Conflict-related intentional injuries in Baghdad, Iraq, 2003-2014: A modeling study and proposed method for calculating burden of injury in conflict.

BACKGROUND: Previous research has focused on the mortality associated with armed conflict as the primary measure of the population health effects of war. However, mortality only demonstrates part of the burden placed on a population by conflict. Injuries and resultant disabilities also have long-term effects on a population and are not accounted for in estimates that focus solely on mortality. Our aim was to demonstrate a new method to describe the effects of both lives lost, and years of disability generated by a given conflict, with data from the US-led 2003 invasion and subsequent occupation of Iraq. METHODS AND FINDINGS: Our data come from interviews conducted in 2014 in 900 Baghdad households containing 5,148 persons. The average household size was 5.72 persons. The majority of the population (55.8%) were between the ages of 19 and 60. Household composition was evenly divided between males and females. Household sample collection was based on methodology previously designed for surveying households in war zones. Survey questions were answered by the head of household or senior adult present. The questions included year the injury occurred, the mechanism of injury, the body parts injured, whether injury resulted in disability and, if so, the length of disability. We present this modeling study to offer an innovative methodology for measuring "years lived with disability" (YLDs) and "years of life lost" (YLLs) attributable to conflict-related intentional injuries, using the Global Burden of Disease (GBD) approach. YLDs were calculated with disability weights, and YLLs were calculated by comparing the age at death to the GBD standard life table to calculate remaining life expectancy. Calculations were also performed using Iraq-specific life expectancy for comparison. We calculated a burden of injury of 5.6 million disability-adjusted life years (DALYs) lost due to conflict-related injuries in Baghdad from 2003 to 2014. The majority of DALYs lost were attributable to YLLs, rather than YLDs, 4.99 million YLLs lost (95% uncertainty interval (UI) 3.87 million to 6.13 million) versus 616,000 YLDs lost (95% UI 399,000 to 894,000). Cause-based analysis demonstrated that more DALYs were lost to due to gunshot wounds (57%) than any other cause. Our study has several limitations. Recall bias regarding the reporting and attribution of injuries is possible. Second, we have no data past the time of the interview, so we assumed individuals with ongoing disability at the end of data collection would not recover, possibly counting more disability for injuries occurring later. Additionally, incomplete data could have led to misclassification of deaths, resulting in an underestimation of the total burden of injury. CONCLUSIONS: In this study, we propose a methodology to perform burden of disease calculations for conflict-related injuries (expressed in DALYs) in Baghdad from 2003 to 2014. We go beyond previous reports of simple mortality to assess long-term population health effects of conflict-related intentional injuries. Ongoing disability is, in cross section, a relatively small 10% of the total burden. Yet, this small proportion creates years of demands on the health system, persistent limitations in earning capacity, and continuing burdens of care provision on family members.

Court-imposed fines as a feature of the homelessness-incarceration nexus: a cross-sectional study of the relationship between legal debt and duration of homelessness in Seattle, Washington, USA.

BACKGROUND: Legal system involvement is a policy-driven risk factor for homelessness. Legal financial obligations (LFOs), such as court fees, fines and restitution, can endanger the financial security of those ensnared in the criminal justice system. In this study we measured the effect of incarceration and LFOs on duration of homelessness in Seattle, WA, USA. METHODS: To analyze the relationship between incarceration, debt and duration of homelessness, we interviewed 101 adults experiencing homelessness and living in city-sanctioned encampments and tiny house villages in Seattle, WA in 2017-18. We collected personal housing history, presence and amount of debt, and measures of legal system involvement. RESULTS: Our respondents experienced homelessness an average of 41 months during the current episode. Nearly two-thirds reported being convicted of a crime, and 78% had been incarcerated. More than 25% reported owing current legal fines. Individuals with legal fine debt experienced 22.9 months of additional homelessness after considering the effects of race, age, and gender. CONCLUSION: We confirmed a strong association between homelessness and legal trouble. Among high-income countries, the USA has the highest rates of legal system involvement and the highest rates of homelessness; the relationship between the two may be connected.

