Rapidly adapted community health strategies to prevent treatment interruption and improve COVID-19 detection for Syrian refugees and the host population with hypertension and diabetes in Jordan.

BACKGROUND: We evaluated community health volunteer (CHV) strategies to prevent non-communicable disease (NCD) care disruption and promote coronavirus disease 2019 (COVID-19) detection among Syrian refugees and vulnerable Jordanians, as the pandemic started. METHODS: Alongside medication delivery, CHVs called patients monthly to assess stockouts and adherence, provide self-management and psychosocial support, and screen and refer for complications and COVID-19 testing. Cohort analysis was undertaken of stockouts, adherence, complications and suspected COVID-19. Multivariable models of disease control assessed predictors and non-inferiority of the strategy pre-/post-initiation. Cost-efficiency and patient/staff interviews assessed implementation. RESULTS: Overall, 1119 patients were monitored over 8 mo. The mean monthly proportion of stockouts was 4.9%. The monthly proportion non-adherent (past 5/30 d) remained below 5%; 204 (18.1%) patients had complications, with 63 requiring secondary care. Mean systolic blood pressure and random blood glucose remained stable. For hypertensive disease control, age 41-65 y (OR 0.46, 95% CI 0.2 to 0.78) and with diabetes (OR 0.73, 95% CI 0.54 to 0.98) had decreased odds, and with baseline control had increased odds (OR 3.08, 95% CI 2.31 to 4.13). Cumulative suspected COVID-19 incidence (2.3/1000 population) was suggestive of ongoing transmission. While cost-efficient (108 US${\$}$/patient/year), funding secondary care was challenging. CONCLUSIONS: During multiple crises, CHVs prevented care disruption and reinforced COVID-19 detection.

Integrating community health volunteers into non-communicable disease management among Syrian refugees in Jordan: a causal loop analysis.

OBJECTIVES: Globally, there is emerging evidence on the use of community health workers and volunteers in low-income and middle-income settings for the management of non-communicable diseases (NCDs), provision of out-of-clinic screening, linkage with health services, promotion of adherence, and counselling on lifestyle and dietary changes. Little guidance exists on the role of this workforce in supporting NCD care for refugees who lack access to continuous care in their host country. The goals of this work were to evaluate the current roles of community health volunteers (CHVs) in the management of diabetes and hypertension (HTN) among Syrian refugees and to suggest improvements to the current primary care model using community health strategies. SETTING AND PARTICIPANTS: A participatory, multistakeholder causal loop analysis workshop with representatives from the Ministry of Health of Jordan, non-governmental organisations, United Nations agencies, CHVs and refugee patients was conducted in June 2019 in Amman, Jordan. PRIMARY OUTCOME: This causal loop analysis workshop was used to collaboratively develop a causal loop diagram and CHV strategies designed to improve the health of Syrian refugees with diabetes and HTN living in Jordan. RESULTS: During the causal loop analysis workshop, participants collaboratively identified and mapped how CHVs might improve care among diagnosed patients. Possibilities identified included the following: providing psychosocial support and foundational education on their conditions, strengthening self-management of complications (eg, foot checks), and monitoring patients for adherence to medications and collection of basic health monitoring data. Elderly refugees with restricted mobility and/or uncontrolled disease were identified as a key population where CHVs could provide home-based blood glucose and blood pressure measurement and targeted health education to provide more precise monitoring. CONCLUSIONS: CHV programmes were cited as a key strategy to implement secondary prevention of morbidity and mortality among Syrian refugees, particularly those at high risk of decompensation.

Mortality in Rohingya refugee camps in Bangladesh: historical, social, and political context.

