Too few epidemiologists in humanitarian crises: a critical gap that needs addressing. A new course organised by the Italian Association of Epidemiology

The current humanitarian crises in Ukraine and Gaza, along with the chronic crises, and the climate-related disasters, have exposed the limitations of the humanitarian system. Within these contexts, humanitarian organisations frequently struggle with collecting, analysing, interpreting, and utilising health data, due to the challenging environments in which they operate and funding constraints. It is precisely in these contexts that field epidemiology plays a crucial, but often overlooked role.Field epidemiologists face unique challenges, including rapidly changing conditions, poor-quality data, and biases. Despite these difficulties, accurate epidemiological data are essential for needs assessment, guidance on interventions, and advocacy. Conventional methods often need adaptation for crisis settings, and there are still gaps in measurement.This article discusses the role of epidemiology in such contexts, noting a shortage of trained 'humanitarian epidemiologists' and specialised training as major issues.To address these needs, the Italian Association of Epidemiology organised a course in early 2024 to enhance the epidemiological skills of staff working in humanitarian crises and introduce traditional epidemiologists to crisis-specific challenges. The course covered key concepts and methods of field epidemiology, emphasising the use of secondary health data. Its positive reception underscored the demand for such specialised training.Improving public health information collection and use in humanitarian crises is an ethical and practical necessity. Indeed, investing in field epidemiology and recognising its importance can enhance humanitarian interventions and better serve vulnerable populations.

Sexual violence in conflicts: the shadow pandemic. A review of controversial issues.

This article explores the persistent and deeply troubling issue of conflict-related sexual violence (CRSV) throughout history and in contemporary conflicts. It examines the roots of wartime sexual violence in wartime, the evolving international legal framework for the protection of civilians, and the emergence of concerns about the protection of women and girls from such violence. The article delves into controversial aspects, including competing theories to explain CRSV, the challenges in obtaining accurate data on its prevalence, and the often-overlooked issue of CRSV against men and boys. It also addresses the cultural and societal factors that perpetuate CRSV and the long-lasting consequences on survivors. The article concludes by underscoring the importance of comprehensive care for survivors and the need to tackle the deep-seated causes of this violence, including gender inequality.

Not only COVID-19. Not only Ukraine. Under-reported hunger crises in the Horn of Africa and the politics around them.

Funding requirements for humanitarian needs have reached a record high, driven by Ukraine's war, other conflicts worldwide, the COVID-19 pandemic, climate change-related disasters, economic slowdown, and their combined global consequences. More people are in need of humanitarian assistance, and more are forcibly displaced than ever before, the majority of them from countries facing acute food insecurity. The largest global food crisis in modern history is unfolding. Particularly, in the Horn of Africa, levels of hunger are alarmingly high, with countries edging close to famine. This article discusses why and how famine, which had declined in frequency and lethality, is resurging, using Somalia and Ethiopia as 'mini case studies', emblematic as they are of a broader trend. Technical and political aspects of food crises and their consequences on health are analysed. The article examines some of the most contentious issues around famine: the data challenges for declaring it and the use of starvation as a weapon of war. The article concludes with the claim that the elimination of famine is possible, but only through political action. Humanitarians can warn of an impending crisis and mitigate some of its consequences, but they are powerless in the face of an ongoing famine, like those described in Somalia and Ethiopia.

COVID in Africa, one year later.

This paper presents an update of last year analysis of COVID in sub-Sahara Africa (SSA). The number of confirmed cases and deaths has dramatically increased, partially driven by the expanded diagnostic capacity, but it is an unknown undercount of people infected: we are blind with respect to the real size of the pandemic. The aggregate numbers mask a substantial heterogeneity: South Africa accounts for almost half of the cases in the region; Ethiopia, the second top country in the ranking, follows from afar, with only 6% of reported cases. There are signs that the third wave of COVID, driven by the more transmissible Delta variant, is easing off.The concerns that the pandemic would have affected more severely the most vulnerable populations (refugees and internally displaced persons) have not been confirmed: there is no evidence of hospitals overwhelmed nor of high mortality in humanitarian settings, a pattern that has not found an explanation.As of now, only 1% of African has been vaccinated, a sign of vaccine inequity and of 'a catastrophic moral failure' of rich countries, which have secured a surplus of hundred million COVID vaccines that they cannot use.The combined effects of the pandemic and control measures have been particularly severe in SSA economies, where underemployment and job insecurity prevail. Reduced export of commodities, collapse of tourism and agriculture, decline of foreign investment, aid, and remittances have driven million Africans in extreme poverty. The international financial institutions have shifted their strategies from austerity to a strong package of grants and concessional loans to support poor countries, including those in SSA, to cope with the immediate consequences of the pandemic, under the lemma 'vaccine policy is the most important economic policy'.

