Conflict

Sean M Kivlehan, Amy Allen, Olha Viun, Dmitry A Makarov, Daniel Schnorr, Sonny Patel, Sergii A Ryzhenko, Phuong Pham, and Timothy B Erickson. 6/14/2022. “Evaluation of change in emergency care knowledge and skills among front-line healthcare providers in Ukraine with the Basic Emergency Care course: a pretest/post-test study.” BMJ Open. Read PublicationAbstract

Objective: Evaluate the change in participant emergency care knowledge and skill confidence after implementation of the WHO-International Committee of the Red Cross (ICRC) Basic Emergency Care (BEC) course.

Design: Pretest/post-test quasi-experimental study.

Setting: Mechnikov Hospital in Dnipro, Ukraine.

Participants: Seventy-nine participants engaged in the course, of whom 50 (63.3%) completed all assessment tools. The course was open to healthcare providers of any level who assess and treat emergency conditions as part of their practice. The most common participant profession was resident physician (24%), followed by health educator (18%) and prehospital provider (14%).

Interventions: The 5-day WHO-ICRC BEC course.

Primary and secondary outcome measures: Change in pre-course and post-course knowledge and skill confidence assessments. Open-ended written feedback was collected upon course completion and analysed for common themes.

Results: Participant knowledge assessment scores improved from 19 (IQR 15–20) to 22 (IQR 19–23) on a 25-point scale (p<0.001). Participant skill confidence self-assessment scores improved from 2.5 (IQR 2.1–2.8) to 2.9 (IQR 2.5–3.3) on a 4-point scale (p<0.001). The most common positive feedback themes were high-quality teaching and useful skill sessions. The most common constructive feedback themes were translation challenges and request for additional skill session time.

Conclusions: This first implementation of the WHO-ICRC BEC course for front-line healthcare providers in Ukraine was successful and well received by participants. This is also the first report of a BEC implementation outside of Africa and suggests that the course is also effective in the European context, particularly in humanitarian crisis and conflict settings. Future research should evaluate long-term knowledge retention and the impact on patient outcomes. Further iterations should emphasise local language translation and consider expanding clinical skills sessions.

Valerie A. Dobiesz, Madeline Schwid, Roger D. Dias, Benjamin Aiwonodagbon, Baraa Tayeb, Adrienne Fricke, Phuong Pham, and Timothy B. Erickson. 4/2022. “Maintaining Health Professional Education During War: A Scoping Review.” Medical Education. Read PublicationAbstract

Purpose: War negatively impacts health professional education when healthcare is needed most. The aims of this scoping review are to describe the scope of barriers and targeted interventions to maintaining health professional education during war and summarize the research.

Methods: We conducted a scoping review between June 20, 2018, and August 2, 2018. The search was restricted to English publications including peer reviewed publications without date ranges involving war and health professional education (medical school, residency training, and nursing school), with interventions described to maintain educational activities. Two independent reviewers completed inclusion determinations and data abstraction. Thematic coding was performed using an inductive approach allowing dominant themes to emerge. The frequency of barrier and intervention themes and illustrative quotes were extracted. Articles were divided into modern/postmodern categories to permit temporal and historical analysis of thematic differences.

Results: Screening identified 3,271 articles, with 56 studies meeting inclusion criteria. Publication dates ranged from 1914-2018 with 16 unique wars involving 17 countries. The studies concerned medical students (61.4%), residents (28.6%) and nursing students (10%). Half involved the modern era and half the postmodern era. Thematic coding identified 5 categories of barriers and targeted interventions in maintaining health professions education during war: curriculum, personnel, wellness, resources, and oversight, with most involving curriculum and personnel. The distribution of themes among various health professional trainees was similar. The frequency and specifics changed temporally reflecting innovations in medical education and war, with increased focus on oversight and personnel during the modern era and greater emphasis on wellness, curriculum, and resources during the postmodern era.

Conclusions: There are overarching categories of barriers and targeted interventions in maintaining health professional education during war which evolve over time. These may serve as a useful framework to strategically support future research and policy efforts.

Sonny S. Patel and Timothy B. Erickson. 3/2022. “The new humanitarian crisis in Ukraine: Coping with the public health impact of hybrid warfare, mass migration, and mental health trauma.” Disaster Medicine and Public Health Preparedness. Read PublicationAbstract

One of the largest mass movements of displaced people from their homelands in recent history must be recognized and assisted by the Free World. The unprovoked Russian attacks on Ukraine during February-March 2022 will leave long-lasting devastating effects on millions of innocent victims. Nations worldwide, especially NATO member countries, will need to intervene to ameliorate the situation. This letter describes major public health issues apart from the COVID-19 pandemic that are emerging concerns, such as shortages of healthcare professionals, chronic care treatments and health prevention services, disinformation communication campaigns affecting the healthcare infrastructure, and the generational impact of the conflict on people’s mental health. A global response and public health support need immediate action including humanitarian assistance, food security, clean water supplies, adequate shelter, and safe transportation out of the active military zones.

