Conflict and Health - Most accessed articles

Uranium and other contaminants in hair from the parents of children with congenital anomalies in Fallujah, Iraq

Samira Alaani — 2011-09-02T00:00:00Z

Background: Recent reports have drawn attention to increases in congenital birth anomalies and cancer in Fallujah Iraq blamed on teratogenic, genetic and genomic stress thought to result from depleted Uranium contamination following the battles in the town in 2004. Contamination of the parents of the children and of the environment by Uranium and other elements was investigated using Inductively Coupled Plasma Mass Spectrometry. Hair samples from 25 fathers and mothers of children diagnosed with congenital anomalies were analysed for Uranium and 51 other elements. Mean ages of the parents was: fathers 29.6 (SD 6.2); mothers: 27.3 (SD 6.8). For a sub-group of 6 women, long locks of hair were analysed for Uranium along the length of the hair to obtain information about historic exposures. Samples of soil and water were also analysed and Uranium isotope ratios determined. Results: Levels of Ca, Mg, Co, Fe, Mn, V, Zn, Sr, Al, Ba, Bi, Ga, Pb, Hg, Pd and U (for mothers only) were significantly higher than published mean levels in an uncontaminated population in Sweden. In high excess were Ca, Mg, Sr, Al, Bi and Hg. Of these only Hg can be considered as a possible cause of congenital anomaly. Mean levels for Uranium were 0.16 ppm (SD: 0.11) range 0.02 to 0.4, higher in mothers (0.18 ppm SD 0.09) than fathers (0.11 ppm; SD 0.13). The highly unusual non-normal Fallujah distribution mean was significantly higher than literature results for a control population Southern Israel (0.062 ppm) and a non-parametric test (Mann Whitney-Wilcoxon) gave p = 0.016 for this comparison of the distribution. Mean levels in Fallujah were also much higher than the mean of measurements reported from Japan, Brazil, Sweden and Slovenia (0.04 ppm SD 0.02). Soil samples show low concentrations with a mean of 0.76 ppm (SD 0.42) and range 0.1-1.5 ppm; (N = 18). However it may be consistent with levels in drinking water (2.28 μgL-1) which had similar levels to water from wells (2.72 μgL-1) and the river Euphrates (2.24 μgL-1). In a separate study of a sub group of mothers with long hair to investigate historic Uranium excretion the results suggested that levels were much higher in the past. Uranium traces detected in the soil samples and the hair showed slightly enriched isotopic signatures for hair U238/U235 = (135.16 SD 1.45) compared with the natural ratio of 137.88. Soil sample Uranium isotope ratios were determined after extraction and concentration of the Uranium by ion exchange. Results showed statistically significant presence of enriched Uranium with a mean of 129 with SD5.9 (for this determination, the natural Uranium 95% CI was 132.1 < Ratio < 144.1). Conclusions: Whilst caution must be exercised about ruling out other possibilities, because none of the elements found in excess are reported to cause congenital diseases and cancer except Uranium, these findings suggest the enriched Uranium exposure is either a primary cause or related to the cause of the congenital anomaly and cancer increases. Questions are thus raised about the characteristics and composition of weapons now being deployed in modern battlefields

Malaria control in Timor-Leste during a period of political instability: what lessons can be learned?

Joao Martins — 2009-12-16T00:00:00Z

Background: Malaria is a major global health problem, often exacerbated by political instability, conflict, and forced migration.ObjectivesTo examine the impact of political upheaval and population displacement in Timor-Leste (2006) on malaria in the country.MethodCase study approach drawing on both qualitative and quantitative methods including document reviews, in-depth interviews, focus group discussions, site visits and analysis of routinely collected data.FindingsThe conflict had its most profound impact on Dili, the capital city, in which tens of thousands of people were displaced from their homes. The conflict interrupted routine malaria service programs and training, but did not lead to an increase in malaria incidence. Interventions covering treatment, insecticide treated nets (ITN) distribution, vector control, surveillance and health promotion were promptly organized for internally displaced people (IDPs) and routine health services were maintained. Vector control interventions were focused on IDP camps in the city rather than on the whole community. The crisis contributed to policy change with the introduction of Rapid Diagnostic Tests and artemether-lumefantrine for treatment. Conclusions: Although the political crisis affected malaria programs there were no outbreaks of malaria. Emergency responses were quickly organized and beneficial long term changes in treatment and diagnosis were facilitated.