Solidarity and disparity: Declining labor union density and changing racial and educational mortality inequities in the United States.

BACKGROUND: Recently, United States life expectancy has stagnated or declined for the poor and working class and risen for the middle and upper classes. Declining labor-union density-the percent of workers who are unionized-has precipitated burgeoning income inequity. We examined whether it has also exacerbated racial and educational mortality inequities. METHODS: From CDC, we obtained state-level all-cause and overdose/suicide mortality overall and by gender, gender-race, and gender-education from 1986-2016. State-level union density and demographic and economic confounders came from the Current Population Survey. State-level policy confounders included the minimum wage, the generosity of Aid to Families with Dependent Children or Temporary Assistance for Needy Families, and the generosity of unemployment insurance. To model the exposure-outcome relationship, we used marginal structural modeling. Using state-level inverse-probability-of-treatment-weighted Poisson models with state and year fixed effects, we estimated 3-year moving average union density's effects on the following year's mortality rates. Then, we tested for gender, gender-race, and gender-education effect-modification. Finally, we estimated how racial and educational all-cause mortality inequities would change if union density increased to 1985 or 1988 levels, respectively. RESULTS: Overall, a 10% increase in union density was associated with a 17% relative decrease in overdose/suicide mortality (95% confidence interval [CI]: 0.70, 0.98), or 5.7 lives saved per 100 000 person-years (95% CI: -10.7, -0.7). Union density's absolute (lives-saved) effects on overdose/suicide mortality were stronger for men than women, but its relative effects were similar across genders. Union density had little effect on all-cause mortality overall or across subgroups, and modeling suggested union-density increases would not affect mortality inequities. CONCLUSIONS: Declining union density (as operationalized in this study) may not explain all-cause mortality inequities, although increases in union density may reduce overdose/suicide mortality.

Perceptions, experiences and expectations of Iraqi medical students.

BACKGROUND: The environment for medical education in Iraq has been difficult for many years. The 2003 invasion of Iraq accelerated a steady emigration of faculty and graduates. Kidnappings and deaths of doctors became commonplace. To understand current career plans, expectations and perceptions of medical students, three Baghdad medical schools were surveyed. METHODS: Written questionnaires were completed by 418 medical students variously in their 4th, 5th and 6th (final)years of training. We asked about perceptions of the quality of their medical education, the quality of health services in Iraq generally, and about deaths, injuries and migration of faculty, classmates and family. RESULTS: The average age of students was 22 years, with 59% women. Most students (90%) were originally from Baghdad. Although there were some positive responses, many students (59%) rated the overall quality of their medical education as fair or poor. Three-fourths of students believed the quality of hospital care in Iraq to be only fair or poor. A majority of students (57%) stated they were thinking frequently or all the time about leaving Iraq after graduation. Reasons given for leaving included the desire for further education, seeking a better lifestyle and fleeing conflict. Leading reasons for staying included the pull of friends and family, familiarity with the health system, and a sense of responsibility to the country. Nearly one in five (18%) students reported the death of a family member attributable to intentional violence, and 15% reported the violent death of a medical school classmate or faculty member since the 2003 invasion. Half the students reported at least one school faculty members had left Iraq because of the war. CONCLUSION: Medical students hold a mediocre view of the quality of their medical education and of Iraq's health system. Many of their faculty members have left the country. The majority of students may leave Iraq after graduation, afforded the opportunity. This poses a significant problem for staffing an already demoralized and stressed health system. Current circumstances suggest the situation will continue to deteriorate.

The Role of Labor Unions in Creating Working Conditions That Promote Public Health.

