Public health equity in refugee situations

Addressing increasing concerns about public health equity in the context of violent conflict and the consequent forced displacement of populations is complex. Important operational questions now faced by humanitarian agencies can to some extent be clarified by reference to relevant ethical theory. Priorities of service delivery, the allocation choices, and the processes by which they are arrived at are now coming under renewed scrutiny in the light of the estimated two million refugees who fled from Iraq since 2003

An algorithm to assess methodological quality of nutrition and mortality cross-sectional surveys: development and application to surveys conducted in Darfur, Sudan

Background Nutrition and mortality surveys are the main tools whereby evidence on the health status of populations affected by disasters and armed conflict is quantified and monitored over time. Several reviews have consistently revealed a lack of rigor in many surveys. We describe an algorithm for analyzing nutritional and mortality survey reports to identify a comprehensive range of errors that may result in sampling, response, or measurement biases and score quality. We apply the algorithm to surveys conducted in Darfur, Sudan. Methods We developed an algorithm based on internationally agreed upon methods and best practices. Penalties are attributed for a list of errors, and an overall score is built from the summation of penalties accrued by the survey as a whole. To test the algorithm reproducibility, it was independently applied by three raters on 30 randomly selected survey reports. The algorithm was further applied to more than 100 surveys conducted in Darfur, Sudan. Results The Intra Class Correlation coefficient was 0.79 for mortality surveys and 0.78 for nutrition surveys. The overall median quality score and range of about 100 surveys conducted in Darfur were 0.60 (0.12-0.93) and 0.675 (0.23-0.86) for mortality and nutrition surveys, respectively. They varied between the organizations conducting the surveys, with no major trend over time. Conclusion Our study suggests that it is possible to systematically assess quality of surveys and reveals considerable problems with the quality of nutritional and particularly mortality surveys conducted in the Darfur crisis.BioMed Central Open acces

A review of methodology and analysis of nutrition and mortality surveys conducted in humanitarian emergencies from October 1993 to April 2004

<p>Abstract</p> <p>Background</p> <p>Malnutrition prevalence and mortality rates are increasingly used as essential indicators to assess the severity of a crisis, to follow trends, and to guide decision-making, including allocation of funds. Although consensus has slowly developed on the methodology to accurately measure these indicators, errors in the application of the survey methodology and analysis have persisted. The aim of this study was to identify common methodological weaknesses in nutrition and mortality surveys and to provide practical recommendations for improvement.</p> <p>Methods</p> <p>Nutrition (N = 368) and crude mortality rate (CMR; N = 158) surveys conducted by 33 non-governmental organisations and United Nations agencies in 17 countries from October 1993 to April 2004 were analysed for sampling validity, precision, quality of measurement and calculation according to several criteria.</p> <p>Results</p> <p>One hundred and thirty (35.3%) nutrition surveys and 5 (3.2%) CMR surveys met the criteria for quality. Quality of surveys varied significantly depending on the agency. The proportion of nutrition surveys that met criteria for quality rose significantly from 1993 to 2004; there was no improvement for mortality surveys during this period.</p> <p>Conclusion</p> <p>Significant errors and imprecision in the methodology and reporting of nutrition and mortality surveys were identified. While there was an improvement in the quality of nutrition surveys over the years, the quality of mortality surveys remained poor. Recent initiatives aimed at standardising nutrition and mortality survey quality should be strengthened. There are still a number of methodological issues in nutrition and mortality surveys in humanitarian emergencies that need further study.</p

Sanitation, human rights, and disaster management

Purpose The purpose of this paper is to link debates around the international law on human rights and disaster management with the evolving debate around the human right to sanitation, in order to explore the extent to which states are obliged to account for sanitation in their disaster management efforts. Design/methodology/approach The paper is based on analysis of existing laws and policy relating to human rights, sanitation and disaster management. It further draws upon relevant academic literature. Findings The paper concludes that, while limitations exist, states have legal obligations to provide sanitation to persons affected by a disaster. It is further argued that a human rights-based approach to sanitation, if respected, can assist in strengthening disaster management efforts, while focusing on the persons who need it the most. Research limitations/implications The analysis in this paper focuses on the obligations of states for people on their territory. Due to space limitations, it does not examine the complex issues relating to enforcement mechanisms available to disaster victims. Originality/value This is the first scholarly work directly linking the debates around international human rights law and disaster management, with human rights obligations in relation to sanitation. The clarification of obligation in relation to sanitation can assist in advocacy and planning, as well as in ensuring accountability and responsibility for human rights breaches in the disaster context

