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.

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.

Advocates Make a Difference in Duration of Homelessness and Quality of Life.

Social support is known to protect against homelessness and improve the wellbeing of people experiencing homelessness, but the role of professional versus informal advocates has not been studied in relation to the duration of homelessness and quality of life. We measured the effect of the presence and quality of formal (professional) and informal (family or friend) advocates on these outcomes. Our team interviewed 67 adults experiencing homelessness at tiny house villages and self-organized encampments in Seattle/King County, Washington in 2018-2019. The duration of homelessness was 19.6 months shorter for those with a high-quality informal advocate, compared to those without, while controlling for race, age, gender, and sexuality. However, this difference did not reach statistical significance at the alpha 0.05 level (p = .069). Additionally, those with high-quality informal advocates had 5.3 times the odds (p = .010) of reporting high quality of life compared to those without. The effect of at least one high-quality, professional advocate was insignificant in our model. Our results suggest social workers and other professional advocates integrate methods that strengthen clients' informal relationships into their practice.

Association Between Subnational Vaccine Coverage, Migration, and Incident Cases of Measles, Mumps, and Rubella in Iraq, 2001-2016.

OBJECTIVE: This analysis examines governorate-level disease incidence as well as the relationship between incidence and the number of persons of concern for three vaccine-preventable diseases-measles, mumps, and rubella-between 2001 and 2016. METHODS: Using Iraqi Ministry of Health and United Nations High Commissioner for Refugees (UNHCR) data, we performed descriptive analyses of disease incidence and conducted a pooled statistical analysis with a linear mixed effects regression model to examine the role of vaccine coverage and migration of persons of concern on subnational disease incidence. RESULTS: We found large variability in governorate-level incidence, particularly for measles (on the order of 100x). We identified decreases in incident measles cases per 100,000 persons for each additional percent vaccinated (0.82, 95% CI: [0.64, 1.00], p-value < 0.001) and for every additional 10,000 persons of concern when incorporating displacement into our model (0.26, 95% CI: [0.22, 0.30], p-value < 0.001). These relationships were insignificant for mumps and rubella. CONCLUSIONS: National level summary statistics do not adequately capture the high geospatial disparity in disease incidence between 2001 and 2016. This variability is complicated by MMR vaccine coverage and the migration of "persons of concern" (refugees) during conflict. We found that even when vaccine coverage was constant, measles incidence was higher in locations with more displaced persons, suggesting conflict fueled the epidemic in ways that vaccine coverage could not control.

African Physician Migration to High-Income Nations: Diverse Motives to Emigrate ("We Are not Florence Nightingale") or Stay in Africa ("There Is No Place Like Home") Comment on "Doctor Retention: A Cross-sectional Study of How Ireland Has Been Losing the Battle".

Research in assessing the global and asymmetric flows of health workers in general, and international medical graduates in particular, is fraught with controversy. The complex goal of improving health status of the citizens of home nations while ensuring the right of health workers to migrate generates policy discussions and decisions that often are not adequately informed by evidence. In times of global public health crises like the current coronavirus disease 2019 (COVID-19) global pandemic, the need for equitable distribution and adequate training of health workers globally becomes even more pressing. Brugha et al report suboptimal training and working conditions among Irish and foreign medical doctors practicing in Ireland, while predicting large-scale outward migration. We comment on health personnel migration and retention based on our own experience in this area of research. Drawing from our examination of medical migration dynamics from sub-Saharan Africa, we argue for greater consideration of health workforce retention in research and policy related to resource-limited settings. The right to health suggests the need to retain healthcare providers whose education was typically subsidized by the home nation. The right to migrate may conflict with the right to health. Hence, a deeper understanding is needed as to healthcare worker motives based on interactions of psychosocial processes, economic and material determinants, and quality of work environments.

Presence of Any Medical Debt Associated With Two Additional Years of Homelessness in a Seattle Sample.

Although medical debt has been associated with housing instability, almost no research has connected homelessness to medical debt. We interviewed 60 individuals experiencing homelessness in Seattle, selected from those participating in self-governed encampments organized by a homeless advocacy organization. Most respondents reported having at least one kind of debt, with two-thirds reporting current medical debt. Almost half reported trouble paying medical bills for themselves or family members. Almost one-third believed medical debt was in part responsible for their current housing situation. More than half with medical debt incurred this debt while they were covered under insurance. People who had trouble paying medical bills experienced a more recent episode of homelessness 2 years longer than those who did not have such trouble, even after controlling for race, education, age, gender, and health status. People of color who had trouble paying medical bills reported almost 1 year more homelessness than whites.

