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On the frontline of eastern Burma's chronic conflict – Listening to the voices of local health workers
Abstract
Globally, attacks on and interferences with health workers and healthcare delivery, including targeted violence towards providers, attacks on hospitals and delays and denial of health care, represent a serious humanitarian and human rights issue. However, gaps in research about these events persist, limiting the evidence base from which to understand and address the problem. This paper focuses on experiences of local health workers in eastern Burma's chronic conflict, including their strategies for addressing security and ensuring access to vulnerable ethnic communities in the region. Face-to-face in-depth interviews were conducted in June and August 2012 with 27 health workers from three health organizations that operate throughout eastern Burma, with their operational head quarters located in Mae Sot, Tak Province, Thailand. Qualitative analysis found that health workers in this setting experience violent and non-violent interferences with their work, and that the Burmese government's military activities in the region have severely impacted access to care, which remains restricted. Data show that innovative security strategies have emerged, including the important role of the community in ensuring securer access to health care. This study underscores health workers' concern for improved data collection to support the rights of health workers to provide health care, and the rights of community members to receive health care in conflict-affected settings. Findings will inform the development of an incident reporting form to improve systematic data collection and documentation of attacks on health in this setting.
... In Burundi, attacks on health workers occurred 'across ethnic lines', and health workers "preferred to [work] in areas where they felt their safety and security was guaranteed, and that might be within their own community" [41]. Ethnicity or locality was found to be a factor in health worker vulnerability in the conflict in Myanmar as well [55], where ethnic groups fought the national government and the health workers provided care to targeted ethnic groups. There were anecdotal reports of similar vulnerabilities in South Sudan [44]. ...
... For instance, a study in Mozambique highlighted that "196 peripheral health posts and health centers had been destroyed and another 288 had been looted and/or forced to close," noting that this loss of health services has "hit people hardest in the rural areas where people are most in need of health care" [43]. In eastern Myanmar, qualitative interviews with health workers identified frequent attacks on clinics, which could not reopen because the military set up landmines around them [55]. Studies repeatedly noted the specificity of context and conflict. ...
... Chen and Wong used secondary analysis of literature to identify and characterize violent attacks on ambulances in Syria in 2016 and 2017 [85]. In other studies, delays at checkpoints, violence against mobile clinics and other transport-related violence featured more prominently than physical violence against ambulances [46,55,66,70,77,83]. Incidents such as looting of medical equipment [41,44], and disruption of medication cold chains [80] received little attention in the research literature on attacks on healthcare. ...
Background
Attacks on health care in armed conflict, including those on health workers, facilities, patients and transports, represent serious violations of human rights and international humanitarian law. Information about these incidents and their characteristics are available in myriad forms: as published research or commentary, investigative reports, and within online data collection initiatives. We review the research on attacks on health to understand what data they rely on, what subjects they cover and what gaps exist in order to develop a research agenda going forward.
Methods and findings
This study utilizes a systematic review of peer-reviewed to identify and understand relevant data about attacks on health in situations of conflict. We identified 1479 papers published before January 1, 2020 using systematic and hand-searching and chose 45 articles for review that matched our inclusion criteria. We extracted data on geographical and conflict foci, methodology, objectives and major themes. Among the included articles, 26 focused on assessment of evidence of attacks, 15 on analyzing their impacts, three on the legal and human rights principles and one on the methods of documentation. We analyzed article data to answer questions about where and when attacks occur and are investigated, what types of attacks occur, who is perpetrating them, and how and why they are studied. We synthesized cross-cutting themes on the impacts of these attacks, mitigation efforts, and gaps in existing data.
Conclusion
Recognizing limitations in the review, we find there have been comparatively few studies over the past four decades but the literature is growing. To deepen the discussions of the scope of attacks and to enable cross-context comparisons, documentation of attacks on health must be enhanced to make the data more consistent, more thorough, more accessible, include diverse perspectives, and clarify taxonomy. As the research on attacks on health expands, practical questions on how the data is utilized for advocacy, protection and accountability must be prioritized.
... Attacks on health careboth deliberate and indiscriminateare a recurring feature of several contemporary conflicts, despite protections afforded to health care workers and facilities under international humanitarian law (Briody et al., 2018). Conflict has devastating effects on health systems, both directly through attacks on health infrastructure, personnel and patients, and indirectly through interferences that disrupt health care delivery (Footer et al., 2014). ...
... One study demonstrated that out of 921 violent incidents affecting health care in 22 conflict-affected countries, 91% were of violence inflicted on local health workers (ICRC, 2013). Recent studies exploring the experiences of health workers in conflict and post-conflict settings have highlighted the heightened vulnerability of health workers to physical attacks, arrests, and intimidation as well as their exposure to stresses stemming from increased workload, economic hardship and poor working conditions (Footer et al., 2014(Footer et al., , 2018Fouad et al., 2017;Witter et al., 2017). ...
... Clearly evident from the data are the various ways in which conflict impacts and undermines health workers' wellbeing and safety. Consistent with other studies conducted in conflict settings, physical attacks, threats, and obstruction by armed factions were among the documented ways through which the conflict directly affected health workers' lives (Footer et al., 2014(Footer et al., , 2018Witter et al., 2017). These manifestations of violence can be understood as part of a broader pattern of 'generalized violence' against healthcare which Rubenstein and Bittle (2010) find are a distinguishing feature of several recent armed conflicts. ...
The war in Yemen, described as the world’s ‘worst humanitarian crisis,’ has seen numerous attacks against health care. While global attention to attacks on health workers has increased significantly over the past decade, gaps in research on the lived experiences of frontline staff persist. This study draws on perspectives of frontline health workers in Yemen to understand the impact of the ongoing conflict on their personal and professional lives. Forty-three facility-based health workers’ interviews, and 6 focus group discussions with community-based health workers and midwives were conducted in Sana’a, Aden and Taiz governorates at the peak of the Yemen conflict. Data were analyzed using content analysis methods. Findings highlight the extent and range of violence confronting health workers in Yemen as well as the coping strategies they use to attenuate the impact of acute and chronic stressors resulting from conflict. We find that the complex security situation – characterized by multiple parties to the conflict, politicization of humanitarian aid and constraints in humanitarian access – was coupled with everyday stressors that prevented health workers from carrying out their work. Participants reported sporadic attacks by armed civilians, tensions with patients, and harassment at checkpoints. Working conditions were dire, and participants reported chronic suspension of salaries as well as serious shortages of essential supplies and medicines. Themes specific to coping centered around fatalism and religious motivation, resourcefulness and innovation, and sense of duty and patriotism. Our findings demonstrate that health workers experience substantial stress and face various pressures while delivering lifesaving services in Yemen. While they exhibit considerable resilience and coping, they have needs that remain largely unaddressed. Accordingly, the humanitarian community should direct more attention to responding to the mental health and psychosocial needs of health workers, while actively working to ameliorate the conditions in which they work.
... In Black Zones, soldiers are empowered to do harm, having the right to shoot opposition forces on sight (Footer et al., 2014). This is a decision that often includes the targeting of aid workers and medical personnel attempting to bring supplies to villages in disputed zones (Footer et al., 2014). ...
... In Black Zones, soldiers are empowered to do harm, having the right to shoot opposition forces on sight (Footer et al., 2014). This is a decision that often includes the targeting of aid workers and medical personnel attempting to bring supplies to villages in disputed zones (Footer et al., 2014). ...
... These poor health outcomes may be due to the limitations on the availability of basic health services during times of conflict. Health workers from Kachin and Kayin have described a "general climate of insecurity and fear" for civilians and health care providers alike (Footer et al., 2014). ...
