Impacts of attacks to female health care workers in three territories of Colombia.

BACKGROUND: This study explores the impacts of attacks perpetrated in the context of armed conflict, to female health workers in three Colombian territories. METHODS: We conducted a document review of the reports and databases of the Colombian Truth Commission, 17 in-depth semi-structured interviews with experts on the national and regional armed conflict and the medical mission, and 26 female health workers who were victims of attacks. RESULTS: Experts and female health workers reported attacks to health activities, facilities, equipment, and personnel, including attacks to traditional doctors belonging to indigenous communities. The most frequent attacks were threats and retention of health personnel; theft of supplies and medicines; damage and use of infrastructure and means of transport for purposes other than health care; and hinderance of health service provision. The attacks occurred in a framework of structural violence that intersects with poverty, racism, and gender bias. The impacts of these attacks include gender-based violence, significant disruption of the lives of health workers, and physical, emotional, psychological, social, and economic effects on the victims and their families. The government response to protect victims and populations has been absent or insufficient. CONCLUSIONS: Attacks to health care were reported in all the studied territories obstructing adequate health care. Impacts of these attacks affect negatively the professional and personal life of the workers and are aggravated by structural violence and absent or little institutional response.

Water and war: The effect of functioning chlorinated water stations in reducing waterborne diseases during conflict in northwest Syria, 2017-2021.

Since 2011, Syria has been engulfed in a complex conflict marked by both targeted and indiscriminate attacks on civilians and civilian infrastructure. Water infrastructure has been continuously targeted, exacerbating problems with contamination of and access to clean adequate drinking water, and increasing the risk of waterborne diseases. We aimed to determine whether having access to more functional and chlorinated water stations is associated with a reduced risk of waterborne disease in northwest Syria. We examined the effect of functioning chlorinated water stations on the incidence of waterborne disease in 10 districts of Northwest Syria between January 1, 2017, and June 30, 2021, using weekly reported disease surveillance data and data from a water, sanitation, and hygiene (WASH) system evaluation program of the Assistance Coordination Unit (ACU). We ran eight negative binomial models to examine the association between functioning chlorinated water stations and the incidence of four of the five waterborne diseases: acute bloody diarrhea (ABD), acute other diarrhea (AOD), acute jaundice syndrome (AJS), and severe typhoid fever (STF). Dose-response models were used to investigate how the incidence of disease can theoretically be reduced as functioning and chlorinated water stations strategically increase. Compared to areas with lower quintiles of functioning and chlorinated water stations, the rates of the four waterborne diseases were lower in areas with higher quintiles of functioning and chlorinated water stations. Exposure to functioning water stations had a stronger association with lower rates of waterborne diseases than exposure to chlorinated water stations. Dose-response models demonstrate a potential for curbing the incidence of acute diarrhea and acute jaundice syndrome. The results of this study provide an understanding of the effects of water station functionality and chlorination in conflict settings. These findings support greater prioritization of WASH activities in countries experiencing violence against civilian infrastructure.

"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.

"There is a fear that you will be attacked just for the act of working in health": a survey of experiences of violence against healthcare in Colombia.

