Have attacks on healthcare become the new normal? a public health call to action for armed conflicts before it is too late.

The scale of attacks on healthcare has become more visible and its impact greater in recent armed conflicts in Ukraine, Sudan and Myanmar. In these conflicts, combatants systematically target health facilities and ambulances. We need to ensure that attacks on healthcare do not become the new norm amongst governmental troops and non-State armed groups. There is limited evidence about why and how attacks on healthcare have become "normal" practice amongst many combatants, despite the likely tactical and strategic costs to themselves. We are convinced that the problem now needs to be tackled like any other public health issue by assessing: the scale of the problem; who is the most at risk; identifying risk factors; developing new interventions to prevent the risks or address the issue; and evaluating the effectiveness of these interventions.

"Actually, the psychological wounds are more difficult than physical injuries:" a qualitative analysis of the impacts of attacks on health on the personal and professional lives of health workers in the Syrian conflict.

INTRODUCTION: Attacks on healthcare in armed conflict have far-reaching impacts on the personal and professional lives of health workers, as well as the communities they serve. Despite this, even in protracted conflicts such as in Syria, health workers may choose to stay despite repeated attacks on health facilities, resulting in compounded traumas. This research explores the intermediate and long-term impacts of such attacks on healthcare on the local health professionals who have lived through them with the aim of strengthening the evidence base around such impacts and better supporting them. METHODS: We undertook purposive sampling of health workers in northwest and northeast Syria; we actively sought to interview non-physician and female health workers as these groups are often neglected in similar research. In-depth interviews (IDIs) were conducted in Arabic and transcribed into English for framework analysis. We used an a priori codebook to explore the short- and long-term impacts of attacks on the health workers and incorporated emergent themes as analysis progressed. RESULTS: A total of 40 health workers who had experienced attacks between 2013 and 2020 participated in IDIs. 13 were female (32.5%). Various health cadres including doctors, nurses, midwives, pharmacists, students in healthcare and technicians were represented. They were mainly based in Idlib (39.5%), and Aleppo (37.5%) governorates. Themes emerged related to personal and professional impacts as well as coping mechanisms. The key themes include firstly the psychological harms, second the impacts of the nature of the attacks e.g. anticipatory stress related to the 'double tap' nature of attacks as well as opportunities related to coping mechanisms among health workers. CONCLUSION: Violence against healthcare in Syria has had profound and lasting impacts on the health workforce due to the relentless and intentional targeting of healthcare facilities. They not only face the challenges of providing care for a conflict-affected population but are also part of the community themselves. They also face ethical dilemmas in their work leading to moral distress and moral injury. Donors must support funding for psychosocial support for health workers in Syria and similar contexts; the focus must be on supporting and enhancing existing context-specific coping strategies.

Pandemic detention: life with COVID-19 behind bars in Maryland.

Background: People incarcerated during the COVID-19 pandemic face higher vulnerability to infection due to structural and social factors in carceral settings. Additionally, due to the higher prevalence of chronic health conditions among carceral populations, they are also at risk for more severe COVID-19 disease. This study was designed to explore the experiences of people incarcerated in prisons and jails in Maryland during the height of the pandemic. Methods: We conducted semi-structured phone interviews between January 2021 and April 2022 with ten individuals incarcerated in Maryland carceral facilities during the height of the U.S. COVID-19 pandemic and were subsequently released from prison or jail. We transcribed the interviews, coded them, and engaged in content analysis, an inductive analytical approach to developing themes and meaning from qualitative data. Results: Four themes emerged from participants' descriptions of their experiences: (1) distress from fear, vulnerability, and lack of knowledge about COVID-19 and how to protect themselves, (2) shortcomings of prison and jail administrators and other personnel through lack of transparency and arbitrary and punitive enforcement of COVID-19 protocols, (3) lack of access to programming and communication with others, and (4) absence of preparation for release and access to usual re-entry services. Conclusion: Participants responded that the prison and jails' response during the COVID-19 pandemic was ill-prepared, inconsistent, and without appropriate measures to mitigate restrictions on liberty and prepare them for release. The lack of information sharing amplified their sense of fear and vulnerability unique to their incarceration status. Study findings have several institutional implications, such as requiring carceral facilities to establish public health preparedness procedures and making plans publicly available.