Fifty-two maternal deaths occurred between September 2017 and August 2018 in the Rohingya refugee camps in Ukhia and Teknaf Upazilas, Cox's Bazar District, Bangladesh. Behind every one of these lives lost is a complex narrative of historical, social, and political forces, which provide an important context for reproductive health programming in Rohingya camps. Rohingya women and girls have experienced human rights violations in Myanmar for decades, including government-sponsored sexual violence and population control efforts. An extension of nationalist, anti-Rohingya policies, the attacks of 2017 resulted in the rape and murder of an unknown number of women. The socio-cultural context among Rohingya and Bangladeshi host communities limits provision of reproductive health services in the refugee camps, as does a lack of legal status and continued restrictions on movement. In this review, the historical, political, and social contexts have been overlaid below on the Three Delays Model, a conceptual framework used to understand the determinants of maternal mortality. Attempts to improve maternal mortality among Rohingya women and girls in the refugee camps in Bangladesh should take into account these complex historical, social and political factors in order to reduce maternal mortality.

Qualitative evidence of crimes against humanity: the August 2017 attacks on the Rohingya in northern Rakhine State, Myanmar.

BACKGROUND: The Rohingya ethnic minority population in northern Rakhine state, Myanmar, have experienced some of the most protracted situations of persecution. Government-led clearance operations in August 2017 were one of many, but notably one of the most devastating, attacks on the population. The study aimed to conduct a multiphase mixed-methods assessment of the prevalence and contexts of violence and mortality across affected hamlets in northern Rakhine State during the August 2017 attacks. This publication describes qualitative accounts by Rohingya community leaders from affected hamlets, with a focus on the events and environment leading up to and surrounding the attacks. METHODS: Qualitative in-depth interviews were conducted with Rohingya community leaders representing 88 northern Rakhine state hamlets across three townships affected by the August 2017 attacks (Maungdaw, n = 34; Buthidaung, n = 42; Rathedaung, n = 12). Prior quantitative surveys conducted among representative hamlet leaders allowed for preliminary screening and identification of interview candidates: interviewees were then selected based on prior reports of 10 or more deaths among Rohingya hamlet community members, mass rape, and/or witness of mass graves in a hamlet or during displacement. Recorded interviews were transcribed, translated, and thematically coded. RESULTS: Rohingya leaders reported that community members were subjected to systematic civil oppression characterized by severe restrictions on travel, marriage, education, and legal rights, regular denial of citizenship rights, and unsubstantiated accusations of terrorist affiliations in the months prior to August 2017. During the attacks, Rohingya civilians (inclusive of women, men, children, and elderly) reportedly suffered severe, indiscriminate violence perpetrated by Myanmar security forces. Crimes against children and sexual violence were widespread. Bodies of missing civilians were discovered in mass graves and, in some cases, desecrated by armed groups. Myanmar Armed Forces (Tatmadaw), consisting of the Army, Navy, and Border Guard Police continued to pursue, assault, and obstruct civilians in flight to Bangladesh. CONCLUSIONS: Qualitative findings corroborate previously published evidence of widespread and systematic violence by the Myanmar security forces against the Rohingya. The accounts describe intentional oppression of Rohingya civilians leading up to the August 2017 attacks and coordinated and targeted persecution of Rohingya by state forces spanning geographic distances, and ultimately provide supporting evidence for investigations of crimes against humanity and acts of genocide.

Documentation of human rights abuses among Rohingya refugees from Myanmar.