Prevalence of plasmodium falciparumin active conflict areas of eastern Burma: a summary of cross-sectional data

Adam Richards — 2007-09-05T00:00:00Z

Background: Burma records the highest number of malaria deaths in southeast Asia and may represent a reservoir of infection for its neighbors, but the burden of disease and magnitude of transmission among border populations of Burma remains unknown. Methods: Plasmodium falciparum (Pf) parasitemia was detected using a HRP-II antigen based rapid test (Paracheck-Pf®). Pf prevalence was estimated from screenings conducted in 49 villages participating in a malaria control program, and four retrospective mortality cluster surveys encompassing a sampling frame of more than 220,000. Crude odds ratios were calculated to evaluate Pf prevalence by age, sex, and dry vs. rainy season. Results: 9,796 rapid tests were performed among 28,410 villagers in malaria program areas through four years (2003: 8.4%, 95% CI: 8.3 – 8.6; 2004: 7.1%, 95% CI: 6.9 – 7.3; 2005:10.5%, 95% CI: 9.3 – 11.8 and 2006: 9.3%, 95% CI: 8.2 – 10.6). Children under 5 (OR = 1.99; 95% CI: 1.93 – 2.06) and those 5 to 14 years (OR = 2.24, 95% CI: 2.18 – 2.29) were more likely to be positive than adults. Prevalence was slightly higher among females (OR = 1.04, 95% CI: 1.02 – 1.06) and in the rainy season (OR = 1.48, 95% CI: 1.16 – 1.88). Among 5,538 rapid tests conducted in four cluster surveys, 10.2% were positive (range 6.3%, 95% CI: 3.9 – 8.8; to 12.4%, 95% CI: 9.4 – 15.4). Conclusion: Prevalence of plasmodium falciparum in conflict areas of eastern Burma is higher than rates reported among populations in neighboring Thailand, particularly among children. This population serves as a large reservoir of infection that contributes to a high disease burden within Burma and likely constitutes a source of infection for neighboring regions.

Sexual violence in the protracted conflict of DRC: Programming for rape survivors in South Kivu

Birthe Steiner — 2009-03-15T00:00:00Z

Background: Despite international acknowledgement of the linkages between sexual violence and conflict, reliable data on its prevalence, the circumstances, characteristics of perpetrators, and physical or mental health impacts is rare. Among the conflicts that have been associated with widespread sexual violence has been the one in the Democratic Republic of the Congo (DRC). Methods: From 2003 till to date Malteser International has run a medico-social support programme for rape survivors in South Kivu province, DRC. In the context of this programme, a host of data was collected. We present these data and discuss the findings within the frame of available literature. Results: Malteser International registered 20,517 female rape survivors in the three year period 2005–2007. Women of all ages have been targeted by sexual violence and only few of those – and many of them only after several years – sought medical care and psychological help. Sexual violence in the DRC frequently led to social, especially familial, exclusion. Members of military and paramilitary groups were identified as the main perpetrators of sexual violence. Conclusion: We have documented that in the DRC conflict sexual violence has been – and continues to be – highly prevalent in a wide area in the East of the country. Humanitarian programming in this field is challenging due to the multiple needs of rape survivors. The easily accessible, integrated medical and psycho-social care that the programme offered apparently responded to the needs of many rape survivors in this area.

Ethics of conducting research in conflict settings

Nathan Ford — 2009-07-10T00:00:00Z

Humanitarian agencies are increasingly engaged in research in conflict and post-conflict settings. This is justified by the need to improve the quality of assistance provided in these settings and to collect evidence of the highest standard to inform advocacy and policy change. The instability of conflict-affected areas, and the heightened vulnerability of populations caught in conflict, calls for careful consideration of the research methods employed, the levels of evidence sought, and ethical requirements. Special attention needs to be placed on the feasibility and necessity of doing research in conflict-settings, and the harm-benefit ratio for potential research participants.

