Delivering health and nutrition interventions for women and children in different conflict contexts: a framework for decision making on what, when, and how.

Existing global guidance for addressing women's and children's health and nutrition in humanitarian crises is not sufficiently contextualised for conflict settings specifically, reflecting the still-limited evidence that is available from such settings. As a preliminary step towards filling this guidance gap, we propose a conflict-specific framework that aims to guide decision makers focused on the health and nutrition of women and children affected by conflict to prioritise interventions that would address the major causes of mortality and morbidity among women and children in their particular settings and that could also be feasibly delivered in those settings. Assessing local needs, identifying relevant interventions from among those already recommended for humanitarian settings or universally, and assessing the contextual feasibility of delivery for each candidate intervention are key steps in the framework. We illustratively apply the proposed decision making framework to show what a framework-guided selection of priority interventions might look like in three hypothetical conflict contexts that differ in terms of levels of insecurity and patterns of population displacement. In doing so, we aim to catalyse further iteration and eventual field-testing of such a decision making framework by local, national, and international organisations and agencies involved in the humanitarian health response for women and children affected by conflict.

The political and security dimensions of the humanitarian health response to violent conflict.

The nature of armed conflict throughout the world is intensely dynamic. Consequently, the protection of non-combatants and the provision of humanitarian services must continually adapt to this changing conflict environment. Complex political affiliations, the systematic use of explosive weapons and sexual violence, and the use of new communication technology, including social media, have created new challenges for humanitarian actors in negotiating access to affected populations and security for their own personnel. The nature of combatants has also evolved as armed, non-state actors might have varying motivations, use different forms of violence, and engage in a variety of criminal activities to generate requisite funds. New health threats, such as the COVID-19 pandemic, and new capabilities, such as modern trauma care, have also created new challenges and opportunities for humanitarian health provision. In response, humanitarian policies and practices must develop negotiation and safety capabilities, informed by political and security realities on the ground, and guidance from affected communities. More fundamentally, humanitarian policies will need to confront a changing geopolitical environment, in which traditional humanitarian norms and protections might encounter wavering support in the years to come.

Delivering health interventions to women, children, and adolescents in conflict settings: what have we learned from ten country case studies?

Armed conflict disproportionately affects the morbidity, mortality, and wellbeing of women, newborns, children, and adolescents. Our study presents insights from a collection of ten country case studies aiming to assess the provision of sexual, reproductive, maternal, newborn, child, and adolescent health and nutrition interventions in ten conflict-affected settings in Afghanistan, Colombia, Democratic Republic of the Congo, Mali, Nigeria, Pakistan, Somalia, South Sudan, Syria, and Yemen. We found that despite large variations in contexts and decision making processes, antenatal care, basic emergency obstetric and newborn care, comprehensive emergency obstetric and newborn care, immunisation, treatment of common childhood illnesses, infant and young child feeding, and malnutrition treatment and screening were prioritised in these ten conflict settings. Many lifesaving women's and children's health (WCH) services, including the majority of reproductive, newborn, and adolescent health services, are not reported as being delivered in the ten conflict settings, and interventions to address stillbirths are absent. International donors remain the primary drivers of influencing the what, where, and how of implementing WCH interventions. Interpretation of WCH outcomes in conflict settings are particularly context-dependent given the myriad of complex factors that constitute conflict and their interactions. Moreover, the comprehensiveness and quality of data remain limited in conflict settings. The dynamic nature of modern conflict and the expanding role of non-state armed groups in large geographic areas pose new challenges to delivering WCH services. However, the humanitarian system is creative and pluralistic and has developed some novel solutions to bring lifesaving WCH services closer to populations using new modes of delivery. These solutions, when rigorously evaluated, can represent concrete response to current implementation challenges to modern armed conflicts.

Ethical considerations for vaccination programmes in acute humanitarian emergencies.

