A call from 40 public health scientists for an end to the continuing humanitarian and environmental catastrophe in Gaza.

An under-recognised aspect of the current humanitarian catastrophe in Gaza is the impact of the war on the environment and the associated risks for human health. This commentary contextualises these impacts against the background of human suffering produced by the overwhelming violence associated with the use of military force against the general population of Gaza. In calling for an immediate cessation to the violence, the authors draw attention to the urgent need to rebuild the health care system and restore the physical and human infrastructure that makes a liveable environment possible and promotes human health and well-being, especially for the most vulnerable in the population. Environmental remediation should therefore form one of the most important parts of international efforts to assist reconstruction, through which we hope Palestinians and Israelis will achieve lasting peace, health, and sustainable development, all as part of accepted international human rights obligations.

Barriers to sustainable health research leadership in the Global South: Time for a Grand Bargain on localization of research leadership?

BACKGROUND: Strong Global South (GS) health research leadership, itself both dependent on and a requisite for strong health research systems, is essential to generate locally relevant research and ensure that evidence is translated into policy and practice. Strong GS health research systems and leadership are important for health development and in turn for strong health systems. However, many GS countries struggle to produce research and to improve performance on widely used research metrics measuring productivity and reflecting leadership. Drawing on literature from a rapid review, this viewpoint paper considers the barriers to GS health research leadership and proposes strategies to address these challenges. FINDINGS: GS researchers and institutions face numerous barriers that undermine health research leadership potential. Barriers internal to the GS include researcher-level barriers such as insufficient mentorship, limited financial incentives and time constraints. Institutional barriers include limited availability of resources, restrictive and poorly developed research infrastructures, weak collaboration and obstructive policies and procedures. Structural barriers include political will, politicization of research and political instability. External barriers relate to the nature and extent of Global North (GN) activities and systems and include allocation and distribution of funding and resources, characteristics and focus of GN-GS research collaborations, and publication and information dissemination challenges. CONCLUSIONS: Strengthening GS health research leadership requires acknowledgement of the many barriers, and adoption of mitigating measures by a range of actors at the institutional, national, regional and global levels. Particularly important are leadership capacity development integrating researcher, institutional and systems initiatives; new GN-GS partnership models emphasizing capacity exchange and shared leadership; supporting GS research communities to set, own and drive their research agendas; addressing biases against GS researchers; ensuring that GS institutions address their internal challenges; enhancing South-South collaborations; diversifying research funding flow to the GS; and learning from models that work. The time has come for a firm commitment to improving localization of research leadership, supported by adequate funding flow, to ensure strong and sustainable research systems and leadership in and from the GS. Just as the humanitarian donor and aid community adopted the Grand Bargain commitment to improve funding flow through local and national responders in times of crisis, we strongly urge the global health research community to adopt a Grand Bargain for research leadership.

Schools of public health in low and middle-income countries: an imperative investment for improving the health of populations?

BACKGROUND: Public health has multicultural origins. By the close of the nineteenth century, Schools of Public Health (SPHs) began to emerge in western countries in response to major contemporary public health challenges. The Flexner Report (1910) emphasized the centrality of preventive medicine, sanitation, and public health measures in health professional education. The Alma Ata Declaration on Primary Health Care (PHC) in 1978 was a critical milestone, especially for low and middle-income countries (LMICs), conceptualizing a close working relationship between PHC and public health measures. The Commission on Social Determinants of Health (2005-2008) strengthened the case for SPHs in LMICs as key stakeholders in efforts to reduce global health inequities. This scoping review groups text into public health challenges faced by LMICs and the role of SPHs in addressing these challenges. MAIN TEXT: The challenges faced by LMICs include rapid urbanization, environmental degradation, unfair terms of global trade, limited capacity for equitable growth, mass displacements associated with conflicts and natural disasters, and universal health coverage. Poor governance and externally imposed donor policies and agendas, further strain the fragile health systems of LMICs faced with epidemiological transition. Moreover barriers to education and research imposed by limited resources, political and economic instability, and unbalanced partnerships additionally aggravate the crisis. To address these contextual challenges effectively, SPHs are offering broad based health professional education, conducting multidisciplinary population based research and fostering collaborative partnerships. SPHs are also looked upon as the key drivers to achieve sustainable development goals (SDGs). CONCLUSION: SPHs in LMICs can contribute to overcoming several public health challenges being faced by LMICs, including achieving SDGs. Most importantly they can develop cadres of competent and well-motivated public health professionals: educators, practitioners and researchers who ask questions that address fundamental health determinants, seek solutions as agents of change within their mandates, provide specific services and serve as advocates for multilevel partnerships. Funding support, human resources, and agency are unfortunately often limited or curtailed in LMICs, and this requires constructive collaboration between LMICs and counterpart institutions from high income countries.