Vincenzo Bollettino and Lea Ivy Manzanero. 3/2022. “Climate Change and Civil-Military Coordination in the Philippines: How climate change disasters will impact aid delivery in areas affected by conflict.” Climate, Disaster and Development Journal. Read PublicationAbstract

The Philippines is one of the most disaster-prone countries in the world and frequently ranks among the top three countries most impacted by disasters. Ongoing conflict with non-state armed actors results in scenarios where civilians are impacted by both conflict and natural hazards. The result is a situation where civilian relief agencies operate in proximity to the military. We argue that there is an important need for principled civil-military coordination in these contexts to ensure the integrity of security operations to support peace and stability while preserving the independence of humanitarian actors serving crisis-affected populations.


The research reveals significant challenges in protecting the integrity of independence of both military and humanitarian actors in areas impacted by both conflict and disaster and underscores the need for principled humanitarian civil-military coordination to avert threats to both humanitarian aid workers and disaster affected populations. The findings are particularly relevant to South East Asia where the use of military in disaster response is common. The findings also underscore the need for research on the role of militaries in responding to disasters in light of anticipated impacts of climate change. 

Jocelyn Kelly, Emily Ausubel, Emma Kenny, Meredith Blake, Christine Heckman, Sonia Rastogi, and Vandana Sharma. 9/2021. “Measuring gender-based violence risk mitigation in humanitarian settings: results from a comprehensive desk review and systematic mapping.” BMJ Open. Read PublicationAbstract

Objectives: To systematically document measurement approaches used in the monitoring and evaluation of gender-based violence (GBV) risk mitigation activities, categorise the types of available literature produced by sector, identify existing tools and measures and identify knowledge gaps within the humanitarian sector.

Design: Systematic mapping and in-depth review.

Data sources: Pubmed, Global Health, PsychInfo, ReliefWeb, OpenGrey (grey literature), Google Scholar, Web of Science (Social Science Index)

Eligibility criteria: a structured search strategy was systematically applied to 17 databases as well as registers, websites and other resources to identify materials published between 1 January 2005 and 15 May 2019.

Data extraction and synthesis: Those resources that met the inclusion criteria underwent a comprehensive full-text review. A detailed matrix was developed and key data from each resource were extracted to allow for the assessment of patterns in thematic areas.

Results: A total of 2108 documents were screened. Overall, 145 documents and 112 tools were reviewed, representing 10 different humanitarian sectors. While numerous resources exist, many lack sufficient information on how to monitor outputs or outcomes of GBV risk mitigation activities. There is also limited guidance on how to integrate the measurement of GBV risk mitigation into existing monitoring and evaluation frameworks. Those reports that aimed to measure GBV risk mitigation activities mostly employed qualitative methods and few measured the impact of a GBV risk mitigation with robust research designs.

Conclusions: Recent efforts to adapt humanitarian response to COVID-19 have highlighted new and existing challenges for GBV risk mitigation. There is a significant gap in the evidence base around the effectiveness of GBV risk mitigation across all sectors. Understanding and strengthening measurement approaches in GBV risk mitigation remains a critical task for humanitarian response.

Erica Nelson and Saira Khan. 8/2021. Climate and Migration in East and the Horn of Africa: Spatial Analysis of Migrants’ Flows Data.Abstract

The drivers of human displacement are becoming more and more complex, ranging from conflict and persecution to the increasingly pertinent variables of heightened mobility and social media influences. Of rapidly but appropriately escalating concern is the impact of climate change. While the intensity and severity of climate-induced disasters and climate-related migration will be unevenly distributed across space and time, the World Bank estimates that approximately 140 million people will be displaced globally due to climate-related reasons by 2050. The effects of climate change are expected to be particularly pronounced in Africa, where rising temperatures, unpredictable anomalous rainfall and high vulnerability to extreme natural hazards will continue to exacerbate conflict and harm local and regional human, economic, and environmental security.