Humanitarian emergencies result in a breakdown of critical health-care services and often make vulnerable communities dependent on external agencies for care. In resource-constrained settings, this may occur against a backdrop of extreme poverty, malnutrition, insecurity, low literacy and poor infrastructure. Under these circumstances, providing food, water and shelter and limiting communicable disease outbreaks become primary concerns. Where effective and safe vaccines are available to mitigate the risk of disease outbreaks, their potential deployment is a key consideration in meeting emergency health needs. Ethical considerations are crucial when deciding on vaccine deployment. Allocation of vaccines in short supply, target groups, delivery strategies, surveillance and research during acute humanitarian emergencies all involve ethical considerations that often arise from the tension between individual and common good. The authors lay out the ethical issues that policy-makers need to bear in mind when considering the deployment of mass vaccination during humanitarian emergencies, including beneficence (duty of care and the rule of rescue), non-maleficence, autonomy and consent, and distributive and procedural justice.

Les urgences humanitaires entraînent une rupture des services de soins de santé essentiels et elles rendent souvent les communautés vulnérables dépendantes des organismes externes pour leurs soins. Dans les milieux où les ressources sont comptées, cela peut se produire sur fond d'extrême pauvreté, de malnutrition, d'insécurité, de faible niveau d'alphabétisation et d'infrastructures insuffisantes. Dans ces circonstances, fournir nourriture, eau et abri, tout en limitant les épidémies de maladies transmissibles, devient une préoccupation centrale. Lorsqu'il existe des vaccins sûrs et efficaces pour limiter les risques d'épidémies, leur éventuel déploiement est un facteur clé pour satisfaire les besoins sanitaires d'urgence. Les considérations éthiques sont essentielles pour se prononcer sur le déploiement de la vaccination. La distribution de vaccins en quantités limitées, les groupes cibles, les stratégies de vaccination, la surveillance et la recherche lors de situations d'urgence humanitaire graves impliquent tous des considérations éthiques souvent nées de la tension entre le bien individuel et le bien commun. Les auteurs exposent les questions éthiques que les décideurs doivent garder à l'esprit lorsqu'ils envisagent le déploiement d'une vaccination de masse pendant les urgences humanitaires, notamment la bénéficience (devoir de diligence et devoir d'assistance), la non-maléficience, l'autonomie et le consentement, ainsi que la justice de répartition et l'équité procédurale.

Las emergencias humanitarias causan el desplome de los servicios de atención de salud esenciales y, a menudo, provocan que la atención sanitaria de las comunidades vulnerables pase a depender de organismos externos. En entornos con recursos limitados esto puede darse en un contexto de pobreza extrema, desnutrición, inseguridad, bajos niveles de alfabetización e infraestructuras deficientes. Bajo estas circunstancias, suministrar alimentos, agua y refugio, así como limitar la aparición de brotes de enfermedades transmisibles representan las principales preocupaciones. Cuando se dispone de vacunas eficaces y seguras para reducir el riesgo de aparición de brotes de enfermedades, la distribución potencial de las mismas constituye un factor clave en las situaciones de emergencia sanitaria. Las consideraciones éticas son fundamentales a la hora de decidir sobre la distribución de las vacunas. La asignación de vacunas con suministro limitado, los grupos destinatarios de las mismas, las estrategias de entrega, así como la monitorización y los estudios durante las emergencias humanitarias graves implican consideraciones éticas que, a menudo, derivan de un enfrentamiento entre el beneficio individual y el bien común. Los autores exponen los problemas éticos que los responsables políticos deben tener en cuenta a la hora de considerar cómo distribuir la vacunación masiva durante las emergencias humanitarias, lo cual incluye principios como la beneficencia (el deber de atención y la regla del rescate), la no maleficencia, la autonomía y el consentimiento, así como la justicia distributiva y procesal.

COVID-19 control in low-income settings and displaced populations: what can realistically be done?

COVID-19 prevention strategies in resource limited settings, modelled on the earlier response in high income countries, have thus far focused on draconian containment strategies, which impose movement restrictions on a wide scale. These restrictions are unlikely to prevent cases from surging well beyond existing hospitalisation capacity; not withstanding their likely severe social and economic costs in the long term. We suggest that in low-income countries, time limited movement restrictions should be considered primarily as an opportunity to develop sustainable and resource appropriate mitigation strategies. These mitigation strategies, if focused on reducing COVID-19 transmission through a triad of prevention activities, have the potential to mitigate bed demand and mortality by a considerable extent. This triade is based on a combination of high-uptake of community led shielding of high-risk individuals, self-isolation of mild to moderately symptomatic cases, and moderate physical distancing in the community. We outline a set of principles for communities to consider how to support the protection of the most vulnerable, by shielding them from infection within and outside their homes. We further suggest three potential shielding options, with their likely applicability to different settings, for communities to consider and that would enable them to provide access to transmission-shielded arrangements for the highest risk community members. Importantly, any shielding strategy would need to be predicated on sound, locally informed behavioural science and monitored for effectiveness and evaluating its potential under realistic modelling assumptions. Perhaps, most importantly, it is essential that these strategies not be perceived as oppressive measures and be community led in their design and implementation. This is in order that they can be sustained for an extended period of time, until COVID-19 can be controlled or vaccine and treatment options become available.

