They do their utmost: promise and limits of palliative care in two refugee camps in Rwanda, a qualitative study.

After often gruelling journeys, some refugees arrive at secure locations with severe injury or illness. Others find themselves shortly thereafter facing a life-limiting health condition. Palliative care has been the focus of recent research, and of academic and aid sector dialogue. In this study, we ask: What are experiences and needs of patients and care providers? What opportunities and obstacles exist to enhance or introduce means of reducing suffering for patients facing serious illness and injury in crisis settings? We present findings of a qualitative sub-study within a larger programme of research exploring moral and practical dimensions of palliative care in humanitarian crisis contexts. This paper presents vignettes about palliative care from refugees and care providers in two refugee camps in Rwanda, and is among the first to provide empirical evidence on first-hand experiences of individuals who have fled protracted conflict and face dying far from home. Along with narratives of their experiences, participants provided a range of recommendations from small (micro) interventions that are low cost, but high impact, through to larger (macro) changes at the systems and societal levels of benefit to policy developers and decision-makers.

International humanitarian narratives of disasters, crises, and Indigeneity.

Narratives are a means of making sense of disasters and crises. The humanitarian sector communicates stories widely, encompassing representations of peoples and events. Such communications have been critiqued for misrepresenting and/or silencing the root causes of disasters and crises, depoliticising them. What has not been researched is how such communications represent disasters and crises in Indigenous settings. This is important because processes such as colonisation are often at the origin but are typically masked in communications. A narrative analysis of humanitarian communications is employed here to identify and characterise narratives in humanitarian communications involving Indigenous Peoples. Narratives differ based upon how the humanitarians who produce them think that disasters and crises should be governed. The paper concludes that humanitarian communications reflect more about the relationship between the international humanitarian community and its audience than reality, and underlines that narratives mask global processes that link audiences of humanitarian communications with Indigenous Peoples.

Localisation requires trust: an interface perspective on the Rohingya response in Bangladesh.

Local actors are promoted as important agents in the humanitarian sector's latest reform efforts. Opinions on the exact meaning and the best means of implementing localisation differ, however. Applying an interface perspective, this paper analyses how the Rohingya response in Cox's Bazar, Bangladesh, became an arena of contestation, competition, and sometimes convergence among different actors in relation to localisation. It shows how misconceptions and divergent understandings of localisation and the best methods of achieving it were prevalent and hampered the joint endeavours of international and local humanitarian bodies. Although both sides sought common ground, conflicting views, interests, and perceptions of 'self' and 'other' stood in the way. A lack of trust between international and local organisations intensified divisions. The paper argues, therefore, that the humanitarian sector needs to engage in trust-building between the various entities involved in humanitarian response if localisation is to be realised, including addressing underlying structural and systemic issues of (neo)colonialism, racism, and classism.

Negotiating rights and faith: a study of rights-based approaches to humanitarian action in Pakistan.

'Rights-based approaches' (RBAs) have become a well-established concept over the past two decades, informing the work of diverse actors involved in development and humanitarian aid. Faith-based organisations have increasingly embraced the RBA, although not without contestation. Drawing on new qualitative data from Pakistan, this paper examines how 'global' RBA norms are operationalised in 'local' contexts characterised by great normative diversity and identifies three dominant normative frameworks used by non-governmental organisations in the translation of RBAs: humanitarian standards; citizens' rights; and Islamic principles. It utilises a case study of RBAs in Pakistan and reveals the significance of religion and religious entities in the translation of rights. From this example, the paper makes a conceptual distinction between 'instrumental' and 'substantial' modes of engagement, a framing that allows for a more detailed analysis of how humanitarian actors deal with religion and rights than what is often found in studies of humanitarian action.

The effectiveness of forecast-based humanitarian assistance in anticipation of extreme winters: a case study of vulnerable herders in Mongolia.

This paper presents evidence relating to a forecast-based cash and non-food item distribution among vulnerable herder households during the 2017-18 dzud (extreme winter) season in Mongolia, and analyses the results of a quasi-experimental study evaluating its impacts. An innovative approach in disaster risk reduction, forecast-based financing (FbF) can have short- and long-term benefits to vulnerable households but remains understudied. The paper contributes information on a multimodal FbF programme offering one-off cash grants and in-kind veterinary kits. The data found significant effects of reduced mortality and increased offspring survival in some types of livestock, and that the timing of FbF assistance is crucial, as reported early assistance correlated to positive outcomes in terms of reduced animal mortality. These findings can be used to design more effective FbF interventions, to understand better the appropriateness of FbF designs, and to use early warnings and early actions to help people prepare and withstand disasters such as dzuds.