We sought to portray how collective bargaining contracts promote public health, beyond their known effect on individual, family, and community well-being. In November 2014, we created an abstraction tool to identify health-related elements in 16 union contracts from industries in the Pacific Northwest. After enumerating the contract-protected benefits and working conditions, we interviewed union organizers and members to learn how these promoted health. Labor union contracts create higher wage and benefit standards, working hours limits, workplace hazards protections, and other factors. Unions also promote well-being by encouraging democratic participation and a sense of community among workers. Labor union contracts are largely underutilized, but a potentially fertile ground for public health innovation. Public health practitioners and labor unions would benefit by partnering to create sophisticated contracts to address social determinants of health.

Road traffic injuries in Baghdad from 2003 to 2014: results of a randomised household cluster survey.

INTRODUCTION: Around 50 million people are killed or left disabled on the world's roads each year; most are in middle-income cities. In addition to this background risk, Baghdad has been plagued by decades of insecurity that undermine injury prevention strategies. This study aimed to determine death and disability and household consequences of road traffic injuries (RTIs) in postinvasion Baghdad. METHODS: A two-stage, cluster-randomised, community-based household survey was performed in May 2014 to determine the civilian burden of injury from 2003 to 2014 in Baghdad. In addition to questions about household member death, households were interviewed regarding crash specifics, healthcare required, disability, relatedness to conflict and resultant financial hardship. RESULTS: Nine hundred households, totalling 5148 individuals, were interviewed. There were 86 RTIs (16% of all reported injuries) that resulted in 8 deaths (9% of RTIs). Serious RTIs increased in the decade postinvasion and were estimated to be 26 341 in 2013 (350 per 100 000 persons). 53% of RTIs involved pedestrians, motorcyclists or bicyclists. 51% of families directly affected by a RTI reported a significant decline in household income or suffered food insecurity. CONCLUSIONS: RTIs were extremely common and have increased in Baghdad. Young adults, pedestrians, motorcyclists and bicyclists were the most frequently injured or killed by RTCs. There is a large burden of road injury, and the families of road injury victims suffered considerably from lost wages, often resulting in household food insecurity. Ongoing conflict may worsen RTI risk and undermine efforts to reduce road traffic death and disability.

Developing hospital accreditation standards in Uganda.

BACKGROUND: Whereas accreditation is widely used as a tool to improve quality of healthcare in the developed world, it is a concept not well adapted in most developing countries for a host of reasons, including insufficient incentives, insufficient training and a shortage of human and material resources. The purpose of this paper is to describe refining use and outcomes of a self-assessment hospital accreditation tool developed for a resource-limited context. METHODS: We invited 60 stakeholders to review a set of standards (from which a self-assessment tool was developed), and subsequently refined them to include 485 standards in 7 domains. We then invited 60 hospitals to test them. A study team traveled to each of the 40 hospitals that agreed to participate providing training and debrief the self-assessment. The study was completed in 8 weeks. RESULTS: Hospital self-assessments revealed hospitals were remarkably open to frank rating of their performance and willing to rank all 485 measures. Good performance was measured in outreach programs, availability of some types of equipment and running water, 24-h staff calls systems, clinical guidelines and waste segregation. Poor performance was measured in care for the vulnerable, staff living quarters, physician performance reviews, patient satisfaction surveys and sterilizing equipment. CONCLUSION: We have demonstrated the feasibility of a self-assessment approach to hospital standards in low-income country setting. This low-cost approach may be used as a good precursor to establishing a national accreditation body, as indicated by the Ministry's efforts to take the next steps. Copyright © 2015 John Wiley & Sons, Ltd.

Domestic violence, marital control, and family planning, maternal, and birth outcomes in Timor-Leste.