BACKGROUND: Colombia has experienced decades of conflict between the government and non-state actors. Attacks on healthcare have been a grave but regular facet of that violence. In response, the Misión Médica (MM) program was developed to support, protect, and defend healthcare. Sporadic violence continues, with many recent attacks perpetrated not by armed actors but by residents. Given the history of conflict and ongoing violence, we sought to capture the perspectives of both healthcare workers (HCWs) and community members (CMs) regarding the characteristics and impacts of attacks on health in Colombia to gain insight into how to better prevent violence and mitigate its impacts. METHODS: A cross-sectional survey was conducted from January to March 2021 in seven departments in Colombia in regions that witnessed attacks on healthcare. Questionnaires were administered to HCWs and CMs via purposive sampling, probing their experiences with attacks on health with both closed and open-ended questions. The categorical responses were stratified by health worker vs. non-health worker and descriptively analyzed. Narrative responses were analyzed via a hybrid deductive/inductive thematic approach. RESULTS: Seventy-three individuals participated in the study (36 HCWs and 37 cm). Approximately 77% of HCWs believed that attacks on healthcare impacted health outcomes while 68% of CMs did not see a direct connection between violence against healthcare and poor health outcomes. Awareness of the MM program was significantly different between HCWs (83.3%) and CMs (37.8%). The survey responses explored the characteristics of attacks on health, compounded impacts of violence on the health system, personal impacts, and perspectives on mitigation efforts. CONCLUSIONS: The study demonstrates that: (1) attacks on healthcare are context-dependent and require a local lens for mitigation and management; (2) both HCWs and CMs have critical perspectives that must be considered, (3) the impacts of violence against healthcare are complex and compounded and (4) that awareness of the legal protections of the Geneva Conventions must be combined with education on the health impacts for robust protection strategies. Critically, Both CMs and HCWs experience fear and psychosocial ramifications of these attacks, suggesting the need for stronger protections and resources to support the health workforce and the local community.

Exploring Bias in Restraint Use: Four Strategies to Mitigate Bias in Care of the Agitated Patient in the Emergency Department.

Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethicolegal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional, and health system level to help mitigate bias and improve care. Reprinted from Acad Emerg Med 2021; 28:1061-1066, with permission from John Wiley & Sons. Copyright © 2021.

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.

Consistency of reports of violence from northern Rakhine state in August 2017.

BACKGROUND: In August 2017, Myanmar's Armed Forces, the Tatmadaw, launched an orchestrated attack on hundreds of Rohingya-majority villages in northern Rakhine state. This study seeks to validate the consistency of previous reports of violence against the Rohingya people in the region carried out by the Tatmadaw, Border Guard Police, and Rakhine villagers in the late summer and early fall of 2017. METHODS: Internal validation data is from a three-armed study. Data analyzed in the external triangulation was sourced through a literature review of known, publicly available surveys and interviews. Both sets of data documented instances of violence against the Rohingya people in northern Rakhine state during the late summer and early fall of 2017. Consistency was evaluated across five indicators of violence: arson, presence of mass graves, reports of sexual violence and human injuries, as well as human fatalities, across 611 locales in northern Rakhine state. Further analysis was conducted to measure consistency of reports by locale and across locales by indicator. RESULTS: Overall, an internal validation of 94 hamlets found that 98% of these locales were consistent across at least four of the five indicators (80% + consistency). Arson and reports of human injuries were the most consistent indicators across locales (100% and 99% consistency, respectively) and sexual violence was the least consistent indicator, with 84% of participating locales exhibiting consistent reports of sexual violence between the qualitative and quantitative data. Similarly, an external validation of 57 locations found that 50 of the 57 locations (88%) were consistent across indicators. Arson was the most consistent across sources (96%), whereas source agreement across locations was the least consistent for reports of sexual violence (58%). CONCLUSION: The government of Myanmar has denied involvement in the 2017 attacks on Rohingya communities in northern Rakhine state and purports that reports of the violence and destruction are overstated. However, consistent reporting from multiple sources on the same locales clearly underscores the veracity of the evidence documented, both by investigative groups and as recounted by Rohingya survivors of violence. It is our hope that this cataloging and comparison of available data, along with this study's assessment of its consistency, will aid ongoing accountability efforts.

Ensuring Rights while Protecting Health: The Importance of Using a Human Rights Approach in Implementing Public Health Responses to COVID-19.

