'Nowhere and no one is safe': spatial analysis of damage to critical civilian infrastructure in the Gaza Strip during the first phase of the Israeli military campaign, 7 October to 22 November 2023.

BACKGROUND: Since the Hamas attacks in Israel on 7 October 2023, the Israeli military has launched an assault in the Gaza Strip, which included over 12,000 targets struck and over 25,000 tons of incendiary munitions used by 2 November 2023. The objectives of this study include: (1) the descriptive and inferential spatial analysis of damage to critical civilian infrastructure (health, education, and water facilities) across the Gaza Strip during the first phase of the military campaign, defined as 7 October to 22 November 2023 and (2) the analysis of damage clustering around critical civilian infrastructure to explore broader questions about Israel's adherence to International Humanitarian Law (IHL). METHODS: We applied multi-temporal coherent change detection on Copernicus Sentinel 1-A Synthetic Aperture Radar (SAR) imagery to detect signals indicative of damage to the built environment through 22 November 2023. Specific locations of health, education, and water facilities were delineated using open-source building footprint and cross-checked with geocoded data from OCHA, OpenStreetMap, and Humanitarian OpenStreetMap Team. We then assessed the retrieval of damage at and with close proximity to sites of health, education, and water infrastructure in addition to designated evacuation corridors and civilian protection zones. The Global Moran's I autocorrelation inference statistic was used to determine whether health, education, and water facility infrastructure damage was spatially random or clustered. RESULTS: During the period under investigation, in the entire Gaza Strip, 60.8% (n = 59) of health, 68.2% (n = 324) of education, and 42.1% (n = 64) of water facilities sustained infrastructure damage. Furthermore, 35.1% (n = 34) of health, 40.2% (n = 191) of education, and 36.8% (n = 56) of water facilities were functionally destroyed. Applying the Global Moran's I spatial inference statistic to facilities demonstrated a high degree of damage clustering for all three types of critical civilian infrastructure, with Z-scores indicating < 1% likelihood of cluster damage occurring by random chance. CONCLUSION: Spatial statistical analysis suggests widespread damage to critical civilian infrastructure that should have been provided protection under IHL. These findings raise serious allegations about the violation of IHL, especially in light of Israeli officials' statements explicitly inciting violence and displacement and multiple widely reported acts of collective punishment.

The impact of COVID-19 on statewide EMS use for cardiac emergencies and stroke in Massachusetts.

OBJECTIVE: To evaluate the impact of coronavirus disease 2019 (COVID-19) on emergency medical services (EMS) use for time-sensitive medical conditions. We examined EMS use for cardiac arrest, stroke, and other cardiac emergencies across Massachusetts during the peak of the COVID-19 pandemic, evaluating their relationship to statewide COVID-19 incidence and a statewide emergency declaration. METHODS: A retrospective analysis of all EMS calls between February 15 and May 15, 2020 and the same time period for 2019. EMS call volumes were compared before and after March 10, the date of a statewide emergency declaration. RESULTS: A total of 408,758 calls were analyzed, of which 49,405 (12.1%) represented stroke, cardiac arrest, or other cardiac emergencies. Average call volume before March 10 was similar in both years but decreased significantly after March 10, 2020 by 18.7% (P < 0.001). Compared to 2019, there were 35.6% fewer calls for cardiac emergencies after March 10, 2020 (153.6 vs 238.4 calls/day, P < 0.001) and 12.3% fewer calls for stroke (40.0 vs 45.6 calls/day, P = 0.04). Calls for cardiac arrest increased 18.2% (28.6 vs 24.2 calls/day, P < 0.001). Calls for respiratory concerns also increased (208.8 vs 199.7 calls/day, P < 0.001). There was no significant association between statewide incidence of COVID-19 and EMS call volume. CONCLUSIONS: EMS use for certain time-sensitive conditions decreased after a statewide emergency declaration, irrespective of actual COVID-19 incidence, suggesting the decrease was related to perception instead of actual case counts. These findings have implications for public health messaging. Measures must be taken to clearly inform the public that immediate emergency care for time-sensitive conditions remains imperative.

