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  • "With every passing day I feel like a candle, melting little by little." experiences of long-term displacement amongst Syrian refugees in Shatila, Lebanon.

    Syam, H; Venables, E; Sousse, B; Severy, N; Saavedra, L; Kazour, F (BioMed Central, 2019-10-10)
    BACKGROUND: Long term displacement and exposure to challenging living conditions can influence family dynamics; gender roles; violence at home and in the community and mental well-being. This qualitative study explores these issues as perceived by Syrian refugees who have been living in Shatila, a Palestinian camp in South Beirut, Lebanon, for at least 2 years. METHODS: Twenty eight in-depth interviews with men and women were conducted between February and June 2018. Women were recipients of mental health services, and men were recruited from the local community. Interviews were conducted in Arabic, translated, transcribed, coded and analysed using thematic content analysis. RESULTS: Our results show patterns of harsh living conditions similar to those described earlier in the course of the Syrian refugee crisis. Lack of infrastructure, overcrowding, cramped rooms and violence were all reported. Participants also described a lack of social support, discrimination and harassment within the host community, as well as limited social support networks within their own Syrian refugee community. Family dynamics were affected by the increased responsibilities on men, women and children; with additional economic and employment demands on men, women assuming the roles of 'mother and father' and children having to work and contribute to the household. Participants discussed several types of violence, including parental violence against children and violence in the community. Violence against women was also reported. Reported mental health issues included depression, anxiety, sadness, frustration, hopelessness, self-neglect and a loss of sense of self and self-worth. Some participants expressed a wish to die. CONCLUSIONS: This study describes experiences of changing gender roles, family dynamics, violence and mental health after long-term displacement in in Shatila camp, South Beirut as perceived by Syrian refugees. A lack of safety and security coupled with economic hardship rendered refugees even more susceptible to exploitation and harassment. Parental violence was the most commonly reported type of domestic violence.
  • Integrating palliative care and symptom relief into responses to humanitarian crises.

    Krakauer, EL; Daubman, BR; Aloudat, T (Australasian Medical Publishing Company Ltd, 2019-08-01)
  • In island containment: a qualitative exploration of social support systems among asylum seekers in a mental health care programme on Lesvos Island, Greece.

    Episkopou, M; Venables, E; Whitehouse, K; Eleftherakos, C; Zamatto, F; de Bartolome Gisbert, F; Severy, N; Barry, D; Van den Bergh, R (BioMed Central, 2019-07-22)
    BACKGROUND: Social support is a core determinant of health and plays a key role in the healing process of people with mental health problems and those who have been exposed to torture or other traumatic events. At the same time, social support is particularly challenging to build in such populations, as self-isolation and social withdrawal are common consequences of traumatic incidents. Defining social support is also challenging as there is no globally adequate definition. Our aim was to explore how social support was understood by Médecins Sans Frontières (MSF) beneficiaries, and how they perceived their needs on Lesvos Island, Greece to be met. METHODS: This was a qualitative study, based on exploratory free-listing interviews that explored how MSF beneficiaries on Lesvos understood and defined social support, followed by a series of in-depth interviews through which participants explained how they perceived their needs to be met. The study was conducted over a period of two weeks in August 2018, with 32 migrants and asylum seekers (22 male, 10 female) enrolled in the mental health services of MSF on Lesvos Island. The majority of interviewees were single men of African origin who had resided in Moria camp between 2 months and 2.5 years. Countries of origin include Syria, Afghanistan, Cameroon, Democratic Republic of Congo (DRC), Iraq, Iran, Nigeria, Senegal and other West African countries. RESULTS: Participants defined social support as the practical, informational and emotional support that people receive from organisations, friends and family members. Results revealed a lack of community links, isolation, tensions and conflict, insufficient amenities and limited orientation to services that lead to and amplify isolation, discrimination and tension. Most of the participants received little or no support both formally from organisations and informally from other migrants and asylum seekers in the camp. CONCLUSIONS: Functional support networks are urgently required to overcome the consequences of restrictive policies which force people into containment and remove their support systems. Actors who are involved in providing social support, including MSF, are strongly encouraged to engage in activities that work towards building and strengthening peer support networks and creating a sense of community.
  • High levels of mortality, exposure to violence and psychological distress experienced by the internally displaced population of Ein Issa camp prior to and during their displacement in Northeast Syria, November 2017.