Release, Reentry, and Reintegration During COVID-19: Perspectives of Individuals Recently Released from the Federal Bureau of Prisons.

Introduction: The COVID-19 pandemic had a large negative impact on people in U.S. prisons. Expedited releases from prison were one strategy used to decrease morbidity and mortality from COVID-19. However, little is known about the reentry experiences of those being rapidly released from custody early in the pandemic. Methods: We aimed to examine the perspectives of former residents in the Federal Bureau of Prisons (BOP) regarding release, reentry, and reintegration into their respective communities. We conducted semistructured interviews with 21 recently released individuals primarily recruited through legal aid organizations between September and October 2021. Subjects were incarcerated before and during the early surge in the COVID-19 pandemic. We coded transcripts thematically with domains developed a priori in which we revised iteratively and inductively based on the data. Results: Several major themes emerged. Participants reported that they needed to advocate for themselves to take advantage of the early release process. Compared with normal circumstances, they reported a lack of reentry planning and preparation before participants were released. Finally, experiences with reintegration varied but were often more challenging due to COVID-19. Discussion: Residents released during COVID-19 reported many challenges with reentry that could have been mitigated by support and guidance from the BOP. Reentry is a process that should begin prelease and continues postrelease to ensure individuals have adequate structural and social supports. Health Equity Implications: Inadequate reentry support has significant impacts on the health and well-being of recently released individuals and contributes to the broader context of achieving health equity for minitorized groups who are disproportionately overrepresented in prisons. Policy and practice reform is needed to address the time-sensitive, life-threatening challenges individuals face when transitioning from prison to community.

COVID-19 Restrictions In Jails And Prisons: Perspectives From Carceral Leaders.

COVID-19 has been an unprecedented challenge in carceral facilities. As COVID-19 outbreaks spread in the US in early 2020, many jails, prisons, juvenile detention centers, and other carceral facilities undertook infection control measures such as increased quarantine and reduced outside visitation. However, the implementation of these decisions varied widely across facilities and jurisdictions. We explored how carceral decision makers grappled with ethically fraught public health challenges during the pandemic. We conducted semistructured interviews during May-October 2021 with thirty-two medical and security leaders from a diverse array of US jails and prisons. Although some facilities had existing detailed outbreak plans, most plans were inadequate for a rapidly evolving pandemic such as COVID-19. Frequently, this caused facilities to enact improvised containment plans. Quarantine and isolation were rapidly adopted across facilities in response to COVID-19, but in an inconsistent manner. Decision makers generally approached quarantine and isolation protocols as a logistical challenge, rather than an ethical one. Although they recognized the hardships imposed on incarcerated people, they generally saw the measures as justified. Comprehensive outbreak control guidelines for pandemic diseases in carceral facilities are urgently needed to ensure that future responses are more equitable and effective.

The crisis of maternal and child health in Afghanistan.

BACKGROUND: The Taliban takeover in August 2021 brought global economic sanctions, economic collapse, and draconian restrictions on women's freedom of movement, work, political participation, and education. This study examined Afghan health workers' experiences and perceptions of availability and quality of maternal and child health care since then. METHODS: We conducted a survey, using a convenience sample, of health workers from urban, semi-rural, and rural public and private clinics and hospitals across the 34 provinces, covering changes in working conditions, safety, health care access and quality, maternal and infant mortality as well as perceptions about the future of maternal and child health and health care. Interviews were conducted with a subsample of health workers to further explore their perceptions of changes in working conditions, quality of care, and health outcomes since the Taliban takeover. RESULTS: 131 Afghan practicing health care workers completed the survey. The majority were women (80%) working in facilities located in urban areas. Most female health workers (73.3%) reported that they have not always been safe when going to and from work; 81% because of harassment by the Taliban when they did not have male accompaniment. Almost half of the respondents (42.9%) reported a decrease in availability of maternal and child care and 43.8% stated that conditions for providing care were "worse" or "much worse" than before. Almost one-third (30.2%) indicated that changed working conditions negatively impacted their ability to provide quality care, and 26.2% reported an increase in obstetric and newborn complications. Health workers also reported (38.1% )an increase in sick child needs and an increase in child malnutrition (57.1%0. 57.1% reported decreases in work attendance and 78.6% a decrease in morale and motivation. Qualitative interviews (n = 10) of a subsample of survey participants expanded on these findings. CONCLUSION: The combination of economic collapse, lack of sustained donor support for health care and Taliban interference with human rights has severely compromised access and quality of maternal and child health care. Strong and concerted international pressure on the Taliban to respect women and children rights to essential health service is critical for the future of the Afghan population.