Historic fertility declines across Asia suggest that significant social change and the institutional provision of family planning are necessary preconditions for reducing fertility, but Myanmar’s fertility decline took place during a time of authoritarian control and conflict, and prior to the introduction of government family planning programs. This thesis integrates classical demographic methods with geospatial measures of physical and social remoteness and conflict exposure to understand how these factors interact with and potentially influence sexual and reproductive decision making and fertility outcomes in Myanmar. Using newly released census and Demographic Health Survey data, this thesis begins by presenting methods for estimating fertility in Myanmar at several administrative levels, including the introduction of a Myanmar-specific standard fertility schedule. The associations between district level social and demographic characteristics and total fertility are assessed, demonstrating the importance of social and physical remoteness on fertility. Next, factors associated with fertility are examined using the proximate determinants of fertility framework. The social and economic factors associated with entry into marriage are then explored. Finally, the thesis combines individual level reproductive health and fertility data with geolocated conflict-event data to further examine the relationships between conflict exposure and fertility. Ultimately, it is through these processes that this thesis describes fertility changes across Myanmar, contributing to a deeper understanding of how classical demographic theory can be understood and applied to fragile states.
... Armed conflict can dramatically change the way young women access and benefit from (in theory, at least) structures such as legislative justice mechanisms, stable governance and policing which protect them from sexual violence or coercion, as well as processes for participation and demonstration which allow young women to voice their concerns. Issues of insecurity and fear of reprisal and attack can therefore limit access to health services [11][12][13]. Similarly, progressive social policy for SRH, which facilitates sexual education and access to family planning methods can be curtailed as well as livelihood safety nets to prevent destitution. ...
... Kottegoda et al. (2008), for example, drew attention to the protective nature of traditional midwives in contexts of conflict when access to formal medical access and support was reduced [32]. Footer et al. (2014) found that health workers, community/village leaders and local health organisations in Eastern Burma were active in devising strategies to maintain the provision of health services, despite attacks [13]. Communities have also been key in ensuring the continuity of education -which is widely considered as a key protective factor for young women. ...
... Kottegoda et al. (2008), for example, drew attention to the protective nature of traditional midwives in contexts of conflict when access to formal medical access and support was reduced [32]. Footer et al. (2014) found that health workers, community/village leaders and local health organisations in Eastern Burma were active in devising strategies to maintain the provision of health services, despite attacks [13]. Communities have also been key in ensuring the continuity of education -which is widely considered as a key protective factor for young women. ...
Background:
It is assumed that knowing what puts young women at risk of poor sexual health outcomes and, in turn, what protects them against these outcomes, will enable greater targeted protection as well as help in designing more effective programmes. Accordingly, efforts have been directed towards mapping risk and protective factors onto general ecological frameworks, but these currently do not take into account the context of modern armed conflict. A literature overview approach was used to identify SRH related risk and protective factors specifically for young women affected by modern armed conflict.
Processes of risk and protection:
A range of keywords were used to identify academic articles which explored the sexual and reproductive health needs of young women affected by modern armed conflict. Selected articles were read to identify risk and protective factors in relation to sexual and reproductive health. While no articles explicitly identified 'risk' or 'protective' factors, we were able to extrapolate these through a thorough engagement with the text. However, we found that it was difficult to identify factors as either 'risky' or 'protective', with many having the capacity to be both risky and protective (i.e. refugee camps or family). Therefore, using an ecological model, six environments that impact upon young women's lives in contexts of modern armed conflict are used to illustrate the dynamic and complex operation of risk and protection - highlighting processes of protection and the 'trade-offs' between risks.
Conclusion:
We conclude that there are no simple formulaic risk/protection patterns to be applied in every conflict and post-conflict context. Instead, there needs to be greater recognition of the 'processes' of protection, including the role of 'trade-offs' (what we term as 'protection at a price'), in order to further effective policy and practical responses to improve sexual and reproductive health outcomes during or following armed conflict. Focus on specific 'factors' (such as 'female headed household') takes attention away from the processes through which factors manifest themselves and which often determine whether the factor will later be considered 'risk inducing' or protective.
... Yet alongside this physical terrain of obstruction, displacement, and attacks, conflict entails a less visible set of political relationships (de Waal, 2010;Parkinson, 2013), historical exclusions (Wilkinson and Leach, 2015), and exercises of violence that are tacit or symbolic in nature (Bhatia, 2005). Past studies examine such realities "behind the tangible" through the experiences of health providers in clinic settings (Arnold et al., 2018, 35;Carruth, 2015;Footer et al., 2014). Yet since health interventions operate in a "relational web extending well beyond formal care settings" (Mayhew et al., 2022, 7), a socio-political vantage beyond clinic walls is needed (Parkinson and Behrouzan, 2015). ...
... First, when the "ignorant public" frame is applied to societies facing conflict, it undermines civilian voices. From Burma, Footer et al. (2014) show that although local professionals documented healthcare practices, they lacked a "validated reporting forum" to be taken seriously (379). These obstacles reflect Foucault's (2003) description of dominant rules of discourse that authorize certain sources of knowledge and disqualify others. ...
... In addition, participants reported what could be described as negative coping mechanisms including the use of sedatives or engaging in dark humour (Participants 1, 4, 8). However, participants spoke of the importance of bonding or talking with colleagues as a means of providing emotional and social support with those who could understand the pressures they faced (Participants 9,14,16,23,25,27). ...
... Their coping mechanisms derived from their roots in the community and solidarity with the community and their colleagues [26]. In Myanmar, too, the rootedness of health workers in communities became a major means both of ensuring access to health care in the face of persistent violence and to cope with violence when it was inflicted on them [27]. ...
Introduction
Attacks on healthcare in armed conflict have far-reaching impacts on the personal and professional lives of health workers, as well as the communities they serve. Despite this, even in protracted conflicts such as in Syria, health workers may choose to stay despite repeated attacks on health facilities, resulting in compounded traumas. This research explores the intermediate and long-term impacts of such attacks on healthcare on the local health professionals who have lived through them with the aim of strengthening the evidence base around such impacts and better supporting them.
Methods
We undertook purposive sampling of health workers in northwest and northeast Syria; we actively sought to interview non-physician and female health workers as these groups are often neglected in similar research. In-depth interviews (IDIs) were conducted in Arabic and transcribed into English for framework analysis. We used an a priori codebook to explore the short- and long-term impacts of attacks on the health workers and incorporated emergent themes as analysis progressed.
Results
A total of 40 health workers who had experienced attacks between 2013 and 2020 participated in IDIs. 13 were female (32.5%). Various health cadres including doctors, nurses, midwives, pharmacists, students in healthcare and technicians were represented. They were mainly based in Idlib (39.5%), and Aleppo (37.5%) governorates. Themes emerged related to personal and professional impacts as well as coping mechanisms. The key themes include firstly the psychological harms, second the impacts of the nature of the attacks e.g. anticipatory stress related to the ‘double tap’ nature of attacks as well as opportunities related to coping mechanisms among health workers.
Conclusion
Violence against healthcare in Syria has had profound and lasting impacts on the health workforce due to the relentless and intentional targeting of healthcare facilities. They not only face the challenges of providing care for a conflict-affected population but are also part of the community themselves. They also face ethical dilemmas in their work leading to moral distress and moral injury. Donors must support funding for psychosocial support for health workers in Syria and similar contexts; the focus must be on supporting and enhancing existing context-specific coping strategies.
... Finally, much reporting on the scope and nature of violence directly affecting health service delivery in complex security environments is generated by organizations working in those environments (Abu Sa' Da et al., 2013). Over the past decade, organizational initiatives to collect data on incidents of violence against health workers have increasingly become more systematic in their approaches and within the research community, there are promising new initiatives for data collection (Footer et al., 2014). For example, there has been more attention paid to gathering data on national and locally-employed staff who bear the brunt of violence, as opposed to international, expatriate staff. ...
... Although the knowledge base has grown, there remain significant gaps in data collection and analysis (Abu Sa' Da et al., 2013;Footer et al., 2014), namely that there is currently no global-level, health-specific data set the issue. As a result, it can be difficult to uncouple data on health service delivery from that of humanitarian work more broadly. ...
Complex security environments are characterized by violence (including, but not limited to “armed conflict” in the legal sense), poverty, environmental disasters and poor governance. Violence directly affecting health service delivery in complex security environments includes attacks on individuals (e.g. doctors, nurses, administrators, security guards, ambulance drivers and translators), obstructions (e.g. ambulances being stopped at checkpoints), discrimination (e.g. staff being pressured to treat one patient instead of another), attacks on and misappropriation of health facilities and property (e.g. vandalism, theft and ambulance theft by armed groups), and the criminalization of health workers. This paper examines the challenges associated with researching the context, scope and nature of violence directly affecting health service delivery in these environments. With a focus on data collection, it considers how these challenges affect researchers’ ability to analyze the drivers of violence and impact of violence.
