Solving the jigsaw of conflict-related environmental damage: Utilizing open-source analysis to improve research into environmental health risks.

Investigation of the environmental impacts of armed conflict has been made easier in recent years with the development of new and improved methods for documenting and monitoring environmental damage and pollution. For decades, research into conflict-linked environmental damage and its links to human health have been overlooked and research underfunded, hindering a complete humanitarian response and effective post-conflict reconstruction. Recent developments in the field of open-source investigation have shown promising results due to the increased use of mobile phones, access to the internet and freely available methods for remote observation by satellite. Utilizing and analysing these sources of data can help us to understand how conflicts are associated with environmental damage, pollution and their negative impacts upon public health. Further research and development in this field will help to inform more effective humanitarian responses, mitigate risks to health and identify priorities for post-conflict reconstruction programs. Data-driven open-source research can also strengthen international discussions on state accountability for military activities and build a case for the responsibility of warring parties to protect the environment as well as the people who depend on it.

A conceptual framework for capacity strengthening of health research in conflict: the case of the Middle East and North Africa region.

BACKGROUND: In conflict settings, research capacities have often been de-prioritized as resources are diverted to emergency needs, such as addressing elevated morbidity, mortality and health system challenges directly and/or indirectly associated to war. This has had an adverse long-term impact in such protracted conflicts such as those found in the Middle East and North Africa region (MENA), where research knowledge and skills have often been compromised. In this paper, we propose a conceptual framework for health research capacity strengthening that adapts existing models and frameworks in low- and middle-income countries and uses our knowledge of the MENA context to contextualise them for conflict settings. METHODS: The framework was synthesized using "best fit" framework synthesis methodology. Relevant literature, available in English and Arabic, was collected through PubMed, Google Scholar and Google using the keywords: capacity building; capacity strengthening; health research; framework and conflict. Grey literature was also assessed. RESULTS: The framework is composed of eight principal themes: "structural levels", "the influence of the external environment", "funding, community needs and policy environment", "assessing existing capacity and needs", "infrastructure and communication", "training, leadership and partnership", "adaptability and sustainability", and "monitoring and evaluation"; with each theme being supported by examples from the MENA region. Our proposed framework takes into consideration safety, infrastructure, communication and adaptability as key factors that affect research capacity strengthening in conflict. As it is the case more generally, funding, permissible political environments and sustainability are major determinants of success for capacity strengthening for health research programmes, though these are significantly more challenging in conflict settings. Nonetheless, health research capacity strengthening should remain a priority. CONCLUSION: The model presented is the first framework that focuses on strengthening health research capacity in conflict with a focus on the MENA region. It should be viewed as a non-prescriptive reference tool for health researchers and practitioners, from various disciplines, involved in research capacity strengthening to evaluate, use, adapt and improve. It can be further extended to include representative indicators and can be later evaluated by assessing its efficacy for interventions in conflict settings.

Developing institutions for cancer care in low-income and middle-income countries: from cancer units to comprehensive cancer centres.

Global cancer centres operate across different sizes, scales, and ecosystems. Understanding the essential aspects of the creation, organisation, accreditation, and activities within these settings is crucial for developing an affordable, equitable, and quality cancer care, research, and education system. Robust guidelines are scarce for cancer units, cancer centres, and comprehensive cancer centres in low-income and middle-income countries. However, some robust examples of the delivery of complex cancer care in centres in emerging economies are available. Although it is impossible to create an optimal system to fit the unique needs of all countries for the delivery of cancer care, we summarise what has been published about the development and management of cancer centres in low-income and middle-income countries so far and highlight the need for clinical and political leadership.

Changing therapeutic geographies of the Iraqi and Syrian wars.

The health consequences of the ongoing US-led war on terror and civil armed conflicts in the Arab world are much more than the collateral damage inflicted on civilians, infrastructure, environment, and health systems. Protracted war and armed conflicts have displaced populations and led to lasting transformations in health and health care. In this report, we analyse the effects of conflicts in Iraq and Syria to show how wars and conflicts have resulted in both the militarisation and regionalisation of health care, conditions that complicate the rebuilding of previously robust national health-care systems. Moreover, we show how historical and transnational frameworks can be used to show the long-term consequences of war and conflict on health and health care. We introduce the concept of therapeutic geographies--defined as the geographic reorganisation of health care within and across borders under conditions of war.