"It was like you were being literally punished for getting sick": formerly incarcerated people's perspectives on liberty restrictions during COVID-19.

BACKGROUND: COVID-19 has greatly impacted the health of incarcerated individuals in the US. The goal of this study was to examine perspectives of recently incarcerated individuals on greater restrictions on liberty to mitigate COVID-19 transmission. METHODS: We conducted semi-structured phone interviews from August through October 2021 with 21 people who had been incarcerated in Bureau of Prisons (BOP) facilities during the pandemic. Transcripts were coded and analyzed, using a thematic analysis approach. RESULTS: Many facilities implemented universal "lockdowns," with time out of the cell often limited to one hour per day, with participants reporting not being able to meet all essential needs such as showers and calling loved ones. Several study participants reported that repurposed spaces and tents created for quarantine and isolation provided "unlivable conditions." Participants reported receiving no medical attention while in isolation, and staff using spaces designated for disciplinary purposes (e.g., solitary housing units) for public health isolation purposes. This resulted in the conflation of isolation and discipline, which discouraged symptom reporting. Some participants felt guilty over potentially causing another lockdown by not reporting their symptoms. Programming was frequently stopped or curtailed and communication with the outside was limited. Some participants relayed that staff threatened to punish noncompliance with masking and testing. Liberty restrictions were purportedly rationalized by staff with the idea that incarcerated people should not expect freedoms, while those incarcerated blamed staff for bringing COVID-19 into the facility. CONCLUSIONS: Our results highlighted how actions by staff and administrators decreased the legitimacy of the facilities' COVID-19 response and were sometimes counterproductive. Legitimacy is key in building trust and obtaining cooperation with otherwise unpleasant but necessary restrictive measures. To prepare for future outbreaks facilities must consider the impact of liberty-restricting decisions on residents and build legitimacy for these decisions by communicating justifications to the extent possible.

COVID-19 vaccination hesitancy and uptake: Perspectives from people released from the Federal Bureau of Prisons.

People in United States (US) prisons and jails have been disproportionately impacted by the COVID-19 pandemic. This is due to challenges containing outbreaks in facilities and the high rates of health conditions that increase the risk of adverse outcomes. Vaccination is one strategy to disrupt COVID-19 transmission, but there are many factors impeding vaccination while in custody. We aimed to examine the perspectives of former residents in the Federal Bureau of Prisons (BOP) regarding COVID-19 vaccine hesitancy and acceptance. Between September-October 2021, we conducted semi-structured interviews with 21 recently released individuals who were incarcerated before and during COVID-19 and coded transcripts thematically. We assessed perceptions of the vaccine rollout and factors shaping vaccination uptake in custody and after release. The vaccine was available to seven participants in custody, of whom three were vaccinated. Interviewees had mixed attitudes about how vaccines were distributed, particularly with priority given to staff. Most were reluctant to get vaccinated in custody for varying reasons including observing staff declining to be vaccinated, lack of counseling to address specific questions about safety, and general lack of trust in the carceral system. By contrast, twelve got vaccinated post-release because of greater trust in community health care and stated they would not have done so while incarcerated. For residents in the BOP, COVID-19 vaccination was not simply a binary decision, instead they weighed the costs and benefits with most deciding against getting vaccinated. Institutions of incarceration must address these concerns to increase vaccine uptake as the pandemic continues.

A Human Rights Framework for Advancing the Standard of Medical Care for Incarcerated People in the United States in the Time of COVID-19.

The COVID-19 pandemic has underscored the lack of resources and oversight that hinders medical care for incarcerated people in the United States. The US Supreme Court has held that "deliberate indifference" to "serious medical needs" violates the Constitution. But this legal standard does not assure the consistent provision of health care services. This leads the United States to fall behind European nations that define universal standards of care grounded in principles of human rights and the ideal of equivalence that incarcerated and non-incarcerated people are entitled to the same health care. In this paper, we review a diverse legal and policy literature and undertake a conceptual analysis of policy issues related to the standard of care in correctional health; we then describe a framework for moving incrementally closer toward a universal standard. The expansion of Medicaid funding and benefits to corrections facilities, alongside a system of comprehensive and enforceable external oversight, would meaningfully raise the standard of care. Although these changes on their own will not resolve all of the thorny health problems posed by mass incarceration, they present a tangible opportunity to move closer to the human rights ideal.