... This is key to their success and ability to reach areas historically inaccessible to humanitarian assistance. All organizations work to provide health care in accordance with principles of medical impartiality, although their actual or perceived affiliation to armed groups has increased their vulnerability [32]. ...
... The data collected by this instrument goes beyond typical security incident reporting forms, by capturing both violent and non-violent forms of interference with healthcare, such as confiscation of medicines, delays at checkpoints, obstruction of access, and intimidation and threats. Research in this setting indicates that such interferences are more frequent than violent events, and have negative consequences for access to and delivery of healthcare [32]. Increased reporting of nonviolent events can assist health organizations in assessing the frequency and impact of incidents that health workers may have previously considered an 'everyday event'. ...
Background:
Attacks on health care in armed conflict and other civil disturbances, including those on health workers, health facilities, patients and health transports, represent a critical yet often overlooked violation of human rights and international humanitarian law. Reporting has been limited yet local health workers working on the frontline in conflict are often the victims of chronic abuse and interferences with their care-giving. This paper reports on the validation and revision of an instrument designed to capture incidents via a qualitative and quantitative evaluation method.
Methods:
Based on previous research and interviews with experts, investigators developed a 33-question instrument to report on attacks on healthcare. These items would provide information about who, what, where, when, and the impact of each incident of attack on or interference with health. The questions are grouped into 4 domains: health facilities, health workers, patients, and health transports. 38 health workers who work in eastern Burma participated in detailed discussion groups in August 2013 to review the face and content validity of the instrument and then tested the instrument based on two simulated scenarios. Completed forms were graded to test the inter-rater reliability of the instrument.
Results:
Face and content validity were confirmed with participants expressing that the instrument would assist in better reporting of attacks on health in the setting of eastern Burma where they work. Participants were able to give an accurate account of relevant incidents (86% and 82% on Scenarios 1 and 2 respectively). Item-by-item review of the instrument revealed that greater than 95% of participants completed the correct sections. Errors primarily occurred in quantifying the impact of the incident on patient care. Revisions to the translated instrument based on the results consisted primarily of design improvements and simplification of some numerical fields.
Conclusion:
This instrument was validated for use in eastern Burma and could be used as a model for reporting violence towards health care in other conflict settings.
... Participants suggested that this damage is not homogenous, rural and already marginalized ethnicities within Myanmar are facing the worst health system impacts: with an already fragile health system and persecution of their health workers, this new assault has resulted in even less access. This disparity spans previous research in Myanmar (pre-coup) as well as ongoing media reporting [46,58]. ...
Background
In Myanmar, ongoing conflict since the 2021 military coup d’etat has been characterized by targeted violence against health workers (HWs), particularly those participating in the pro-democracy movement. Existing knowledge about the challenges faced by health workers in Myanmar is scant, including their perspectives on mitigating their suffering and the broader impact on community health. This knowledge gap prompted our study to assess the extent of the violence, its impact on the workers and the community, and identify resource priorities.
Methods
This qualitative study employed purposive and snowball sampling to recruit health workers affiliated with the Civil Disobedience Movement (CDM). We interviewed 24 HWs in Myanmar between July and December 2022, predominantly physicians and nurses. We used a semi-structured interview guide and conducted interviews remotely due to the security situation. We adopted content analysis to understand participation in the CDM movement, experiences of violence, personal and professional impacts, the sequelae to community health, how HWs responded as well as their ongoing needs.
Results
Thematic content analysis revealed that violence was both individually targeted and widespread. Health workers faced professional, financial, and personal impacts as a result. The health system as a whole has been severely diminished. Health workers have had to adapt to continue to provide care, for example some fled to rural areas and worked clandestinely, exchanging their services for food and shelter. In those settings, they continued to face insecurity from airstrikes and arrests. Health workers have also experienced moral distress and burden due to their resistance and protest against the regime.
Conclusion
The coup and ensuing violence severely disrupted the healthcare system, resulting in shortages of supplies, reduced quality of care, and exacerbated challenges during the COVID-19 pandemic. Despite facing significant hardships, HWs remained resilient, engaging in resistance efforts within the CDM and seeking support from local communities and international organizations. They expressed a need for increased awareness, financial assistance, and concrete support for the health system to address the crisis.
... Participants suggested that this damage is not homogenous, rural and already marginalized ethnicities within Myanmar are facing the worst health system impacts: with an already fragile health system and persecution of their health workers, this new assault has resulted in even less access. This disparity spans previous research in Myanmar (pre-coup) as well as ongoing media reporting (59,60). ...
Background
In Myanmar, ongoing conflict since the 2021 military coup d’etat has been characterized by targeted violence against health workers (HWs), particularly those participating in the pro-democracy movement. Existing knowledge about the challenges faced by health workers in Myanmar is scant, including their perspectives on mitigating their suffering and the broader impact on community health. This knowledge gap prompted our study to assess the extent of the violence, its impact on the workers and the community, and identify resource priorities.
Methods
This qualitative study employed purposive and snowball sampling to recruit health workers affiliated with the Civil Disobedience Movement (CDM). We interviewed 24 HWs in Myanmar between July and December 2022, predominantly physicians and nurses. We used a semi-structured interview guide and conducted interviews remotely due to the security situation. We adopted content analysis to understand participation in the CDM movement, experiences of violence, personal and professional impacts, the sequelae to community health, how HWs responded as well as their ongoing needs.
Results
Thematic content analysis revealed that violence was both individually targeted and widespread. Health workers faced professional, financial, and personal impacts as a result. The health system as a whole has been severely diminished. Health workers have had to adapt to continue to provide care, for example some fled to rural areas and worked clandestinely, exchanging their services for food and shelter. In those settings, they continued to face insecurity from airstrikes and arrests. Health workers have also experienced moral distress and burden due to their resistance and protest against the regime.
Conclusion
The coup and ensuing violence severely disrupted the healthcare system, resulting in shortages of supplies, reduced quality of care, and exacerbated challenges during the COVID-19 pandemic. Despite facing significant hardships, HWs remained resilient, engaging in resistance efforts within the CDM and seeking support from local communities and international organizations. They expressed a need for increased awareness, financial assistance, and concrete support for the health system to address the crisis.
... As a mitigation against violence toward to health professionals in conflict zones, the local community can be more directly engaged in ensuring secure access to health care (14), documenting and publicizing breaches rapidly (15). And also negotiating directly with conflict parties to ensure fair and safe provision of health services (16). ...
The current conflict in Ukraine exposes many health care workers to severe stress. As refugees from the conflict arrive in different parts of the continent, almost all of Europe's health care systems will be challenged by the experience from conflict-exposed individuals. This will inevitably put a strain on health care staff some of whom may be traumatized vicariously. However, those who have encountered conflict and war directly, will likely suffer the greatest stress. The current situation requires the support of pan-European health professionals and investment in follow-up research and analysis of the situation.
... [34][35][36][37] Acts of violence against health result not only in loss of life and health services directly due to the violence, but also lead to long-term morbidity and mortality from disrupted health systems, the destruction of facilities, loss of supplies and the shortage of health service providers. [38][39][40][41][42][43] Since the Syrian civil war started in 2011, health services in particular have been victim to hundreds of aerial bombardments. 25 Additionally, personnel have been arrested and tortured, ambulances and vaccine convoys looted and destroyed, and patients killed and blocked from access. ...
Background
Hundreds of thousands of people have been killed during the Syrian civil war and millions more displaced along with an unconscionable amount of destroyed civilian infrastructure.
Methods
We aggregate attack data from Airwars, Physicians for Human Rights and the Safeguarding Health in Conflict Coalition/Insecurity Insight to provide a summary of attacks against civilian infrastructure during the years 2012–2018. Specifically, we explore relationships between date of attack, governorate, perpetrator and weapon for 2689 attacks against five civilian infrastructure classes: healthcare, private, public, school and unknown. Multiple correspondence analysis (MCA) via squared cosine distance, k-means clustering of the MCA row coordinates, binomial lasso classification and Cramer’s V coefficients are used to produce and investigate these correlations.