Weaponised uranium and adverse health outcomes in Iraq: a systematic review.

BACKGROUND: The US military first deployed depleted uranium (DU) weapons in Iraq during the Gulf War in 1990 and in the 2003 invasion of Iraq. Research into the health impacts of DU has been mired in debate and controversy. Research funded by the US government has denied the health risks posed by DU to the Iraqi population, while opponents have claimed that DU is responsible for increased rates of birth defects and cancers in Iraq. Others assert that the public health impacts of DU weapons remain uncertain. This systematic review identified, appraised and synthesised all human observational studies assessing adverse health outcomes associated with DU exposure among the Iraqi population. To our knowledge, no systematic review has been conducted on the topic previously. METHODS: We searched 11 electronic databases for human observational studies published between 1990 and 2020 that measured association between exposure to weaponised uranium and health outcomes (including cancer, birth defects, immune system function and mortality) among the Iraqi population. We assessed risk of bias using the Navigation Guide's risk of bias tool and rated certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach (PROSPERO: CRD42018108225). RESULTS: Our searches identified 2601 records, of which 28 met our inclusion criteria. We identified five additional eligible reports from other sources. Two articles reported the results of multiple relevant studies; our final set included 33 articles reporting on 36 eligible studies. Most studies (n=30, 83%) reported a positive association between uranium exposure and adverse health outcomes. However, we found that the reviewed body of evidence suffers from a high risk of bias. CONCLUSION: The available evidence suggests possible associations between exposure to depleted uranium and adverse health outcomes among the Iraqi population. More primary research and the release of missing data are needed to design meaningful health and policy interventions in Iraq.

Heavy Metal Toxicity in Armed Conflicts Potentiates AMR in A. baumannii by Selecting for Antibiotic and Heavy Metal Co-resistance Mechanisms.

Acinetobacter baumannii has become increasingly resistant to leading antimicrobial agents since the 1970s. Increased resistance appears linked to armed conflicts, notably since widespread media stories amplified clinical reports in the wake of the American invasion of Iraq in 2003. Antimicrobial resistance is usually assumed to arise through selection pressure exerted by antimicrobial treatment, particularly where treatment is inadequate, as in the case of low dosing, substandard antimicrobial agents, or shortened treatment course. Recently attention has focused on an emerging pathogen, multi-drug resistant A. baumannii (MDRAb). MDRAb gained media attention after being identified in American soldiers returning from Iraq and treated in US military facilities, where it was termed "Iraqibacter." However, MDRAb is strongly associated in the literature with war injuries that are heavily contaminated by both environmental debris and shrapnel from weapons. Both may harbor substantial amounts of toxic heavy metals. Interestingly, heavy metals are known to also select for antimicrobial resistance. In this review we highlight the potential causes of antimicrobial resistance by heavy metals, with a focus on its emergence in A. baumanni in war zones.

High-Cost Cancer Treatment Across Borders in Conflict Zones: Experience of Iraqi Patients in Lebanon.

PURPOSE: Conflict-induced cross-border travel for medical treatment is commonly observed in the Middle East. There has been little research conducted on the financial impact this has on patients with cancer or on how cancer centers can adapt their services to meet the needs of this population. This study examines the experience of Iraqi patients seeking care in Lebanon, aiming to understand the social and financial contexts of conflict-related cross-border travel for cancer diagnosis and treatment. PATIENTS AND METHODS: After institutional review board approval, 60 Iraqi patients and caregivers seeking cancer care at a major tertiary referral center in Lebanon were interviewed. RESULTS: Fifty-four respondents (90%) reported high levels of financial distress. Patients relied on the sale of possessions (48%), the sale of homes (30%), and vast networks to raise funds for treatment. Thematic analysis revealed several key drivers for undergoing cross-border treatment, including the conflict-driven exodus of Iraqi oncology specialists; the destruction of hospitals or road blockages; referrals by Iraqi physicians to Lebanese hospitals; the geographic proximity of Lebanon; and the lack of diagnostic equipment, radiotherapy machines, and reliable provision of chemotherapy in Iraqi hospitals. CONCLUSION: As a phenomenon distinct from medical tourism, conflict-related deficiencies in health care at home force patients with limited financial resources to undergo cancer treatment in neighboring countries. We highlight the importance of shared decision making and consider the unique socioeconomic status of this population of patients when planning treatment.