Modeling pastoralist movement in response to environmental variables and conflict in Somaliland: Combining agent-based modeling and geospatial data.

Pastoralism is widely practiced in arid lands and is the primary means of livelihood for approximately 268 million people across Africa. Environmental, interpersonal, and transactional variables such as vegetation and water availability, conflict, ethnic tensions, and private/public land delineation influence the movements of these populations. The challenges of climate change and conflict are widely felt by nomadic pastoralists in Somalia, where resources are scarce, natural disasters are increasingly common, and protracted conflict has plagued communities for decades. Bereft of real-time data, researchers and programmatic personnel often turn to post hoc analysis to understand the interaction between climate, conflict, and migration, and design programs to address the needs of nomadic pastoralists. By designing an Agent-Based Model to simulate the movement of nomadic pastoralists based on typologically-diverse, historical data of environmental, interpersonal, and transactional variables in Somaliland and Puntland between 2008 and 2018, this study explores how pastoralists respond to changing environments. Through subsequent application of spatial analysis such as choropleth maps, kernel density mapping, and standard deviational ellipses, we characterize the resultant pastoralist population distribution in response to these variables. Outcomes demonstrate a large scale spatio-temporal trend of pastoralists migrating to the southeast of the study area with high density areas in the south of Nugaal, the northwest of Sool, and along the Ethiopian border. While minimal inter-seasonal variability is seen, multiple analyses support the consolidation of pastoralists to specifically favorable regions. Exploration of the large-scale population, climate, and conflict trends allows for cogent narratives and associative hypotheses regarding the pastoralist migration during the study period. While this model produces compelling associations between pastoralist movements and terrestrial and conflict variables, it relies heavily on assumptions and incomplete data that are not necessarily representative of realities on the ground. Given the paucity of data regarding pastoralist decision-making and migration, validation remains challenging.

Access to Care and Prevalence of Hypertension and Diabetes Among Syrian Refugees in Northern Jordan.

Importance: The management of noncommunicable diseases in humanitarian crises has been slow to progress from episodic care. Understanding disease burden and access to care among crisis-affected populations can inform more comprehensive management. Objective: To estimate the prevalence of hypertension and diabetes with biological measures and to evaluate access to care among Syrian refugees in northern Jordan. Design, Setting, and Participants: This cross-sectional study was undertaken from March 25 to April 26, 2019, in the districts of Ramtha and Mafraq, Jordan. Seventy clusters of 15 households were randomly sampled, and chain referral was used to sample Syrian households, representative of 59 617 Syrian refugees. Adults were screened and interviewed about their access to care. Data analysis was performed from May to September 2019. Exposures: Primary care delivered through a humanitarian organization since 2012. Main Outcomes and Measures: The main outcomes were self-reported prevalence of hypertension and diabetes among adults aged 18 years or older and biologically based prevalence among adults aged 30 years or older. The secondary outcome was access to care during the past month among adults aged 18 years or older with a diagnosis of hypertension or diabetes. Results: In 1022 randomly sampled households, 2798 adults aged 18 years or older, including 275 with self-reported diagnoses (mean [SD] age, 56.5 [13.2] years; 174 women [63.3%]), and 915 adults aged 30 years or older (608 women [66.5%]; mean [SD] age, 46.0 [12.8] years) were screened for diabetes and hypertension. Among adults aged 18 years or older, the self-reported prevalence was 17.2% (95% CI, 15.9%-18.6%) for hypertension, 9.8% (95% CI, 8.6%-11.1%) for diabetes, and 7.3% (95% CI, 6.3%-8.5%) for both conditions. Among adults aged 30 years or older, the biologically based prevalence was 39.5% (95% CI, 36.4%-42.6%) for hypertension, 19.3% (95% CI, 16.7%-22.1%) for diabetes, and 13.5% (95% CI, 11.4%-15.9%) for both conditions. Adjusted for age and sex, prevalence for all conditions increased with age, and women had a higher prevalence of diabetes than men (adjusted prevalence ratio, 1.3%; 95% CI, 1.0%-1.7%), although the difference was not significant. Complications (57.4%; 95% CI, 51.5%-63.1%) and obese or overweight status (82.8%; 95% CI, 79.7%-85.5%) were highly prevalent. Among adults aged 30 years or older with known diagnoses, 94.1% (95% CI, 90.9%-96.2%) currently took medication. Among adults aged 18 years or older with known diagnoses, 26.8% (95% CI, 21.3%-33.1%) missed a medication dose in the past week, and 49.1% (95% CI, 43.3%-54.9%) sought care in the last month. Conclusions and Relevance: During this protracted crisis, obtaining care for noncommunicable diseases was feasible, as demonstrated by biologically based prevalence that was only moderately higher than self-reported prevalence. The high prevalence of complications and obese or overweight status, however, suggest inadequate management. Programs should focus on reinforcing adherence and secondary prevention to minimize severe morbidity.