    Vernier, L; Cramond, V; Hoetjes, M; Lenglet, A; Hoare, T; Malaeb, R; Carrion Martin, AI (BioMed Central, 2019-07-11)
    BACKGROUND: War in Syria has lasted for more than eight years, causing population displacement, collapse of medical and public health services, extensive violence and countless deaths. Since November 2016, military operations in Northeast Syria intensified. In October 2017 a large influx of internally displaced persons (IDPs) arrived to Ein Issa camp, Raqqa governate. Médecins Sans Frontières (MSF) assessed the health status of recently arrived IDPs in Ein Issa camp. METHODS: MSF carried out a cross-sectional survey using simple random sampling between 8 and 18 November 2017, enrolling households who had arrived to Ein Issa camp since 1 October 2017. A questionnaire collected data on demographics, history of displacement, retrospective one-year mortality, two-week morbidities, non-communicable diseases, exposure to violence in the last year and two-week psychological distress symptoms among all household members as well as vaccination status in children aged 6 to 59 months. The latter were also screened for malnutrition. Prevalence estimates and mortality rates were calculated with their 95% confidence interval. Mortality rates were calculated as the number of deaths/10,000 persons/day using the individual person-day contribution of all household members. RESULTS: MSF surveyed 257 households (1482 participants). They reported 31 deaths in the previous year, resulting in a crude mortality rate of 0.56 deaths/10,000 persons/day (95%CI: 0.39-0.80). Conflict-related violence was the most frequently reported cause of death (64.5%). In the previous year, 31.7% (95%CI: 29.4-34.2) of the participants experienced at least one violent episode. The most frequent type of violence reported was witnessing atrocities (floggings, executions or public body displays); 18.9% (95%CI: 17.0-21.0) of the population and 9.8% (95%CI: 7.9-12.0) of the children under 15 years had witnessed such atrocities. In men over 14 years, 15.8% (95%CI: 11.9-20.8) were detained/kidnapped and 11.3% (95%CI: 8.0-15.8) tortured/beaten/attacked. In the two weeks prior to interview, 14.4% (95%CI: 10.6-19.3) of the respondents felt so hopeless that they did not want to carry on living most of the time. CONCLUSIONS: High levels of mortality, exposure to violence and psychological distress were reported. These survey results increase understanding of the impact of the conflict on the IDP population in Northeast Syria.
  • Refugee camp health services utilisation by non-camp residents as an indicator of unaddressed health needs of surrounding populations: a perspective from Mae La refugee camp in Thailand during 2006 and 2007.

    Alexakis, LC; Athanasiou, M; Konstantinou, A (African Field Epidemiology Network, 2019-04-17)
    INTRODUCTION: This study explored the differences on the level of medical care required by camp and non-camp resident patients during utilisation of the health services in Mae La refugee camp, Tak province, Thailand during the years 2006 and 2007. METHODS: Data were extracted from camp registers and the Health Information System used during the years 2006 and 2007 and statistical analysis was performed. RESULTS: The analysis showed that during 2006 and 2007 non-camp resident patients, coming from Thailand as well as Myanmar, who sought care in the outpatient department (OPD) of the camp required at a significantly higher proportion admission to the inpatient department (IPD) or referral to the district hospital compared to camp resident patients. Although there was a statistically significant increased mortality of the non-camp resident patients admitted in the IPD compared to camp resident patients, there was no significant difference in mortality among these two groups when the referrals to the district hospital were analysed. CONCLUSION: Non-camp resident patients tended to need a more advanced level of medical care compared to camp resident patients. Provided that this it is further validated, the above observed pattern might be potentially useful as an indirect indicator of unaddressed health needs of populations surrounding a refugee camp.
  • Collaboration between Médecins Sans Frontières and Oxford Medical Case Reports

    Balinska, MA; Watts, RA (Oxford University Press, 2019-04-15)
  • The aftermath of Cyclone Idai—building bridges where we can

    Frieden, M (BMJ Publishing Group, 2019-04-03)
    Marthe Frieden is the medical team leader in MSF’s emergency response to the destruction caused by tropical Cyclone Idai. On the night of 15 March, the cyclone hit Zimbabwe’s mountainous Manicaland province, causing flooding and deadly landslides, particularly in the Chimanimani District. Before Idai hit, Marthe was working on an MSF pilot project for managing diabetes and hypertension in the nearby Chipinge District, in partnership with Zimbabwe’s health ministry. Writing from the worst hit districts of Chimanimani and Chipinge, Marthe describes the events of the first six days as an MSF team of 10 people rapidly switched from their regular activities to emergency mode.
  • Screening of asymptomatic rheumatic heart disease among refugee/migrant children and youths in Italy.

