The economic burden of cancer care for Syrian refugees: a population-based modelling study.

BACKGROUND: Cancer represents a substantial health burden for refugees and host countries. However, no reliable data on the costs of cancer care for refugees are available, which limits the planning of official development assistance in humanitarian settings. We aimed to model the direct costs of cancer care among Syrian refugee populations residing in Jordan, Lebanon, and Turkey. METHODS: In this population-based modelling study, direct cost per capita and per incident case for cancer care were estimated using generalised linear models, informed by a representative dataset of cancer costs drawn from 27 EU countries. A range of regression specifications were tested, in which cancer costs were modelled using different independent variables: gross domestic product (GDP) per capita, crude or age-standardised incidence, crude or age-standardised mortality, and total host country population size. Models were compared using the Akaike information criterion. Total cancer care costs for Syrian refugees in Jordan, Lebanon, and Turkey were calculated by multiplying the estimated direct cancer care costs (per capita) by the total number of Syrian refugees, or by multiplying the estimated direct cancer costs (per incident case [crude or age-standardised]) by the number of incident cancer cases in Syrian refugee populations. All costs are expressed in 2017 euros (€). FINDINGS: Total cancer care costs for all 4·74 million Syrian refugees in Jordan, Lebanon, and Turkey in 2017 were estimated to be €140·23 million using the cost per capita approach, €79·02 million using the age-standardised incidence approach, and €33·68 million using the crude incidence approach. Under the lowest estimation, and with GDP and total country population as model predictors, the financial burden of cancer care was highest for Turkey (€25·18 million), followed by Lebanon (€6·40 million), and then Jordan (€2·09 million). INTERPRETATION: Cancer among the Syrian refugee population represents a substantial financial burden for host countries and humanitarian agencies, such as the UN Refugee Agency. New ways to provide financial assistance need to be found and must be coupled with clear, prioritised pathways and models of care for refugees with cancer. FUNDING: UK Research and Innovation Global Challenges Research Fund: Research for Health in Conflict-Middle East and North Africa region (R4HC-MENA).

Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet-American University of Beirut Commission on Syria.

The conflict in Syria presents new and unprecedented challenges that undermine the principles and practice of medical neutrality in armed conflict. With direct and repeated targeting of health workers, health facilities, and ambulances, Syria has become the most dangerous place on earth for health-care providers. The weaponisation of health care-a strategy of using people's need for health care as a weapon against them by violently depriving them of it-has translated into hundreds of health workers killed, hundreds more incarcerated or tortured, and hundreds of health facilities deliberately and systematically attacked. Evidence shows use of this strategy on an unprecedented scale by the Syrian Government and allied forces, in what human rights organisations described as a war-crime strategy, although all parties seem to have committed violations. Attacks on health care have sparked a large-scale exodus of experienced health workers. Formidable challenges face health workers who have stayed behind, and with no health care a major factor in the flight of refugees, the effect extends well beyond Syria. The international community has left these violations of international humanitarian and human rights law largely unanswered, despite their enormous consequences. There have been repudiated denunciations, but little action on bringing the perpetrators to justice. This inadequate response challenges the foundation of medical neutrality needed to sustain the operations of global health and humanitarian agencies in situations of armed conflict. In this Health Policy, we analyse the situation of health workers facing such systematic and serious violations of international humanitarian law. We describe the tremendous pressures that health workers have been under and continue to endure, and the remarkable resilience and resourcefulness they have displayed in response to this crisis. We propose policy imperatives to protect and support health workers working in armed conflict zones.

Alcohol use during the great recession of 2008-2009.

AIMS: The aim of this study was to assess changes in alcohol use in the USA during the Great Recession. METHODS: Drinking participation, drinking frequency, drinking intensity, total alcohol consumption and frequency of binge drinking were assessed in a nationally representative sample of 2,050,431 US women and men aged 18 and older, interviewed between 2006 and 2010. RESULTS: The prevalence of any alcohol use significantly declined during the economic recession, from 52.0% in 2006-2007 to 51.6% in 2008-2009 (P < 0.05), corresponding to 880,000 fewer drinkers (95% confidence interval [CI] 140,000 to 1.6 million). There was an increase, however, in the prevalence of frequent binging, from 4.8% in 2006-2007 to 5.1% in 2008-2009 (P < 0.01), corresponding to 770,000 more frequent bingers (95% CI 390,000 to 1.1 million). Non-Black, unmarried men under 30 years, who recently became unemployed, were at highest risk for frequent binging. CONCLUSION: During the Great Recession there was an increase in abstention from alcohol and a rise in frequent binging.