Caring for Critically Ill Patients in Humanitarian Settings.

Critical care medicine is far from the first medical field to come to mind when humanitarian action is mentioned, yet both critical care and humanitarian action share a fundamental purpose to save the lives and ease the suffering of people caught in acute crises. Critically ill children and adults will be present regardless of resource limitations and irrespective of geography, regional or cultural contexts, insecurity, or socioeconomic status, and they may be even more prevalent in a humanitarian crisis. Critical care is not limited to the walls of a hospital, and all hospitals will have critically ill patients regardless of designating a specific ward an ICU. Regular and consistent consideration of critical care principles in humanitarian settings provides crucial guidance to intensivists and nonintensivists alike. A multidisciplinary, systematic approach to patient care that encourages critical thinking, checklists that encourage communication among team members, and context-specific critical care rapid response teams are examples of critical care constructs that can provide high-quality critical care in all environments. Promoting critical care principles conveys the message that critical care is an integral part of health care and should be accessible to all, no matter the setting. These principles can be effectively adopted in humanitarian settings by normalizing them to everyday clinical practice. Equally, core humanitarian principles-dignity, accountability, impartiality, neutrality-can be applied to critical care. Applying principles of critical care in a context-specific manner and applying humanitarian principles to critical care can improve the quality of patient care and transcend barriers to resource limitations.

Forensic anthropology in the global investigation of humanitarian and human rights abuse: Perspective from the published record.

Forensic anthropologists have played key roles in the historical development of forensic science applications to global humanitarian and human rights issues. These anthropological initiatives can be traced back to the Smithsonian seminar organized by T. D. Stewart in 1968 and published in 1970. Key developments include the 1984 delegation sent by the American Association for the Advancement of Science to Argentina and the formation of the Argentine Forensic Anthropology Team. Subsequent highlights include major anthropological involvement in support of investigations by international criminal tribunals, formation of forensic anthropology teams in different countries and activities of the International Commission of Missing Persons and the forensic unit of the International Committee of the Red Cross. Recent developments feature the formation of the Humanitarian and Human Rights Resource Center of the American Academy of Forensic Sciences and its support of worthwhile projects in many countries. The published record provides historical perspective on these developments.

Humanitarian aid in the archives: introduction.

How might historical perspectives assist the goal of improving humanitarian responses? This introduction to a special issue of Disasters on the history of humanitarian action explores this question and outlines how the other submissions to the edition, each with its own approach and focus area from the nineteenth-century to the present today, make different contributions to understanding of humanitarian action. The paper argues that the value of history lies not so much in the information it might offer, but in the challenges it can pose to habitual ways of thinking and in the skills of investigation and interpretation it fosters. These attributes make historical perspectives a potentially valuable addition to the critical questioning of humanitarian practitioners and policymakers. The paper advocates integrating history into a more reflective attitude to change and a more adventurous and holistic approach to innovation, as opposed to simply using it to 'learn lessons'.

Navigating the profits and pitfalls of governmental partnerships: the ICRC and intergovernmental relief, 1918-23.

The International Committee of the Red Cross (ICRC) is today a staunch proponent of the need for humanitarian organisations to remain independent of state interests, yet it deliberately solicited intergovernmental intervention in international relief after the First World War of 1914-18. This paper examines why an organisation committed to upholding the independence and impartiality of humanitarian action might still choose to partner with governmental bodies. It also highlights the historical beginnings of a linkage between international aid and geopolitics. To secure governmental funding for refugee relief during the 1920s, the ICRC argued that the humanitarian crises of the post-war years were a threat to the political and social stability of Europe. While this has become axiomatic, the interwar history of the ICRC demonstrates that the perceived connection between relief and geopolitical stability is historically constructed, and that it must continue to be asserted persuasively to be effective.

Ethics in humanitarian settings-relevance and consequences for dialysis and kidney care.