Results
Frequencies and proportions of attacks against the civilian infrastructure classes by year, governorate, perpetrator and weapon are presented. MCA results identify variation along the first two dimensions for the variables year, governorate, perpetrator and healthcare infrastructure in four topics of interest: (1) Syrian government attacks against healthcare infrastructure, (2) US-led Coalition offensives in Raqqa in 2017, (3) Russian violence in Aleppo in 2016 and (4) airstrikes on non-healthcare infrastructure. These topics of interest are supported by results of the k-means clustering, binomial lasso classification and Cramer’s V coefficients.
Discussion
Findings suggest that violence against healthcare infrastructure correlates strongly with specific perpetrators. We hope that the results of this study provide researchers with valuable data and insights that can be used in future analyses to better understand the Syrian conflict.
... Six studies reported that both male and female HCWs face similar difficulties when working in conflict zones, which include limited supplies and equipment, insufficient medications, shortage of qualified personnel, and increase in workload and working days, as well as low or lack of pay, and economic insecurity [41,42,[44][45][46][47]. Studies also showed similar exposures to dangerous conditions and physical hazards, including threats, harassment, injury, death due to combat exposure, attacks on healthcare facilities, as well as arrests and direct assault for both male and female HCWs [44,46,[48][49][50][51][52]. ...
The occupational health literature has established that sex and gender are associated with all dimensions of the workplace. Sex and/or gender (sex/gender) factors play an important role in shaping the experiences, exposures, and health outcomes of male and female healthcare providers working in war and conflict settings. This study aims to (1) assess how sex/gender is considered in the occupational health literature on healthcare workers in conflict settings, and (2) identify the gaps in incorporating sex/gender concepts in this literature. A scoping review was carried out and nine electronic databases were searched using a comprehensive search strategy. Two reviewers screened the titles/abstracts and full-texts of the studies using specific inclusion and exclusion criteria. Key information was extracted from the studies and four themes were identified. Of 7679 identified records, 47 were included for final review. The findings underlined the harsh working conditions of healthcare workers practicing in conflict zones and showed sex/gender similarities and differences in experiences, exposures and health outcomes. This review revealed a dearth of articles with adequate consideration of sex/gender in the study design. Sex/gender-sensitive research in occupational health is necessary to develop effective occupational health and safety policies to protect men and women healthcare workers in conflict settings.
... Healthcare personnel and patients have been arrested, killed, maimed, tortured, interrogated, and blocked from receiving or providing care. Even bombings and shelling of hospitals sometimes go unreported, and other attacks, such as looting, obstructing passage at checkpoints, and threats to healthcare workers are usually not systematically tracked [8,9]. Attacks on health workers, facilities, and transports, and on the wounded and sick, violate international human rights law and international humanitarian law [10][11][12]. ...
Background
Violent attacks on and interferences with hospitals, ambulances, health workers, and patients during conflict destroy vital health services during a time when they are most needed and undermine the long-term capacity of the health system. In Syria, such attacks have been frequent and intense and represent grave violations of the Geneva Conventions, but the number reported has varied considerably. A systematic mechanism to document these attacks could assist in designing more protection strategies and play a critical role in influencing policy, promoting justice, and addressing the health needs of the population.
Methods and findings
We developed a mobile data collection questionnaire to collect data on incidents of attacks on healthcare directly from the field. Data collectors from the Syrian American Medical Society (SAMS), using the tool or a text messaging system, recorded information on incidents across four of Syria’s northern governorates (Aleppo, Idleb, Hama, and Homs) from January 1, 2016, to December 31, 2016. SAMS recorded a total of 200 attacks on healthcare in 2016, 102 of them using the mobile data collection tool. Direct attacks on health facilities comprised the majority of attacks recorded (88.0%; n = 176). One hundred and twelve healthcare staff and 185 patients were killed in these incidents. Thirty-five percent of the facilities were attacked more than once over the data collection period; hospitals were significantly more likely to be attacked more than once compared to clinics and other types of healthcare facilities. Aerial bombs were used in the overwhelming majority of cases (91.5%). We also compared the SAMS data to a separate database developed by Physicians for Human Rights (PHR) based on media reports and matched the incidents to compare the results from the two methods (this analysis was limited to incidents at health facilities). Among 90 relevant incidents verified by PHR and 177 by SAMS, there were 60 that could be matched to each other, highlighting the differences in results from the two methods. This study is limited by the complexities of data collection in a conflict setting, only partial use of the standardized reporting tool, and the fact that limited accessibility of some health facilities and workers and may be biased towards the reporting of attacks on larger or more visible health facilities.
Conclusions
The use of field data collectors and use of consistent definitions can play an important role in the tracking incidents of attacks on health services. A mobile systematic data collection tool can complement other methods for tracking incidents of attacks on healthcare and ensure the collection of detailed information about each attack that may assist in better advocacy, programs, and accountability but can be practically challenging. Comparing attacks between SAMS and PHR suggests that there may have been significantly more attacks than previously captured by any one methodology. This scale of attacks suggests that targeting of healthcare in Syria is systematic and highlights the failure of condemnation by the international community and medical groups working in Syria of such attacks to stop them.
... Qualitative data collected in the form of field notes from participant observations and notes taken during key informant discussions were analysed by two members of the research team using a deductive thematic analysis approach based on the components already defined in the SYSRA framework. Information from 137 and 77 papers from the horizontal and vertical literature reviews respectively were extracted in NVIVO, with codes structured around individual components of the SYSRA framework; this information was integrated with findings from the qualitative analysis component of the situational assessment (Davis et al. 2015;Footer et al. 2014;Grundy et al. 2014;Htet et al. 2015;Low et al. 2014;Parmar et al. 2014Parmar et al. , 2015. ...
There are numerous challenges in planning and implementing effective disease control programmes in Myanmar, which is undergoing internal political and economic transformations whilst experiencing massive inflows of external funding. The objective of our study-involving key informant discussions, participant observations and linked literature reviews-was to analyse how tuberculosis (TB) control strategies in Myanmar are influenced by the broader political, economic, epidemiological and health systems context using the Systemic Rapid Assessment conceptual and analytical framework. Our findings indicate that the substantial influx of donor funding, in the order of one billion dollars over a 5-year period, may be too rapid for the country's infrastructure to effectively utilize. TB control strategies thus far have tended to favour medical or technological approaches rather than infrastructure development, and appear to be driven more by perceived urgency to 'do something' rather informed by evidence of cost-effectiveness and sustainable long-term impact. Progress has been made towards ambitious targets for scaling up treatment of drug-resistant TB, although there are concerns about ensuring quality of care. We also find substantial disparities in health and funding allocation between regions and ethnic groups, which are related to the political context and health system infrastructure. Our situational assessment of emerging TB control strategies in this transitioning health system indicates that large investments by international donors may be pushing Myanmar to scale up TB and drug-resistant TB services too quickly, without due consideration given to the health system (service delivery infrastructure, human resource capacity, quality of care, equity) and epidemiological (evidence of effectiveness of interventions, prevention of new cases) context.
... 33 The impact of humanitarian emergencies on health workers and service provision is also extensive and includes the destruction of health facilities, infrastructure, frequent and prolonged shortages in drugs and equipment, loss of qualified health staff, and restricted access to healthcare. 34 Numerous humanitarian organisations have established community health programmes as a means to increase access to health services during and after humanitarian emergencies in a bid to overcome infrastructural weakness, promote healthy behaviours and task-shift primary care to available cadres. 10 35 Specifically, CHWs in emergency settings are often used to provide essential services under restrictive and sometimes dangerous situations, and have the potential to contribute to the sustainability of health programmes in the postconflict and recovery stages. 36 Optimising the performance of CHWs in humanitarian emergencies is likely to be critical to achieving good health outcomes across health conditions, age groups and contexts. ...
Introduction
Understanding what enhances the motivation and performance of community health workers (CHWs) in humanitarian emergencies represents a key research gap within the field of human resources for health. This paper presents the research protocol for the Performance ImprovEment of CHWs in Emergency Settings (PIECES) research programme. Enhancing Learning and Research in Humanitarian Action (ELRHA) funded the development of this protocol as part of their Health in Humanitarian Crises (R2HC) call (No.19839). PIECES aims to understand what factors improve the performance of CHWs in level III humanitarian emergencies.