Flying into the hurricane: A case study of UAV use in damage assessment during the 2017 hurricanes in Texas and Florida.

Unmanned aerial vehicles (UAVs) or drones have been used by disaster relief organizations in the United States since 2005. However, their place in the disaster response ecosystem-the standardization, utility, ethical, and legal challenges of drone use-remains largely unstudied. This case series describes how UAVs were used by two teams of responders for damage assessment purposes during the 2017 southeastern US Hurricanes Harvey and Irma. Data streams ranged from social media, direct observation, participant-observation and semi-directed interviews. Qualitative analysis was performed for thematic content derived from field observation and from post-hoc interviews. Outcomes of the qualitative analysis emphasize the barriers to deploying drones in the disaster context, their tactical implementation, programmatic integration, and ethical and legal challenges. These observations lay the groundwork for both future research on the utilization of drones and the prudent and ethical implementation of programs that employ drones in post-disaster settings.

Beyond mapping: a case for geospatial analytics in humanitarian health.

The humanitarian sector is increasingly adopting geospatial data to support operations. However, the utilization of these data in the humanitarian health arena is predominantly in thematic map format, thereby limiting the full insight and utility of geospatial information. Geospatial analytics, in contrast, including pattern analysis, interpolation, and predictive modeling, have tremendous potential within the field of humanitarian health. This paper explores a variety of historical and contemporary geospatial applications in the public health and humanitarian fields and argues for greater integration of geospatial analysis into humanitarian health research and programming. From remote sensing to create sampling frames, to spatial interpolation for environmental exposure analysis, and multi-objective optimization algorithms for humanitarian logistics, spatial analysis has transformed epistemological paradigms, research methods and programming landscapes across diverse disciplines. The field of humanitarian health, which is inextricably bounded by geography and resource limitations, should leverage the unique capacities of spatial methods and strategically integrate geospatial analytics into research and programming not only to fortify the academic legitimacy and professionalization of the field but also to improve operational efficiency and mitigation strategies.

Optimizing the Use of a Precious Resource: The Role of Emergency Physicians in a Humanitarian Crisis.

Emergency physicians (EP) are uniquely suited to provide care in crises as a result of their broad training, ability to work quickly and effectively in high-pressure, austere settings, and their inherent flexibility. While emergency medicine training is helpful to support the needs of crisis-affected and displaced populations, it is not in itself sufficient. In this article we review what an EP should carefully consider prior to deployment.

Using mobile technology to optimize disease surveillance and healthcare delivery at mass gatherings: a case study from India's Kumbh Mela.