With the increasing frequency and severity of disasters and the increasing number of patients living with kidney disease, on dialysis and with transplants around the world, the need for kidney care in humanitarian settings is increasing. Almost all humanitarian emergencies pose a threat to kidney health because all treatments are highly susceptible to interruption, and interruption can be deadly. Providing support for people requiring dialysis in humanitarian settings can be complex and is associated with many trade-offs. The global kidney care community must become familiar with the ethics, principles and duties essential to meeting the overarching goals of ethical and effective disaster relief. Ethics principles and values must be considered on the individual, public health and global levels. The wellbeing of a single patient must be considered in the context of the competing needs of many others, and optimal treatment may not be possible due to resource constraints. Public health ethics principles, including considerations of triage and resource allocation, maximization of benefit and feasibility, often become directly relevant at the bedside. Individuals delivering humanitarian relief must be well trained, competent, respectful and professional, while involved organizations need to uphold the highest professional and ethical standards. There may be dissonance between ethical guidance and practical realities in humanitarian settings, which for inexperienced individuals may present significant challenges. Sustaining dialysis care in emergencies brings these issues starkly to the fore. Preparedness for dialysis in emergencies is an ethical imperative that mandates multisectoral stakeholder engagement and action, development of surge response plans, clinical and ethics guidance, and transparent priority setting. This manuscript outlines common ethics challenges and considerations that apply in all humanitarian actions, and illustrates their relevance to kidney care as a whole, using examples of how these may apply to dialysis and kidney disaster relief efforts in humanitarian settings.

Invitation withdrawn: humanitarian action, United Nations peacekeeping, and state sovereignty in Chad.

This paper looks at the three-way relationship between the Government of Chad, humanitarians, and the United Nations Mission in the Central African Republic and Chad (MINURCAT) from 2004 until June 2011. Chad was never comfortable with the international presence of either humanitarians or peacekeepers and asserted its sovereignty increasingly during this period. MINURCAT was deployed in 2008 to protect humanitarian workers and to facilitate the provision of humanitarian assistance in eastern Chad. This association between the UN mission and humanitarian agencies contributed to making the latter the target of repressive practices by the government, such as the imposition of armed escorts. Facing a steep learning curve, Chad and its state officials gradually appropriated the discourse of the humanitarian and international community and ultimately, in 2010, requested the departure of MINURCAT, claiming that they could meet the protection needs of vulnerable populations in eastern Chad on their own.

Introduction: evidence-based action in humanitarian crises.

This introductory paper sets the stage for this special issue of Disasters on evidence-based action in humanitarian crises. It reviews definition(s) of evidence and it examines the different disciplinary and methodological approaches to collecting and analysing evidence. In humanitarian action, the need for evidence-based approaches sometimes is viewed in tension with a principled approach, often unnecessarily. Choosing appropriate research methods depends on the objectives of the researcher, in particular whether the research focuses on the intervention and/or the context and the length and complexity of the causal chains involved. The paper concludes by defining some trends in evidence-based approaches in crises: the move away from inputs and outputs of humanitarian action towards outcomes and impacts; the shift towards a higher degree of partnerships in research, and the participation of users and target groups; and the acceptance of a broad array of approaches to establish evidence.

The Integration of Social Science for Community Engagement in the Humanitarian Fields of Conflicts and Disasters: A Scoping Review.

Community engagement (CE) is essential to humanitarian assistance, and the social sciences have been credited in recent epidemics and disease outbreaks as having played a crucial, supportive role. Broadening this attention to other humanitarian fields, this scoping review asks what lessons learned can be found in grey and peer-reviewed literature on the integration of the social sciences in CE for conflicts and disasters. Using an analytical framework developed through a UNICEF-led project called Social Science for Community Engagement (SS4CE) in Humanitarian Action, we identified 1093 peer reviewed publications and 315 grey literature reports of possible relevance. The results show that only a small minority-18 publications and 4 reports-tangibly comment on the relevance of social sciences, mostly only in passing and implicitly. While social science techniques are used and the importance of understanding a community's cultural, linguistic, and religious context is emphasized, further discussion on the integration of transdisciplinary and multidisciplinary social sciences is absent. Furthermore, CE is mostly seen as an instrumental ('means to an end') involvement, for example to collect data in emergency situations and receive feedback on interventions, but not as a critical and transformative intervention. We conclude that unlike the attention given to social sciences in disease outbreaks, there is a knowledge gap and an accordingly proper planning and implementation gap regarding the potentiality of social science to improve CE across all humanitarian contexts of disasters and conflicts.

Impediments to localization agenda: humanitarian space in the Rohingya response in Bangladesh.