Methods and analysis
The suggested protocol uses a realist evaluation with multiple cases across the 3 country sites: Turkey, Iraq and Lebanon. Working with International Medical Corps (IMC), an initial programme theory was elicited through literature and document reviews, semistructured interviews and focus groups with IMC programme managers and CHWs. Based on this initial theory, this protocol proposes a combination of semistructured interviews, life histories and critical incident narratives, surveys and latent variable modelling of key constructs to explain how contextual factors work to trigger mechanisms for specific outcomes relating to IMC's 300+ CHWs' performance. Participants will also include programme staff, CHWs and programme beneficiaries. Realist approaches will be used to better understand ‘what works, for whom and under what conditions’ for improving CHW performance within humanitarian contexts.
Ethics and dissemination
Trinity College Dublin's Health Policy and Management/Centre for Global Health Research Ethics Committee gave ethical approval for the protocol development phase. For the full research project, additional ethical approval will be sought from: Université St. Joseph (Lebanon), the Ethics Committee of the Ministry of Health in Baghdad (Iraq) and the Middle East Technical University (Turkey). Dissemination activities will involve a mixture of research feedback, policy briefs, guidelines and recommendations, as well as open source academic articles.
... 4 In addition, access to health services may become restricted because providers lack security and fear reprisal and attack. [5][6][7] During Shia-Sunni hostilities in Gilgit Town, Pakistan, hospital and clinic staff who belonged to certain faith-based groups were killed or were prevented from providing services, which reduced provision of and access to obstetric services and resulted in increased maternal morbidity and mortality. 8 Forced migration and displacement further increase young women's vulnerability by breaking down family and community structures. ...
... These two papers, as well as the papers by Footer et al. (2014) and Rutayisire and Richters (2014), tell us important things about the experiences of humanitarian workers. The study of violence against health workers in eastern Burma (Footer et al., discussed above), and steps taken to circumvent violence while attempting to provide services, is a reminder that these are not experiences of foreign humanitarians alone but particularly acute experiences of local health workers in settings of conflict. ...
... In This article aims to advocate for the government and donors to acknowledge and build on the gains of the EHOs and CBHOs in health system strengthening, and not to risk alienating the local worker and ethnic communities. Although numerous studies had been conducted concerning health workers in eastern Burma/Myanmar on various topics, such as malaria knowledge (16), medic's experiences of trauma and mental health (17), health workers' strategies for addressing security and ensuring access to vulnerable ethnic communities (18), and perspectives from MHWs on delivering community-based care (19), this article is the first known attempt to document how the ethnic system of task shifting during the conflict period has effectively contributed toward the development of a strong ethnic health workforce to satisfy the essential health needs of the population in the EHOs' and CBHOs' service areas. It represents an empirical effort to map the health workforce (in their numbers, services, and training content) that is currently operating in Karen State. ...
Background:
Burma/Myanmar was controlled by a military regime for over 50 years. Many basic social and protection services have been neglected, specifically in the ethnic areas. Development in these areas was led by the ethnic non-state actors to ensure care and the availability of health services for the communities living in the border ethnic-controlled areas. Political changes in Burma/Myanmar have been ongoing since the end of 2010. Given the ethnic diversity of Burma/Myanmar, many challenges in ensuring health service coverage among all ethnic groups lie ahead.
Methods:
A case study method was used to document how existing human resources for health (HRH) reach the vulnerable population in the ethnic health organizations' (EHOs) and community-based organizations' (CBHOs) service areas, and their related information on training and services delivered. Mixed methods were used. Survey data on HRH, service provision, and training were collected from clinic-in-charges in 110 clinics in 14 Karen/Kayin townships through a rapid-mapping exercise. We also reviewed 7 organizational and policy documents and conducted 10 interviews and discussions with clinic-in-charges.
Findings:
Despite the lack of skilled medical professionals, the EHOs and CBHOs have been serving the population along the border through task shifting to less specialized health workers. Clinics and mobile teams work in partnership, focusing on primary care with some aspects of secondary care. The rapid-mapping exercise showed that the aggregate HRH density in Karen/Kayin state is 2.8 per 1,000 population. Every mobile team has 1.8 health workers per 1,000 population, whereas each clinic has between 2.5 and 3.9 health workers per 1,000 population. By reorganizing and training the workforce with a rigorous and up-to-date curriculum, EHOs and CBHOs present a viable solution for improving health service coverage to the underserved population.
Conclusion:
Despite the chronic conflict in Burma/Myanmar, this report provides evidence of the substantive system of health care provision and access in the Karen/Kayin State over the past 20 years. It underscores the climate of vulnerability of the EHOs and CBHOs due to lack of regional and international understanding of the political complexities in Burma/Myanmar. As Association of Southeast Asian Nations (ASEAN) integration gathers pace, this case study highlights potential issues relating to migration and health access. The case also documents the challenge of integrating indigenous and/or cross-border health systems, with the ongoing risk of deepening ethnic conflicts in Burma/Myanmar as the peace process is negotiated.
Healthcare workers (HCW) play a crucial role in reducing maternal and infant mortality. However, in contexts of endemic armed conflicts, such as in the Democratic Republic of Congo (DRC), these professionals must operate under extreme working conditions, which can affect the quality of care. This study aims to assess the working environment and challenges faced by maternal and neonatal HCW in the DRC to better understand their ability to deliver quality care in a prolonged war context.
We conducted a cross-sectional study in the North and South Kivu provinces in Eastern DRC. The study primarily targeted healthcare facilities in eight health zones. An evaluation aligned with the structure/process dimensions (profile and perception of the work environment of HCW) according to Donabedian was conducted. A descriptive and comparative analysis of the health zones (HZs) using the Chi-square test and T test was performed. Informed consent was obtained for participation in the study.
A total of 200 HCW were enrolled in the study, 71% of whom were women, with an average age of 37.5 years. Nurses were the majority, followed by midwives, while general practitioners represented 10.67%. On average, HCW worked approximately 67 h per week. A third of HCW do not feel well-prepared and are dissatisfied with their work environment, reporting gaps in discussions about interpersonal skills, promotion opportunities, and professional development. Disparities in treatment were observed, with notable inequalities in training, time off, work hours, function, and promotions, often exacerbated by gender. Less than 30% received bonuses, and 90% did not receive non-monetary incentives. Verbal threats and assaults, humiliations, and physical assaults from colleagues and patients were common, with a higher incidence in women and from North Kivu. Finally, nearly a quarter of HCW felt exposed to insecurity in and around their facilities, a perception more pronounced in North Kivu than in South Kivu.
This study shows that HCW in the DRC, particularly in conflict zones, work under extremely difficult conditions, characterized by intensive hours, lack of training, professional inequalities, and high insecurity. These challenges may compromise quality of care and the well-being of providers, underscoring the urgency of strengthening their protection and support to maintain the resilience of the healthcare system.
This study shows that maternal and neonatal Healthcare provider in the Eastern DRC, particularly in conflict affected zones, work under extremely difficult conditions, characterized by intensive hours, lack of training, professional inequalities, and high insecurity. These challenges may compromise quality of care and the well-being of providers, underscoring the urgency of strengthening their protection and support to maintain the resilience of the healthcare system.
A claim is often made that medical neutrality requires that health workers practicing in conflict settings or in situations of political violence refrain from taking a position on controversies of a political, racial, religious, or ideological nature. The admonition is also applied to human rights documentation and reporting and advocating for political change. That position, however, is highly problematic, in part because the phase is “medical neutrality” is not contained in international law and because has at least three different meanings: immunity from attack, impartiality, and political neutrality. More importantly, refraining from political engagement is inconsistent with contemporary medical ethics, including obligations to prevent abuses, report those that take place, and advance health equity. Moreover, the humanitarian principle of humanity, on which the purported obligation is predicated, is not morally grounded and lacks the status of the companion principles of humanity and impartiality. These principles both justify and encourage health professionals to engage in political matters that can protect the rights and health of patients and the larger populations. In taking such stances, health professionals can employ decision-making processes that account for possibly conflicting values and obligations and assessing the benefits, burdens, and risks of alternative courses of action.
