Prioritizing vulnerable populations and women on the frontlines: COVID-19 in humanitarian contexts.

The COVID-19 outbreak has been declared a global pandemic and cases are being reported among displaced populations that are particularly vulnerable to infection. Humanitarian workers on the frontlines of the response are working in some of the most challenging contexts and also face elevated risk of contracting COVID-19 and potential stigmatization or violence in the community. Women humanitarians may be at even greater risk, but their protection is dependent on organization-specific policies and procedures. Without gender balance in leadership positions, the specific needs of women may not be prioritized and women may not be included in decision-making or design of responses. Ensuring gender equitable access to personal protective equipment and information is imperative, but additional measures must be put into place to ensure the protection of women on the frontlines while reducing COVID-19 deaths and adverse health effects among displaced populations.

Moving from data collection to application: a systematic literature review of surgical capacity assessments and their applications.

BACKGROUND: Over the past decade, assessments of surgical capacity in low- and middle-income countries (LMICs) have contributed to our understanding of barriers to the delivery of surgical services in a number of countries. It is yet unclear, however, how the findings of these assessments have been applied and built upon within the published literature. METHODS: A systematic literature review of surgical capacity assessments in LMICs was performed to evaluate current levels of understanding of global surgical capacity and to identify areas for future study. A reverse snowballing method was then used to follow-up citations of the identified studies to assess how this research has been applied and built upon in the literature. RESULTS: Twenty-one papers reporting the findings of surgical capacity assessments conducted in 17 different LMICs in South Asia, East Asia and Pacific, Latin America and the Caribbean, and sub-Saharan Africa were identified. These studies documented substantial deficits in human resources, infrastructure, equipment, and supplies. Only seven additional papers were identified which applied or built upon the studies. Among these, capacity assessment findings were most commonly used to develop novel tools and intervention strategies, but they were also used as baseline measurements against which updated capacity assessments were compared. CONCLUSIONS: While the global surgery community has made tremendous progress in establishing baseline values of surgical capacity in LMICs around the world, further work is necessary to build upon and apply the foundational knowledge established through these efforts. Capacity assessment data should be coordinated and used in ongoing research efforts to monitor and evaluate progress in global surgery and to develop targeted intervention strategies. Intervention strategy development may also be further incorporated into the evaluation process itself.

Respondent-driven sampling to assess outcomes of sexual violence: a methodological assessment.

Sexual violence is pervasive in eastern Democratic Republic of Congo (DRC). Survivors of sexual violence encounter numerous challenges, and women with a sexual violence-related pregnancy (SVRP) face even more complex sequelae. Because of the stigma associated with SVRP, there is no conventional sampling frame and, therefore, a paucity of research on SVRP outcomes. Respondent-driven sampling (RDS), used to study this "hidden" population, uses a peer recruitment sampling system that maintains strict participant privacy and controls and tracks recruitment. If RDS assumptions are met and the sample attains equilibrium, sample weights to correct for biases associated with traditional chain referral sampling can be calculated. Questionnaires were administered to female participants who were raising a child from a SVRP and/or who terminated a SVRP. A total of 852 participants were recruited from October 9, 2012, to November 7, 2012. There was rapid recruitment, and there were long referral chains. The majority of the variables reached equilibrium; thus, trends established in the sample population reflected the target population's trends. To our knowledge, this is the first study to use RDS to study outcomes of sexual violence. RDS was successfully applied to this population and context and should be considered as a sampling methodology in future sexual violence research.

Academic affiliated training centers in humanitarian health, Part I: program characteristics and professionalization preferences of centers in North America.

The collaborative London based non-governmental organization network ELRHA (Enhancing Learning and Research for Humanitarian Assistance) supports partnerships between higher education institutions and humanitarian organizations worldwide with the objective to enhance the professionalization of the humanitarian sector. While coordination and control of the humanitarian sector has plagued the response to every major crisis, concerns highlighted by the 2010 Haitian earthquake response further catalyzed and accelerated the need to ensure competency-based professionalization of the humanitarian health care work force. The Harvard Humanitarian Initiative sponsored an independent survey of established academically affiliated training centers in North America that train humanitarian health care workers to determine their individual training center characteristics and preferences in the potential professionalization process. The survey revealed that a common thread of profession-specific skills and core humanitarian competencies were being offered in both residential and online programs with additional programs offering opportunities for field simulation experiences and more advanced degree programs. This study supports the potential for the development of like-minded academic affiliated and competency-based humanitarian health programs to organize themselves under ELRHA's regional "consultation hubs" worldwide that can assist and advocate for improved education and training opportunities in less served developing countries.