In response to the COVID-19 pandemic, governments around the world have implemented public health policies that limit individual freedoms in order to control disease transmission. While such limitations on liberties are sometimes necessary for pandemic control, many of these policies have been overly broad or have neglected to consider the costs for populations already susceptible to human rights violations. Furthermore, the pandemic has exacerbated preexisting inequities based on health care access, poverty, racial injustice, refugee crises, and lack of education. The worsening of such human rights violations increases the need to utilize a human rights approach in the response to COVID-19. This paper provides a global overview of COVID-19 public health policy interventions implemented from January 1 to June 30, 2020, and identifies their impacts on the human rights of marginalized populations. We find that over 70% of these public health policies negatively affect human rights in at least one way or for at least one population. We recommend that policy makers take a human rights approach to COVID-19 pandemic control by designing public health policies focused on the most marginalized groups in society. Doing so would allow for a more equitable, realistic, and sustainable pandemic response that is centered on the needs of those at highest risk of COVID-19 and human rights violations.

Measles in conflict-affected northern Syria: results from an ongoing outbreak surveillance program.

BACKGROUND: The Syrian conflict has dramatically changed the public health landscape of Syria since its onset in March of 2011. Depleted resources, fractured health systems, and increased security risks have disrupted many routine services, including vaccinations, across several regions in Syria. Improving our understanding of infectious disease transmission in conflict-affected communities is imperative, particularly in the Syrian conflict. We utilize surveillance data from the Early Warning Alert and Response Network (EWARN) database managed by the Assistance Coordination Unit (ACU) to explore trends in the incidence of measles in conflict-affected northern Syria and analyze two consecutive epidemics in 2017 and 2018. METHODS: We conducted a retrospective time-series analysis of the incidence of clinically suspected cases of measles using EWARN data between January 2015 and June 2019. We compared regional and temporal trends to assess differences between geographic areas and across time. RESULTS: Between January 2015 and June 2019, there were 30,241 clinically suspected cases of measles reported, compared to 3193 cases reported across the whole country in the decade leading up to the conflict. There were 960 regional events that met the measles outbreak threshold and significant differences in the medians of measles incidence across all years (p-value < 0.001) and in each pairwise comparison of years as well as across all geographic regions (p-value < 0.001). Although most governorates faced an elevated burden of cases in every year of the study, the measles epidemics of 2017 and 2018 in the governorates of Ar-Raqqa, Deir-Ez-Zor, and Idlib accounted for over 71% of the total suspected cases over the entire study period. CONCLUSIONS: The 2017 and 2018 measles epidemics were the largest since Syria eliminated the disease in 1999. The regions most affected by these outbreaks were areas of intense conflict and displacement between 2014 and 2018, including districts in Ar-Raqqa, Deir-Ez-Zor, and Idlib. The spread of measles in northern Syria serves as an indicator of low immunization coverage and limited access to care and highlights the Syrian peoples' vulnerability to infectious diseases and vaccine preventable diseases in the setting of the current conflict.

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.

Violence against healthcare in conflict: a systematic review of the literature and agenda for future research.

BACKGROUND: Attacks on health care in armed conflict, including those on health workers, facilities, patients and transports, represent serious violations of human rights and international humanitarian law. Information about these incidents and their characteristics are available in myriad forms: as published research or commentary, investigative reports, and within online data collection initiatives. We review the research on attacks on health to understand what data they rely on, what subjects they cover and what gaps exist in order to develop a research agenda going forward. METHODS AND FINDINGS: This study utilizes a systematic review of peer-reviewed to identify and understand relevant data about attacks on health in situations of conflict. We identified 1479 papers published before January 1, 2020 using systematic and hand-searching and chose 45 articles for review that matched our inclusion criteria. We extracted data on geographical and conflict foci, methodology, objectives and major themes. Among the included articles, 26 focused on assessment of evidence of attacks, 15 on analyzing their impacts, three on the legal and human rights principles and one on the methods of documentation. We analyzed article data to answer questions about where and when attacks occur and are investigated, what types of attacks occur, who is perpetrating them, and how and why they are studied. We synthesized cross-cutting themes on the impacts of these attacks, mitigation efforts, and gaps in existing data. CONCLUSION: Recognizing limitations in the review, we find there have been comparatively few studies over the past four decades but the literature is growing. To deepen the discussions of the scope of attacks and to enable cross-context comparisons, documentation of attacks on health must be enhanced to make the data more consistent, more thorough, more accessible, include diverse perspectives, and clarify taxonomy. As the research on attacks on health expands, practical questions on how the data is utilized for advocacy, protection and accountability must be prioritized.