Health care is attacked in many contemporary conflicts despite the Geneva Conventions. The war in Syria has become notorious for targeted violence against health care. This qualitative study describes health care workers' experiences of violence using semi-structured interviews (n = 25) with professionals who have been working in Syria. The participants were selected using a snowball sampling method and interviewed in Turkey and Europe between 2016-2017. Analysis was conducted using content analysis. Results revealed that the most destructive and horrific forms of violence health care workers have experienced were committed mostly by the Government of Syria and the Islamic State. Non-state armed groups and Kurdish Forces have also committed acts of violence against health care, though their scope and scale were considered to have a lower mortality. The nature of violence has evolved during the conflict: starting from verbal threats and eventually leading to hospital bombings. Health care workers were not only providers of health care to injured demonstrators, they also participated in non- violent anti-government actions. The international community has not taken action to protect health care in Syria. For health workers finding safe environments in which to deliver health care has been impossible.
Background
Health care workers (HCWs) are essential for the delivery of health care services in conflict areas and in rebuilding health systems post-conflict.
Objective
The aim of this study was to systematically identify and map the published evidence on HCWs in conflict and post-conflict settings. Our ultimate aim is to inform researchers and funders on research gap on this subject and support relevant stakeholders by providing them with a comprehensive resource of evidence about HCWs in conflict and post-conflict settings on a global scale.
Methods
We conducted a systematic mapping of the literature. We included a wide range of study designs, addressing any type of personnel providing health services in either conflict or post-conflict settings. We conducted a descriptive analysis of the general characteristics of the included papers and built two interactive systematic maps organized by country, study design and theme.
Results
Out of 13,863 identified citations, we included a total of 474 studies: 304 on conflict settings, 149 on post-conflict settings, and 21 on both conflict and post-conflict settings. For conflict settings, the most studied counties were Iraq (15%), Syria (15%), Israel (10%), and the State of Palestine (9%). The most common types of publication were opinion pieces in conflict settings (39%), and primary studies (33%) in post-conflict settings. In addition, most of the first and corresponding authors were affiliated with countries different from the country focus of the paper. Violence against health workers was the most tackled theme of papers reporting on conflict settings, while workforce performance was the most addressed theme by papers reporting on post-conflict settings. The majority of papers in both conflict and post-conflict settings did not report funding sources (81% and 53%) or conflicts of interest of authors (73% and 62%), and around half of primary studies did not report on ethical approvals (45% and 41%).
Conclusions
This systematic mapping provides a comprehensive database of evidence about HCWs in conflict and post-conflict settings on a global scale that is often needed to inform policies and strategies on effective workforce planning and management and in reducing emigration. It can also be used to identify evidence for policy-relevant questions, knowledge gaps to direct future primary research, and knowledge clusters.
Objectives
To explore the impact of the conflict, including the use of chemical weapons, in Syria on healthcare through the experiences of health providers using a public health and human rights lens.
Design
A qualitative study using semi-structured interviews conducted in-person or over Skype using a thematic analysis approach.
Setting
Interviews were conducted with Syrian health workers operating in opposition-held Syria in cooperation with a medical relief organisation in Gaziantep, Turkey.
Participants
We examined data from 29 semi-structured in-depth interviews with a sample of health professionals with current or recent work-related experience in opposition-controlled areas of Syria, including respondents to chemical attacks.
Results
Findings highlight the health worker experience of attacks on health infrastructure and services in Syria and consequences in terms of access and scarcity in availability of essential medicines and equipment. Quality of services is explored through physicians’ accounts of the knock-on effect of shortages of equipment, supplies and personnel on the right to health and its ethical implications. Health workers themselves were found to be operating under extreme conditions, in particular responding to the most recent chemical attacks that occurred in 2017, with implications for their own health and mental well-being.
Conclusions
The study provides unique insight into the impact war has had on Syrian’s right to health through the accounts of a sample of Syrian health professionals, with continuing relevance to the current conflict and professional issues facing health workers in conflict settings.
Imagine that an American physician volunteered to treat wounded children through the Ministry of Health in Gaza, controlled by Hamas. Or that a Palestinian nurse attending to injured fighters in Gaza spoke out against the firing of rockets into Israel, was threatened with arrest, and sought asylum in the United States. Under U.S. law, the doctor could be subject to prosecution, and the nurse could be denied asylum-in the first case, because she provided medical care under the direction or control of a designated terrorist organization; in the second, because he knowingly provided care to a member of a terrorist organization. The question of whether a terrorist is entitled to medical care, though largely theoretical, has generated considerable discussion, with near unanimity that there is no moral basis to refuse to treat. But whether a health professional can be punished for providing medical care either to terrorists or under the auspices of a terrorist organization has received little attention from either a moral or legal perspective, although such situations arise throughout the world.
© 2015 The Hastings Center.
The purpose of this study was to identify the problems faced by ambulance drivers working in a conflict zone.
This study was conducted on ambulance drivers working for the four major hospitals in Kashmir, India. The drivers were interviewed and asked a series of 30 work-related questions. The individual interviews were conducted over a three-month period in the valley of Kashmir that was affected by continuous violence, strict curfew, and strikes.
A total of 35 ambulance drivers were interviewed. Drivers worked an average of 60 h/wk, and they drove an average of 160 km/d. Twenty-nine (83%) of the drivers experienced >1 threat of physical harm; 18 (54%) experienced physical assaults; and 31 (89%) reported evidence of psychological morbidity associated with their jobs.
The atmosphere of conflict on the streets of Kashmir impacted the ambulance drivers adversely, both physically as well as mentally. The stress faced by these professionals in conflict zones during their duty hours should be recognized, and corrective measures must be put in place.
Iftikhar Ud Din , Zubia Mumtaz , and Anushka Ataullahjan examine the difficulties experienced by Pakistan’s lady health workers
Pakistan is in the midst of Islamic militant violence. Although the conflict in the Swat district in northern Pakistan has officially ended, there is a threat of Taliban re-emergence and the Pakistani military continues to fight the militants.1 2
Swat is in the Himalayan region, and its high mountains, green meadows, and clear lakes made it a popular destination with tourists looking for skiing, hiking, fishing, and ancient statues of Buddha. The Taliban invasion during 2006-9 not only destroyed the tourist industry, it unleashed a reign of terror on the local population. A key feature of the Taliban militancy was a systematic attack on people suspected of behaviours that were in violation of the Taliban’s interpretation of the principles of Islam.
The Taliban publicly beheaded residents accused of crimes and hung their bodies in the busiest square of Mingora, the district capital. They prohibited polio vaccination campaigns for children, schooling of girls,3 and women working outside the home. Women working in schools and health centres have either been fired or killed,4 and those in non-governmental organisations have been forced to stop work. Men were killed for shaving their beards, listening to music, and watching movies.
Over the three year siege of Swat, Islamic militants destroyed 165 girls’ schools, 80 video shops, and 22 barber shops.4 They also destroyed infrastructure, including bridges, police checkpoints, and a generating grid station that provided electricity to 1.8 million people.5
Health infrastructure in Pakistan has also been targeted: 29% of health facilities in the province of Khyber Pukhtunkhwa have been damaged in the conflict between the Taliban and the government forces.6 Health workers have been killed inside healthcare facilities as …
The past three decades have been a time of considerable global conflict, affecting over 50 countries and causing substantial impacts on civilian health. While many effects are direct results of violence, conflict also impinges on health through indirect means. The restricted mobility of health care staff and patients, targeting of health care workers, and stressful working conditions disrupt the ability of health care workers in conflict zones to function effectively. This paper explores the challenges experienced by health care workers in West Bank, Palestine, as well as their strategies of persistence. Research activities included participant observation and interviews with health care providers, which were then analysed for common themes.
Results demonstrated that the Israeli military occupation of the West Bank considerably impacts civilians’ access to both urgent and preventive care. While attempting to deliver care, providers encountered disruptions, harassment and violence, which interrupted care and contributed to job stress. Professional perseverance was evident, but its influence was limited by enduring constraints. This study thus underscores the importance of accountability to international law regarding the rights of civilians to health care in conflict zones. Health professionals may play a particular role in advocating for just and dignified resolutions to conflicts.