Demographics and care-seeking behaviors of sexual violence survivors in South Kivu province, Democratic Republic of Congo.

OBJECTIVES: One of the most striking features of the ongoing conflict in the Democratic Republic of Congo (DRC) is the use of sexual violence. In spite of the brutality of these crimes, the experiences of women affected by sexual violence in Eastern DRC remain poorly characterized. This analysis aimed to (1) provide detailed demographics of sexual violence survivors presenting to Panzi Hospital; (2) examine how demographic factors might impact patterns of sexual violence; and (3) describe care-seeking behavior among sexual violence survivors. METHODS: The demographics and care-seeking behavior of sexual violence survivors in South Kivu Province were described from a retrospective registry-based study of sexual violence survivors presenting to Panzi Hospital (2004-2008). RESULTS: A total of 4311 records were reviewed. The mean age of survivors was 35 years. Most women (53%) were married, self-identified with the Bashi tribe (65%), and reported agriculture as their livelihood (74%). The mean time delay between sexual assault and seeking care was 10.4 months. Five reasons were identified to help explain the lengthy delays to seeking care: waiting for physical symptoms to develop or worsen before seeking medical attention, lack of means to access medical care, concerns that family would find out about the sexual assault, stigma surrounding sexual violence, and being abducted into sexual slavery for prolonged periods of time. CONCLUSIONS: Many sexual assault survivors have very delayed presentations to medical attention. Promoting timely access of medical care may best be facilitated by reducing stigma and by educating women about the benefits of early medical care, even in the absence of injuries or symptoms.

'If your husband doesn't humiliate you, other people won't': gendered attitudes towards sexual violence in eastern Democratic Republic of Congo.

More than a decade of fighting in the Democratic Republic of the Congo (DRC) has resulted in extensive human rights abuses, of which sexual and gender-based violence (SGBV) is one of the most salient and disturbing features. This paper uses qualitative data, based on 10 focus groups with 86 women and men to better understand gendered community perspectives on SGBV and its consequences in South Kivu. We conclude that for many survivors, rape has consequences far beyond the physiological and psychological trauma associated with the attack. Respondents say sexual violence has become a societal phenomenon, in which the community isolation and shame experienced as a result of the attack become as important as concerns about the attack itself. Male focus group participants explain their own feelings of shame and anger associated with knowing their female relatives were raped. These findings highlight the complexity of community reintegration for survivors and identify a number of programmatic and policy implications, such as the need for counselling for survivors of sexual violence with their families as well as individually; the importance of income-generating training; and the need for improved justice mechanisms to bring perpetrators to justice.

Medical complications associated with earthquakes.

Major earthquakes are some of the most devastating natural disasters. The epidemiology of earthquake-related injuries and mortality is unique for these disasters. Because earthquakes frequently affect populous urban areas with poor structural standards, they often result in high death rates and mass casualties with many traumatic injuries. These injuries are highly mechanical and often multisystem, requiring intensive curative medical and surgical care at a time when the local and regional medical response capacities have been at least partly disrupted. Many patients surviving blunt and penetrating trauma and crush injuries have subsequent complications that lead to additional morbidity and mortality. Here, we review and summarise earthquake-induced injuries and medical complications affecting major organ systems.

Sexual violence trends between 2004 and 2008 in South Kivu, Democratic Republic of Congo.