(Dis)connectivities in wartime: The therapeutic geographies of Iraqi healthcare-seeking in Lebanon.

The proliferation of conflicts across borders of Middle Eastern States has transformed the landscapes of health and healthcare across the region. In the case of Iraq, state healthcare has collapsed under the strain of protracted conflicts. Meanwhile, Lebanon's post-war healthcare system is booming, and becoming more privatised. In this paper, we build on an ethnographic study on the movements and experiences of Iraqi patients in Lebanon to show how one of the consequences of war is the rise of alternative forms of healthcare-seeking practices and survival strategies - a therapeutic geography that is embedded in regional economies and geopolitical relations and reconfigurations. We argue for the need to reimagine the disconnectivity and connectivity of healthcare systems under war and conflict as grounded in the empirical realities and experiences of mobility in the Middle East.

A summary and appraisal of existing evidence of antimicrobial resistance in the Syrian conflict.

Antimicrobial resistance (AMR) in populations experiencing war has yet to be addressed, despite the abundance of contemporary conflicts and the protracted nature of twenty-first century wars, in combination with growing global concern over conflict-associated bacterial pathogens. The example of the Syrian conflict is used to explore the feasibility of using existing global policies on AMR in conditions of extreme conflict. The available literature on AMR and prescribing behaviour in Syria before and since the onset of the conflict in March 2011 was identified. Overall, there is a paucity of rigorous data before and since the onset of conflict in Syria to contextualize the burden of AMR. However, post onset of the conflict, an increasing number of studies conducted in neighbouring countries and Europe have reported AMR in Syrian refugees. High rates of multidrug resistance, particularly Gram-negative organisms, have been noted amongst Syrian refugees when compared with local populations. Conflict impedes many of the safeguards against AMR, creates new drivers, and exacerbates existing ones. Given the apparently high rates of AMR in Syria, in neighbouring countries hosting refugees, and in European countries providing asylum, this requires the World Health Organization and other global health institutions to address the causes, costs, and future considerations of conflict-related AMR as an issue of global governance.

Antimicrobial resistance in the context of the Syrian conflict: Drivers before and after the onset of conflict and key recommendations.

Current evidence describing antimicrobial resistance (AMR) in the context of the Syrian conflict is of poor quality and sparse in nature. This paper explores and reports the major drivers of AMR that were present in Syria pre-conflict and those that have emerged since its onset in March 2011. Drivers that existed before the conflict included a lack of enforcement of existing legislation to regulate over-the-counter antibiotics and notification of communicable diseases. This contributed to a number of drivers of AMR after the onset of conflict, and these were also compounded by the exodus of trained staff, the increase in overcrowding and unsanitary conditions, the increase in injuries, and economic sanctions limiting the availability of required laboratory medical materials and equipment. Addressing AMR in this context requires pragmatic, multifaceted action at the local, regional, and international levels to detect and manage potentially high rates of multidrug-resistant infections. Priorities are (1) the development of a competent surveillance system for hospital-acquired infections, (2) antimicrobial stewardship, and (3) the creation of cost-effective and implementable infection control policies. However, it is only by addressing the conflict and immediate cessation of the targeting of health facilities that the rehabilitation of the health system, which is key to addressing AMR in this context, can progress.

Challenging the stereotypes: men, withdrawal, and reproductive health in Lebanon.

In Lebanon, coitus interruptus or withdrawal remains a widely practiced method of family planning. Our research sought to understand the role of men in reproductive health in Lebanon by focusing on this common practice. Our main questions were: Why is it that the practice persists when more effective modern methods of family planning are available? How is the decision taken to practice withdrawal? When is withdrawal practiced and with whom? And, finally, does the practice of withdrawal affect sexual pleasure and the sexual relationship more generally?To answer these questions, we embarked on a small exploratory study using in-depth interviews with 16 open-ended questions. We found that the most important reason for the continuing practice of withdrawal is fear of side effects from other methods. Men and women expect pleasure and fulfillment in sexual relations, but they are willing to limit their pleasure to limit their fertility by means they consider safe. No one prototypical practice of withdrawal seems to exist, and this may explain whether or not the method fails to prevent pregnancy.