Humanitarian Health Research Articles

Closing well: national and international humanitarian workers\u2019 perspectives on the ethics of closing humanitarian health projects

Project closure is a core feature of humanitarian action. However, how decisions to end projects are made, and how closure is planned and implemented, has implications for upholding ethical commitments, and can have positive or negative consequences for affected communities, local stakeholders, and humanitarian organizations and their staff. To better understand the ethical dimensions of closing humanitarian projects, we undertook an investigation of national and international humanitarian workers’ experiences.Guided by interpretive description methodology, we conducted an exploratory qualitative study with two rounds of semi-structured interviews. Four national and five international staff of non-governmental organizations with experience of humanitarian health project closure took part. The participants had diverse professional roles and disciplinary backgrounds. All participants took part in the first round of interviews which focused on experiences and perceptions of ethics and project closure. Analysis of these interviews contributed to the development of a draft “ethics guidance note.” Five of the participants took part in the second round of interviews which focused on receiving feedback on the draft guidance note. We used constant comparative techniques and a recursive approach to data collection and analysis. In this article, we draw on both rounds of interviews to present findings related to how participants understood and experienced ethical responsibilities, challenges, and opportunities for humanitarian project closure.We identified six recurrent ethical concerns highlighted by interviewees regarding closure of humanitarian projects: respectfully engaging with partners and stakeholders, planning responsively, communicating transparently, demonstrating care for local communities and staff during project closure, anticipating and acting to minimize harms, and attending to sustainability and project legacy. We present these ethical concerns according to the temporal horizon of humanitarian action, that is, arising across five phases of a project’s timeline: design, implementation, deciding whether to close, implementing closure, and post-closure.This exploratory study contributes to discussions concerning the ethics of project closure by illuminating how they are experienced and understood from the perspectives of national and international humanitarian workers. The interview findings contributed to the development of an ethics guidance note that aims to support project closures that minimize harms and uphold values, while being mindful of the limits of ethical ideals in non-ideal circumstances.

Improving mental health and psychosocial wellbeing in humanitarian settings: reflections on research funded through R2HC

Major knowledge gaps remain concerning the most effective ways to address mental health and psychosocial needs of populations affected by humanitarian crises. The Research for Health in Humanitarian Crisis (R2HC) program aims to strengthen humanitarian health practice and policy through research. As a significant portion of R2HC’s research has focused on mental health and psychosocial support interventions, the program has been interested in strengthening a community of practice in this field. Following a meeting between grantees, we set out to provide an overview of the R2HC portfolio, and draw lessons learned. In this paper, we discuss the mental health and psychosocial support-focused research projects funded by R2HC; review the implications of initial findings from this research portfolio; and highlight four remaining knowledge gaps in this field. Between 2014 and 2019, R2HC funded 18 academic-practitioner partnerships focused on mental health and psychosocial support, comprising 38% of the overall portfolio (18 of 48 projects) at a value of approximately 7.2 million GBP. All projects have focused on evaluating the impact of interventions. In line with consensus-based recommendations to consider a wide range of mental health and psychosocial needs in humanitarian settings, research projects have evaluated diverse interventions. Findings so far have both challenged and confirmed widely-held assumptions about the effectiveness of mental health and psychosocial interventions in humanitarian settings. They point to the importance of building effective, sustained, and diverse partnerships between scholars, humanitarian practitioners, and funders, to ensure long-term program improvements and appropriate evidence-informed decision making. Further research needs to fill knowledge gaps regarding how to: scale-up interventions that have been found to be effective (e.g., questions related to integration across sectors, adaptation of interventions across different contexts, and optimal care systems); address neglected mental health conditions and populations (e.g., elderly, people with disabilities, sexual minorities, people with severe, pre-existing mental disorders); build on available local resources and supports (e.g., how to build on traditional, religious healing and community-wide social support practices); and ensure equity, quality, fidelity, and sustainability for interventions in real-world contexts (e.g., answering questions about how interventions from controlled studies can be transferred to more representative humanitarian contexts).