Health and ecological sustainability in the Arab world: a matter of survival.

Discussions leading to the Rio+20 UN conference have emphasised the importance of sustainable development and the protection of the environment for future generations. The Arab world faces large-scale threats to its sustainable development and, most of all, to the viability and existence of the ecological systems for its human settlements. The dynamics of population change, ecological degradation, and resource scarcity, and development policies and practices, all occurring in complex and highly unstable geopolitical and economic environments, are fostering the poor prospects. In this report, we discuss the most pertinent population-environment-development dynamics in the Arab world, and the two-way interactions between these dynamics and health, on the basis of current data. We draw attention to trends that are relevant to health professionals and researchers, but emphasise that the dynamics generating these trends have implications that go well beyond health. We argue that the current discourse on health, population, and development in the Arab world has largely failed to convey a sense of urgency, when the survival of whole communities is at stake. The dismal ecological and development records of Arab countries over the past two decades call for new directions. We suggest that regional ecological integration around exchange of water, energy, food, and labour, though politically difficult to achieve, offers the best hope to improve the adaptive capacity of individual Arab nations. The transformative political changes taking place in the Arab world offer promise, indeed an imperative, for such renewal. We call on policy makers, researchers, practitioners, and international agencies to emphasise the urgency and take action.

A conceptual framework on pre- and post-displacement stressors: the case of Syrian refugees.

Researchers have documented multiple stressors and mental health problems along the journey of refugees as they are displaced to seek refuge in nearby and remote host countries. This article examines published research on Syrian refugees to propose a framework to conceptualize Syrian refugees' pre- and post-stressors and their collective impact on their mental health. The proposed framework provides a comprehensive understanding of the interconnected pathways between pre-displacement stressors, post-displacement stressors, and mental health outcomes for Syrian refugees. Pre-displacement stressors are best captured by the concept of trauma centrality and emotional suppression. Post-displacement stressors, categorized under financial, political, and social themes, have a direct impact on the mental health of the refugees, but could also play a partial mediating role on the impact of pre-displacement stressors on mental health. The framework suggests a direct pathway between the experience of war-related traumatic events and mental health and introduces the country of residence as a potential moderator of the severity of mental health. The latter is primarily influenced by local policies and the host communities' acceptance of refugees. We believe that the proposed framework can guide the work of researchers, policymakers, and practitioners concerned with the mental health and well-being of Syrian refugees. Additionally, although based on the experience of Syrian refugees, it presents a holistic perspective that could be adapted in other refugee settings.

Conflict-related health research in Syria, 2011-2019: a scoping review for The Lancet - AUB Commission on Syria.

BACKGROUND: The volume of health-related publications on Syria has increased considerably over the course of the conflict compared with the pre-war period. This increase is largely attributed to commentaries, news reports and editorials rather than research publications. This paper seeks to characterise the conflict-related population and humanitarian health and health systems research focused inside Syria and published over the course of the Syrian conflict. METHODS: As part of a broader scoping review covering English, Arabic and French literature on health and Syria published from 01 January 2011 to 31 December 2019 and indexed in seven citation databases (PubMed, Medline (OVID), CINAHL Complete, Global Health, EMBASE, Web of Science, Scopus), we analyzed conflict-related research papers focused on health issues inside Syria and on Syrians or residents of Syria. We classified research articles based on the major thematic areas studied. We abstracted bibliometric information, study characteristics, research focus, funding statements and key limitations and challenges of conducting research as described by the study authors. To gain additional insights, we examined, separately, non-research publications reporting field and operational activities as well as personal reflections and narrative accounts of first-hand experiences inside Syria. RESULTS: Of 2073 papers identified in the scoping review, 710 (34%) exclusively focus on health issues of Syrians or residents inside Syria, of which 350 (49%) are conflict-related, including 89 (25%) research papers. Annual volume of research increased over time, from one publication in 2013 to 26 publications in 2018 and 29 in 2019. Damascus was the most frequently studied governorate (n = 33), followed by Aleppo (n = 25). Papers used a wide range of research methodologies, predominantly quantitative (n = 68). The country of institutional affiliation(s) of first and last authors are predominantly Syria (n = 30, 21 respectively), the United States (n = 25, 19 respectively) or the United Kingdom (n = 12, 10 respectively). The majority of authors had academic institutional affiliations. The most frequently examined themes were health status, the health system and humanitarian assistance, response or needs (n = 38, 34, 26 respectively). Authors described a range of contextual, methodological and administrative challenges in conducting research on health inside Syria. Thirty-one publications presented field and operational activities and eight publications were reflections or first-hand personal accounts of experiences inside Syria. CONCLUSIONS: Despite a growing volume of research publications examining population and humanitarian health and health systems issues inside conflict-ravaged Syria, there are considerable geographic and thematic gaps, including limited research on several key pillars of the health system such as governance, financing and medical products; issues such as injury epidemiology and non-communicable disease burden; the situation in the north-east and south of Syria; and besieged areas and populations. Recognising the myriad of complexities of researching active conflict settings, it is essential that research in/on Syria continues, in order to build the evidence base, understand critical health issues, identify knowledge gaps and inform the research agenda to address the needs of the people of Syria following a decade of conflict.