Unstable gynaecological patient with an ankle monitor: implications of US Immigration and Customs Enforcement's Alternatives to Detention programme in the healthcare setting.

We review the case of an unstable gynaecological patient in the USA who presented with profuse vaginal bleeding after spontaneous miscarriage and was ultimately diagnosed with a uterine arteriovenous malformation managed with interventional radiology embolisation of her uterine artery. Her case was complicated by the presence of an ankle monitoring device which had been placed by US Immigration and Customs Enforcement as part of the Alternatives to Detention programme in which she was enrolled during her immigration proceedings. The device prompted important considerations regarding the potential use of cautery, MRI compatibility and device-related trauma, in addition to causing significant anxiety for the patient, who was concerned about how the team's actions could affect her immigration case. Discussion of her course and shared perspective highlights the unique clinical and medicolegal considerations presented by the expanded use of ankle monitoring devices for electronic surveillance (or 'e-carceration') of non-violent immigrants and others.

What Does Ethics Demand of Health Care Practice in Conflict Zones?

Human rights violations in armed conflict against community members, displaced persons, and health workers include combatants' uses of threats and coercion, attacks on health facilities, and abuses against civilians. Traditional clinical and public health ethical obligations are not sufficient to guide practice in those spaces. This article describes some of the complex realities of health practice in conflict zones that challenge adherence to clinicians' ethical obligations and create severe risks to the health, well-being, and dignity of the people they serve. It also proposes some solutions to these challenges.

'We will never give up': a qualitative study of ethical challenges Syrian health workers face in situations of extreme violence.

Active conflict settings constitute challenging operating environments for humanitarian health organisations and workers. An emerging feature of some conflicts is direct violence against health workers, facilities, and patients. Since the start of the war in 2011, Syria has endured extreme and deliberate violent attacks on health facilities and workers. This paper reports on the findings from a qualitative study that examined the lived experiences of Syrian humanitarian health workers facing extreme ethical challenges and coping with moral distress. In-depth interviews were carried out with 58 front-line health workers in north-western and southern Syria. Participants described a number of ethical and operational challenges experienced while providing services in extreme conditions, as well as strategies used to deal with them. The complex intersection of personal and organisational challenges is considered and findings are linked to key ethical and humanitarian principles. Both practical recommendations and action steps are provided to guide humanitarian health organisations.

Overview of attacks against civilian infrastructure during the Syrian civil war, 2012-2018.

BACKGROUND: Hundreds of thousands of people have been killed during the Syrian civil war and millions more displaced along with an unconscionable amount of destroyed civilian infrastructure. METHODS: We aggregate attack data from Airwars, Physicians for Human Rights and the Safeguarding Health in Conflict Coalition/Insecurity Insight to provide a summary of attacks against civilian infrastructure during the years 2012-2018. Specifically, we explore relationships between date of attack, governorate, perpetrator and weapon for 2689 attacks against five civilian infrastructure classes: healthcare, private, public, school and unknown. Multiple correspondence analysis (MCA) via squared cosine distance, k-means clustering of the MCA row coordinates, binomial lasso classification and Cramer's V coefficients are used to produce and investigate these correlations. RESULTS: Frequencies and proportions of attacks against the civilian infrastructure classes by year, governorate, perpetrator and weapon are presented. MCA results identify variation along the first two dimensions for the variables year, governorate, perpetrator and healthcare infrastructure in four topics of interest: (1) Syrian government attacks against healthcare infrastructure, (2) US-led Coalition offensives in Raqqa in 2017, (3) Russian violence in Aleppo in 2016 and (4) airstrikes on non-healthcare infrastructure. These topics of interest are supported by results of the k-means clustering, binomial lasso classification and Cramer's V coefficients. DISCUSSION: Findings suggest that violence against healthcare infrastructure correlates strongly with specific perpetrators. We hope that the results of this study provide researchers with valuable data and insights that can be used in future analyses to better understand the Syrian conflict.