Addressing obstacles to the inclusion of palliative care in humanitarian health projects: a qualitative study of humanitarian health professionals\u2019 and policy makers\u2019 perceptions

BackgroundHumanitarian non-governmental organizations provide assistance to communities affected by war, disaster and epidemic. A primary focus of healthcare provision by these organizations is saving lives; however, curative care will not be sufficient, appropriate, or available for some patients. In these instances, palliative care approaches to ease suffering and promote dignity are needed. Though several recent initiatives have increased the probability of palliative care being included in humanitarian healthcare response, palliative care remains minimally integrated in humanitarian health projects.MethodsWe conducted a qualitative study using interpretive description methodology to investigate humanitarian policy-makers’ and health care professionals’ experiences and perceptions of palliative care during humanitarian crises. In this article, we report on the analysis of in-depth interviews with 24 participants related to their perceptions of obstacles to providing palliative care in humanitarian crises, and opportunities for overcoming these obstacles. Among the participants, 23 had experience as humanitarian health professionals, and 12 had experience with policy development and organizational decision-making.ResultsParticipants discussed various obstacles to the provision of palliative care in humanitarian crises. More prominent obstacles were linked to the life-saving ethos of humanitarian organizations, priority setting of scarce resources, institutional and donor funding, availability of guidance and expertise in palliative care, access to medication, and cultural specificity around death and dying. Less prominent obstacles related to continuity of care after project closure, equity, security concerns, and terminology.ConclusionOpportunities exist for overcoming the obstacles to providing palliative care in humanitarian crises. Doing so is necessary to ensure that humanitarian healthcare can fulfill its objectives not only of saving lives, but also of alleviating suffering and promoting dignity of individuals who are ill or injured during a humanitarian crises, including persons who are dying or likely to die.

Researching the delivery of health and nutrition interventions for women and children in the context of armed conflict: lessons on research challenges and strategies from BRANCH Consortium case studies of Somalia, Mali, Pakistan and Afghanistan

BackgroundThe BRANCH Consortium recently conducted 10 mixed-methods case studies to investigate the provision of health and nutrition interventions for women and children in conflict-affected countries, aiming to better understand the dominant influences on humanitarian health actors’ programmatic decision-making and how such actors surmount intervention delivery barriers. In this paper, the research challenges encountered and the mitigating strategies employed by the case study investigators in four of the BRANCH case study contexts are discussed: Somalia, Mali, Pakistan and Afghanistan.DiscussionMany of the encountered research challenges were anticipated, with investigators adopting mitigation strategies in advance or early on, but others were unexpected, with implications for how studies were ultimately conducted and how well the original study aims were met. Insecurity was a fundamental challenge in all study contexts, with restricted geographical access and concerns for personal safety affecting sampling and data collection plans, and requiring reliance on digital communications, remote study management, and off-site team meetings wherever possible. The need to navigate complex local sociopolitical contexts required maximum reliance on local partners’ knowledge, expertise and networks, and this was facilitated by early engagement with a wide range of local study stakeholders. Severe lack of reliable quantitative data on intervention coverage affected the extent to which information from different sources could be triangulated or integrated to inform an understanding of the influences on humanitarian actors’ decision-making.ConclusionStrong local partners are essential to the success of any project, contributing not only technical and methodological capacity but also the insight needed to truly understand and interpret local dynamics for the wider study team and to navigate those dynamics to ensure study rigour and relevance. Maintaining realistic expectations of data that are typically available in conflict settings is also essential, while pushing for more resources and further methodological innovation to improve data collection in such settings. Finally, successful health research in the complex, dynamic and unpredictable contexts of conflict settings requires flexibility and adaptability of researchers, as well as sponsors and donors.

Geospatial analysis: a new frontier in humanitarian health research?

Geospatial analysis: a new frontier in humanitarian health research?

Knowledge Management Referral System Using Artificial Intelligent Techniques

Knowledge management is an emerging area which is gaining interest from organization and governments. As moving nowadays toward building organizational knowledge, knowledge management will play a fundamental role towards the success of transforming tacit knowledge into organizational explicit knowledge during current big data and high level of competencies between organizations to provide promptly and required services. One of the key building blocks for developing and advancing this field of knowledge management is artificial intelligence. organizations need to be able to exchange information, queries, and requests with some other beneficiaries and agencies that they share a common unified domain. One possible approach to this issue is Automating Knowledge, the methods which have been used to employ Semantic techniques for modeling about provide automatic accurate information extracts inquiry’s answer from the proposed knowledge management system. This paper will clarify the future of knowledge management system and the methodology of its link to artificial intelligence in organizations when it’s come to providing humanitarian emergency assistant, services and health care as the current global pandemic virus. The advanced proposed system will enable beneficiaries, employees and external official entities to get instantly automatically replay for various inquiries without required humanitarian intervention unless it's necessary! and enable to save ’ transfer ’ retrieve and generate new knowledge through three levels depending on the semantic technique, natural language processing algorithms and Ontology techniques in extracting inquiry’s answer in the first level then using chat system with an employee in the second level and through sending email to the specialist in the last third level. The validity of the method is proved in this comprehensive intelligent inquiry system. Showing the effectiveness of this approach by testing it on a humanitarian agency. The experimental results were extremely encouraging as such organization did not own automatic knowledge management system as its provisions on this research paper, so its recommended to use it in a large area as the proposed system show outperforms baseline methods and improve the accuracy answering by 86%.