    Condemi, F; Rossi, G; Miguel, L; Pagano, A; Zamatto, F; Marini, S; Romeo, F; De Maio, G (BioMed Central, 2019-04-02)
    Rheumatic heart disease (RHD) is a chronic condition responsible of congestive heart failure, stroke and arrhythmia. Almost eradicated in high-income countries (HIC), it persists in low- and middle-income countries. The purpose of the study was to assess the feasibility and meaningfulness of ultrasound-based RHD screening among the population of unaccompanied foreign minors in Italy and determine the burden of asymptomatic RHD among this discrete population. From February 2016 to January 2018, Médecins Sans Frontières conducted a weekly mobile screening by echocardiography in reception centers and family houses for unaccompanied foreign minors in Rome, followed by fix echocardiographic retesting for those resulting positive at screening. 'Definite' and 'borderline' cases were defined according to the World Hearth Federation criteria. Six hundred fifty-three individuals (13-26 years old) were screened; 95.6% were below 18 years old (624/653). Six 'definite RHD' were identified at screening, yielding a detection rate of 9.2‰ (95% CI 4.1-20.3‰), while 285 (436.4‰) were defined as 'borderline' (95% CI 398.8-474.9‰). Out of 172 "non-negative borderline" cases available for being retested (113 "non-negative borderline" lost in follow-up), additional 11 were categorized as 'definite RHD', for a total of 17 'definite RHD', yielding a final prevalence of 26.0‰ (95% CI 16.2-41.5‰) (17/653), and 122 (122/653) were confirmed as 'borderline' (final prevalence of 186.8‰, 95% CI 158.7-218.7). In multivariate logistic regression analysis the presence of systolic murmur was a strong predictor for both 'borderline' (OR 4.3 [2.8-6.5]) and 'definite RHD' (OR 5.2 [1.7-15.2]), while no specific country/geographic area of origin was statistically associated with an increased risk of latent, asymptomatic RHD. Screening for RHD among the unaccompanied migrant minors in Italy proved to be feasible. The burden of 'definite RHD' was similar to that identified in resource-poor settings, while the prevalence of 'borderline' cases was higher than reported in other studies. In view of these findings, the health system of high-income countries, hosting migrants and asylum seekers, are urged to adopt screening for RHD in particular among the silent and marginalized population of refugee and migrant children.
  • Delays in arrival and treatment in emergency departments: Women, children and non-trauma consultations the most at risk in humanitarian settings

    Guzman, IB; Cuesta, JG; Trelles, M; Jaweed, O; Cherestal, S; van Loenhout, JAF; Guha-Sapir, D (Public Library of Science, 2019-03-05)
    Introduction Delays in arrival and treatment at health facilities lead to negative health outcomes. Individual and external factors could be associated with these delays. This study aimed to assess common factors associated with arrival and treatment delays in the emergency departments (ED) of three hospitals in humanitarian settings. Methodology This was a cross-sectional study based on routine data collected from three MSF-supported hospitals in Afghanistan, Haiti and Sierra Leone. We calculated the proportion of consultations with delay in arrival (>24 hours) and in treatment (based on target time according to triage categories). We used a multinomial logistic regression model (MLR) to analyse the association between age, sex, hospital and diagnosis (trauma and non-trauma) with these delays. Results We included 95,025 consultations. Males represented 65.2%, Delay in arrival was present in 27.8% of cases and delay in treatment in 27.2%. The MLR showed higher risk of delay in arrival for females (OR 1.2, 95% CI 1.2–1.3), children <5 (OR 1.4, 95% CI 1.4–1.5), patients attending to Gondama (OR 30.0, 95% CI 25.6–35.3) and non-trauma cases (OR 4.7, 95% CI 4.4–4.8). A higher risk of delay in treatment was observed for females (OR 1.1, 95% CI 1.0–1.1), children <5 (OR 2.0, 95% CI 1.9–2.1), patients attending to Martissant (OR 14.6, 95% CI 13.9–15.4) and non-trauma cases (OR 1.6, 95% CI 1.5–1.7). Conclusions Women, children <5 and non-trauma cases suffered most from delays. These delays could relate to educational and cultural barriers, and severity perception of the disease. Treatment delay could be due to insufficient resources with consequent overcrowding, and severity perception from medical staff for non-trauma patients. Extended community outreach, health promotion and support to community health workers could improve emergency care in humanitarian settings.
  • Treating Syrian refugees with diabetes and hypertension in Shatila refugee camp, Lebanon: Médecins Sans Frontières model of care and treatment outcomes.