Background: Planning for mass gatherings often includes temporary healthcare systems to address the needs of attendees. However, paper-based record keeping has traditionally precluded the timely application of collected clinical data for epidemic surveillance or optimization of healthcare delivery. We evaluated the feasibility of harnessing ubiquitous mobile technologies for conducting disease surveillance and monitoring resource utilization at the Allahabad Kumbh Mela in India, a 55-day festival attended by over 70 million people. Methods: We developed an inexpensive, tablet-based customized disease surveillance system with real-time analytic capabilities, and piloted it at five field hospitals. Results: The system captured 49 131 outpatient encounters over the 3-week study period. The most common presenting complaints were musculoskeletal pain (19%), fever (17%), cough (17%), coryza (16%) and diarrhoea (5%). The majority of patients received at least one prescription. The most common prescriptions were for antimicrobials, acetaminophen and non-steroidal anti-inflammatory drugs. There was great inter-site variability in caseload with the busiest hospital seeing 650% more patients than the least busy hospital, despite identical staffing. Conclusions: Mobile-based health information solutions developed with a focus on user-centred design can be successfully deployed at mass gatherings in resource-scarce settings to optimize care delivery by providing real-time access to field data.

Does spending on refugees make a difference? A cross-sectional study of the association between refugee program spending and health outcomes in 70 sites in 17 countries.

BACKGROUND: Numerous simultaneous complex humanitarian emergencies strain the ability of local governments and the international community to respond, underscoring the importance of cost-effective use of limited resources. At the end of 2011, 42.5 million people were forcibly displaced, including 10.4 million refugees under the mandate of the United Nations High Commissioner for Refugees (UNHCR). UNHCR spent US$1.65 billion on refugee programs in 2011. We analyze the impact of aggregate-level UNHCR spending on mortality of refugee populations. METHODS: Using 2011 budget data, we calculated purchasing power parity adjusted spending, disaggregated by population planning groups (PPGs) and UNHCR Results Framework objectives. Monthly mortality reported to UNHCR's Health Information System from 2011 to 2012 was used to calculate crude (CMR) and under-5 (U5MR) mortality rates, and expressed as ratios to country of asylum mortality. Log-linear regressions were performed to assess correlation between spending and mortality. RESULTS: Mortality data for 70 refugee sites representing 1.6 million refugees in 17 countries were matched to 20 PPGs. Median 2011 spending was $623.27 per person (constant 2011 US$). Median CMR was 2.4 deaths per 1,000 persons per year; median U5MR was 18.1 under-5 deaths per 1,000 live births per year. CMR was negatively correlated with total spending (p = 0.027), and spending for fair protection processes and documentation (p = 0.005), external relations (p = 0.034), logistics and operations support (p = 0.007), and for healthcare (p = 0.046). U5MR ratio was negatively correlated with total spending (p = 0.015), and spending for favorable protection environment (p = 0.024), fair protection processes and documentation (p = 0.003), basic needs and essential services (p = 0.027), and within basic needs, for healthcare services (p = 0.007). CONCLUSION: Increased UNHCR spending on refugee populations is correlated with lower mortality, likely reflecting unique refugee vulnerabilities and dependence on aid. Future analyses using more granular data can further elucidate the health impact of humanitarian sector spending, thereby guiding policy choices.

Public health aspects of the world's largest mass gathering: The 2013 Kumbh Mela in Allahabad, India.

India's Kumbh Mela remains the world's largest and longest mass gathering. The 2013 event, where participants undertook a ritual bath, hosted over 70 million Hindu pilgrims during 55 days on a 1936 hectare flood plain at the confluence of the Yamuna and Ganga Rivers. On the holiest bathing days, the population surged. Unlike other religious, cultural, and sports mass gatherings, the Kumbh Mela's administration cannot estimate or limit the participant number. The event created serious and uncommon public health challenges: initiating crowd safety measures where population density and mobility directly contact flowing bodies of water; providing water, sanitation, and hygiene to a population that frequently defecates in the open; and establishing disease surveillance and resource use measures within a temporary health delivery system. We review the world's largest gathering by observing first-hand the public health challenges, plus the preparations for and responses to them. We recommend ways to improve preparedness.

An assessment of antenatal care among Syrian refugees in Lebanon.