In the East and Horn of Africa (EHoA) in particular, the dependence on rain-fed agriculture and pastoralism means that livelihoods and food security are inextricably linked and affected by long-term or sudden environmental changes and natural hazards. The extreme natural hazards that have struck EHoA in recent years have caused widespread hunger, displacement, loss of critical infrastructure and livelihoods, and death

In an effort to understand the complex variables that influence migration, the International Organization for Migration (IOM) developed the Displacement Tracking Matrix (DTM) to track and gather information about populations on the move. The Flow Monitoring Registry (FMR) captures a wealth of data about the migratory routes, the demographics and nationality of migrants, reasons for migration, modes of transportation used to facilitate movement, and vulnerabilities experienced by these populations. While the descriptive data provides a wealth of information, more can be done to analyze the complexities of and interactions between migration, conflict, environmental changes, and climate-related events. Climate projections further suggest that environmental changes will likely further lead to decreased water availability, lowered agricultural productivity, and increased disease transmission in the region, producing complex ramifications regarding local and regional conflicts, economics, politics, and migration.

The porous borders in EHoA have contributed to some of the highest volumes of cross border movement in the world. In 2020 alone, EHoA hosted 6.5 million internally displaced persons (IDPs) and 3.5 million refugees and asylum seekers.6 In the same year, the Horn of Africa experienced unusually high levels of precipitation leading to disastrous floods and landslides and creating ideal conditions for an detrimental locust plague towards the end of 2019 that devastated crops and disrupted livelihoods. The extreme precipitation experienced across much of the Horn in 2019 was preceded by anomalous rainfall the previous year. 2018 was particularly hot and dry in the Horn of Africa, with positive temperature anomalies of around 2°C and below-average precipitation contributing to drought-like conditions in Somalia, Eritrea, and Djibouti while Kenya and Sudan experienced above-average precipitation.8 The drought-like conditions in Somalia, Eritrea, and Djibouti contributed to widespread food insecurity that affected approximately 12 million people. These extreme weather conditions are increasingly exacerbating the already complex and interconnected factors driving migration in the Horn of Africa, and are only expected to escalate in the future.

For this study, the IOM RDH in Nairobi partnered with the Humanitarian Geoanalytics Program at the Harvard Humanitarian Initiative to leverage spatial analytics to investigate migration flows in the East and Horn of Africa and Yemen. Geospatial analytics hold tremendous potential to introduce new ways of thinking, build research capacity, study impacts, and facilitate costeffective programming. The adoption of geospatial methods into research oriented towards populations on the move, gives us the capacity to accurately characterize the spatial heterogeneity of migrating populations. Furthermore, by incorporating environmental variables into this spatial analysis, we begin to reveal relationships previously undiscovered that could contribute to a richer understanding regarding migration in the region.

Luissa Vahedi, Jessica Anania, and Jocelyn Kelly. 8/2021. Gender-Based Violence and COVID-19 in Fragile Settings: A Syndemic Model. Read PublicationAbstract
The long-standing pandemic of gender-based violence has been worsened by COVID-19 and related containment measures, particularly in fragile settings marked by conflict, poverty, and weak infrastructure. At the same time, the implementation of gender-insensitive COVID-19 control policies can exacerbate the community transmission of COVID-19. These interactions form a syndemic—two or more pandemics whose interactions compound the severity of each. This report identifies the key avenues through which these two pandemics have synergistic effects and offers recommendations for mitigating their impact.
Sonny S. Patel, Oleksii Sukhovii, Oleksandr Zvinchuk, Julian H. Neylan, and Timothy Erickson. 2021. “Converging Impact of the Ongoing Conflict and COVID-19 Pandemic on Mental Health and Substance Use Disorders in Ukraine.” Journal of Emergency Management. Read PublicationAbstract

Since the Russian annexation of the Autonomous Republic of Crimea and the subsequent occupation of parts of the Donetsk and Luhansk regions, Ukraine has been facing increasing security and healthcare challenges. The seven-year war in East Ukraine has led to a rise in substance and alcohol use and increasing addiction rates among veterans, internally displaced persons, and civilian survivors. This article examines the combined impact of the ongoing Russo–Ukrainian conflict and COVID-19 pandemic on substance use in Ukraine. It also gives an overview of the institutions in place to monitor and improve mental health in the country. The article highlights the urgent need for further funding and research on substance and alcohol addiction, with vulnerable populations affected by the conflict during the COVID-19 pandemic. Frontline healthcare workers in this region should anticipate an increased burden of patients suffering from substance use disorders who are in need of emergency management intervention and proper behavioral health referrals.

Sonny S. Patel, Bernard McCaul, Gabriela Cáceres, Laura E.R. Peters, Ronak Patel, and Aaron Clark-Ginsberg. 4/2021. “Delivering the promise of the Sendai Framework for Disaster Risk Reduction in fragile and conflict-affected contexts (FCAC): A case study of the NGO GOAL's response to the Syria conflict.” Progress in Disaster Science. Read PublicationAbstract

The Sendai Framework for Disaster Risk Reduction (SFDRR) has helped to reduce global disaster risk, but there has been a lack of progress in disaster risk reduction (DRR) for people living in fragile and conflict affected contexts (FCAC). Given the mounting evidence that DRR cannot be implemented through conventional approaches in FCAC, serious efforts must be made to understand how to meet SFDRR's goals. This paper offers a case study of international non-governmental organization GOAL's programming that responds to the protracted crisis in Syria, with a critical discussion on SFDRR and how to adapt humanitarian relief and disaster resilience.