    Kayali, M; Moussally, K; Lakis, C; Abrash, MA; Sawan, C; Reid, A; Edwards, J (BioMed Central, 2019-01-01)
    Médecins Sans Frontières (MSF) has been providing primary care for non-communicable diseases (NCDs), which have been increasing in low to middle-income countries, in the Shatila refugee camp, Beirut, Lebanon, using a comprehensive model of care to respond to the unmet needs of Syrian refugees. The objectives of this study were to: 1) describe the model of care used and the Syrian refugee population affected by diabetes mellitus (DM) and/or hypertension (HTN) who had ≥ one visit in the MSF NCD clinic in Shatila in 2017, and 2) assess 6 month treatment outcomes. A descriptive retrospective cohort study using routinely collected program data for a model of care for patients with DM and HTN consisting of four main components: case management, patient support and education counseling, integrated mental health, and health promotion. Of 2644 Syrian patients with DM and/or HTN, 8% had Type-1 DM, 30% had Type-2 DM, 30% had HTN and 33% had DM + HTN. At intake, patients had a median age of 53, were predominantly females (63%), mostly from outside the catchment area (70%) and diagnosed (97%) prior to enrollment. After 6 months of care compared to intake: 61% of all patients had controlled DM (HbA1C < 8%) and 50% had controlled blood pressure (BP: < 140/90 mmHg) compared to 29 and 32%, respectively ( The MSF model of care for DM and HTN operating in the Shatila refugee camp is feasible, and showed promising outcomes among enrolled individuals. It may be replicated in similar contexts to respond to the increasing burden of NCDs among refugees in the Middle-East and elsewhere.
  • Perceptions of Healthcare-Associated Infection and Antibiotic Resistance among Physicians Treating Syrian Patients with War-Related Injuries

    Älgå, A; Karlow Herzog, K; Alrawashdeh, M; Wong, S; Khankeh, H; Stålsby Lundborg, C (MDPI, 2018-12-01)
    Healthcare-associated infections (HAIs) constitute a major contributor to morbidity and mortality worldwide, with a greater burden on low- and middle-income countries. War-related injuries generally lead to large tissue defects, with a high risk of infection. The aim of this study was to explore how physicians in a middle-income country in an emergency setting perceive HAI and antibiotic resistance (ABR). Ten physicians at a Jordanian hospital supported by Médecins Sans Frontières were interviewed face-to-face. The recorded interviews were transcribed verbatim and analyzed by qualitative content analysis with an inductive and deductive approach. The participants acknowledged risk factors of HAI and ABR development, such as patient behavior, high numbers of injured patients, limited space, and non-compliance with hygiene protocols, but did not express a sense of urgency or any course of action. Overuse and misuse of antibiotics were reported as main contributors to ABR development, but participants expressed no direct interrelationship between ABR and HAI. We conclude that due to high patient load and limited resources, physicians do not see HAI as a problem they can prioritize. The knowledge gained by this study could provide insights for the allocation of resources and development of hygiene and wound treatment protocols in resource-limited settings.
  • This is not a drill

    Carenzo, L (Springer Link, 2018-11-14)
  • Antibiotic resistance in Palestine: an emerging part of a larger crisis

    Kanapathipillai, R; Malou, N; Baldwin, K; Marty, P; Rodaix, C; Mills, C; Herard, P; Saim, M (The BMJ, 2018-10-15)
  • A life in waiting: Refugees' mental health and narratives of social suffering after European Union border closures in March 2016.