Nurses confronting the coronavirus: Challenges met and lessons learned to date

Registered nurses are an essential workforce group across the globe. They use their expertise and skill sets every day in clinical practice to protect, promote, and advocate on behalf of patients and families under their care. In this article we discuss the physical, emotional, and moral stresses that nurses are experiencing in their day-to-day practice settings created by the novel coronavirus. We consider the demands placed on nurses by unexpected patient surges within hospital environments and inadequate personal protective equipment and other critical resources, challenging nurses’ ability to meet their professional and ethical obligations. We also share our thoughts on supporting nurses and others now, and ideas for needed healing for both individuals and organizations as we move forward. Finally, we argue for the need for substantive reform of institutional processes and systems that can deliver quality care in the future when faced with another devastating humanitarian and public health crises.

\u201cTo die is better for me\u201d, social suffering among Syrian refugees at a noncommunicable disease clinic in Jordan: a qualitative study

BackgroundThe conflict in Syria has required humanitarian agencies to implement primary-level services for non-communicable diseases (NCDs) in Jordan, given the high NCD burden amongst Syrian refugees; and to integrate mental health and psychosocial support into NCD services given their comorbidity and treatment interactions. However, no studies have explored the mental health needs of Syrian NCD patients. This paper aims to examine the interaction between physical and mental health of patients with NCDs at a Médecins Sans Frontières (MSF) clinic in Irbid, Jordan, in the context of social suffering.MethodsThis qualitative study involved sixteen semi-structured interviews with Syrian refugee and Jordanian patients and two focus groups with Syrian refugees attending MSF’s NCD services in Irbid, and eighteen semi-structured interviews with MSF clinical, managerial and administrative staff. These were conducted by research staff in August 2017 in Irbid, Amman and via Skype. Thematic analysis was used.ResultsRespondents describe immense suffering and clearly perceived the interconnectedness of their physical wellbeing, mental health and social circumstances, in keeping with Kleinman’s theory of social suffering. There was a ‘disconnect’ between staff and patients’ perceptions of the potential role of the NCD and mental health service in alleviating this suffering. Possible explanations identified included respondent’s low expectations of the ability of the service to impact on the root causes of their suffering, normalisation of distress, the prevailing biomedical view of mental ill-health among national clinicians and patients, and humanitarian actors’ own cultural standpoints.ConclusionSyrian and Jordanian NCD patients recognise the psychological dimensions of their illness but may not utilize clinic-based humanitarian mental health and psychosocial support services. Humanitarian agencies must engage with NCD patients to elicit their needs and design culturally relevant services.

Civic Responsibility and Global Health Care: Audiology Service Learning in Africa

PurposeMany health professions engage service learning via international humanitarian health care or study abroad programs toward an improved sense of civic responsibility, an aspect that has been inadequately analyzed in hearing health care. The purpose of this study is to evaluate how the curriculum of an international humanitarian health care program in South Africa influenced U.S. graduate students' civic responsibility and their educators' perspectives on audiology study abroad service learning programs.MethodParticipants (n= 14) in this study abroad program included seven female graduate audiology students, five community partners, and two educators. Quantitative data were derived from pre- and postprogram administration of the Public Affairs Scale (Levesque-Bristol & Cornelius-White, 2012). Qualitative data sources included student journals, student exit interview, educator field notes and discussions, and responses to the community partner evaluation survey completed by host site personnel.ResultsA comparison of pre- and postprogram Public Affairs Scale ratings revealed that students demonstrated a significant increase in community engagement, cultural competence, and ethical leadership. Qualitative data revealed themes referenced to practitioners, clients, and context. Further thematic analysis identified three key results including foregrounding health as a development of people, educators and students as critically oriented public intellectuals, and global dialogue for pedagogic (audiology) justice.Discussion and ConclusionCarefully designed study abroad curricular contributed to audiology graduate students' increased service learning, civic responsibility, and civic engagement. Quantitative and qualitative analyses revealed that student service learning experiences were mediated by resources and people in the local context. This study abroad curriculum facilitated educators' thinking regarding the placement of audiology health services and audiology educational models in a globalized world. Health professional pedagogic considerations should be designed for humanitarian health care so that service learning focuses the production of critically oriented practitioners who are competent at enacting practices in global service learning programs.