The Arab Spring and health: two years on.

The "Arab Spring" has touched almost all countries in the Middle East and North Africa. While most attention has focused on security and political developments, there are significant consequences for population health. These include immediate problems, such as violent deaths and injuries, population displacement, and damage to essential infrastructure, but also longer term vulnerabilities not yet addressed by the political changes, including high unemployment, the low status of women, erosion of already weak welfare systems, and rising food prices. It will be important to tackle these underlying issues while not repeating the mistakes made in other countries that have undergone rapid political transition.

National survey of mental health and life satisfaction of gig workers: the role of loneliness and financial precarity.

OBJECTIVES: To compare the mental health and life satisfaction of those employed in the gig work and contingent work with those in full-time or part-time work and the unemployed in the UK during the COVID-19 pandemic. To explore the possible mechanisms of latent and manifest benefits of employment, such as financial precarity and loneliness. DESIGN: Cross-sectional survey. PARTICIPANTS: A representative sample of 17 722 employed and unemployed British adults, including 429 gig workers. People with disability, retirees and full-time students are not included in the sample. MAIN OUTCOME MEASURES: Mental health (General Health Questionnaire-12 score) and life satisfaction (a direct question from UK Household Longitudinal Study (UKHLS)) as outcomes. Self-reported loneliness (four widely used questions from UKHLS) and financial precarity (a direct question from UKHLS) as mediators. RESULTS: Gig workers reported mental health and life satisfaction worse than those employed full time and part time, but better than the unemployed. Mediation analyses showed that gig workers' worse mental health and life satisfaction than other workers were explained by their higher levels of loneliness and financial precarity, while gig workers' better mental health and life satisfaction than the unemployed were explained by their less financial precarity. CONCLUSIONS: Informal and freelance economy provided manifest benefits of employment to gig workers compared with unemployment but lacked latent benefits of employment. Public policies should provide social support to freelance and contingent workers to reduce their loneliness and improve their psychological well-being, especially during the COVID-19 pandemic.

The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis.

BACKGROUND: There is widespread concern that the present economic crisis, particularly its effect on unemployment, will adversely affect population health. We investigated how economic changes have affected mortality rates over the past three decades and identified how governments might reduce adverse effects. METHODS: We used multivariate regression, correcting for population ageing, past mortality and employment trends, and country-specific differences in health-care infrastructure, to examine associations between changes in employment and mortality, and how associations were modified by different types of government expenditure for 26 European Union (EU) countries between 1970 and 2007. FINDINGS: We noted that every 1% increase in unemployment was associated with a 0.79% rise in suicides at ages younger than 65 years (95% CI 0.16-1.42; 60-550 potential excess deaths [mean 310] EU-wide), although the effect size was non-significant at all ages (0.49%, -0.04 to 1.02), and with a 0.79% rise in homicides (95% CI 0.06-1.52; 3-80 potential excess deaths [mean 40] EU-wide). By contrast, road-traffic deaths decreased by 1.39% (0.64-2.14; 290-980 potential fewer deaths [mean 630] EU-wide). A more than 3% increase in unemployment had a greater effect on suicides at ages younger than 65 years (4.45%, 95% CI 0.65-8.24; 250-3220 potential excess deaths [mean 1740] EU-wide) and deaths from alcohol abuse (28.0%, 12.30-43.70; 1550-5490 potential excess deaths [mean 3500] EU-wide). We noted no consistent evidence across the EU that all-cause mortality rates increased when unemployment rose, although populations varied substantially in how sensitive mortality was to economic crises, depending partly on differences in social protection. Every US$10 per person increased investment in active labour market programmes reduced the effect of unemployment on suicides by 0.038% (95% CI -0.004 to -0.071). INTERPRETATION: Rises in unemployment are associated with significant short-term increases in premature deaths from intentional violence, while reducing traffic fatalities. Active labour market programmes that keep and reintegrate workers in jobs could mitigate some adverse health effects of economic downturns. FUNDING: Centre for Crime and Justice Studies, King's College, London, UK; and Wates Foundation (UK).