Patriarchal traditions and a history of armed conflict in Timor-Leste provide a context that facilitates violence against women. More than a third of ever-married Timorese women report physical and/or sexual domestic violence (DV) perpetrated by their most recent partner. DV violates women's rights and may threaten their reproductive health. Marital control may also limit women's reproductive control and healthcare access. Our study investigated relationships between DV and marital control and subsequent family planning, maternal healthcare, and birth outcomes in Timor-Leste. Using logistic regression, we examined 2009-2010 Demographic and Health Survey data from a nationally representative sample of 2,951 women in Timor-Leste. We controlled for age, education, and wealth. We limited our analyses of pregnancy- and birth-related outcomes to those from the 6 months preceding the survey. Rural women with controlling husbands were less likely than other rural women to have an unmet need for family planning (Adj. OR 0.6; 95 % CI 0.4-0.9). Rural women who experienced DV were more likely than other rural women to have an unplanned pregnancy (Adj. OR 2.6; 95 % CI 1.4-4.8), fewer than four antenatal visits (Adj. OR 2.3; 95 % CI 1.1-4.9), or a baby born smaller than average (Adj. OR 3.1; 95 % CI 1.4-6.7). DV and marital control were not associated with the tested outcomes among urban women. Given high rates of DV internationally, our findings have important implications. Preventing DV may benefit both women and future generations. Furthermore, rural women who experience DV may benefit from targeted interventions that mediate associated risks of negative family planning, maternal healthcare, and birth outcomes.

The role of public health in the prevention of war: rationale and competencies.

In 2009 the American Public Health Association approved the policy statement, "The Role of Public Health Practitioners, Academics, and Advocates in Relation to Armed Conflict and War." Despite the known health effects of war, the development of competencies to prevent war has received little attention. Public health's ethical principles of practice prioritize addressing the fundamental causes of disease and adverse health outcomes. A working group grew out of the American Public Health Association's Peace Caucus to build upon the 2009 policy by proposing competencies to understand and prevent the political, economic, social, and cultural determinants of war, particularly militarism. The working group recommends that schools of public health and public health organizations incorporate these competencies into professional preparation programs, research, and advocacy.

Namibian prisoners describe barriers to HIV antiretroviral therapy adherence.

Little is available in scholarly literature about how HIV-positive prisoners, especially in low-income countries, access antiretroviral therapy (ART) medication. We interviewed 18 prisoners at a large prison in Namibia to identify barriers to medication adherence. The lead nurse researcher was a long-standing clinic employee at the prison, which afforded her access to the population. We identified six significant barriers to adherence, including (1) the desire for privacy and anonymity in a setting where HIV is strongly stigmatized; (2) the lack of simple supports for adherence, such as availability of clocks; (3) insufficient access to food to support the toll on the body of ingesting taxing ART medications; (4) commodification of ART medication; (5) the brutality and despair in the prison setting, generally leading to discouragement and a lack of motivation to strive for optimum health; and (6) the lack of understanding about HIV, how it is transmitted, and how it is best managed. Because most prisoners eventually transition back to communitysettings when their sentences are served, investments in prison health represent important investments in public health.

Characteristics of home care workers who leave their jobs: a cross-sectional study of job satisfaction and turnover in Washington State.

Attracting and retaining a stable and motivated home care workforce has become a top policy priority. We surveyed 402 former home care workers in Washington State. We compared these "leavers" to current home care workers recently surveyed. Those who left the profession were more highly educated, had higher household income, and were more likely to be White. Those newly employed have better benefits, wages, hours, and career mobility than in their home care jobs. The low status and poor pay of home care workers may result in the inability of the profession to retain those who face better prospects.

The Locations of Palestine and the U.S. in the Global Map of Homelessness: Part 2.

It's now well appreciated that social determinants of health are the strongest predictors of our health and well-being. A good argument could be made that housing is at the top of the pyramid of these determinants. And, surprisingly, housing is also the social determinant that could rapidly turn on a dime-that is, with sufficient political will, creating access to housing could be radically expanded in short order. (Unfortunately, of course, it's true one can also become suddenly homeless, since few protections exist in policy or capitalist economies to prevent it). That alone sets it apart from social factors such as education and racism-conditions that take a long time to change. In contrast to long-term interventions (education) or culturally stubborn and historically rooted problems (racism), housing is rapidly malleable. In this article, we describe the social condition of homelessness in two settings, comparing and contrasting the concepts, causes, and consequences, along with how people are mobilizing to challenge the conditions that create their housing insecurity. As we review the factors that create housing conditions in each setting, we propose some universal international principles for a new approach to the human right of decent and secure housing.