Challenges of controlling sleeping sickness in areas of violent conflict: experience in the Democratic Republic of Congo

Jacqueline Tong — 2011-05-26T00:00:00Z

Background: Human African trypanosomiasis (HAT), or sleeping sickness, is a fatal neglected tropical disease if left untreated. HAT primarily affects people living in rural sub-Saharan Africa, often in regions afflicted by violent conflict. Screening and treatment of HAT is complex and resource-intensive, and especially difficult in insecure, resource-constrained settings. The country with the highest endemicity of HAT is the Democratic Republic of Congo (DRC), which has a number of foci of high disease prevalence. We present here the challenges of carrying out HAT control programmes in general and in a conflict-affected region of DRC. We discuss the difficulties of measuring disease burden, medical care complexities, waning international support, and research and development barriers for HAT.DiscussionIn 2007, Médecins Sans Frontières (MSF) began screening for HAT in the Haut-Uélé and Bas-Uélé districts of Orientale Province in northeastern DRC, an area of high prevalence affected by armed conflict. Through early 2009, HAT prevalence rate of 3.4% was found, reaching 10% in some villages. More than 46,000 patients were screened and 1,570 treated for HAT during this time. In March 2009, two treatment centres were forced to close due to insecurity, disrupting patient treatment, follow-up, and transmission-control efforts. One project was reopened in December 2009 when the security situation improved, and another in late 2010 based on concerns that population displacement might reactivate historic foci. In all of 2010, 770 patients were treated at these sites, despite a limited geographical range of action for the mobile teams.SummaryIn conflict settings where HAT is prevalent, targeted medical interventions are needed to provide care to the patients caught in these areas. Strategies of integrating care into existing health systems may be unfeasible since such infrastructure is often absent in resource-poor contexts. HAT care in conflict areas must balance logistical and medical capacity with security considerations, and community networks and international-response coordination should be maintained. Research and development for less complicated, field-adapted tools for diagnosis and treatment, and international support for funding and program implementation, are urgently needed to facilitate HAT control in these remote and insecure areas.

The burden of acute respiratory infections in crisis-affected populations: a systematic review

Anna Bellos — 2010-02-11T00:00:00Z

Crises due to armed conflict, forced displacement and natural disasters result in excess morbidity and mortality due to infectious diseases. Historically, acute respiratory infections (ARIs) have received relatively little attention in the humanitarian sector. We performed a systematic review to generate evidence on the burden of ARI in crises, and inform prioritisation of relief interventions. We identified 36 studies published since 1980 reporting data on the burden (incidence, prevalence, proportional morbidity or mortality, case-fatality, attributable mortality rate) of ARI, as defined by the International Classification of Diseases, version 10 and as diagnosed by a clinician, in populations who at the time of the study were affected by natural disasters, armed conflict, forced displacement, and nutritional emergencies. We described studies and stratified data by age group, but did not do pooled analyses due to heterogeneity in case definitions. The published evidence, mainly from refugee camps and surveillance or patient record review studies, suggests very high excess morbidity and mortality (20-35% proportional mortality) and case-fatality (up to 30-35%) due to ARI. However, ARI disease burden comparisons with non-crisis settings are difficult because of non-comparability of data. Better epidemiological studies with clearer case definitions are needed to provide the evidence base for priority setting and programme impact assessments. Humanitarian agencies should include ARI prevention and control among infants, children and adults as priority activities in crises. Improved data collection, case management and vaccine strategies will help to reduce disease burden.

Six rapid assessments of alcohol and other substance use in populations displaced by conflict