Mapping University-Based Master of Public Health Programs in the Arab world.

Background: The Arab world faces numerous health challenges that mandate a competent public health workforce and strengthening public health education. Objective: To analyze university-based Master of Public Health (MPH) programs offered at Faculties of Public Health (FPH) and of Medicine (FM) in Arab countries. Methods: We searched a regional database of academic public health institutions, conducted a search of university websites, and reviewed websites of the Association of Arab Universities and World Directory of Medical Schools. A factsheet for each MPH program was emailed to deans of respective faculties for validation and completion. We examined associations between presence of such programs and population size and Human Development Index (HDI). Findings: A total of 19 FPH and 10 FM at 28 universities offer MPH programs (7 programs per 100 million population). Ten countries offer no MPH programs; the remaining 12 offer 1-5 programs each. Ten MPH programs were initiated over 45 years (1965-2009) and another 19 over 10 years (2010-2019). No correlation was observed between offering an MPH program and the country's HDI or population size. Less than half of the programs admit students from fields outside health. FPH and FM-based programs are comparable in offering core disciplines but FPH programs offer more Social and Behavioral Sciences (83% vs. 60%). More FM-based programs provide practicum training (78% vs. 53%); 10 programs offer none. Epidemiology, alone or with Biostatistics, and Health Management and Policy are the two most frequently offered MPH concentrations. None of the MPH programs offer a concentration on public health in conflict or humanitarian crises; only one offers a certificate on the theme. Only three programs, all FPH-based, reported international accreditation. Conclusions: The recent increase in MPH programs in Arab countries is encouraging. Critical gaps are absence of MPH programs in 10 countries, less coverage of the social sciences, and lack of practicum experience in 10 programs. Upgrading and promoting public health education across the region to fill these gaps calls for collaboration among existing MPH programs. More in-depth analysis of the history and mission of these programs, as well as their admission criteria and curricula, is needed.

Policies on return and reintegration of displaced healthcare workers towards rebuilding conflict-affected health systems: a review for The Lancet-AUB Commission on Syria.

BACKGROUND: War and armed conflicts severely disrupt all health system components, including the healthcare workforce. Although data is limited on the scale of health care worker (HCW) displacement in conflict zones, it is widely acknowledged that conflict conditions result in the displacement of a significant portion of qualified HCWs from their country of origin. While voluntary HCW return is integral to health system rebuilding in conflict-affected and post-conflict settings, there has been little exploration of the nature of national or international policies which encourage HCW return and reintegration to their home countries in the post-conflict period. METHODS: We conducted a systematic review to identify policies and policy recommendations intended to facilitate the return of displaced HCWs to their home countries and acknowledge their contribution to rebuilding the post-conflict health system. We searched three bibliographic databases and a range of organisational and national health agency websites to identify peer-reviewed articles and grey literature published in English or Arabic between 1 January 1990 to 24 January 2021, and extracted relevant information. We classified policies and policy recommendations using an adapted version of the UNHCR 4Rs Framework. RESULTS: We identified nine peer-review articles and four grey literature reports that fit our inclusion criteria, all of which were published in English. These covered issues of repatriation (n = 3), reintegration (n = 2), health system rehabilitation and reconstruction (n = 2); six documents covered several of these themes. Information was available for nine conflict contexts: Afghanistan, Iraq, Kosovo, Lebanon, Namibia, Northern Uganda, South Sudan, Timor Leste, and Zimbabwe. Findings demonstrate that health system rebuilding and rehabilitation serve as precursors and reinforcers of the successful return, repatriation, and reintegration of displaced HCWs. CONCLUSIONS: Despite the significant numbers of HCWs displaced by conflict, this study identified few specific policies and limited information explicitly focused on the repatriation and reintegration of such workers to their home country in the post-conflict period. Additional research is needed to understand the particular barriers faced by conflict-displaced HCWs in returning to their home country. Conflict-affected and post-conflict states should develop policies and initiatives that address factors within and beyond the health sector to encourage displaced HCW return and provide sustainable reintegration solutions for those who return to post-conflict health systems.