Virginia M. Tran, Laila Fozouni, Jana K. Denkinger, Caroline Rometsch, Florian Junne, Patrick Vinck, and Phuong Pham. 7/2021. “Factors influencing utilization and perception of health care: a qualitative study among traumatized Yazidi refugees in Germany.” BMC Psychiatry. Read PublicationAbstract

Background: Ensuring adequate utilization of healthcare services for displaced populations is critical, yet there are well-documented treatment gaps. Yazidi women captured by the Islamic State (IS) were subjected to extreme trauma and violence. This study aims to understand perceptions of healthcare providers and utilization of these services among women who experienced extreme trauma.

Methods: This is a qualitative study with voluntary participation offered to approximately 400 women resettled through the Special Quota Program. An empirical approach was used to collect data and a grounded theory approach was used for content analysis. Participants ranked their interactions with providers on a Likert scale. Posttraumatic stress disorder (PTSD) symptoms were assessed using the impact of event scale-revised questionnaire.

Results: A total of 116 Yazidi women participated in this study. The women experienced an average of 6.8 months of captivity by IS and 93% met criteria for probable PTSD. Eighty-three percent of the women interacted with a physician; 80% found this interaction helpful. Sixty-nine percent interacted with psychologists; 61% found this interaction helpful. Six themes emerged: “reminders of trauma” and “hopelessness” in relation to the traumatic experience; “immediate relief” and “healing through pharmaceutical treatment” in relation to provider interventions, and “support” and “cultural differences” in relation to interactions with providers.

Conclusions: There exist major barriers to care for Yazidi women who experienced extreme trauma, particularly in regards to psychiatric care. Perceptions of healthcare providers and perceived effectiveness of therapy are critical factors that must be taken into consideration to improve healthcare utilization and outcomes.

Amir Khorram-Manesh, Frederick M. Burkle Jr., Phatthranit Phattharapornjaroen, Milad Ahmadi Marzaleh, Mohammed Al Sultan, Matti Mantysaari, Eric Carlström, Krzysztof Goniewicz, Emelia Santamaria, John David Comandante, Robert Dobson, Boris Hreckovski, Glenn-Egil Torgersen, Luc J. Mortelmans, Mirjam de Jong, and Yohan Robinson. 11/2020. “The Development of Swedish Military Healthcare System: Part II-Re-evaluating the Military and Civilian Healthcare Systems in Crises Through a Dialogue and Study Among Practitioners.” Military Medicine.Abstract

Introduction: Historical changes have transformed Sweden from being an offensive to a defensive and collaborative nation with national and international engagement, allowing it to finally achieve the ground for the civilian–military collaboration and the concept of a total defense healthcare. At the same time, with the decreasing number of international and interstate conflicts, and the military’s involvement in national emergencies and humanitarian disaster relief, both the need and the role of the military healthcare system within the civilian society have been challenged. The recent impact of the COVID-19 in the USA and the necessity of military involvement have led health practitioners to anticipate and re-evaluate conditions that might exceed the civilian capacity of their own countries and the need to have collaboration with the military healthcare. This study investigated both these challenges and views from practitioners regarding the benefits of such collaboration and the manner in which it would be initiated.

Material and Method: A primary study was conducted among responsive countries using a questionnaire created using the Nominal Group Technique. Relevant search subjects and keywords were extracted for a systematic review of the literature, according to the PRISMA model.

Results: The 14 countries responding to the questionnaire had either a well-developed military healthcare system or units created in collaboration with the civilian healthcare. The results from the questionnaire and the literature review indicated a need for transfer of military medical knowledge and resources in emergencies to the civilian health components, which in return, facilitated training opportunities for the military staff to maintain their skills and competencies.

Conclusions: As the world witnesses a rapid change in the etiology of disasters and various crises, neither the military nor the civilian healthcare systems can address or manage the outcomes independently. There is an opportunity for both systems to develop future healthcare in collaboration. Rethinking education and training in war and conflict is indisputable. Collaborative educational initiatives in disaster medicine, public health and complex humanitarian emergencies, international humanitarian law, and the Geneva Convention, along with advanced training in competency-based skill sets, should be included in the undergraduate education of health professionals for the benefit of humanity.

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