    Bjertrup, PJ; Bouhenia, M; Mayaud, P; Perrin, C; Ben Farhat, J; Blanchet, K (Elsevier, 2018-10)
    In 2015, an estimated 856,723 refugees, predominantly from Syria, Afghanistan, and Iraq arrived in Greece as an entry point into the European Union. The border of the Former Yugoslav Republic of Macedonia closed in March 2016, blocking a popular route for refugees through Europe, and left around 60,000 people stranded in Greece. OBJECTIVE: A mixed-method study was conducted among refugees in the regions of Attica, Epirus, and Samos between November 2016 and February 2017. The epidemiological survey showed that depending on study sites between 73% and 100% of the refugees suffered from anxiety disorder. The explanatory qualitative study aimed to understand refugees' mental health and narratives of social suffering in regards to experienced violence, the effect of current border closures, and the lack of an onward journey. METHOD: The explanatory qualitative study included 47 in-depth interviews and five focus group discussions with refugees purposely recruited through the concomitant epidemiological survey, representing both genders and a range of nationalities and ages. Data were thematically analysed to identify emergent patterns and categories using NVivo 11. RESULTS: The refugees overwhelmingly reported experiencing uncertainty and lack of control over their current life and future, which caused psychosocial distress and suffering. The passivity of life in refugee camps aggravated feelings of meaninglessness and powerlessness. The disruption of key social networks and absence of interactions with the surrounding Greek society led to feelings of isolation and being unwelcome. CONCLUSIONS: Refugees in Greece experience psychosocial distress and social suffering as a consequence of their uncertain and disrupted lives and the loss of social networks. Faster and transparent asylum procedures, the development of meaningful and empowering activities, and fostered social interactions with the surrounding society would contribute to alleviating their psychosocial suffering.
  • Migrant and refugee populations: a public health and policy perspective on a continuing global crisis

    Abbas, M; Aloudat, T; Bartolomei, J; Carballo, M; Durieux-Paillard, S; Gabus, L; Jablonka, A; Jackson, Y; Kaojaroen, K; Koch, D; et al. (BMC, 2018-09-20)
    The 2015-2017 global migratory crisis saw unprecedented numbers of people on the move and tremendous diversity in terms of age, gender and medical requirements. This article focuses on key emerging public health issues around migrant populations and their interactions with host populations. Basic needs and rights of migrants and refugees are not always respected in regard to article 25 of the Universal Declaration of Human Rights and article 23 of the Refugee Convention. These are populations with varying degrees of vulnerability and needs in terms of protection, security, rights, and access to healthcare. Their health status, initially conditioned by the situation at the point of origin, is often jeopardised by adverse conditions along migratory paths and in intermediate and final destination countries. Due to their condition, forcibly displaced migrants and refugees face a triple burden of non-communicable diseases, infectious diseases, and mental health issues. There are specific challenges regarding chronic infectious and neglected tropical diseases, for which awareness in host countries is imperative. Health risks in terms of susceptibility to, and dissemination of, infectious diseases are not unidirectional. The response, including the humanitarian effort, whose aim is to guarantee access to basic needs (food, water and sanitation, healthcare), is gripped with numerous challenges. Evaluation of current policy shows insufficiency regarding the provision of basic needs to migrant populations, even in the countries that do the most. Governments around the world need to rise to the occasion and adopt policies that guarantee universal health coverage, for migrants and refugees, as well as host populations, in accordance with the UN Sustainable Development Goals. An expert consultation was carried out in the form of a pre-conference workshop during the 4th International Conference on Prevention and Infection Control (ICPIC) in Geneva, Switzerland, on 20 June 2017, the United Nations World Refugee Day.
  • "It never happened to me, so I don’t know if there are procedures”: identification and case management of torture survivors in the reception and public health system of Rome, Italy