The relationship between armed conflict and reproductive, maternal, newborn and child health and nutrition status and services in northeastern Nigeria: a mixed-methods case study.

BACKGROUND: Armed conflict between the militant Islamist group Boko Haram, other insurgents, and the Nigerian military has principally affected three states of northeastern Nigeria (Borno, Adamawa, Yobe) since 2002. An intensification of the conflict in 2009 brought the situation to increased international visibility. However, full-scale humanitarian intervention did not occur until 2016. Even prior to this period of armed conflict, reproductive, maternal, neonatal, and child health indicators were extremely low in the region. The presence of local and international humanitarian actors, in the form of United Nations agencies and non-governmental organizations, working in concert with concerned federal, state, and local entities of the Government of Nigeria, were able to prioritize and devise strategies for the delivery of health services that resulted in marked improvement of health status in the subset of the population in which this could be measured. Prospects for the future remain uncertain. METHODS: Interviews were conducted with more than 60 respondents from government, United Nations agencies, and national and international non-governmental organizations. Quantitative data on intervention coverage indicators from publicly available national surveys (Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS)), National Nutrition and Health Surveys (NNHS)) were descriptively analyzed. RESULTS: Overall, indicators of low reproductive, maternal, neonatal, and child health (RMNCH) status and intervention coverage were found in the pre-intervention period (prior to 2016) and important improvements were noted following the arrival of international humanitarian assistance, even while armed conflict and adverse conditions persisted. Security issues, workforce limitations, and inadequate financing were frequently cited obstacles. CONCLUSION: It is assumed that armed conflict would have a negative impact on the health status of the affected population, but pre-conflict indicators can be so depressed that this effect is difficult to measure. When this is the case, health sector intervention by the international community can often result in marked improvements in the accessible population. What might happen upon the departure of the humanitarian organizations cannot be predicted with an appreciable degree of certainty.

Investigating the delivery of health and nutrition interventions for women and children in conflict settings: a collection of case studies from the BRANCH Consortium.

Globally, the number of people affected by conflict is the highest in history, and continues to steadily increase. There is currently a pressing need to better understand how to deliver critical health interventions to women and children affected by conflict. The compendium of articles presented in this Conflict and Health Collection brings together a range of case studies recently undertaken by the BRANCH Consortium (Bridging Research & Action in Conflict Settings for the Health of Women and Children). These case studies describe how humanitarian actors navigate and negotiate the multiple obstacles and forces that challenge the delivery of health and nutrition interventions for women, children and adolescents in conflict-affected settings, and to ultimately provide some insight into how service delivery can be improved.

Foods Distributed During Federal Disaster Relief Response in Puerto Rico After Hurricane María Did Not Fully Meet Federal Nutrition Recommendations.

BACKGROUND: Emergency foods distributed during a federal disaster relief response must follow the federal Dietary Guidelines for Americans according to the 1990 National Nutrition Monitoring Related Research Act. Nutrition information about emergency foods for household distribution is scarce. METHODS: According to structured observation protocols, foods received daily at a federal distribution center in Puerto Rico after Hurricane María (November 10-25, 2017) were grouped into Dietary Guidelines for Americans ChooseMyPlate food groups. Data about their sodium, saturated fat, added sugar, and fiber content per serving were captured. Registered dietitians designed meal plans with the foods distributed. RESULTS: Of 107 unique food items, 41% were snacks and sweets; and 13%, 4%, 13%, and 7% were fruits, vegetables, proteins, and grains, respectively. Fifty-eight percent of all foods were low in fiber (≤1 g); 46% included high amounts of sodium, saturated fats, or added sugars (≥20% daily value). The registered dietitians were able to design meal plans that complied with the Dietary Guidelines for Americans food group recommendations, but they exceeded upper daily limits for sodium, saturated fat, or added sugars. CONCLUSIONS: In view of projected increases in natural disasters and diet-related chronic diseases, DGA compliance must be improved so that federal emergency foods can support the health of survivors.