BACKGROUND: After more than three years of violence in Syria, Lebanon hosts over one million Syrian refugees creating significant public health concerns. Antenatal care delivery to tens of thousands of pregnant Syrian refugee women is critical to preventing maternal and fetal mortality but is not well characterized given the multiple factors obtaining health data in a displaced population. This study describes antenatal care access, the scope of existing antenatal care, and antenatal and family planning behaviors and practice among pregnant Syrian refugees in various living conditions and multiple geographic areas of Lebanon. METHODS: A field-based survey was conducted between July and October 2013 in 14 main geographic sites of refugee concentration. The assessment evaluated antenatal services among a non-randomized sample of 420 self-identified pregnant Syrian refugee women that included demographics, gestational age, living accommodation, antenatal care coverage, antenatal care content, antenatal health behaviors, antenatal health literacy, and family planning perception and practices. RESULTS: In total, 420 pregnant Syrian refugees living in Lebanon completed the survey. Of these, 82.9% (348) received some antenatal care. Of those with at least one antenatal visit, 222 (63.8%) received care attended by a skilled professional three or more times, 111 (31.9%) 1-2 times, and 15 (4.3%) had never received skilled antenatal care. We assessed antenatal care content defined by blood pressure measurement, and urine and blood sample analyses. Of those who had received any antenatal care, only 31.2% received all three interventions, 18.2% received two out of three, 32.1% received one out of three, and 18.5% received no interventions. Only (41.2%) had an adequate diet of vitamins, minerals, and folic acid. Access, content and health behaviors varied by gestational age, type of accommodation and location in Lebanon. CONCLUSIONS: Standards of antenatal care are not being met for pregnant Syrian refugee women in Lebanon. This descriptive analysis of relative frequencies suggests reproductive health providers should focus attention on increasing antenatal care visits, particularly to third trimester and late gestational age patients and to those in less secure sheltering arrangements. With this approach they can improve care content by providing early testing and interventions per accepted guidelines designed to improve pregnancy outcomes.

Water, Sanitation, and Hygiene at the World's Largest Mass Gathering.

The 2013 Kumbh Mela, a Hindu religious festival and the largest human gathering on earth, drew an estimated 120 million pilgrims to bathe at the holy confluence of the Ganga (Ganges) and Yamuna rivers. To accommodate the massive numbers, the Indian government constructed a temporary city on the flood plains of the two rivers and provided it with roads, electricity, water and sanitation facilities, police stations, and a tiered healthcare system. This phenomenal operation and its impacts have gone largely undocumented. To address this gap, the authors undertook an evaluation and systematic monitoring initiative to study preparedness and response to public health emergencies at the event. This paper describes the water, sanitation, and hygiene components, with particular emphasis on preventive and mitigation strategies; the capacity for surveillance and response to diarrheal disease outbreaks; and the implications of lessons learned for other mass gatherings.

Need for a gender-sensitive human security framework: results of a quantitative study of human security and sexual violence in Djohong District, Cameroon.

BACKGROUND: Human security shifts traditional concepts of security from interstate conflict and the absence of war to the security of the individual. Broad definitions of human security include livelihoods and food security, health, psychosocial well-being, enjoyment of civil and political rights and freedom from oppression, and personal safety, in addition to absence of conflict. METHODS: In March 2010, we undertook a population-based health and livelihood study of female refugees from conflict-affected Central African Republic living in Djohong District, Cameroon and their female counterparts within the Cameroonian host community. Embedded within the survey instrument were indicators of human security derived from the Leaning-Arie model that defined three domains of psychosocial stability suggesting individuals and communities are most stable when their core attachments to home, community and the future are intact. RESULTS: While the female refugee human security outcomes describe a population successfully assimilated and thriving in their new environments based on these three domains, the ability of human security indicators to predict the presence or absence of lifetime and six-month sexual violence was inadequate. Using receiver operating characteristic (ROC) analysis, the study demonstrates that common human security indicators do not uncover either lifetime or recent prevalence of sexual violence. CONCLUSIONS: These data suggest that current gender-blind approaches of describing human security are missing serious threats to the safety of one half of the population and that efforts to develop robust human security indicators should include those that specifically measure violence against women.

Barriers to malaria control among marginalized tribal communities: a qualitative study.