INTRODUCTION: For more than a decade, conflict in the Eastern Democratic Republic of Congo (DRC) has been claiming lives. Within that conflict, sexual violence has been used by militia groups to intimidate and punish communities, and to control territory. This study aimed to: (1) investigate overall frequency in number of Eastern DRC sexual assaults from 2004 to 2008 inclusive; (2) determine if peaks in sexual violence coincide with known military campaigns in Eastern DRC; and (3) study the types of violence and types of perpetrators as a function of time. METHODS: This study was a retrospective, descriptive, registry-based evaluation of sexual violence survivors presenting to Panzi Hospital between 2004 and 2008. RESULTS: A total of 4,311 records were reviewed. Throughout the five-year study period, the highest number of reported sexual assaults occurred in 2004, with a steady decrease in the total number of incidents reported at Panzi Hospital from 2004 through 2008. The highest peak of reported sexual assaults coincided with a known militant attack on the city of Bukavu. A smaller sexual violence peak in April 2004 coincided with a known military clash near Bukavu. Over the five-year period, the number of sexual assaults reportedly perpetrated by armed combatants decreased by 77% (p = 0.086) and the number of assaults reportedly perpetrated by non-specified perpetrators decreased by 92% (p < 0.0001). At the same time, according to the hospital registry, the number of sexual assaults reportedly perpetrated by civilians increased 17-fold (p < 0.0001). This study was limited by its retrospective nature, by the inherent selection bias of studying only survivors presenting to Panzi Hospital, and by the use of a convenience sample within Panzi Hospital. CONCLUSIONS: After years of military rape in South Kivu Province, civilian adoption of sexual violence may be a growing phenomenon. If this is the case, the social mechanisms that prevent sexual violence will have to be rebuilt and sexual violence laws will have to be fully enforced to bring all perpetrators to justice. Proper rehabilitation and reintegration of ex-combatants may also be an important step towards reducing civilian rape in Eastern DRC.

Impact of sexual violence on children in the Eastern Democratic Republic of Congo.

The conflict in the Eastern Democratic Republic of Congo (DRC) has been particularly devastating for children and has been typified by high levels of sexual and gender-based violence (SGBV). In this study, we seek to characterize the patterns and impact of sexual violence on children in the Eastern DRC. Semi-structured questionnaires were administered among a convenience sample of women <18 years of age presenting for post-sexual-violence care at Panzi Hospital in South Kivu, DRC. Analysis included quantitative and qualitative methods to describe the characteristics of the violence, perpetrators, and survivors and to illuminate common themes within the narratives. A total of 389 survivors of SGBV under the age of 18 were interviewed between 2004 and 2008. These paediatric survivors were more likely than adult survivors to have experienced gang rape, been attacked by a civilian perpetrator, and been assaulted during the day. Survivor and perpetrator characteristics were further stratified by type of attack. Reports of violence perpetrated by civilians increased 39-fold while reports of violence perpetrated by armed combatants decreased by 70% between 2004 and 2008. Qualitative analysis of the narratives revealed common themes, such as physical signs and symptoms among SGBV survivors (23.9%), pregnancy resulting from rape (19.3%), perpetrators being brought to justice (18.3%), and neighbourhood men as perpetrators (17.7%). Children in the Eastern DRC continue to face significant threats of sexual violence. By understanding the patterns of this violence, local and international approaches could be more effectively implemented to protect these vulnerable children.

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.

Core curricular elements for fellowship training in international emergency medicine.

OBJECTIVES: The objective was to describe the common educational goals, curricular elements, and methods of evaluation used in international emergency medicine (IEM) fellowship training programs currently. IEM fellowship programs have been developed to provide formal training for emergency physicians (EPs) interested in pursuing careers in IEM. Those fellowships are variable in scope, objectives, and duration. Previously published articles have suggested a general curriculum structure for IEM fellowships. METHODS: A search of MEDLINE, EMBASE, and CINAHL databases from 1950 to June 2008 was performed, combining the terms international, emergency medicine, and fellowship. Online curricula and descriptive materials from IEM fellowships listed by the Society for Academic Emergency Medicine (SAEM) were reviewed. Knowledge and skill areas common to multiple programs were organized in discrete categories. IEM fellowship directors were contacted for input and feedback. RESULTS: Eight articles on IEM fellowships were identified. Two articles described a general structure for fellowship curriculum. Sixteen of 20 IEM fellowship programs had descriptive materials posted online. These information sources, plus input from seven fellowship program directors, yielded the following seven discrete knowledge and skill areas: 1) emergency medicine systems development, 2) humanitarian relief, 3) disaster management, 4) public health, 5) travel and field medicine, 6) program administration, and 7) academic skills. CONCLUSIONS: While IEM fellowships vary with regard to objectives and structure, this article presents an overview of the current focus of IEM fellowship training curricula that could serve as a resource for IEM curriculum development at individual institutions.