    Spissu, C; De Maio, G; Van den Bergh, R; Ali, E; Venables, E; Burtscher, D; Ponthieu, A; Ronchetti, M; Mostarda, N; Zamatto, F (International Rehabilitation Council for Torture Victims, 2018-08-01)
    Background: Access and linkage to care for migrant torture survivors is contingent on their identification and appropriate referral. However, appropriate tools for identification of survivors are not readily available, and the (staff of) reception systems of host countries may not always be equipped for this task. This study explores practices in the identification and case management of torture survivors in the reception structures and in the public health sector in Rome, Italy. Method: Data were analysed manually and codes and themes generated. Results: A non-homogeneous level of awareness and experience with torture survivors was observed, together with a general lack of knowledge on national and internal procedures for correct identification of torture survivors. Identification and case management of torture survivors was mainly carried out by non-trained staff. Participants expressed the need for training to gain experience in the identification and management of torture survivors’ cases, as well support and increased resources at both the reception and public health system levels. Conclusions: The crucial process of identification and prise en charge of survivors of torture among migrant and refugee populations is relegated to nontrained and inexperienced professionals at different levels of the reception system and public health care sector, which may carry a risk of non-identification and possible harm to survivors. Additional resources and structured interventions are urgently needed, in the form of developing procedures, training, and adapted multidisciplinary services.
  • “My mind is not like before”: Psychosocial rehabilitation of victims of torture in Athens

    Womersley, G; Kloetzer, L; Van den Bergh, R; Venables, E; Severy, N; Gkionakis, N; Popontopoulou, C; Kokkiniotis, M; Zamatto, F (International Rehabilitation Council for Torture Victims, 2018-07-26)
    Introduction: The dual trauma of being a victim of torture as well as a refugee is related to a myriad of losses, human rights violations and other dimensions of suffering linked to torture experienced pre-migration, as well as different forms of violence experienced during and after migration. Method: To present three case studies to explore culturally-informed perspectives on trauma among victims of torture and track trajectories of psychosocial rehabilitation in relation to environmental factors. The case studies are part of a larger qualitative study of asylum seekers and refugees in a center for victims of torture in Athens, managed by Médecins Sans Frontières and Babel in collaboration with Greek Council for Refugees, which follows beneficiaries, their care providers and community representatives and leaders. Results: Key themes emerging include the substantial psychological impact of current material realities of migrant victims of torture as they adapt to their new environment and engage in rehabilitation. Delayed asylum trials, poor living conditions and unemployment have a substantial impact on posttraumatic symptoms that in turn influence psychosocial rehabilitation. Personal, social, and cultural resources emerged as having a mediating effect. Discussion: The results highlight the significant impact of the political, legal, and sociocultural environment on psychosocial rehabilitation. Practical implications for interventions are to ensure holistic, interdisciplinary, and culturally sensitive care which includes a focus on environmental factors affecting resilience; and with a dynamic focus on the totality of the individual over isolated pathologies.
  • Infection with high proportion of multidrug-resistant bacteria in conflict-related injuries is associated with poor outcomes and excess resource consumption: a cohort study of Syrian patients treated in Jordan

    Älgå, A; Wong, S; Shoaib, M; Lundgren, K; Giske, CG; Von Schreeb, J; Malmstedt, J (BioMed Central, 2018-05-22)
    Armed conflicts are a major contributor to injury and death globally. Conflict-related injuries are associated with a high risk of wound infection, but it is unknown to what extent infection directly relates to sustainment of life and restoration of function. The aim of this study was to investigate the outcome and resource consumption among civilians receiving acute surgical treatment due to conflict-related injuries. Patients with and without wound infections were compared.
  • Evaluating a Mental Health Program for Palestinian Refugees in Lebanon

    Yassin, N; Taha, A; Ghantous, Z; Atoui, M; Forgione, F (SpringerLink, 2017-09-15)
    Medecins sans Frontière, an international non-governmental organization, initiated a mental health program for Palestinian refugees living in Lebanon. To evaluate the impact of the program after its completion, focus groups were conducted with three target groups: (1) patients, (2) staff, and (3) local community stakeholders. Participants voiced overall satisfaction with the program. The program provided easy access, good quality care, decreased stigma, as perceived by participants, and revealed a sense of community contentedness. In addition, several short-term outcomes were achieved, such as increasing the numbers of patients visiting the center/ receiving mental health treatment. However, lack of planning for sustainability and proper procedures for hand-over of the program constituted a major downfall. Program discontinuation posed ethical dilemmas, common in provisional interventions in underprivileged refugee communities.

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