Qualitative research methodologies, which are oriented to better understanding of the context, meaning and experiences of people's lives, have much to contribute to health promotion. For researchers trained in quantitative methods, writing up qualitative research for a peer-reviewed journal can be a challenge, especially keeping within the prescribed word limits. How well you explain and disseminate your research will influence how others evaluate its quality; this has implications not only for what you write and the terminology you use but for how you structure your article. This paper provides a general guide to presenting qualitative research for publication in a way that has meaning for authors and readers, is acceptable to editors and reviewers, and meets criteria for high standards of qualitative research reporting across the board. We discuss the writing of all sections of an article, placing particular emphasis on how you might best present your findings, illustrating our points with examples drawn from previous issues of this Journal. Overall, we emphasise that reporting qualitative research involves sharing both the process and the findings, that is, revealing both the wood and the trees.
Medical doctors leaving less developed countries are now part of a global labour market. This doctor migration has been extensively studied from economic and health systems perspectives. Seldom, however has the specific role of the conflict or the collapsing state been considered as a cause of migration. Using hospital staffing records we measured the changes in numbers of medical specialists at 12 Iraqi tertiary hospitals (in Baghdad, Basra, Erbil and Mosul) between 2004 and 2007. For doctors leaving their posts, we attempted to determine destinations and circumstances of departure. We counted 1243 specialists in the 12 hospitals on January 1, 2004. This declined to 1166 or 94% of the original number by late 2007. In Baghdad, specialists decreased to 78% by late 2007, Outside Baghdad, specialists numbered 134% of the original count by 2007. In Baghdad, replacements kept pace with losses until 2005, with loss rates peaking in 2006 at 29%. Outside Baghdad, gains exceeded losses each year. Violent event rates associated with the migration of doctors were estimated as: threats 30/1000 doctors; kidnappings 6.7/1000; violent deaths 16.5/1000, and any violent event 36.7/1000. Specialists who left Baghdad were 2.5 times more likely to experience a violent event than doctors elsewhere. Specialists departing teaching hospitals were 2.3 times more likely to experience a violent event than those in general hospitals. Of specialists leaving hospital posts for which data were available, 39% went elsewhere in Iraq and 61% left the country. These findings suggest a major loss of human capital from Iraq's hospital sector, a loss that is likely to require some years to fully replace.
Health indicators are poor and human rights violations are widespread in eastern Burma. Reproductive and maternal health indicators have not been measured in this setting but are necessary as part of an evaluation of a multi-ethnic pilot project exploring strategies to increase access to essential maternal health interventions. The goal of this study is to estimate coverage of maternal health services prior to this project and associations between exposure to human rights violations and access to such services.
Selected communities in the Shan, Mon, Karen, and Karenni regions of eastern Burma that were accessible to community-based organizations operating from Thailand were surveyed to estimate coverage of reproductive, maternal, and family planning services, and to assess exposure to household-level human rights violations within the pilot-project target population. Two-stage cluster sampling surveys among ever-married women of reproductive age (15-45 y) documented access to essential antenatal care interventions, skilled attendance at birth, postnatal care, and family planning services. Mid-upper arm circumference, hemoglobin by color scale, and Plasmodium falciparum parasitemia by rapid diagnostic dipstick were measured. Exposure to human rights violations in the prior 12 mo was recorded. Between September 2006 and January 2007, 2,914 surveys were conducted. Eighty-eight percent of women reported a home delivery for their last pregnancy (within previous 5 y). Skilled attendance at birth (5.1%), any (39.3%) or > or = 4 (16.7%) antenatal visits, use of an insecticide-treated bed net (21.6%), and receipt of iron supplements (11.8%) were low. At the time of the survey, more than 60% of women had hemoglobin level estimates < or = 11.0 g/dl and 7.2% were Pf positive. Unmet need for contraceptives exceeded 60%. Violations of rights were widely reported: 32.1% of Karenni households reported forced labor and 10% of Karen households had been forced to move. Among Karen households, odds of anemia were 1.51 (95% confidence interval [CI] 0.95-2.40) times higher among women reporting forced displacement, and 7.47 (95% CI 2.21-25.3) higher among those exposed to food security violations. The odds of receiving no antenatal care services were 5.94 (95% CI 2.23-15.8) times higher among those forcibly displaced.
Coverage of basic maternal health interventions is woefully inadequate in these selected populations and substantially lower than even the national estimates for Burma, among the lowest in the region. Considerable political, financial, and human resources are necessary to improve access to maternal health care in these communities.
These commonly used methods are appropriate for particular research questions and contexts Qualitative research includes a variety of methodolo-gical approaches with different disciplinary origins and tools. This article discusses three commonly used approaches: grounded theory, mixed methods, and action research. It provides background for those who will encounter these methodologies in their reading rather than instructions for carrying out such research. We describe the appropriate uses, key characteristics, and features of rigour of each approach.
In September 2002, an armed conflict erupted in Côte d'Ivoire which has since divided the country in the government-held south and the remaining territory controlled by the 'Forces Armées des Forces Nouvelles' (FAFN). There is concern that conflict-related population movements, breakdown of health systems and food insecurity could significantly increase the incidence of HIV infections and other sexually-transmitted infections, and hence jeopardize the country's ability to cope with the HIV/AIDS epidemic. Our objective was to assess and quantify the effect this conflict had on human resources and health systems that provide the backbone for prevention, treatment and care associated with HIV/AIDS. We obtained data through a questionnaire survey targeted at key informants in 24 urban settings in central, north and west Côte d'Ivoire and reviewed relevant Ministry of Health (MoH) records. We found significant reductions of health staff in the public and private sector along with a collapse of the health system and other public infrastructures, interruption of condom distribution and lack of antiretrovirals. On the other hand, there was a significant increase of non-governmental organizations (NGOs), some of which claim a partial involvement in the combat with HIV/AIDS. The analysis shows the need that these NGOs, in concert with regional and international organizations and United Nations agencies, carry forward HIV/AIDS prevention and care efforts, which ought to be continued through the post-conflict stage and then expanded to comprehensive preventive care, particularly antiretroviral treatment.
Attacks on and interference with health care services, providers, facilities, transports, and patients in situations of armed conflict, civil disturbance, and state repression pose enormous challenges to health care delivery in circumstances where it is most needed. In times of armed conflict, international humanitarian law (IHL) provides robust protection to health care services, but it also contains gaps. Moreover, IHL does not cover situations where an armed conflict does not exist. This paper focuses on the importance of a human rights approach to addressing these challenges, relying on the highest attainable standard of health as well as to civil and political rights. In particular we take the Committee on Economic, Social and Cultural Rights General Comment No. 14 (on Article 12 of the International Covenant on Economic, Social and Cultural Rights) as a normative framework from which states' obligations to respect, protect and fulfil the right to health across all conflict settings can be further developed.
This article explores how people living in areas of Burma/Myanmar affected by armed conflict (Karen populations in the southeast) and natural disaster (Cyclone Nargis in the Irrawaddy Delta) understand “protection” and act to minimize risks and protect themselves, their families, and communities. What do vulnerable people seek to protect, and how do they view the roles of other stakeholders, including the state, non-state actors (armed and political groups), community-based organizations, and national and international aid agencies? Are these viewed as protection actors, or sources of threat—or a mixture of both?
This article presents a discussion of mixed methods (MM) sampling techniques. MM sampling involves combining well-established qualitative and quantitative techniques in creative ways to answer research questions posed by MM research designs. Several issues germane to MM sampling are presented including the differences between probability and purposive sampling and the probability-mixed-purposive sampling continuum. Four MM sampling prototypes are introduced: basic MM sampling strategies, sequential MM sampling, concurrent MM sampling, and multilevel MM sampling. Examples of each of these techniques are given as illustrations of how researchers actually generate MM samples. Finally, eight guidelines for MM sampling are presented.