Self-reported diseases and their associated risk factors among camp-dwelling conflict-affected internally displaced populations in Nigeria.

Background Conflict in Nigeria displaced millions of people, and some settled in camp-like locations within the country. Evidence on the association between living conditions and health outcomes among these populations are limited. This study investigated the risk factors associated with illnesses among camp-dwelling internally displaced persons (IDPs) in northern Nigeria. Methods A cross-sectional study was conducted in nine camps in 2016. Self-reported data on socio-demography, resource utilization and disease outcomes were collected. Association between health conditions and various factors, including sanitation and healthcare access, was investigated. Results Data from 2253 IDPs showed 81.1% (CI=79.5-82.7) experienced one or more health conditions; however, over 20% did not access healthcare services. Most common diseases were malaria, fever, typhoid and diarrhoea. Multivariable logistic regression presented as adjusted odds ratios(aOR) and 95% confidence intervals(CIs) showed factors significantly associated with increased likelihood of illnesses included being female (aOR=1.53;CI=1.19-1.96), overcrowding (aOR=1.07;CI=1.00-1.36), long-term conditions (aOR=2.72;CI=1.88-3.94), outdoor defecation (aOR=2.37;CI=1.14-4.94) and presence of disease-causing vectors (aOR=3.71;CI=1.60-8.60). Conclusion Most diseases in the camps were communicable. Modifiable risk factors such as overcrowding and poor toilet facilities were associated with increased poor health outcomes. This evidence highlights areas of high priority when planning humanitarian public health interventions.

France's COVID-19 response: balancing conflicting public health traditions

Simmering beneath the surface of France's centrally coordinated response to COVID-19 is a long-standing tension between two French public health traditions. The first tradition has been the foundation of the French state's historical engagement with global humanitarian health, which we have previously described as state humanitarian verticalism.1 Instituted first in the French former colonies, it was widely used in France's international health assistance, including during epidemics, and is still part of France's global health assistance in low-income countries.

Global Nursing in Low-Resource and Middle-Resource Countries: Challenges and Opportunities in Perioperative Practice.

There are marked disparities in supply and demand for specialty-trained health care providers in low-income and middle-income countries (LMIC). Nurses are at the forefront in volunteering to provide humanitarian health support in local, national, and international disasters. Responding to the call to provide expert medical and surgical education and care in LMIC aligns with the passion and purpose of nursing. This article shares a real-world experience of perioperative nurses in partnership with the surgical team to provide cleft lip/palate repair for children in LMIC. It is all in the smile left behind.

Understanding the factors affecting the\xa0humanitarian health and nutrition response for women and children in Somalia since 2000: a case study

BackgroundSomalia has been ravaged by more than two decades of armed conflict causing immense damage to the country’s infrastructure and mass displacement and suffering among its people. An influx of humanitarian actors has sought to provide basic services, including health services for women and children, throughout the conflict. This study aimed to better understand the humanitarian health response for women and children in Somalia since 2000.MethodsThe study utilized a mixed-methods design. We collated intervention coverage data from publically available large-scale household surveys and we conducted 32 interviews with representatives from government, UN agencies, NGOs, and health facility staff. Qualitative data were analyzed using latent content analysis.ResultsThe available quantitative data on intervention coverage in Somalia are extremely limited, making it difficult to discern patterns or trends over time or by region. Underlying sociocultural and other contextual factors most strongly affecting the humanitarian health response for women and children included clan dynamics and female disempowerment. The most salient operational influences included the assessment of population needs, donors’ priorities, and insufficient and inflexible funding. Key barriers to service delivery included chronic commodity and human resource shortages, poor infrastructure, and limited access to highly vulnerable populations, all against the backdrop of ongoing insecurity. Various strategies to mitigate these barriers were discussed. In-country coordination of humanitarian health actors and their activities has improved over time, with federal and state-level ministries of health playing increasingly active roles.ConclusionsEmerging recommendations include further exploration of government partnerships with private-sector service providers to make services available throughout Somalia free of charge, with further research on innovative uses of technology to help reaches remote and inaccessible areas. To mitigate chronic skilled health worker shortages, more operational research is needed on the expanded use of community health workers. Persistent gaps in service provision across the continuum must be addressed, including for adolescents, for example. The is also a clear need for longer term development focus to enable the provision of health and nutrition services for women and children beyond those included in recurrent emergency response.