BACKGROUND: Decades of persecution culminated in a statewide campaign of organized, systematic, and violent eviction of the Rohingya people by the Myanmar government beginning in August 2017. These attacks included the burning of homes and farms, beatings, shootings, sexual violence, summary executions, burying the dead in mass graves, and other atrocities. The Myanmar government has denied any responsibility. To document evidence of reported atrocities and identify patterns, we interviewed survivors, documented physical injuries, and assessed for consistency in their reports. METHODS: We use purposive and snowball sampling to identify survivors residing in refugee camps in Bangladesh. Interviews and examinations were conducted by trained investigators with the assistance of interpreters based on the Istanbul Protocol - the international standard to investigate and document instances of torture and other cruel, inhuman, and degrading treatment. The goal was to assess whether the clinical findings corroborate survivors' narratives and to identify emblematic patterns. RESULTS: During four separate field visits between December 2017 and July 2018, we interviewed and where relevant, conducted physical examinations on a total of 114 refugees. The participants came from 36 villages in Northern Rakhine state; 36 (32%) were female, 26 (23%) were children. Testimonies described several patterns in the violence prior to their flight, including the organization of the attacks, the involvement of non-Rohingya civilians, the targeted and purposeful destruction of homes and eviction of Rohingya residents, and the denial of medical care. Physical findings included injuries from gunshots, blunt trauma, penetrating trauma such as slashings and mutilations, burns, and explosives and from sexual and gender-based violence. CONCLUSIONS: While each survivor's experience was unique, similarities in the types and organization of attacks support allegations of a systematic, widespread, and premeditated campaign of forced displacement and violence. Physical findings were consistent with survivors' narratives of violence and brutality. These findings warrant accountability for the Myanmar military per the Rome Statute of the International Criminal Court (ICC), which has jurisdiction to try individuals for serious international crimes, including crimes against humanity and genocide. Legal accountability for these crimes should be pursued along with medical and psychological care and rehabilitation to address the ongoing effects of violence, discrimination, and displacement.

Migration patterns & their associations with health and human rights in eastern Myanmar after political transition: results of a population-based survey using multistaged household cluster sampling.

BACKGROUND: Myanmar transitioned to a nominally civilian government in March 2011. It is unclear how, if at all, this political change has impacted migration at the household level. METHODS: We present household-level in- and out-migration data gathered during the Eastern Burma Retrospective Mortality Survey (EBRMS) conducted in 2013. Household level in-and out-migration information within the previous year was gathered via a cross-sectional, retrospective, multi-stage population-based cluster randomized survey conducted in eastern Myanmar. Univariate, bivariate and regression analyses were conducted. RESULTS: We conducted a cross-sectional survey of 6620 households across Eastern Myanmar between July and September of 2013. Out-migration outstripped in-migration more than 6:1 overall during the year prior to the survey - for international migration this ratio was 29:1. Most in-migrants had moved to their present location in the study area from other areas in Myanmar (87%). Only 11.3% (27 individuals) had returned from another country (Thailand). Those who migrated out of eastern Myanmar during the previous year were more likely to be male (55.2%), and three times more likely to be between the ages of 15-25 (49.5%) than non-migrants. The primary reason cited for a return to the household was family (26.3%) followed by work (23.2%). The primary reason cited for migrating out of the household was for education (46.4%) followed by work (40.2%). Respondents from households that reported out-migration in the past year were more likely to screen positive for depressive symptoms than households with no migration (PR 1.85; 95% CI 1.16, 2.97). Women in households with in-migration were more likely to be malnourished and had a higher unmet need for contraception. Forced labor, one subset of human rights violations experienced by this population, was reported by more in-migrant (8%) than out-migrant households (2.2%), though this finding did not reach statistical significance. CONCLUSIONS: These analyses suggest that opportunities for employment and education are the primary drivers of migration out of the household, despite an overall improvement in stability and decrease in prevalence of human rights violations found by EBRMS 2013. Additionally, migration into and out of households in eastern Myanmar is associated with changes in health outcomes.

Violence and mortality in the Northern Rakhine State of Myanmar, 2017: results of a quantitative survey of surviving community leaders in Bangladesh.