Exploring bias in restraint use: Four strategies to mitigate bias in care of the agitated patient in the emergency department.

Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethicolegal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional, and health system level to help mitigate bias and improve care.

Health and social impacts of California wildfires and the deficiencies in current recovery resources: An exploratory qualitative study of systems-level issues.

BACKGROUND: Wildfires in California have become more deadly and destructive in recent years, and four of the ten most destructive fires occurred in 2017 and 2018. Through interviews with service providers, this article explores how these recent wildfires have impacted surrounding communities and the role various recovery resources have played in responding to the short- and long-term health and social needs of survivors. METHODS: Using a purposive sampling methodology, we interviewed 21 health and social service personnel who assisted in wildfire recovery efforts in California in 2017 and 2018. The study participants worked or volunteered in medical facilities, social services agencies and philanthropy/nonprofit organizations located in communities affected by wildfires. Participants were asked about three common, overarching themes that fire-impacted communities navigate post-disaster: health issues, social issues, and response and recovery resources. Inductive coding was used to identify common subthemes. RESULTS: The two most frequently discussed social issues during interviews were housing and employment access. Mental and emotional well-being and access to health resources were identified as being the most challenging health concerns that survivors face post-disaster. Participants also identified the following private and public recovery resources that survivors use to attempt to restabilize following the fire: community support, county agencies, the Federal Emergency Management Agency (FEMA,) insurance companies and philanthropic organizations. However, participants noted that the cumulative impacts of these efforts still leave many of their patients and clients without the resources needed to restabilize emotionally, financially and physically. Finally, participants spoke about the community-wide, downstream impacts of wildfires, noting that "survivors" are not only those whose health is immediately compromised by the disaster. CONCLUSION: Given the worsening wildfire seasons in California, we must increase our understanding of both the scope of the health and social issues that survivors navigate following a disaster, as well as the effectiveness and sustainability of recovery resources available to survivors. We must also understand the "ripple effect" that wildfires have on surrounding communalities, impacting housing access, social services, and health care access. More research and support, especially during the current COVID-19 pandemic, is urgently needed to improve our ability to support the health and social needs of wildfire survivors in the future.

Associations between memory loss and trauma in US asylum seekers: A retrospective review of medico-legal affidavits.

BACKGROUND: The U.S. immigration system mandates that persons seeking asylum prove their persecution claim is credible and their fear of returning home is well-founded. However, this population represents a highly trauma-exposed group, with neuropsychiatric symptoms consequent to prior torture or maltreatment that may interfere with cognitive function and their ability to recall their trauma. These memory lapses may be incorrectly perceived by asylum adjudicators as indicators of dishonesty and jeopardize the person's credibility and asylum claim. Our retrospective mixed methods study seeks to present associations between trauma and memory loss in a sample of persons seeking asylum to the U.S. and describe how memory impairments manifest in this trauma-exposed population. METHODS: We randomly selected 200 medico-legal affidavits from 1346 affidavits collected in the past 30 years, as part of the Physicians for Human Rights Asylum Network connecting clinicians with legal providers for medical and/or psychiatric affidavits of U.S. asylum seekers and persons seeking other forms of humanitarian relief (hereafter, "asylum seekers"). Data was extracted from these affidavits using a coding manual informed by the Istanbul Protocol, the global standard for torture documentation. Seven affidavits were excluded due to missing age. We used multiple logistic regression to assess the association of memory loss with neuropsychiatric diagnoses: head trauma, post-traumatic stress disorder (PTSD), and depression. We supplemented these findings with a qualitative content analysis of the affidavits documenting memory loss. Memory loss presented among the asylum seekers' affidavits in several ways: memory gaps of the traumatic event; challenges with presenting a clear chronology of the trauma, avoidance of traumatic memories, and persistent short-term memory loss interfering with daily activity. RESULTS: A majority of the sample received a neuropsychiatric diagnosis: 69% (n = 132) of asylum-seekers received a diagnosis of PTSD and 55% (n = 106) of depression. Head trauma was reported among 30% (n = 58) of affidavits. Further, 68% (n = 131) reported being subject to physical violence and 20% (n = 39) were documented as being at risk of suicide. Memory loss was documented among 21% (n = 40) asylum-seekers. In adjusted models, both PTSD and depression, but not head trauma, were associated with memory loss (p<0.05). CONCLUSION: Stakeholders in the asylum process, spanning the medical, legal and immigration enforcement sectors, must be aware of the interplay of trauma and memory loss and how they might impact immigration proceedings for this vulnerable population.