The article spotlights the impediments of the localization agenda in the Rohingya response in Bangladesh through the notion of humanitarian space. The Rohingyas rely entirely on material aid and humanitarian services in the camps, mainly stemming from international actors committed to the localization agenda, which, however, has not been effectively implemented. Drawing on the definition of humanitarian space as an arena, we investigate the main negotiations within humanitarian space in the Rohingya response and how they impede the realization of the localization agenda. We conducted secondary data analysis on reports published by organizations involved and validated the findings with ten telephone interviews with organizations in Bangladesh. We identified three main negotiations. First, negotiation on the nature of the partnership between local and international humanitarian actors, including the debates on the definition of "local"; second, negotiation concerning the characteristics and appreciation of local capacity; and third, the negotiation related to constraints within the operating environment for humanitarian actors in Cox's Bazar, Bangladesh. We conclude that the lens of humanitarian space is necessary for further understanding the dynamics impeding localization in the Rohingya response in particular and humanitarian action in general.

Gaining community entry with survivors for forensic human rights and humanitarian intervention.

As forensic humanitarian and forensic human rights anthropology has continued to evolve, an ongoing concern in the field is meaningful engagement with survivors and the imperative to do no harm. For forensic anthropologists attempting to engage in grassroots forensic intervention, unaffiliated with an international investigation, means for effectively accessing and engaging communities has not been widely discussed. Here, forensic anthropologists draw on multiple, cross-cultural contexts to discuss methods and techniques for introducing forensic partnerships to communities. To do this, the scientist must consider their positionality as well as that of the stakeholders, develop effective local relationships, and consider a community-grounded approach. This paper argues that drawing on broader cultural anthropological training, ultimately informs one's ability to gain entry into at-risk and vulnerable communities while minimizing harm. To illustrate this point, examples are drawn from Canada, Uganda, Cyprus, and Somaliland.

Humanitarian action in academic institutions: a case study in the ethical stewardship of unidentified forensic cases.

Forensic anthropologists are often responsible for the management of long-term unidentified individuals. Others have contextualised these decedents-many of whom likely belonged to socially, politically, and/or economically marginalised groups in life-as part of a larger identification crisis in the US. However, there has been little discussion surrounding how this humanitarian crisis has manifested in academic institutions, where anthropologists often provide medicolegal consultation and act as long-term stewards of the unidentified. The Identification & Repatriation Initiative was created at the Forensic Anthropology Centre at Texas State University (FACTS) to recognise and investigate unidentified human remains in long-term storage. Our paper outlines common challenges that were encountered during our initial reassessment of unidentified cases at FACTS, emphasising the detrimental impacts of inconsistent procedures, loss of context, and case fatigue. It is likely that other academic institutions face similar challenges, and by highlighting these issues we hope to help initiate a larger conversation concerning ethical stewardship of human remains in these settings. By incorporating humanitarian perspectives into forensic casework, anthropologists in academia can better advocate for the long-term unidentified.Key pointsForensic anthropologists at academic institutions are qualified to act as consultants on forensic casework when requested by jurisdictional authorities and are often responsible for the long-term management of unidentified human remains.The long-term unidentified represent a vulnerable population and academic institutions are not exempt from calls for humanitarian approaches to identification.The Identification and Repatriation Initiative was created at the Forensic Anthropology Centre at Texas State University to acknowledge and investigate unidentified human remains in long-term storage.This paper considers possible ways for humanitarian action to be incorporated into academic settings and suggests anthropologists can better advocate for the unidentified through procedural standardisation, institutional and interagency collaboration and ethical stewardship.

Does Poor Mental Health Impair the Effectiveness of Complementary Food Hygiene Behavior Change Intervention in Rural Malawi?

Mental disorders have the potential to affect an individual's capacity to perform household daily activities such as water, sanitation, and hygiene (food hygiene inclusive) that require effort, time, and strong internal motivation. However, there is limited detailed assessment about the influence of mental health on food hygiene behaviors at household level. We conducted a follow-up study to detect the effects of mental health on food hygiene behaviors after food hygiene intervention delivery to child caregivers in rural Malawi. Face-to-face interviews, based on the Risk, Attitude, Norms, Ability, and Self-regulations (RANAS) model, were conducted with 819 participants (control and intervention group) to assess their handwashing and food hygiene-related behaviors. Mental health was assessed using the validated Self-Reporting Questionnaire. Study results showed a significant negative relationship between mental health and handwashing with soap behavior (r = -0.135) and keeping utensils in an elevated place (r = -0.093). Further, a significant difference was found between people with good versus poor mental health on handwashing with soap behavior (p = 0.050) among the intervention group. The results showed that the influence of the intervention on handwashing with soap behavior was mediated by mental health. Thus, integration of mental health in food hygiene interventions can result in improved outcomes for caregivers with poor mental health.

The humanitarian and outreach ethics charter in ENT. Ethics at the heart of missions.