The Locations of Palestine and the U.S. in the Global Map of Homelessness: Part I.

It's now well appreciated that social determinants of health are the strongest predictors of our health and well-being. A good argument could be made that housing is at the top of the pyramid of these determinants. And, surprisingly, housing is also the social determinant that could rapidly turn on a dime-that is, with sufficient political will, creating access to housing could be radically expanded in short order. (Unfortunately, of course, it's true one can also become suddenly homeless, since few protections exist in policy or capitalist economies to prevent it). That alone sets it apart from social factors such as education and racism-conditions that take a long time to change. In contrast to long-term interventions (education) or culturally stubborn and historically rooted problems (racism), housing is rapidly malleable. In this article, we describe the social condition of homelessness in two settings, comparing and contrasting the concepts, causes, and consequences, along with how people are mobilizing to challenge the conditions that create their housing insecurity. As we review the factors that create housing conditions in each setting, we propose some universal international principles for a new approach to the human right of decent and secure housing.

Mortality in Iraq associated with the 2003-2011 war and occupation: findings from a national cluster sample survey by the university collaborative Iraq Mortality Study.

BACKGROUND: Previous estimates of mortality in Iraq attributable to the 2003 invasion have been heterogeneous and controversial, and none were produced after 2006. The purpose of this research was to estimate direct and indirect deaths attributable to the war in Iraq between 2003 and 2011. METHODS AND FINDINGS: We conducted a survey of 2,000 randomly selected households throughout Iraq, using a two-stage cluster sampling method to ensure the sample of households was nationally representative. We asked every household head about births and deaths since 2001, and all household adults about mortality among their siblings. We used secondary data sources to correct for out-migration. From March 1, 2003, to June 30, 2011, the crude death rate in Iraq was 4.55 per 1,000 person-years (95% uncertainty interval 3.74-5.27), more than 0.5 times higher than the death rate during the 26-mo period preceding the war, resulting in approximately 405,000 (95% uncertainty interval 48,000-751,000) excess deaths attributable to the conflict. Among adults, the risk of death rose 0.7 times higher for women and 2.9 times higher for men between the pre-war period (January 1, 2001, to February 28, 2003) and the peak of the war (2005-2006). We estimate that more than 60% of excess deaths were directly attributable to violence, with the rest associated with the collapse of infrastructure and other indirect, but war-related, causes. We used secondary sources to estimate rates of death among emigrants. Those estimates suggest we missed at least 55,000 deaths that would have been reported by households had the households remained behind in Iraq, but which instead had migrated away. Only 24 households refused to participate in the study. An additional five households were not interviewed because of hostile or threatening behavior, for a 98.55% response rate. The reliance on outdated census data and the long recall period required of participants are limitations of our study. CONCLUSIONS: Beyond expected rates, most mortality increases in Iraq can be attributed to direct violence, but about a third are attributable to indirect causes (such as from failures of health, sanitation, transportation, communication, and other systems). Approximately a half million deaths in Iraq could be attributable to the war. Please see later in the article for the Editors' Summary.

Use of surgical task shifting to scale up essential surgical services: a feasibility analysis at facility level in Uganda.