BACKGROUND: Malaria infection accounts for over one million deaths worldwide annually. India has the highest number of malaria deaths outside Africa, with half among Indian tribal communities. Our study sought to identify barriers to malaria control within tribal populations in malaria-endemic Gadchiroli district, Maharashtra. METHODS AND FINDINGS: This qualitative study was conducted via focus groups and interviews with 84 participants, and included tribal villagers, traditional healers, community health workers (CHWs), medical officers, and district officials. Questions assessed knowledge about malaria, behavior during early stages of infection, and experiences with prevention among tribal villagers and traditional healers. CHWs, medical officers, and district officials were asked about barriers to treating and preventing malaria among tribal populations. Data were inductively analyzed and assembled into broader explanation linking barriers to geographical, cultural and social factors. Findings indicate lack of knowledge regarding malaria symptoms and transmission. Fever cases initially present to traditional healers or informal providers who have little knowledge of malaria or high-risk groups such as children and pregnant women. Tribal adherence with antimalarial medications is poor. Malaria prevention is inadequate, with low-density and inconsistent use of insecticide-treated nets (ITNs). Malaria educational materials are culturally inappropriate, relying on dominant language literacy. Remote villages and lack of transport complicate surveillance by CHWs. Costs of treating malaria outside the village are high. CONCLUSIONS: Geographic, cultural, and social factors create barriers to malaria control among tribal communities in India. Efforts to decrease malaria burden among these populations must consider such realities. Our results suggest improving community-level knowledge about malaria using culturally-appropriate health education materials; making traditional healers partners in malaria control; promoting within-village rapid diagnosis and treatment; increasing ITN distribution and promoting their use as potential strategies to decrease infection rates in these communities. These insights may be used to shape malaria control programs among marginalized populations.

Hunger strikers: ethical and legal dimensions of medical complicity in torture at Guantanamo Bay.

Physicians and other licensed health professionals are involved in force-feeding prisoners on hunger strike at the US Naval Base at Guantanamo Bay (GTMO), Cuba, the detention center established to hold individuals captured and suspected of being terrorists in the wake of September 11, 2001. The force-feeding of competent hunger strikers violates medical ethics and constitutes medical complicity in torture. Given the failure of civilian and military law to end the practice, the medical profession must exert policy and regulatory pressure to bring the policy and operations of the US Department of Defense into compliance with established ethical standards. Physicians, other health professionals, and organized medicine must appeal to civilian state oversight bodies and federal regulators of medical science to revoke the licenses of health professionals who have committed prisoner abuses at GTMO.

Modelling strategic interventions in a population with a total fertility rate of 8.3: a cross-sectional study of Idjwi Island, DRC.

BACKGROUND: Idjwi, an island of approximately 220,000 people, is located in eastern DRC and functions semi-autonomously under the governance of two kings (mwamis). At more than 8 live births per woman, Idjwi has one of the highest total fertility rates (TFRs) in the world. Rapid population growth has led to widespread environmental degradation and food insecurity. Meanwhile family planning services are largely unavailable. METHODS: At the invitation of local leaders, we conducted a representative survey of 2,078 households in accordance with MEASURE DHS protocols, and performed ethnographic interviews and focus groups with key informants and vulnerable subpopulations. Modelling proximate determinates of fertility, we evaluated how the introduction of contraceptives and/or extended periods of breastfeeding could reduce the TFR. RESULTS: Over half of all women reported an unmet need for spacing or limiting births, and nearly 70% named a specific modern method of contraception they would prefer to use; pills (25.4%) and injectables (26.5%) were most desired. We predicted that an increased length of breastfeeding (from 10 to 21 months) or an increase in contraceptive prevalence (from 1% to 30%), or a combination of both could reduce TFR on Idjwi to 6, the average desired number of children. Increasing contraceptive prevalence to 15% could reduce unmet need for contraception by 8%. CONCLUSIONS: To meet women's need and desire for fertility control, we recommend adding family planning services at health centers with NGO support, pursuing a community health worker program, promoting extended breastfeeding, and implementing programs to end sexual- and gender-based violence toward women.

Sexual violence among host and refugee population in Djohong District, Eastern Cameroon.

