Barriers to Health among IDPs in Kabul, Afghanistan: a qualitative study

Background: Forced displacement is a significant problem for regions experiencing prolonged humanitarian crises due to armed conflict. Afghanistan, having experienced over four decades of conflict, has an estimated 1.2 million internally displaced persons (IDPs), a majority of which are concentrated in urban centers. IDPs have limited resources and face challenges accessing health services through traditional channels, leading to a disproportionate burden of morbidity and mortality. Health care facilities created for and existing within IDP camps also face numerous challenges. We aim to understand the structural factors that negatively impact health and the specific barriers to healthcare access for IDPs using qualitative methods. Methods: A brief qualitative study was done to assess the barriers to health faced by IDPs and to understand the experience of providers caring for IDPs. We conducted open-ended interviews using a semi-structured interview guide across three IDP camps in Kabul, Afghanistan between May and June 2017. Participants were interviewed in focus groups, interviewing a total of 37 IDP ag 18 and older. In addition, two former health care providers were interviewed. We used grounded theory to code interviews using a priori and emergent coding, from which several themes and sub-themes emerged. Two independent readers coded the data and discrepancies were resolved by consensus. Results: Human security, water access, limited livelihood and employment, poor housing infrastructure and environmental factors significantly impacted IDP health. Closure of clinics within the camps caused substantial limitations to healthcare service access. Accessing existing health care infrastructure was limited by cost, distance, discrimination, and limited access to medication and vaccinations, particularly for children. Key informant interviews identified healthcare funding and vaccination delivery to be priority problems. Across all focus groups and key informant interviews, there appeared to be a solid and trusted patient-provider relationship. Conclusion Structural factors that negatively impact health coupled with new barriers to healthcare access for IDPs in Kabul are a source of serious concern. Our study identified structural factors that exacerbate poor health and new challenges to healthcare access resulting from the discontinuation of in-camp health services. Further research should be done on the barriers and facilitators of transition from emergency humanitarian response to long-term care for IDPs, as well as on the ability of local health systems to absorb vulnerable populations after humanitarian crises

The Istanbul Protocol: A global stakeholder survey on past experiences, current practices and additional norm setting

Introduction: The Istanbul Protocol (IP) principles and guidelines have served as international norms for the effective investigation and documentation of torture and ill-treatment since 1999. Given the widespread use of the IP and recent calls to update or enhance its norms, we conducted a large-scale study among stakeholders to understand current practices as well as opinions on additional IP norm setting. Methods: Between February 20, 2017 and April 7, 2017, we conducted an online survey of IP users using a combination of criterion and chain sampling. The survey instrument included the following domains of inquiry: 1) respondent characteristics (demographics, anti-torture work, country conditions, and IP training); 2) IP use, importance and practices, and; 3) opinions on additional IP norm setting. Results: The survey was distributed to 177 individuals and 250 organizational representatives with response rates of 78% and 47% respectively. The respondents came from a variety of clinical, legal, academic, and advocacy disciplines from around the world. The respondents indicated that they use the IP for a wide range of anti-torture activities: investigation and documentation, advocacy, training and capacity building, policy reform, prevention, and treatment and rehabilitation of torture survivors. The vast majority (94% of individual respondents and 84% of organizations) reported that the IP is important to their anti-torture work. A majority of individual (60%) and organizational (59%) respondents reported that updating or adding clarifications to the IP would help to address the challenges they face and provided specific suggestions. However, 41% of individuals and 21% of organizational respondents also reported concerns that additional IP norm setting could have negative consequences. Discussion: The IP provides critical guidance for a wide range of torture prevention, accountability, and redress activities and can be enhanced through the development of additional updates and clarifications to respond to the current needs of torture survivors and stakeholders