BACKGROUND: The shortage and mal-distribution of surgical specialists in sub-Saharan African countries is born out of shortage of individuals choosing a surgical career, limited training capacity, inadequate remuneration, and reluctance on the part of professionals to work in rural and remote areas, among other reasons. This study set out to assess the views of clinicians and managers on the use of task shifting as an effective way of alleviating shortages of skilled personnel at a facility level. METHODS: 37 in-depth interviews with key informants and 24 focus group discussions were held to collect qualitative data, with a total of 80 healthcare managers and frontline health workers at 24 sites in 15 districts. Quantitative and descriptive facility data were also collected, including operating room log sheets to identify the most commonly conducted operations. RESULTS: Most health facility managers and health workers supported surgical task shifting and some health workers practiced it. The practice is primarily driven by a shortage of human resources for health. Personnel expressed reluctance to engage in surgical task shifting in the absence of a regulatory mechanism or guiding policy. Those in favor of surgical task shifting regarded it as a potential solution to the lack of skilled personnel. Those who opposed it saw it as an approach that could reduce the quality of care and weaken the health system in the long term by opening it to unregulated practice and abuse of privilege. There were enough patient numbers and basic infrastructure to support training across all facilities for surgical task shifting. CONCLUSION: Whereas surgical task shifting was viewed as a short-term measure alongside efforts to train and retain adequate numbers of surgical specialists, efforts to upscale its use were widely encouraged.

Mutual Aid Praxis Aligns Principles and Practice in Grassroots COVID-19 Responses Across the US.

COVID-19 elicited a rapid emergence of new mutual aid networks in the US, but the practices of these networks are understudied. Using qualitative methods, we explored the empirical ethics guiding US-based mutual aid networks' activities, and assessed the alignment between principles and practices as networks mobilized to meet community needs during 2020-21. We conducted in-depth interviews with 15 mutual aid group organizers and supplemented these with secondary source materials on mutual aid activities and participant observation of mutual aid organizing efforts. We analyzed participants' practices in relation to key mutual aid principles as defined in the literature: 1) solidarity not charity; 2) non-hierarchical organizational structures; 3) equity in decision-making; and 4) political engagement. Our data also yielded a fifth principle, "mutuality," essential to networks' approaches but distinct from anarchist conceptions of mutualism. While mutual aid networks were heavily invested in these ethical principles, they struggled to achieve them in practice. These findings underscore the importance of mutual aid praxis as an intersection between ethical principles and practices, and the challenges that contemporary, and often new, mutual aid networks responding to COVID-19 face in developing praxis during a period of prolonged crisis. We develop a theory-of-change model that illuminates both the opportunities and the potential pitfalls of mutual aid work in the context of structural inequities, and shows how communities can achieve justice-oriented mutual aid praxis in current and future crises.

Cameroon mid-level providers offer a promising public health dentistry model.

BACKGROUND: Oral health services are inadequate and unevenly distributed in many developing countries, particularly those in sub-Saharan Africa. Rural areas in these countries and poorer sections of the population in urban areas often do not have access to oral health services mainly because of a significant shortage of dentists and the high costs of care. We reviewed Cameroon's experience with deploying a mid-level cadre of oral health professionals and the feasibility of establishing a more formal and predictable role for these health workers. We anticipate that a task-shifting approach in the provision of dental care will significantly improve the uneven distribution of oral health services particularly in the rural areas of Cameroon, which is currently served by only 3% of the total number of dentists. METHODS: The setting of this study was the Cameroon Baptist Convention Health Board (BCHB), which has four dentists and 42 mid-level providers. De-identified data were collected manually from the registries of 10 Baptist Convention clinics located in six of Cameroon's 10 regions and then entered into an Excel format before importing into STATA. A retrospective abstraction of all entries for patient visits starting October 2010, and going back in time until 1500 visits were extracted from each clinic. RESULTS: This study showed that mid-level providers in BCHB clinics are offering a full scope of dental work across the 10 clinics, with the exception of treatment for major facial injuries. Mid-level providers alone performed 93.5% of all extractions, 87.5% of all fillings, 96.5% of all root canals, 97.5% of all cleanings, and 98.1% of all dentures. The dentists also typically played a teaching role in training the mid-level providers. CONCLUSIONS: The Ministry of Health in Cameroon has an opportunity to learn from the BCHB model to expand access to oral health care across the country. This study shows the benefits of using a simple, workable, low-cost way to provide needed dental services across Cameroon, particularly in rural areas.