Maternal and child health service delivery in conflict-affected settings: a case study example from Upper Nile and Unity states, South Sudan

BackgroundDecades of war left the Republic of South Sudan with a fragile health system that has remained deprived of resources since the country’s independence. We describe the coverage of interventions for women’s and children’s health in Upper Nile and Unity states, and explore factors that affected service provision during a protracted conflict.MethodsWe conducted a case study using a desk review of publicly available literature since 2013 and a secondary analysis of intervention coverage and conflict-related events from 2010 to 2017. During June through September 2018, we conducted 26 qualitative interviews with technical leads and 9 focus groups among health workers working in women and children’s health in Juba, Malakal, and Bentiu.ResultsCoverage for antenatal care, institutional delivery, and childhood vaccines were low prior to the escalation of conflict in 2013, and the limited data indicate that coverage remained low through 2017. Key factors that determined the delivery of services for women and children in our study sites were government leadership, coordination of development and humanitarian efforts, and human resource capacity. Participants felt that national and local health officials had a limited role in the delivery of services, and financial tracking data showed that funding stagnated or declined for humanitarian health and development programming during 2013–2014. Although health services were concentrated in camp settings, the availability of healthcare providers was negatively impacted by the protracted nature of the conflict and insecurity in the region.ConclusionsHealth care for women and children should be prioritized during acute and protracted periods of conflict by strengthening surveillance systems, coordinating short and long term activities among humanitarian and development organizations, and building the capacity of national and local government officials to ensure sustainability.

Experiments in Scale: Humanitarian Psychiatry in Post-Disaster Turkey

ABSTRACT A massive earthquake that struck Turkey in 1999 generated an unprecedented mobilization of Turkish psychiatrists and psychologists to address the mental and emotional aftermath of the disaster. In this article I examine how these mental health professionals, swept up in a wave of humanitarian compassion, confronted the limits of their own expertise and struggled to improvise a therapeutic response that could match the scale of psychological suffering precipitated by the earthquake. Framing humanitarian and global health interventions as inescapably scalar projects, I explore the pragmatic and imaginative labor involved in making psychiatric expertise scalable, what I characterize as their “work of therapeutic scalability.” In doing so, I raise a series of questions about the psychological subject of disaster, the transnational mobility of technoscientific expertise, and the politics of both life and scale at play in psychiatric humanitarian intervention.

Value of Combining Patient and Provider Incentives in Humanitarian Health Care Service Programs

The below‐par progress toward the Millennium Development Goals in many developing countries has been attributed to the low availability of good quality health care services and to the demand‐side barriers to access. In this study, we analyze an incentive design problem faced by a budget‐constrained humanitarian organization managing a health care service program (e.g., maternal health or HIV services) with different emphasis on the two measures of quality—structural and process. Incentives offered to the health care provider (referred to as supply‐side incentives) are aimed at improving the availability of good quality services and demand‐side incentives are used to encourage patients to seek care. In many developing country health programs, incentive schemes tend to be purely supply‐side focused or purely demand‐side focused. However, our results suggest that by offering the right combination of incentives to the patients and the provider, program performance can be increased up to 20 times, on average, depending on the service offered. Even within the current practice of using one‐sided incentives, there is significant scope for improvement (as much as 14 times, on average) by ensuring that there is better alignment between the incentive scheme and the service offered. In particular, pure supply‐side incentive schemes perform better than pure demand‐side incentive schemes in programs where there is a higher emphasis on structural quality. The opposite result holds true for programs that place a higher emphasis on process quality.

Medical Professionalism and Humanitarian Health Care in the American Age of "-isms".