Documentation of human rights abuses among Rohingya refugees from Myanmar

Background: Decades of persecution culminated in a statewide campaign of organized, systematic, and violent eviction of the Rohingya people by the Myanmar government beginning in August 2017. These attacks included the burning of homes and farms, beatings, shootings, sexual violence, summary executions, burying the dead in mass graves, and other atrocities. The Myanmar government has denied any responsibility. To document evidence of reported atrocities and identify patterns, we interviewed survivors, documented physical injuries, and assessed for consistency in their reports. Methods: We use purposive and snowball sampling to identify survivors residing in refugee camps in Bangladesh. Interviews and examinations were conducted by trained investigators with the assistance of interpreters based on the Istanbul Protocol - the international standard to investigate and document instances of torture and other cruel, inhuman, and degrading treatment. The goal was to assess whether the clinical findings corroborate survivors\u27 narratives and to identify emblematic patterns. Results: During four separate field visits between December 2017 and July 2018, we interviewed and where relevant, conducted physical examinations on a total of 114 refugees. The participants came from 36 villages in Northern Rakhine state; 36 (32%) were female, 26 (23%) were children. Testimonies described several patterns in the violence prior to their flight, including the organization of the attacks, the involvement of non-Rohingya civilians, the targeted and purposeful destruction of homes and eviction of Rohingya residents, and the denial of medical care. Physical findings included injuries from gunshots, blunt trauma, penetrating trauma such as slashings and mutilations, burns, and explosives and from sexual and gender-based violence. Conclusions: While each survivor\u27s experience was unique, similarities in the types and organization of attacks support allegations of a systematic, widespread, and premeditated campaign of forced displacement and violence. Physical findings were consistent with survivors\u27 narratives of violence and brutality. These findings warrant accountability for the Myanmar military per the Rome Statute of the International Criminal Court (ICC), which has jurisdiction to try individuals for serious international crimes, including crimes against humanity and genocide. Legal accountability for these crimes should be pursued along with medical and psychological care and rehabilitation to address the ongoing effects of violence, discrimination, and displacement

Protecting providers and patients: results of an Internet survey of health care workers’ risk perceptions and ethical concerns during the COVID-19 pandemic

Abstract Background The COVID-19 pandemic has generated worldwide scarcity of critical resources to protect against and treat disease. Shortages of face masks and other protective equipment place health workers, already on the frontline of the disease, at higher risk. Moral distress from making difficult decisions about allocating scarce resources and care to patients ill with COVID-19 can further add to burdens health workers face. This study investigates clinical health workers’ risk perceptions and concerns about the ethics of their clinical decision-making, the actions of their institutions to address resource scarcity concerns during the COVID-19 pandemic, and their ability to voice safety concerns, as well as their own views on how scarce resources should be allocated. Methods An online survey was open to health care workers who provide clinical care to patients, with no specialty training or geographic location requirements, from May 19 to June 30, 2020. Participants were recruited through purposive sampling using medical association and institutional email lists, and by snowball sampling. Results Of 839 participants, a majority were physicians (540, 69.4%) working in academic medical centers (270, 35.2%) or private health systems in the community (234, 30.5%) in the USA (760, 90.7%). Most reported being concerned about their own health (494, 73.6%) and about the possibility of spreading COVID-19 to family and friends (534, 85.9%) during the pandemic. All respondents reported shortages or rationing of at least one type of medical resource (e.g., sanitizing supplies and personal protective equipment). More than half of respondents (351, 53.9%) did not feel they received sufficient training in how to allocate scarce resources in the pandemic. Many felt moral distress related to conflicts between institutional constraints and what they believed was right (459, 66.5%). Though a majority (459, 67.7%) reported feeling “comfortable” internally communicating with their administration about safety issues, far fewer reported feeling “confident” speaking publicly about safety issues without retaliation from their institution (255, 37.3%). Conclusions In the face of limited resources, surveyed health care workers reported concern about their own and their families’ health from exposure. Securing adequate protective equipment must be a high priority for pandemic management. In addition, more governmental and facility-level ethical guidance is required for allocation of resources given ongoing scarcity, and facilities must create conditions so health care workers can speak openly about safety issues without fear of retaliation.http://deepblue.lib.umich.edu/bitstream/2027.42/173259/1/12245_2021_Article_341.pd

Overview of attacks against civilian infrastructure during the Syrian civil war, 2012–2018

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. 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. 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. 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