Addressing COVID-19 in humanitarian settings: a call to action.

Refugees and internally displaced persons in humanitarian settings are particularly susceptible to the spread of infectious illnesses such as COVID-19 due to overcrowding and inadequate access to clean water, sanitation, and hygiene facilities. Countries facing conflict or humanitarian emergencies often have damaged or fragmented health systems and little to no capacity to test, isolate, and treat COVID-19 cases. Without a plan to address COVID-19 in humanitarian settings, host governments, aid agencies, and international organizations risk prolonging the spread of the virus across borders, threatening global health security, and devastating vulnerable populations. Stakeholders must coordinate a multifaceted response to address COVID-19 in humanitarian settings that incorporates appropriate communication of risks, sets forth resource-stratified guidelines for the use of limited testing, provides resources to treat affected patients, and engages displaced populations.

The Profile of Non-Communicable Disease (NCD) research in the Middle East and North Africa (MENA) region: Analyzing the NCD burden, research outputs and international research collaboration.

OBJECTIVES: Despite the rising risk factor exposure and non-communicable disease (NCD) mortality across the Middle East and the North African (MENA) region, public health policy responses have been slow and appear discordant with the social, economic and political circumstances in each country. Good health policy and outcomes are intimately linked to a research-active culture, particularly in NCD. In this study we present the results of a comprehensive analysis of NCD research with particular a focus on cancer, diabetes and cardiovascular disease in 10 key countries that represent a spectrum across MENA between 1991 and 2018. METHODS: The study uses a well validated bibliometric approach to undertake a quantitative analysis of research output in the ten leading countries in biomedical research in the MENA region on the basis of articles and reviews in the Web of Science database. We used filters for each of the three NCDs and biomedical research to identify relevant papers in the WoS. The countries selected for the analyses were based on the volume of research outputs during the period of analysis and stability, included Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Turkey and the United Arab Emirates. RESULTS: A total of 495,108 biomedical papers were found in 12,341 journals for the ten MENA countries (here we consider Turkey in the context of MENA). For all three NCDs, Turkey's output is consistently the highest. Iran has had considerable growth in research output to occupy second place across all three NCDs. It appears that, relative to their wealth (measured by GDP), some MENA countries, particularly Oman, Qatar, Kuwait and the United Arab Emirates, are substantially under-investing in biomedical research. In terms of investment on particular NCDs, we note the relatively greater commitment on cancer research compared with diabetes or cardiovascular disease in most MENA countries, despite cardiovascular disease causing the greatest health-related burden. When considering the citation impact of research outputs, there have been marked rises in citation scores in Qatar, Lebanon, United Arab Emirates and Oman. However, Turkey, which has the largest biomedical research output in the Middle East has the lowest citation scores overall. The level of intra-regional collaboration in NCD research is highly variable. Saudi Arabia and Egypt are the dominant research collaborators across the MENA region. However, Turkey and Iran, which are amongst the leading research-active countries in the area, show little evidence of collaboration. With respect to international collaboration, the United States and United Kingdom are the dominant research partners across the region followed by Germany and France. CONCLUSION: The increase in research activity in NCDs across the MENA region countries during the time period of analysis may signal both an increasing focus on NCDs which reflects general global trends, and greater investment in research in some countries. However, there are several risks to the sustainability of these improvements that have been identified in particular countries within the region. For example, a lack of suitably trained researchers, low political commitment and poor financial support, and minimal international collaboration which is essential for wider global impact.

What do the British public think of inequality in health, wealth, and power?