Improved health outcomes in urban slums through infrastructure upgrading.

The world is rapidly urbanizing with over half the population now living in urban areas. As the urban population grows, so does the proportion of these persons living in slums where conditions are deplorable. These conditions concentrate health hazards leading to higher rates of morbidity and mortality. This growing problem creates a unique challenge for policymakers and public health practitioners. While the Millennium Development Goals (MDGs) aim to address these conditions and standards for water and sanitation as well as pertinent health outcomes, little evidence on interventions exists to guide policymakers. Upgrades in slum household water and sanitation systems have not yet been rigorously evaluated to demonstrate whether there is a direct link to improved health outcomes. This study aims to show that slum upgrading as carried out in Ahmedabad, India, led to a significant decline in waterborne illness incidence. We employ a quasi-experimental regression model using health insurance claims (for 2001-2008) as a proxy for passive surveillance of disease incidence. We found that slum upgrading reduced a claimant's likelihood of claiming for waterborne illness from 32% to 14% and from 25% to 10% excluding mosquito-related illnesses. This study shows that upgrades in slum household infrastructure can lead to improved health outcomes and help achieve the MDGs. It also provides guidance on how upgrading in this context using microfinance and a public-private partnership can provide an avenue to affect positive change.

Patterns of sexual violence in Eastern Democratic Republic of Congo: reports from survivors presenting to Panzi Hospital in 2006.

BACKGROUND: Despite the signing of international peace agreements, a deadly war continues in the Democratic Republic of Congo (DRC) and sexual violence is a prominent modus operandi of many military groups operating in the region. METHODS: Retrospective cohort study of women who presented to Panzi Hospital in 2006 requesting post-sexual violence care. Data was extracted and analyzed to describe the patterns of sexual violence. RESULTS: A total of 1,021 medical records were reviewed. A majority of attacks occurred in individual homes (56.5%), with the fields (18.4%) and the forest (14.3%) also being frequent locations of attack. In total, 58.9% of all attacks occurred at night. Of the four primary types of sexual violence, gang rape predominated (59.3%) and rape Not Otherwise Specified (NOS) was also common (21.5%). Sexual slavery was described by 4.9% of the survivors and a combination of gang rape and sexual slavery was described by 11.7%. The mean number of assailants per attack was 2.5 with a range of one to > 15. There were several demographic predictors for sexual slavery. Controlling for age, education level and occupation, a marital status of "single" increased the risk of sexual slavery (OR = 2.97, 95% CI = 1.12-7.85). Similarly, after controlling for other variables, age was a significant predictor of sexual slavery with older women being at a slightly reduced risk (OR = 0.96, 95% CI = 0.92-0.99). Women who experienced sexual slavery were 37 times more likely to have a resultant pregnancy in comparison to those who reported other types of sexual violence (OR = 37.50, 95% CI = 14.57-99.33). CONCLUSIONS: Among sexual violence survivors presenting to Panzi Hospital in 2006, the majority of attacks occurred in women's own homes, often at night. This represents a pattern of violence that differs from other conflict settings and has important implications regarding protection strategies. Sexual violence in South Kivu was also marked with a predominance of gang rape, thus increasing the risk of serious injury as well as the likelihood of an individual woman contracting a sexually transmitted infection (STI). Sexual slavery was noted to be more common among young, single women and was found to have a high rate of resultant pregnancy.

Non-governmental organizational health operations in humanitarian crises: the case for technical support units.

As the humanitarian health response industry grows, there is a need for technical health expertise that can build an evidence base around outcome measures and raise the quality and accountability of the health relief response. We propose the formation of technical support units (TSUs), entities of health expertise institutionalized within humanitarian non-governmental organizations (NGOs), which will bridge the gap between the demand for evidence-based, humanitarian programming and the field capacity to accomplish it. With the input of major humanitarian NGOs and donors, this paper discusses the attributes and capacities ofTSUs; and the mechanisms for creating and enhancing TSUs within the NGO management structure.