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.

International migration of health labour: monitoring the two-way flow of physicians in South Africa.

INTRODUCTION: Although health labour migration is a global phenomenon, studies have neglected the flow of health workers into low-income and middle-income countries (LMICs). In compliance with the data-monitoring recommendation of the WHO Global Code of Practice on the International Recruitment of Health Personnel (Code), we estimated post-Code physician net migration (NM) in South Africa (SA), and SA's net loss of physicians to Organisation for Economic Co-operation and Development (OECD) countries from 2010 to 2014. METHODS: We sourced data from the National Reporting Instrument reports, the OECD and the General Medical Council. Using the numbers of foreign nationals and international medical graduates (IMGs) registered in SA, and SA medical graduates registered in OECD countries (South African-trained international medical graduates (SA-IMGs)) as respective proxies for immigration and emigration, we estimated 'NM' as the difference between immigrant physicians and emigrant physicians and 'net loss' as the difference between OECD-trained IMGs and OECD-based SA-IMGs. RESULTS: In 2010, SA hosted 8443 immigrant physicians, while OECD countries hosted 14 933 SA-IMGs, yielding a NM of -6490 physicians and a NM rate of -18% in SA. By 2014, SA-based immigrant physicians had increased by 4%, while SA-IMGs had decreased by -15%, halving the NM rate to -9%. SA-to-OECD estimated net loss of physicians dropped from -12 739 physicians in 2010 to -10 563 in 2014. IMGs represented 46% of 2010-2014 new registrations in SA, with the UK, Nigeria and the Democratic Republic of the Congo serving as leading sources. Registrants from conflict-scarred Libya increased >100-fold. More than 3400 SA-IMGs exited OECD-based workforces. CONCLUSION: NM is a better measure of the brain drain than simply the emigration fraction. Strengthened health personnel data management and reporting through implementation of the Code-related system of National Health Workforce Accounts will further increase our understanding of health worker mobility in LMICs, with policymakers empowered to make more informed policies to address shortage.

The epidemiology of 32 selected communicable diseases in Iraq, 2004-2016.

BACKGROUND: The 2003 invasion of Iraq significantly undermined population health. However, there is a lack of understanding of how it undermined communicable disease control. This study was performed to assess the incidence trends of 32 communicable diseases in post-conflict Iraq. METHODS: Reported incidence data for 32 communicable diseases (2004-2016) were collected from routine reports sent to the Iraqi Ministry of Health by primary health centers, and general and tertiary hospitals. Incidence (per 100 000) was defined as the number of reported incident cases divided by the population size. Joinpoint regression was used to examine the incidence trends and average annual percentage change (AAPC) for each disease, and the overall incidence rate across the period. RESULTS: Communicable diseases increased significantly during the peak years of the war, especially during the US troop surge period (2007-2009). As US troops withdrew (after 2011), overall communicable diseases decreased. The incidence rate of nearly half of the 32 diseases decreased significantly, while the incidence rate of five increased significantly (hepatitis A, varicella, viral meningitis, cutaneous leishmaniasis, extrapulmonary tuberculosis). CONCLUSIONS: The early foundational strength of Iraq's health system may help explain why infectious disease failed to overwhelm the population following the invasion. Iraq's federal government could exercise its legal authority to manage threats to public health security by expanding the disease surveillance system.

Baccalaureate prepared nurses as the new entry-level nursing cadre in Uganda: A qualitative study of BSN student and faculty perspectives in two universities.

BACKGROUND: Low-income countries suffer chronic problems in producing, employing and distributing their health workers. The World Health Organization advocates for upgrading the number and quality of nursing professionals. As nurses and midwives comprise more than 60% of the health workforce in Uganda, the country's goal to improve nursing education is consistent with international recommendations. OBJECTIVES: To understand the dimensions of Uganda's relatively new baccalaureate-prepared nurse cadre (BSN), we explored the views of students and faculty in relation to training, job prospects, scope of practice, and satisfaction of BSNs in Uganda. DESIGN: We used a descriptive qualitative design. SETTING AND PARTICIPANTS: We interviewed BSN students and faculty at two large public nursing schools in Uganda in 2017. METHODS: We conducted focus group discussions and key informant interviews and used a thematic analysis approach to analyze data. RESULTS: The four overarching themes were: 1) BSN training is viewed as distinct from "bedside" training, 2) A rift between nursing cadres undermines workplace harmony, 3) BSNs are dissatisfied with their salary scale, and 4) BSNs are motivated to move abroad. DISCUSSION: At this moment in the transition, the professional nursing culture within Uganda is not conducive to encouraging BSN entry. To gain traction and momentum for BSNs as an entry-level cadre in Uganda, policy makers might align incentives to encourage BSN trainees, as there are few BSNs within training programs and clinical settings. Increasing lower cadre nurses' understanding of the role of BSNs may help improve relations between nursing cadres. Aligning job descriptions with pay differentials in clinical settings and expanding meaningful job opportunities could help retain BSNs within Uganda.