Despite the importance of public opinion for policy formation and the political salience of inequality, the public's views about the desirability of equality, not only in health but also in economics and politics, has attracted little attention. We report the results of an on-line survey administered in late 2016 in Great Britain (N = 1667 with a response rate of 35-50%). The survey allowed for testing the sensitivity of public opinion across two other variables: absolute versus relative (everyone should have the same versus inequality should be reduced) and bivariate versus univariate (inequality in one domain is judged in relation to inequality in another versus inequality in a domain is judged independently of other domains). It also allowed examination of how far support for equality in one domain overlaps with support for equality in another. We find that for health, economic and political equality a relative conception of equality attracts more support than an absolute conception, and that for health and political equality a bivariate conception attracts more support than a univariate conception. We also find that conceptions of equality affect how much overlap exists between support for different forms of equality, with a bivariate and relative conception resulting in more overlap than a univariate and absolute conception. We also find evidence for Walzer's 'complex equality' theory in which people tolerate inequality in one domain if it does not control inequality in another.

A shorter working week for everyone: How much paid work is needed for mental health and well-being?

There are predictions that in future rapid technological development could result in a significant shortage of paid work. A possible option currently debated by academics, policy makers, trade unions, employers and mass media, is a shorter working week for everyone. In this context, two important research questions that have not been asked so far are: what is the minimum amount of paid employment needed to deliver some or all of the well-being and mental health benefits that employment has been shown to bring? And what is the optimum number of working hours at which the mental health of workers is at its highest? To answer these questions, this study used the UK Household Longitudinal Study (2009-2018) data from individuals aged between 16 and 64. The analytical sample was 156,734 person-wave observations from 84,993 unique persons of whom 71,113 had two or more measurement times. Fixed effects regressions were applied to examine how changes in work hours were linked to changes in mental well-being within each individual over time. This study found that even a small number of working hours (between one and 8 h a week) generates significant mental health and well-being benefits for previously unemployed or economically inactive individuals. The findings suggest there is no single optimum number of working hours at which well-being and mental health are at their highest - for most groups of workers there was little variation in wellbeing between the lowest (1-8 h) through to the highest (44-48 h) category of working hours. These findings provide important and timely empirical evidence for future of work planning, shorter working week policies and have implications for theorising the future models of organising work in society.

Informal healthcare provision in Lebanon: an adaptive mechanism among displaced Syrian health professionals in a protracted crisis.

BACKGROUND: Syrian healthcare workers (HCWs) are among those who fled the Syrian conflict only to face further social and economic challenges in host countries. In Lebanon, this population group cannot formally practice, yet many are believed to be operating informally. These activities remain poorly documented and misunderstood by the academic, policy and humanitarian communities. This study aims to understand mechanisms of informal provision of services, the facilitators and barriers for such practices and to present policy recommendations for building on this adaptive mechanism. METHOD: A qualitative descriptive study based on an in-depth interview approach with a sample of Syrian informal healthcare workers (IHCWs) residing in Lebanon was adopted. Known sponsor networks followed by snowball sampling approaches were used to recruit participants. Data collection occurred between September and December 2017. All interviews were audio-recorded, transcribed and translated into English. An inductive thematic analysis was used. RESULTS: Twenty-two participants were recruited. Motivational factors that led HCWs to practice informally were personal (e.g. source of income/livelihood), societal (cultural competency), and need to fulfill a gap in the formal health service sector. Being connected to a network of IHCWs facilitated initiation of the informal practice until eventually becoming part of a community of informal practice. The central challenge was the informal nature of their practice and its negative consequences. Most IHCWs were afraid of arrest by the government upon identification. Most interviewees indicated being discriminated against by host communities in the form of differential wages and tense interpersonal relationships. Almost all recommended a change in policy allowing them to practice formally under a temporary registration until their return to Syria. CONCLUSION: Our study confirmed the presence of IHCWs operating in Lebanon. Despite its informal nature, participants perceived that this practice was filling a gap in the formal health system and was helping to alleviate the burden of IHCWs and refugee health needs. In line with interviewees' views, we recommend that policy decision makers within humanitarian agencies and the Government of Lebanon explore the possibilities for allowing temporary registration of displaced Syrian IHCW to benefit local host communities and refugee populations.

Correction to: Informal healthcare provision in Lebanon: an adaptive mechanism among displaced Syrian health professionals in a protracted crisis.

[This corrects the article DOI: 10.1186/s13031-019-0224-y.].