BACKGROUND: In August, 2017, Myanmar security forces initiated a widespread response against the Rohingya ethnic minority in Northern Rakhine State, displacing thousands of people to Bangladesh. This attack was purportedly in response to attacks committed by the Arakan Rohingya Salvation Army, a non-state insurgent group, on Myanmar police, Border Guard Police, and military posts, killing 12 security personnel on Aug 25, 2017. This study aimed to capture the experiences of the population from all Rohingya hamlets in the Northern Rakhine State who have been displaced to Bangladesh. METHODS: A quantitative survey was done among Rohingya leaders displaced to refugee camps in Bangladesh. Community leaders from 590 Rohingya hamlets and eight urban wards provided hamlet-level data on the extent, nature, and perpetrators of the violence in Northern Rakhine State in August, 2017, and the resulting morbidity and mortality. RESULTS: From May 28 to July 25, 2018, 462 (77%) of 604 hamlet leaders reported that the primary reason they and their community members fled was because of violence in their hamlet or in a neighbouring hamlet. 568 (94%) respondents reported that they had experienced destruction in their hamlets, including burning or destruction of fields or farms, homes, and mosques; 531 (89%) of 599 respondents reported violence in their hamlets before flight and 373 (64%) of 586 reported violence against civilians in flight. The main perpetrators of violence included but were not limited to Border Guard Police, Myanmar military, and Rakhine extremists. Of the 531 respondents who reported violence in their hamlets, 408 (77%) reported that military forces used helicopters, 372 (70%) reported military vehicles, and 113 (21%) reported tanks in these assaults on civilian communities. We estimate that 7803 Rohingya died from violent and non-violent causes associated with the August, 2017, attacks and subsequent displacement. INTERPRETATION: In 2017, the Rohingya ethnic minority population of Northern Rakhine State were the targets of a campaign of widespread and systematic violence, including violence by state forces. FUNDING: An anonymous grant to Physicians for Human Rights.

Optimizing the Use of a Precious Resource: The Role of Emergency Physicians in a Humanitarian Crisis.

Emergency physicians (EP) are uniquely suited to provide care in crises as a result of their broad training, ability to work quickly and effectively in high-pressure, austere settings, and their inherent flexibility. While emergency medicine training is helpful to support the needs of crisis-affected and displaced populations, it is not in itself sufficient. In this article we review what an EP should carefully consider prior to deployment.

Health and human rights in eastern Myanmar prior to political transition: a population-based assessment using multistaged household cluster sampling.

BACKGROUND: Myanmar/Burma has received increased development and humanitarian assistance since the election in November 2010. Monitoring the impact of foreign assistance and economic development on health and human rights requires knowledge of pre-election conditions. METHODS: From October 2008-January 2009, community-based organizations conducted household surveys using three-stage cluster sampling in Shan, Kayin, Bago, Kayah, Mon and Tanintharyi areas of Myanmar. Data was collected from 5,592 heads of household on household demographics, reproductive health, diarrhea, births, deaths, malaria, and acute malnutrition of children 6-59 months and women aged 15-49 years. A human rights focused survey module evaluated human rights violations (HRVs) experienced by household members during the previous year. RESULTS: Estimated infant and under-five rates were 77 (95% CI 56 to 98) and 139 (95% CI 107 to 171) deaths per 1,000 live births; and the crude mortality rate was 13 (95% CI 11 to 15) deaths per thousand persons. The leading respondent-reported cause of death was malaria, followed by acute respiratory infection and diarrhea, causing 21.2% (95% CI 16.5 to 25.8), 16.6% (95% CI 11.8 to 21.4), and 12.3% (95% CI 8.7 to 15.8), respectively. Over a third of households suffered at least one human rights violation in the preceding year (36.2%; 30.7 to 41.7). Household exposure to forced labor increased risk of death among infants (rate ratio (RR) = 2.2; 95% CI 1.1 to 4.4) and children under five (RR = 2.1; 95% CI 1.3 to 3.6). The proportion of children suffering from moderate to severe acute malnutrition was higher among households that were displaced (prevalence ratio (PR) = 3.3; 95% CI 1.9 to 5.6). CONCLUSIONS: Prior to the 2010 election, populations of eastern Myanmar experienced high rates of disease and death and high rates of HRVs. These population-based data provide a baseline that can be used to monitor national and international efforts to improve the health and human rights situation in the region.