COVID-19 in Africa: the little we know and the lot we ignore.

COVID has stirred up an information deluge that challenges our capacity to absorb and make sense of data. In this unrelenting flow of information, Africa has been largely off the radar, escaping the attention of the scientific literature and the media. International agencies have been the exception: despite the still low numbers of cases and deaths, they have voiced concerns, often in catastrophic terms, on the health, economic and social impacts of COVID in African countries. These concerns contrast sharply with the optimistic view that Africa may be spared the worst consequences of the pandemic.This paper provides a snapshot of a crisis in evolution: its features could change as new data become available and our understanding improves. The paper examines the epidemic trends, the health impact, the containment measures and their possible side effects. Africa has a long experience of responding to epidemics: relevant lessons learned are outlined. The picture of the epidemic and its narrative are heterogenous, given the differing vulnerabilities of African countries and the diverse contexts within their borders. The paper, therefore, singles out selected countries as illustrative of specific situations and advocates for a transnational and subnational approach to future analyses.The virus has shown a strong capacity to adapt; therefore, a response strategy, in order to be effective, needs to be flexible and able to adapt to changes. The paper concludes with the recommendation that affected communities should be engaged in the response, to maintain or build trust. A lesson from the Ebola outbreak of a few years ago was that epidemiologists and community leaders learned, after initial difficulties, how to dialogue and work together.A summary update of the pandemic has been added, in view of its fast evolution.

Decision-making in humanitarian crises: politics, and not only evidence, is the problem.

Accurate, relevant and timely public health information is paramount in a humanitarian crisis: it can help to identify needs and priorities, guide decisions on interventions and resource allocation, monitor trends, evaluate the effectiveness of the response, support advocacy for human rights, and extract lessons that could be relevant in similar contexts. The present review shows, however, that the public health information available in humanitarian crises is, in general, inadequate and that its application is secondary to reasoning and incentives of a political nature, thus contributing to the recurrent failings of humanitarian action. This article reviews the causes of this state of affairs - cultural, political/institutional/methodological and ethical - that hinder the production, dissemination, and use of information for determining which interventions should be implemented or modified. Traditional epidemiological skills and methods are poorly suited to humanitarian contexts. The approaches and tools that have been introduced in crisis contexts require validation and improvement. There is a need for more field "barefoot epidemiologists" who are able to collaborate with anthropologists, demographers, and sociologists to better understand the priorities to be addressed in a crisis. Evidence, however, is not enough per se: it is political will that is the key factor in the use, or not, of information in decision-making concerning humanitarian resources and interventions.

Performance-based financing in low-income and middle-income countries: isn't it time for a rethink?

This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.

Recurrent failings of medical humanitarianism: intractable, ignored, or just exaggerated?

Humanitarian health workers operate in dangerous and uncertain contexts, in which mistakes and failures are common, often have severe consequences, and are regularly repeated, despite being documented by many reviews. This Series paper aims to discuss the failures of medical humanitarianism. We describe why some of these recurrent failings, which are often not identified until much later, seem intractable: they are so entrenched in humanitarian action that they cannot be addressed by simple technical fixes. We argue that relief health-care interventions should be contextualised. Perhaps medical humanitarianism deserves a better reputation than the one at times tarnished by unfair criticism, resulting from inapplicable guiding principles and unrealistic expectations. The present situation is not conducive to radical reforms of humanitarian medicine; complex crises multiply and no political, diplomatic, or military solutions are in sight. Relief agencies have to compete for financial resources that do not increase at the same pace as health needs. Avoiding the repetition of failures requires recognising previous mistakes and addressing them through different policies by donors, stronger documentation and analysis of humanitarian programmes and interventions, increased professionalisation, improved, opportunistic relationships with the media, and better ways of working together with local health stakeholders and through indigenous institutions.