The Elephant in the room: toward a more ethical approach with accountability toward intended beneficiaries in humanitarian aid.

There is considerable tension between the concept of accountability to beneficiaries and its practice in humanitarian aid. The beneficiaries live in a relationship that is asymmetric; upward or horizontal accountability within the aid system alone-even with the best of intentions-might be short-sighted. Could beneficiaries be effectively involved in programing, priority setting or allocation of resources? Is there space for a rights-based approach in aid delivery and operations? The mind-set, governance and structure of operations in aid agencies may need significant institutional reform to share the process of decision-making, and to transform the current dynamic from connecting resources to brokering better governance, true collaboration and co-operation among all stakeholders. This article provides a background and overview of accountability in aid, sheds light onto its underlying challenges, and positive and negative effects through the lens of organizational and social ethics, explores practical and feasible ways to strengthen beneficiaries' participation and empowerment, and call upon aid agencies to integrate beneficiaries' views in aid operations, and exercise true solidarity.

Mental health status among ethnic Albanians seeking medical care in an emergency department two years after the war in Kosovo: a pilot project.

STUDY OBJECTIVE: The long-term psychological effects of war are under appreciated in clinical settings. Describing the postwar psychosocial burden on medical care can help direct public health interventions. We performed an emergency department (ED)-based assessment of the mental health status of ethnic Albanian patients 2 years after the North Atlantic Treaty Organization-led bombing of Serbia and Kosovo in 1999. METHODS: This study was conducted July 30, 2001, to August 30, 2001, in the ED of a hospital in Pristina, Kosovo. Investigators collected data through systematic sampling of every sixth nonacute ED patient presenting for care; 87.7% of patients agreed to participate. Respondents completed a structured questionnaire, including demographic characteristics, the Short Form-36, and the Harvard Trauma Questionnaire. RESULTS: All 306 respondents were ethnic Albanians; mean age was 39 years (SD 17.9 years). Of respondents, 58% had become refugees during the war. Two hundred ninety-six (97%) reported experiencing at least one traumatic event during the war; the average number of traumatic events encountered by participants was 6.6. Forty-three (14%) reported symptoms that met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for posttraumatic stress disorder; mean Short Form-36 Mental Component Summary score was 42.1 (SD 12.5). Separate multivariable linear regression models confirmed our belief that older age, female sex, less than a high school education, and having experienced a greater number of traumatic events would be associated with more posttraumatic stress disorder symptoms and lower Mental Component Summary scores. CONCLUSION: Mental health problems among ED patients in Kosovo, particularly among specific vulnerable populations, are a significant public health concern 2 years after the conflict.

A journal for global health programming.

GHSP aims to improve how programs function at scale, targeting implementers who actually support and carry out programs across all of global health. Thus, we emphasize specific implementation details, using a crisp, accessible, interactive style.

Rebuilding health systems to improve health and promote statebuilding in post-conflict countries: a theoretical framework and research agenda.

Violent conflicts claim lives, disrupt livelihoods, and halt delivery of essential services, such as health care and education. Health systems are often devastated in conflicts as health professionals flee, infrastructure is destroyed, and the supply of drugs and supplies is halted. We propose that early reconstruction of a functioning, equitable health system in countries recovering from conflict is an investment with a range of benefits for post-conflict countries. Building on the growing literature about health systems as social and political institutions, we elaborate a logic model that outlines how health systems may contribute not only to improved health status but also potentially to broader statebuilding and enhanced prospects for peace. Specifically, we propose that careful design of the core elements of the health system by national governments and their development partners can promote reliable provision of essential health services while demonstrating a commitment to equity, strengthening government accountability to citizens, and building the capacity of government to manage core social programs. We review the conceptual basis and extant empirical evidence for these mechanisms, identify knowledge gaps, and suggest a research agenda.