Protecting providers and patients: results of an Internet survey of health care workers' risk perceptions and ethical concerns during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has generated worldwide scarcity of critical resources to protect against and treat disease. Shortages of face masks and other protective equipment place health workers, already on the frontline of the disease, at higher risk. Moral distress from making difficult decisions about allocating scarce resources and care to patients ill with COVID-19 can further add to burdens health workers face. This study investigates clinical health workers' risk perceptions and concerns about the ethics of their clinical decision-making, the actions of their institutions to address resource scarcity concerns during the COVID-19 pandemic, and their ability to voice safety concerns, as well as their own views on how scarce resources should be allocated. METHODS: An online survey was open to health care workers who provide clinical care to patients, with no specialty training or geographic location requirements, from May 19 to June 30, 2020. Participants were recruited through purposive sampling using medical association and institutional email lists, and by snowball sampling. RESULTS: Of 839 participants, a majority were physicians (540, 69.4%) working in academic medical centers (270, 35.2%) or private health systems in the community (234, 30.5%) in the USA (760, 90.7%). Most reported being concerned about their own health (494, 73.6%) and about the possibility of spreading COVID-19 to family and friends (534, 85.9%) during the pandemic. All respondents reported shortages or rationing of at least one type of medical resource (e.g., sanitizing supplies and personal protective equipment). More than half of respondents (351, 53.9%) did not feel they received sufficient training in how to allocate scarce resources in the pandemic. Many felt moral distress related to conflicts between institutional constraints and what they believed was right (459, 66.5%). Though a majority (459, 67.7%) reported feeling "comfortable" internally communicating with their administration about safety issues, far fewer reported feeling "confident" speaking publicly about safety issues without retaliation from their institution (255, 37.3%). CONCLUSIONS: In the face of limited resources, surveyed health care workers reported concern about their own and their families' health from exposure. Securing adequate protective equipment must be a high priority for pandemic management. In addition, more governmental and facility-level ethical guidance is required for allocation of resources given ongoing scarcity, and facilities must create conditions so health care workers can speak openly about safety issues without fear of retaliation.

Safer Viewing: A Study of Secondary Trauma Mitigation Techniques in Open Source Investigations.

Human rights investigators often review graphic imagery of potential war crimes and human rights abuses while conducting open source investigations. As a result, they are at risk of developing secondary trauma, a condition that can produce a range of cognitive and behavioral consequences, including elevated anxiety and distress, depression, and post-traumatic stress disorder. Human rights organizations have traditionally been slow to recognize the risk of secondary trauma. However, in recent years, several university programs offering students practical experience in open source human rights investigations have implemented training on secondary trauma mitigation. We administered a survey to students in these programs to determine whether they are implementing recommended mitigation techniques and to document what techniques they find helpful. From 33 responses, we identified six general practices as helping mitigate secondary trauma: processing graphic content, limiting exposure to graphic content, drawing boundaries between personal life and investigations, bringing positivity into investigations, learning from more experienced investigators, and employing a combination of techniques. We also identified recommendations for institutions to protect the right to health of investigators and to support secondary trauma mitigation, both through frequent training and through practices such as labeling graphic content and emphasizing self-care. The article concludes with areas for future research.