Assaults on patients and medical personnel, facilities, and transports, denial of access to medical services, and misuse of medical facilities and emblems have become a feature of armed conflict despite their prohibition by the laws of war. Strategies to improve compliance with these laws, protection, and accountability are lacking, and regular reporting of violations is absent. A systematic review of the frequency of reporting and types of violations has not been done for more than 15 years. To gain a better understanding of the scope and extent of the problem, we used uniform search criteria to review three global sources of human rights reports in armed conflicts for 2003-08, and in-depth reports on violations committed in armed conflict during 1989-2008. Findings from this review showed deficiencies in the extent and methods of reporting, but also identified three major trends in such assaults: attacks on medical functions seem to be part of a broad assault on civilians; assaults on medical functions are used to achieve a military advantage; and combatants do not respect the ethical duty of health professionals to provide care to patients irrespective of affiliation. WHO needs to lead robust and systematic documentation of these violations, and countries and the medical community need to take steps to improve compliance, protection, and accountability.
In settings where active conflict, resource scarcity, and logistical constraints prevail, provision of maternal health services within health centers and hospitals is unfeasible and alternative community-based strategies are needed. In eastern Burma, such conditions necessitated implementation of the "Mobile Obstetric Maternal Health Worker" (MOM) project, which has employed a community-based approach to increase access to essential maternal health services including emergency obstetric care. Lay Maternal Health Workers (MHWs) are central to the MOM service delivery model and, because they are accessible to both the communities inside Burma and to outside project managers, they serve as key informants for the project. Their insights can facilitate program and policy efforts to overcome critical delays and insufficient management of maternal complications linked to maternal mortality. Focus group discussions (n=9), in-depth interviews (n=18), and detailed case studies (n=14) were collected from MHWs during centralized project management meetings in February and October of 2007. Five case studies are presented to characterize and interpret the realities of reproductive health work in a conflict-affected setting. Findings highlight the process of building supportive networks and staff ownership of the MOM project, accessing and gaining community trust and participation to achieve timely delivery of care, and overcoming challenges to manage and appropriately deliver essential health services. They suggest that some emergency obstetric care services that are conventionally delivered only within healthcare settings might be feasible in community or home-based settings when alternatives are not available. This paper provides an opportunity to hear directly from community-based workers in a conflict setting, perspectives seldom documented in the scientific literature. A rights-based approach to service delivery and its suitability in settings where human rights violations are widespread is highlighted.
The aim of this paper is to compare Glaser's model of theory generation, where theory rises directly and rigorously out of the data, devoid of interpretivism, to Strauss's conceptually descriptive approach that encourages directive questioning and supports an interpretive stance.
The discovery of grounded theory (GT) was born out of a merger between Barney Glaser and Anselm Strauss, the proverbial 'fathers' of GT. Since the co-creation of their approach to theory development through research in 1967, these scholars have taken seemingly divergent paths in further developing and evolving the pragmatic use of GT.
Numerous researchers have used GT as a general method, applying it to both quantitative and qualitative research approaches. In this paper we discuss the stages and strategies of data sampling, collection, coding and analysing used by both Glaser and Strauss. Constant comparative analysis is identified as the primary strategy in the integrated coding and analysing stages of this theorizing method, regardless of the researcher's philosophical or research orientation. We also discuss initial or open coding, advanced coding, memoing, and theoretical sampling, with particular attention to comparing and contrasting the descriptive terms and application strategies that have been suggested by both Glaser and Strauss.
The reported distinctions in the approach, method, and general intent of GT reflected in this paper are not easy to comprehend. The two methods reflect different basic philosophical paradigms, and therefore represent distinct approaches to GT. Researchers need to be clear about which philosophy and resulting analysis approach they are using, and the effect that approach will have on the research process and outcomes.
To estimate mortality rates for populations living in civil war zones in Karen, Karenni, and Mon states of eastern Burma.
Indigenous mobile health workers providing care in conflict zones in Karen, Karenni, and Mon areas of eastern Burma conducted cluster sample surveys interviewing heads of households during 3-month time periods in 2002 and 2003 to collect demographic and mortality data.
In 2002 health workers completed 1290 household surveys comprising 7496 individuals. In 2003, 1609 households with 9083 members were surveyed. Estimates of vital statistics were as follows: infant mortality rate: 135 (95% CI: 96-181) and 122 (95% CI: 70-175) per 1000 live births; under-five mortality rate: 291 (95% CI: 238-348) and 276 (95% CI: 190-361) per 1000 live births; crude mortality rate: 25 (95% CI: 21-29) and 21 (95% CI: 15-27) per 1000 persons per year.
Populations living in conflict zones in eastern Burma experience high mortality rates. The use of indigenous mobile health workers provides one means of measuring health status among populations that would normally be inaccessible due to ongoing conflict.
In 1991, the Somali National Movement fighters recaptured the Somaliland capital city of Hargeisa after a 3-year civil war. The government troops of the dictator General Mohamed Siad Barre fled south, plunging most of Somalia into a state of anarchy that persists to this day. In the north of the region, the redeclaration of independence of Somaliland took place on May 18, 1991. Despite some sporadic civil unrest between 1994 and 1996, and a few tragic killings of members of the international community, the country has enjoyed peace and stability and has an impressive development record. However, Somaliland continues to await international recognition. The civil war resulted in the destruction of most of Somaliland's health-care facilities, compounded by mass migration or death of trained health personnel. Access to good, affordable health care for the average Somali remains greatly compromised. A former medical director of the general hospital of Hargeisa, Abdirahman Ahmed Mohamed, suggested the idea of a link between King's College Hospital in London, UK, and Somaliland. With support from two British colleagues, a fact-finding trip sponsored by the Tropical Health and Education Trust (THET) took place in July, 2000, followed by a needs assessment by a THET programme coordinator. Here, we describe the challenges of health-care reconstruction in Somaliland and the evolving role of the partnership between King's College Hospital, THET, and Somaliland within the context of the growing movement to link UK NHS trusts and teaching institutions with counterparts in developing countries.
Public health problems in armed conflicts have been well documented, however, effective national health policies and international assistance strategies in transition periods from conflict to peace have not been well established. After the long lasted conflicts in Sri Lanka, the Government and the rebel LTTE signed a cease-fire agreement in February 2002. As the peace negotiation has been disrupted since April 2003, a long-term prospect for peace is yet uncertain at present. The objective of this research is to detect unmet needs in health services in Northern Province in Sri Lanka, and to recommend fair and effective health strategies for post-conflict reconstruction. First, we compared a 20-year trend of health services and health status between the post-conflict Northern Province and other areas not directly affected by conflict in Sri Lanka by analyzing data published by Sri Lankan government and other agencies. Then, we conducted open-ended self-administered questionnaires to health care providers and inhabitants in Northern Province, and key informant interviews in Northern Province and other areas. The major health problems in Northern Province were high maternal mortality, significant shortage of human resources for health (HRH), and inadequate water and sanitation systems. Poor access to health facilities, lack of basic health knowledge, insufficient health awareness programs for inhabitants, and mental health problems among communities were pointed by the questionnaire respondents. Shortage of HRH and people's negligence for health were perceived as the major obstacles to improving the current health situation in Northern Province. The key informant interviews revealed that Sri Lankan HRH outside Northern Province had only limited information about the health issues in Northern Province. It is required to develop and allocate HRH strategically for the effective reconstruction of health service systems in Northern Province. The empowerment of inhabitants and communities through health awareness programs and the development of a systematic mental health strategy at the state level are also important. It is necessary to provide with the objective information of gaps in health indicators by region for promoting mutual understanding between Tamil and Sinhalese. International assistance should be provided not only for the post-conflict area but also for other underprivileged areas to avoid unnecessary grievance.
Neglected diseases remain one of the largest causes of disease and mortality. In addition to the difficulties in provision of appropriate drugs for specific diseases, many other factors contribute to the prevalence of such diseases and the difficulties in reducing their burden. We address the role that poor governance and politically motivated oppression have on the epidemiology of neglected diseases. We give case examples including filariasis in eastern Burma and vector-borne diseases (Chagas' disease, leishmaniasis, and yellow fever) in Colombia, we show the links between systematic human rights violations and the effects of infectious disease on health. We also discuss the role of researchers in advocating for and researching within oppressed populations.