The 2003 IOM report Unequal Treatment documented the inferior health care accorded African Americans and Hispanic Americans. Subsequent research has shown that women, the elderly, LGBTQ individuals, and other specific minority groups also receive disparate care. Unequal treatment is often a product of subconscious mental functions including stereotyping and the neurological interconnection of the brain's emotional response and cognitive systems. Because these functions are hard-wired, they are not easily amenable to efforts to eliminate them from our thinking. But identifying and bringing them to light provides the opportunity to counteract them. The ACP-ABIM Professionalism Charter incorporates ameliorative precepts including altruism, moral reasoning, and conscious commitment to equal care. Medical Professionalism and Humanitarian Health Care in the American Age of "-isms" describes how empathetic or humanitarian care not only improves patient outcomes but provides meaning and satisfaction that enhances the well-being of the caregiver and counteracts physician burnout and dropout.

Supporting the use of research evidence in decision-making in crisis zones in low- and middle-income countries: a critical interpretive synthesis

BackgroundDecision-makers in crisis zones are faced with the challenge of having to make health-related decisions under limited time and resource constraints and in light of the many factors that can influence their decisions, of which research evidence is just one. To address a key gap in the research literature about how best to support the use of research evidence in such situations, we conducted a critical interpretive synthesis approach to develop a conceptual framework that outlines the strategies that leverage the facilitators and address the barriers to evidence use in crisis zones.MethodsWe systematically reviewed both empirical and non-empirical literature and used an interpretive analytic approach to synthesise the results and develop the conceptual framework. We used a ‘compass’ question to create a detailed search strategy and conducted electronic searches in CINAHL, EMBASE, MEDLINE, SSCI and Web of Science. A second reviewer was assigned to a representative sample of articles. We purposively sampled additional papers to fill in conceptual gaps.ResultsWe identified 21 eligible papers to be analysed and purposively sampled an additional 6 to fill conceptual gaps. The synthesis resulted in a conceptual framework that focuses on evidence use in crisis zones examined through the lens of four systems – political, health, international humanitarian aid and health research. Within each of the four systems, the framework identifies the most actionable strategies that leverage the facilitators and address the barriers to evidence use.ConclusionsThis study presents a new conceptual framework that outlines strategies that leverage the facilitators and address the barriers to evidence use in crisis zones within different systems. This study expands on the literature pertaining to evidence-informed decision-making.

Building mental health and resilience: regional and global perspectives from the inaugural Syrian American Medical Society Mental Health Mission Trip (July 2 to July 7, 2019)

ABSTRACTThe Syrian conflict has resulted in the most significant refugee crisis since World War II. Current estimates suggest there are over 13.5 million Syrians in need of comprehensive humanitarian assistance as a direct result of the conflict. These humanitarian needs include mental health services to address the elevated rates of psychiatric disorders in this population. Towards this end, the Syrian American Medical Society conducted its inaugural mental health mission trip to Lebanon and Jordan from June to July 2019 to advance the state of mental health care for displaced Syrians. Following two weeks of trainings by international experts in trauma psychology, the mission concluded with a two-day scientific symposium, identifying two key elements for the advancement of humanitarian mental health care: 1) the need for community-based mental health services, and 2) the importance of transitioning from a crisis-response model in humanitarian mental health towards a model of resilience and post-traumatic growth.

Of dreams and nightmares: implementing medical male circumcision in eSwatini (Swaziland)

AbstractThis article uses the accelerated saturation initiative (ASI) Soka Uncobe, which took place in the kingdom of eSwatini in 2011 and 2012, to comment on HIV humanitarian health interventions in Africa. Soka Uncobe, the first ASI on voluntary medical male circumcision, aimed to circumcise 80 per cent of all HIV-negative men aged fifteen to forty-nine years over a twelve-month period. Using written and verbal accounts, I draw attention to the dreams and hopes behind the design of the initiative. I also highlight the dynamics of the implementation of Soka Uncobe, and, in doing so, I chart the path to its ultimate failure by showing the reluctance of the implementation partners (based mainly in the global North) to take seriously what have now become well-known critiques of why humanitarian interventions fail. Ultimately, I suggest that, despite having the potential to produce some critical results, Soka Uncobe was no different from previous transnational humanitarian health interventions. Thus, an exposé of why it failed is pivotal to this article about the dreams that underpinned the first ever ASI related to medical male circumcision.