Conducting a Large Public Health Data Collection Project in Uganda: Methods, Tools, and Lessons Learned.

We report on the implementation experience of carrying out data collection and other activities for a public health evaluation study on whether U.S. President's Emergency Plan for AIDS Relief (PEPFAR) investment improved utilization of health services and health system strengthening in Uganda. The retrospective study period focused on the PEPFAR scale-up, from mid-2005 through mid-2011, a period of expansion of PEPFAR programing and health services. We visited 315 health care facilities in Uganda in 2011 and 2012 to collect routine health management information system data forms, as well as to conduct interviews with health system leaders. An earlier phase of this research project collected data from all 112 health district headquarters, reported elsewhere. This article describes the lessons learned from collecting data from health care facilities, project management, useful technologies, and mistakes. We used several new technologies to facilitate data collection, including portable document scanners, smartphones, and web-based data collection, along with older but reliable technologies such as car batteries for power, folding tables to create space, and letters of introduction from appropriate authorities to create entrée. Research in limited-resource settings requires an approach that values the skills and talents of local people, institutions and government agencies, and a tolerance for the unexpected. The development of personal relationships was key to the success of the project. We observed that capacity building activities were repaid many fold, especially in data management and technology.

Right-to-Work-for-Less: How Janus v. AFSCME Threatens Public Health.

In February 2018, the Supreme Court heard oral arguments in Janus v. AFSCME, a case poised to make right-to-work (or, as some call it, right-to-work-for-less) the law in the public sector. At issue is the constitutionality of requiring non-union members, who benefit from collective bargaining, to pay fees that support contract negotiations on the terms and conditions of their employment. We argue that a win for Janus would threaten public health by eroding organized labor's power to improve working conditions. Furthermore, we critique the dubious legal theory underpinning Janus's case and describe the moneyed political interests backing his legal representation. Finally, we chart a path forward for labor organizing in a post- Janus world, drawing inspiration from the winter 2018 educators' strike in West Virginia. Regardless of how Janus itself is decided, the issues raised in this article remain crucial because the ongoing weakening of unions by legislative and judicial means undermines workers' health and exacerbates inequities.

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.

District Health Officer Perceptions of PEPFAR's Influence on the Health System in Uganda, 2005-2011.

BACKGROUND: Vertically oriented global health initiatives (GHIs) addressing the HIV/AIDS epidemic, including the President's Emergency Plan for AIDS Relief (PEPFAR), have successfully contributed to reducing HIV/AIDS related morbidity and mortality. However, there is still debate about whether these disease-specific programs have improved or harmed health systems overall, especially with respect to non-HIV health needs. METHODS: As part of a larger evaluation of PEPFAR's effects on the health system between 2005-2011, we collected qualitative and quantitative data through semi-structured interviews with District Health Officers (DHOs) from all 112 districts in Uganda. We asked DHOs to share their perceptions about the ways in which HIV programs (largely PEPFAR in the Ugandan context) had helped and harmed the health system. We then identified key themes among their responses using qualitative content analysis. RESULTS: Ugandan DHOs said PEPFAR had generally helped the health system by improving training, integrating HIV and non-HIV care, and directly providing resources. To a lesser extent, DHOs said PEPFAR caused the health system to focus too narrowly on HIV/AIDS, increased workload for already overburdened staff, and encouraged doctors to leave public sector jobs for higher-paid positions with HIV/AIDS programs. CONCLUSION: Health system leaders in Uganda at the district level were appreciative of resources aimed at HIV they could often apply for broader purposes. As HIV infection becomes a chronic disease requiring strong health systems to manage sustained patient care over time, Uganda's weak health systems will require broad infrastructure improvements inconsistent with narrow vertical health programming.