Nadine Ezard — 2011-02-11T00:00:00Z

Background: Substance use among populations displaced by conflict is a neglected area of public health. Alcohol, khat, benzodiazepine, opiate, and other substance use have been documented among a range of displaced populations, with wide-reaching health and social impacts. Changing agendas in humanitarian response-including increased prominence of mental health and chronic illness-have so far failed to be translated into meaningful interventions for substance use. Methods: Studies were conducted from 2006 to 2008 in six different settings of protracted displacement, three in Africa (Kenya, Liberia, northern Uganda) and three in Asia (Iran, Pakistan, and Thailand). We used intervention-oriented qualitative Rapid Assessment and Response methods, adapted from two decades of experience among non-displaced populations. The main sources of data were individual and group interviews conducted with a culturally representative (non-probabilistic) sample of community members and service providers. Results: Widespread use of alcohol, particularly artisanally-produced alcohol, in Kenya, Liberia, Uganda, and Thailand, and opiates in Iran and Pakistan was believed by participants to be linked to a range of health, social and protection problems, including illness, injury (intentional and unintentional), gender-based violence, risky behaviour for HIV and other sexually transmitted infection and blood-borne virus transmission, as well as detrimental effects to household economy. Displacement experiences, including dispossession, livelihood restriction, hopelessness and uncertain future may make communities particularly vulnerable to substance use and its impact, and changing social norms and networks (including the surrounding population) may result in changed - and potentially more harmful-patterns of use. Limited access to services, including health services, and exclusion from relevant host population programmes, may exacerbate the harmful consequences. Conclusions: The six studies show the feasibility and value of conducting rapid assessments in displaced populations. One outcome of these studies is the development of a UNHCR/WHO field guide on rapid assessment of alcohol and other substance use among conflict-affected populations. More work is required on gathering population-based epidemiological data, and much more experience is required on delivering effective interventions. Presentation of these findings should contribute to increased awareness, improved response, and more vigorous debate around this important but neglected area.

Integrating mental health into primary care for displaced populations: the experience of Mindanao, Philippines

Yolanda Mueller — 2011-03-07T00:00:00Z

Background: For more than forty years, episodes of violence in the Mindanao conflict have recurrently led to civilian displacement. In 2008, Medecins Sans Frontieres set up a mental health program integrated into primary health care in Mindanao Region. In this article, we describe a model of mental health care and the characteristics and outcomes of patients attending mental health services. Methods: Psychologists working in mobile clinics assessed patients referred by trained clinicians located at primary level. They provided psychological first aid, brief psychotherapy and referral for severe patients. Patient characteristics and outcomes in terms of Self-Reporting Questionnaire (SRQ20) and Global Assessment of Functioning score (GAF) are described. Results: Among the 463 adult patients diagnosed with a common mental disorder with at least two visits, median SRQ20 score diminished from 7 to 3 (p < 0.001) and median GAF score increased from 60 to 70 (p < 0.001). Baseline score and score at last assessment were different for both discharged patients and defaulters (p < 0.001). Conclusions: Brief psychotherapy sessions provided at primary level during emergencies can potentially improve patients' symptoms of distress.

Resilience of refugees displaced in the developing world: a qualitative analysis of strengths and struggles of urban refugees in Nepal

Fiona Thomas — 2011-09-24T00:00:00Z

Background: Mental health and psychosocial wellbeing are key concerns in displaced populations. Despite urban refugees constituting more than half of the world's refugees, minimal attention has been paid to their psychosocial wellbeing. The purpose of this study was to assess coping behaviour and aspects of resilience amongst refugees in Kathmandu, Nepal. Methods: This study examined the experiences of 16 Pakistani and 8 Somali urban refugees in Kathmandu, Nepal through in-depth individual interviews, focus groups, and Photovoice methodology. Such qualitative approaches enabled us to broadly discuss themes such as personal experiences of being a refugee in Kathmandu, perceived causes of psychosocial distress, and strategies and resources for coping. Thematic network analysis was used in this study to systematically interpret and code the data. Results: Our findings highlight that urban refugees' active coping efforts, notwithstanding significant adversity and resulting distress, are most frequently through primary relationships. Informed by Axel Honneth's theory on the struggle for recognition, findings suggest that coping is a function beyond the individual and involves the ability to negotiate recognition. This negotiation involves not only primary relationships, but also the legal order and other social networks such as family and friends. Honneth's work was used because of its emphasis on the importance of legal recognition and larger structural factors in facilitating daily coping. Conclusions: Understanding how urban refugees cope by negotiating access to various forms of recognition in the absence of legal-recognition will enable organisations working with them to leverage such strengths and develop relevant programmes. In particular, building on these existing resources will lead to culturally compelling and sustainable care for these populations.