The following is a population-based survey of the Central African Republic (CAR) female refugee population displaced to rural Djohong District of Eastern Cameroon and associated female Cameroonian host population to characterise the prevalence and circumstances of sexual violence. A population-based, multistage, random cluster survey of 600 female heads of household was conducted during March 2010. Women heads of household were asked about demographics, household economy and assets, level of education and sexual violence experienced by the respondent only. The respondents were asked to describe the circumstances of their recent assault. The lifetime prevalence of sexual violence among Djohong district female heads of household is 35.2% (95% CI 28.7-42.2). Among heads of household who reported a lifetime incident of sexual violence, 64.0% (95% CI 54.3-72.5) suffered sexual violence perpetrated by their husband or partner. Among the host population, 3.9% (95% CI 1.4-10.5) reported sexual violence by armed groups compared to 39.0% (95% CI 25.6-54.2) of female refugee heads of household. Women who knew how to add and subtract were less likely to report sexual violence during their lifetime (OR 0.16, 95% CI 0.08-0.34). Sexual violence is common among refugees and host population in Eastern Cameroon. Most often, perpetrators are partners/husbands or armed groups.

Investigation of a cholera outbreak in Ethiopia's Oromiya Region.

OBJECTIVES: In late June 2006, Ethiopia's Oromiya Region was affected by an outbreak of acute watery diarrhea, subsequently confirmed to be caused by Vibrio cholerae O1, a pathogen not known to be endemic to this area. Despite initial control efforts, the outbreak quickly spread to neighboring zones and regions. The Oromiya Health Bureau required public health assistance to investigate the outbreak, determine potential causes, and assess the adequacy of the response, particularly given the concern that the number of cases being reported by health care personnel might represent only a fraction of what actually existed in the community. METHODS: A physician-epidemiologist-led team assessed the Guji, Bale, and East Shewa zones from September 15 to October 9, 2006. By using a purposive sample, we surveyed health bureau staff and cholera treatment center (CTC) staff and community members, assessed CTC sites, and interviewed key personnel of the various organizations responding to the outbreak. RESULTS: The cholera cases mapped along the Ganale River. The individual attack rates were low (ranging from ~ 0.03% to ~ 4.12%), as was the overall attack rate for all 3 zones (almost 0.50%). The individual CTC case fatality rates ranged from 0% to 6.4%, and the overall case fatality rate was 1.11%. There was a trend toward men being disproportionately affected. This outbreak resulted primarily from poor sanitation and insufficient access to clean water. In Oromiya, the outbreak was addressed by a prompt and effective response, which included village chairmen at the community level. The use of community-based workers was successful and likely contributed significantly to control of the outbreak. CONCLUSION: Future epidemics will undoubtedly occur unless basic water and sanitation deficiencies are properly addressed. This outbreak prompts the need for increased local public health capacity to apply prevention strategies and establish ongoing surveillance. Signatories to the World Health Organization International Health Regulations must report outbreaks of nonendemic diseases.

A participatory approach to assessing refugee perceptions of health services.

OBJECTIVE: The necessity and value of beneficiary input is widely recognized by the humanitarian community. Nevertheless, limited beneficiary involvement occurs due to various barriers. This study explores the effectiveness of an innovative, participatory approach to assessing beneficiary perceptions in resource-limited settings. METHODS: A unique hybrid of qualitative and quantitative methodologies assessed perceptions of health programs within five refugee camps in Kenya and Tanzania. A database of perceptions and opinions was established through key-informant interviews, focus group discussions and free-response questionnaires among refugees, community leaders and healthcare providers. Each participant subsequently force-ranked the collected views into quasi-normal distribution according to level of agreement. Responses were analyzed using by-person factor analysis software. FINDINGS: Eighty-one individuals (96%) successfully completed the participatory exercise. The methodologies identified detailed levels of consensus, rank-ordered priorities and unique sub-population opinions. CONCLUSION: The authors illustrate benefits and feasibility of qualitative quantitative participatory methodology in assessing beneficiary perceptions of refugee services.