Introduction to collection: confronting the challenges of health research in humanitarian crises.

BACKGROUND: Humanitarian crises, such as armed conflict, forced displacement, natural disasters, and major disease outbreaks, take a staggering toll on human health, especially in low-resource settings. Yet there is a dearth of robust evidence to inform the governments, non-governmental organizations (NGOs), and other humanitarian organizations on how to best respond to them. The Fogarty International Center of the U.S. National Institutes of Health commissioned a collection of Research in Practice articles that highlights the experiences of scientists conducting research in the context of humanitarian crises. Unlike traditional research papers, the case analyses in this collection go beyond what research was completed and focus on why the research was important and how it was conducted in these extremely challenging settings. DISCUSSION: The papers selected for this collection span 27 countries, cover a broad range of humanitarian crises, and discuss a wide variety of disease and health risk factors. Of the 23 papers in the collection, 17 include an author from the affected country and five papers were authored by humanitarian NGOs. Throughout the collection, 43% of the authors were from low- and middle-income countries. Across the collection, some general themes emerged that are broadly applicable. Importantly, there is a clear need for more, high-quality research to address evidence gaps. Community engagement, already a key element to global health research, was highlighted as especially important for research involving populations dealing with severe trauma and disruption. Partnership with humanitarian actors, including local governments, local and international NGOs, and UN agencies, was found to be a critical strategy as well. CONCLUSION: A variety of audiences will find this collection useful. Global health educators can utilize papers to facilitate discussion around public health practice and equitable partnerships, among other topics. Humanitarian response organizations may use the collection to consider how research may inform and improve their work. Global health researchers, funders, and other stakeholders may use the collection to stimulate dialogue around key scientific research questions and better appreciate the importance of conducting research in humanitarian crises in the context of achieving broader global health goals.

The challenges of sustainable access to safe drinking water in rural areas of developing countries: case of Zawtar El-Charkieh, Southern Lebanon.

Adequate and safe water is important for human health and well-being, economic production, and sustainable development. Failure to ensure the safety of drinking water may expose the community to the risk of outbreaks of waterborne and infectious diseases. Although drinking water is a basic human right, many people do not have access to safe and adequate drinking water or proper sanitation facilities. The authors conducted a study to assess the quantity, cost, continuity, coverage, and quality of drinking water in the village of Zawtar El-Charkieh, Lebanon. Their aim was to identify the challenges of sustainable access to safe drinking water in order to determine the short-term management actions and long-term strategies to improve water quality. Results revealed that contamination of the source, absence of any disinfection method or insufficient dose, poor maintenance operations, and aging of the networks are significant factors contributing to water contamination during the storage and distribution process. Establishing a comprehensive drinking water system that integrates water supply, quality, and management as well as associated educational programs in order to ensure the safety and sustainability of drinking water supplies is essential.

Attitudes and practices of public health academics towards research funding from for-profit organizations: cross-sectional survey.

OBJECTIVES: The growing trend of for-profit organization (FPO)-funded university research is concerning because resultant potential conflicts of interest might lead to biases in methods, results, and interpretation. For public health academic programmes, receiving funds from FPOs whose products have negative health implications may be particularly problematic. METHODS: A cross-sectional survey assessed attitudes and practices of public health academics towards accepting funding from FPOs. The sampling frame included universities in five world regions offering a graduate degree in public health; 166 academics responded. Descriptive, bivariate, and logistic regression analyses were conducted. RESULTS: Over half of respondents were in favour of accepting funding from FPOs; attitudes differed by world region and gender but not by rank, contract status, % salary offset required, primary identity, or exposure to an ethics course. In the last 5 years, almost 20% of respondents had received funding from a FPO. Sixty per cent of respondents agreed that there was potential for bias in seven aspects of the research process, when funds were from FPOs. CONCLUSIONS: Globally, public health academics should increase dialogue around the potential harms of research and practice funded by FPOs.