Humanitarian action, in the broad sense, including global outreach missions by ENT physicians, has been effective for many years. These volunteer missions have not had any specific regulatory framework, be it medical, social or above all ethical. The testimony of ENT physicians in certain "recipient" countries, in particular during the 2017 Paris Congress of the International Federation of Otorhinolaryngological Societies (IFOS), revealed the importance of adequate coordination between "provider" and "recipient" teams. Several ethical reports have been made, but few specifically focused on ENT outreach. The present review is based on feedback from several missions given to the French Society of OtoRhinoLaryngology and Head and Neck Surgery (SFORL) and IFOS, and on a review of the literature. A specific charter of global outreach and humanitarian missions in ENT has been drawn up. This review is essential for optimizing the sharing of knowledge and training in otorhinolaryngology across the world while respecting mandatory sociocultural and ethical rules.

Conducting operational research in humanitarian settings: is there a shared path for humanitarians, national public health authorities and academics?

In humanitarian contexts, it is a difficult and multi-faceted task to enlist academics, humanitarian actors and health authorities in a collaborative research effort. The lack of research in such settings has been widely described in the past decade, but few have analysed the challenges in building strong and balanced research partnerships. The major issues include considering operational priorities, ethical imperatives and power differentials. This paper analyses in two steps a collaborative empirical endeavour to assess health service utilization by Syrian refugee and Lebanese women undertaken by the International Committee of the Red Cross (ICRC), the Lebanese Ministry of Public Health (MoPH) and the Harvard François-Xavier Bagnoud (FXB) Center. First, based on challenges documented in the literature, we shed light on how we negotiated appropriate research questions, methodologies, bias analyses, resource availability, population specificities, security, logistics, funding, ethical issues and organizational cultures throughout the partnership. Second, we describe how the negotiations required each partner to go outside their comfort zones. For the academics, the drivers to engage included the intellectual value of the collaboration, the readiness of the operational partners to conduct an empirical investigation and the possibility that such work might lead to a better understanding in public health terms of how the response met population needs. For actors responding to the humanitarian crisis (the ICRC and the MOPH), participating in a technical collaboration permitted methodological issues to be worked through in the context of deliberations within the wider epistemic community. We find that when they collaborate, academics, humanitarian actors and health authorities deploy their respective complementarities to build a more comprehensive approach. Barriers such as the lack of uptake of research results or weak links to the existing literature were overcome by giving space to define research questions and develop a longer-term collaboration involving individual and institutional learning. There is the need ahead of time to create balanced decision-making mechanisms, allow for relative financial autonomy, and define organizational responsibilities. Ultimately, mutual respect, trust and the recognition of each other's expertise formed the basis of an initiative that served to better understand populations affected by conflict and meet their needs.

Addressing obstacles to the inclusion of palliative care in humanitarian health projects: a qualitative study of humanitarian health professionals' and policy makers' perceptions.

BACKGROUND: Humanitarian non-governmental organizations provide assistance to communities affected by war, disaster and epidemic. A primary focus of healthcare provision by these organizations is saving lives; however, curative care will not be sufficient, appropriate, or available for some patients. In these instances, palliative care approaches to ease suffering and promote dignity are needed. Though several recent initiatives have increased the probability of palliative care being included in humanitarian healthcare response, palliative care remains minimally integrated in humanitarian health projects. METHODS: We conducted a qualitative study using interpretive description methodology to investigate humanitarian policy-makers' and health care professionals' experiences and perceptions of palliative care during humanitarian crises. In this article, we report on the analysis of in-depth interviews with 24 participants related to their perceptions of obstacles to providing palliative care in humanitarian crises, and opportunities for overcoming these obstacles. Among the participants, 23 had experience as humanitarian health professionals, and 12 had experience with policy development and organizational decision-making. RESULTS: Participants discussed various obstacles to the provision of palliative care in humanitarian crises. More prominent obstacles were linked to the life-saving ethos of humanitarian organizations, priority setting of scarce resources, institutional and donor funding, availability of guidance and expertise in palliative care, access to medication, and cultural specificity around death and dying. Less prominent obstacles related to continuity of care after project closure, equity, security concerns, and terminology. CONCLUSION: Opportunities exist for overcoming the obstacles to providing palliative care in humanitarian crises. Doing so is necessary to ensure that humanitarian healthcare can fulfill its objectives not only of saving lives, but also of alleviating suffering and promoting dignity of individuals who are ill or injured during a humanitarian crises, including persons who are dying or likely to die.