Measles vaccination in humanitarian emergencies: a review of recent practice

<p>Abstract</p> <p>Background</p> <p>The health needs of children and adolescents in humanitarian emergencies are critical to the success of relief efforts and reduction in mortality. Measles has been one of the major causes of child deaths in humanitarian emergencies and further contributes to mortality by exacerbating malnutrition and vitamin A deficiency. Here, we review measles vaccination activities in humanitarian emergencies as documented in published literature. Our main interest was to review the available evidence focusing on the target age range for mass vaccination campaigns either in response to a humanitarian emergency or in response to an outbreak of measles in a humanitarian context to determine whether the current guidance required revision based on recent experience.</p> <p>Methods</p> <p>We searched the published literature for articles published from January 1, 1998 to January 1, 2010 reporting on measles in emergencies. As definitions and concepts of emergencies vary and have changed over time, we chose to consider any context where an application for either a Consolidated Appeals Process or a Flash Appeal to the UN Central Emergency Revolving Fund (CERF) occurred during the period examined. We included publications from countries irrespective of their progress in measles control as humanitarian emergencies may occur in any of these contexts and as such, guidance applies irrespective of measles control goals.</p> <p>Results</p> <p>Of the few well-documented epidemic descriptions in humanitarian emergencies, the age range of cases is not limited to under 5 year olds. Combining all data, both from preventive and outbreak response interventions, about 59% of cases in reports with sufficient data reviewed here remain in children under 5, 18% in 5-15 and 2% above 15 years. In instances where interventions targeted a reduced age range, several reports concluded that the age range should have been extended to 15 years, given that a significant proportion of cases occurred beyond 5 years of age.</p> <p>Conclusions</p> <p>Measles outbreaks continue to occur in humanitarian emergencies due to low levels of pre-existing population immunity. According to available published information, cases continue to occur in children over age 5. Preventing cases in older age groups may prevent younger children from becoming infected and reduce mortality in both younger and older age groups.</p

A new method to estimate mortality in crisis-affected and resource-poor settings: validation study

Background Data on mortality rates are crucial to guide health interventions in crisis-affected and resource-poor settings. The methods currently available to collect mortality data in such settings feature important methodological limitations. We developed and validated a new method to provide near real-time mortality estimates in such settings

Treating childhood pneumonia in hard-to-reach areas: A model-based comparison of mobile clinics and community-based care

BACKGROUND: Where hard-to-access populations (such as those living in insecure areas) lack access to basic health services, relief agencies, donors, and ministries of health face a dilemma in selecting the most effective intervention strategy. This paper uses a decision mathematical model to estimate the relative effectiveness of two alternative strategies, mobile clinics and fixed community-based health services, for antibiotic treatment of childhood pneumonia, the world's leading cause of child mortality. METHODS: A "Markov cycle tree" cohort model was developed in Excel with Visual Basic to compare the number of deaths from pneumonia in children aged 1 to 59 months expected under three scenarios: 1) No curative services available, 2) Curative services provided by a highly-skilled but intermittent mobile clinic, and 3) Curative services provided by a low-skilled community health post. Parameter values were informed by literature and expert interviews. Probabilistic sensitivity analyses were conducted for several plausible scenarios. RESULTS: We estimated median pneumonia-specific under-5 mortality rates of 0.51 (95% credible interval: 0.49 to 0.541) deaths per 10,000 child-days without treatment, 0.45 (95% CI: 0.43 to 0.48) with weekly mobile clinics, and 0.31 (95% CI: 0.29 to 0.32) with CHWs in fixed health posts. Sensitivity analyses found the fixed strategy superior, except when mobile clinics visited communities daily, where rates of care-seeking were substantially higher at mobile clinics than fixed posts, or where several variables simultaneously differed substantially from our baseline assumptions. CONCLUSIONS: Current evidence does not support the hypothesis that mobile clinics are more effective than CHWs. A CHW strategy therefore warrants consideration in high-mortality, hard-to-access areas. Uncertainty remains, and parameter values may vary across contexts, but the model allows preliminary findings to be updated as new or context-specific evidence becomes available. Decision analytic modelling can guide needed field-based research efforts in hard-to-access areas and offer evidence-based insights for decision-makers

Identifying priority healthcare trainings in frozen conflict situations: The case of Nagorno Karabagh

<p>Abstract</p> <p>Introduction</p> <p>Health care in post-war situations, where the system's human and fixed capital are depleted, is challenging. The addition of a frozen conflict situation, where international recognition of boundaries and authorities are lacking, introduces further complexities.</p> <p>Case description</p> <p>Nagorno Karabagh (NK) is an ethnically Armenian territory locked within post-Soviet Azerbaijan and one such frozen conflict situation. This article highlights the use of evidence-based practice and community engagement to determine priority areas for health care training in NK. Drawing on the precepts of APEXPH (Assessment Protocol for Excellence in Public Health) and MAPP (Mobilizing for Action through Planning and Partnerships), this first-of-its-kind assessment in NK relied on in-depth interviews and focus group discussions supplemented with expert assessments and field observations. Training options were evaluated against a series of ethical and pragmatic principles.</p> <p>Discussion and Evaluation</p> <p>A unique factor among the ethical and pragmatic considerations when prioritizing among alternatives was NK's ambiguous political status and consequent sponsor constraints. Training priorities differed across the region and by type of provider, but consensus prioritization emerged for first aid, clinical Integrated Management of Childhood Illnesses, and Adult Disease Management. These priorities were then incorporated into the training programs funded by the sponsor.</p> <p>Conclusions</p> <p>Programming responsive to both the evidence-base and stakeholder priorities is always desirable and provides a foundation for long-term planning and response. In frozen conflict, low resource settings, such an approach is critical to balancing the community's immediate humanitarian needs with sponsor concerns and constraints.</p