriers to reporting GBV among female refugees. Individual interview participants (n=37) included female refugees (≥15 years), who were survivors of GBV, living in urban or one of three camps settings in Ethiopia, and originating from six conflict countries. Focus group discussion participants (11 groups; 77 participants) included health, protection and community service staff working in the urban or camp settings. Interviews and discussions were conducted in the language of preference, with assistance by interpreters when needed, and transcribed for analysis by grounded-theory technique. Results Single and multiple counts of GBV were reported and ranged from psychological and social violence; rape, gang rape, sexual coercion, and other sexual violence; abduction; and physical violence. Domestic violence was predominantly reported to occur when participants were living in the host country. Opportunistic violence, often manifested by rape, occurred during transit when women depended on others to reach their destination. Abduction within the host country, and often across borders, highlighted the constant state of vulnerability of refugees. Barriers to reporting included perceived and experienced stigma in health settings and in the wider community, lack of awareness of services, and inability to protect children while mothers sought services. Conclusions Findings demonstrate that GBV persists across the span of the refugee experience, though there is a transition in the range of perpetrators and types of GBV that are experienced. Further, survivors experience significant individual and system barriers to disclosure and service utilization. The findings suggest that routine GBV screening by skilled service providers offers a strategy to confidentially identify and refer survivors to needed services within refugee settings, potentially enabling survivors to overcome existing barriers.
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Affiliation(s)
- Andrea L Wirtz
- Department of Emergency Medicine, Johns Hopkins Medical Institutes, Baltimore, USA.
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25
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Abstract
Health systems face enormous challenges in fragile and post-conflict states. This paper will review recent literature to better understand how, within a context of economic volatility, political instability, infrastructural collapse and human resource scarcity, population health deteriorates and requires significant attention and resources to rebuild. Classifications of fragile and post-conflict states differ among organizations and reviewing the basic consensus as well as differences will assist in clarifying how organizations use these terms and how statistics on these nations come about. Of particular interest is the increase in local conflicts within states that may not affect national mortality and morbidity but pose heavy burdens on regional populations. Recent research on sexual and reproductive health, children's health and mental health within fragile and post-conflict states highlights the effects of healthcare systems and their breakdown on communities. We propose a research agenda to further explore knowledge gaps concerning health in fragile and post-conflict states.
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Affiliation(s)
- Rohini J Haar
- St Luke's-Roosevelt Hospital, Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, USA.
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26
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Abstract
Despite increasing experience in health reconstruction in societies emerging from conflict, the policy basis for investing in the development of equitable and effective health systems in the wake of war remains unsettled. Consideration of post-conflict health reconstruction is almost entirely absent in donor policies on global health. Practically by default, health programmes are seen increasingly as an element of stabilisation and security interventions in the aftermath of armed conflict. That perspective, however, lacks an evidence base and can skew health programmes towards short-term security and stabilisation goals that have a marginal impact and violate the principles of equity, non-discrimination, and quality, which are central to sound health systems and public acceptance of them. A better approach is to ground policy in legitimacy, viewing health both as a core social institution and one that, if developed according to human rights principles, including equity, non-discrimination, participation and accountability, can advance the effectiveness and the quality of governance in the emerging state.
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Affiliation(s)
- Leonard S Rubenstein
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
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27
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Affiliation(s)
- Farrah J Mateen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21231, USA
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28
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Affiliation(s)
- Leonard S Rubenstein
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205, USA.
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29
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Abstract
Assaults on patients and medical personnel, facilities, and transports, denial of access to medical services, and misuse of medical facilities and emblems have become a feature of armed conflict despite their prohibition by the laws of war. Strategies to improve compliance with these laws, protection, and accountability are lacking, and regular reporting of violations is absent. A systematic review of the frequency of reporting and types of violations has not been done for more than 15 years. To gain a better understanding of the scope and extent of the problem, we used uniform search criteria to review three global sources of human rights reports in armed conflicts for 2003-08, and in-depth reports on violations committed in armed conflict during 1989-2008. Findings from this review showed deficiencies in the extent and methods of reporting, but also identified three major trends in such assaults: attacks on medical functions seem to be part of a broad assault on civilians; assaults on medical functions are used to achieve a military advantage; and combatants do not respect the ethical duty of health professionals to provide care to patients irrespective of affiliation. WHO needs to lead robust and systematic documentation of these violations, and countries and the medical community need to take steps to improve compliance, protection, and accountability.
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Affiliation(s)
- Leonard S Rubenstein
- Johns Hopkins Bloomberg School of Public Health, John Hopkins University, Baltimore, MD 21205, USA.
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Rubenstein LS. First, do no harm: health professionals and Guantánamo. Seton Hall Law Rev 2007; 37:733-48. [PMID: 17506212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
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London L, Rubenstein LS, Baldwin-Ragaven L, Van Es A. Dual Loyalty among Military Health Professionals: Human Rights and Ethics in Times of Armed Conflict. Camb Q Healthc Ethics 2006; 15:381-91. [PMID: 17066764 DOI: 10.1017/s096318010606049x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Leslie London
- School of Public Health and Family Medicine, University of Cape Town, South Africa
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Rubenstein LS. Medicine and war. Hastings Cent Rep 2004; 34:3. [PMID: 15666881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Rubenstein LS. Is Ethical Corporate Medical Practice An Oxymoron? Health Aff (Millwood) 2003. [DOI: 10.1377/hlthaff.22.6.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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35
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36
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Rubenstein LS. Human rights and fair access to medication. Emory Int Law Rev 2003; 17:525-34. [PMID: 15732190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Rubenstein LS. Psychiatric experimentation: the lessons of history. J Calif Alliance Ment Ill 2001; 5:22-4. [PMID: 11653310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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de Gruchy J, Rubenstein LS. Will South African physicians build a culture of human rights? Lancet 2000; 355:838. [PMID: 10711942 DOI: 10.1016/s0140-6736(00)01336-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- J de Gruchy
- Physicians for Human Rights, Washington, DC 20005, USA
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Rubenstein LS. Physicians and the ethic of human rights. Minn Med 1999; 82:46-8. [PMID: 10431546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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Rubenstein LS. Physicians and the Universal Declaration of Human Rights. J Ambul Care Manage 1998; 21:76-8. [PMID: 10181850 DOI: 10.1097/00004479-199807000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Faenza MM, Rubenstein LS. An advocacy perspective on the AMBHA/NASMHPD White Paper. Behav Healthc Tomorrow 1996; 5:24-8. [PMID: 10157572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Rosenthal E, Rubenstein LS. International human rights advocacy under the "Principles for the Protection of Persons with Mental Illness". Int J Law Psychiatry 1993; 16:257-300. [PMID: 8125675 DOI: 10.1016/0160-2527(93)90001-u] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- E Rosenthal
- Mental Disability Rights International, Washington, D.C
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Rubenstein LS. Financial barriers to care. Hosp Community Psychiatry 1990; 41:1257-8. [PMID: 2249810 DOI: 10.1176/ps.41.11.1257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Rubenstein LS, Koyanagi C, Manes J. Mental health funding. Hosp Community Psychiatry 1987; 38:410-2. [PMID: 3570192 DOI: 10.1176/ps.38.4.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
In the past, the legal and medical perspectives on issues relating to compulsory treatment focused on the individual's interest in liberty on the one hand and the physician's authority to treat on the other. Neither of these perspectives addresses the contemporary realities of treatment of chronically mentally ill people in the United States. The author suggests an emerging advocacy perspective that focuses on the quality of treatment.
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