Medical Humanitarian Organizations Research Articles

Protecting Confidentiality in the Digital Ecosystem of Humanitarian Aid

Protecting Confidentiality in the Digital Ecosystem of Humanitarian Aid

Snakebite envenoming at MSF: A decade of clinical challenges and antivenom access issues.

The medical humanitarian organization Médecins Sans Frontières (MSF) provides medical care in more than 70 countries and admits more than 7000 cases of snakebite in its facilities each year. We describe our activities against snakebite in three African countries: Central African Republic, South Sudan and Ethiopia, in which different models of care have been developed. A standard protocol using two different antivenoms depending on the patient's syndrome has been introduced, and a simple blood coagulation test is performed to detect venom-induced coagulopathy. Other services, including surgery for necrotizing wounds, are offered in the facilities where MSF admits a large number of snakebite patients. All services, including provision of antivenom, are offered free-of-charge in MSF-supported facilities. Community-based activities focusing on preventive measures and prompt transport to hospital have been developed in a few MSF projects. The provision of quality care and treatment, including effective antivenoms, without out-of-pocket payments by the patients, probably explains why MSF has admitted an increasing number of snakebite victims over the last years. This model requires significant resources and monitoring, including regular training of healthcare workers on treatment protocols and a considerable budget for antivenom procurement.

Time, space and health: using the life history calendar methodology applied to mobility in a medical-humanitarian organisation

ABSTRACT In the medical humanitarian context, the challenging task of collecting health information from people on the move constitutes a key element to identifying critical health care needs and gaps. Médecins Sans Frontières (MSF), during its long history of working with migrants, refugees and mobile populations in different contexts, has acknowledged how crucial it is to generate detailed context-related data on migrant and refugee populations in order to adapt the response interventions to their needs and circumstances. In 2019, the Brazilian Medical Unit/MSF developed the Migration History Tool (MHT), an application based on the life history method which was created in close dialogue with field teams in order to respond to information needs emerging from medical operations in mobile populations. The tool was piloted in two different contexts: firstly, among mobile populations transiting and living in Beitbridge and Musina, at the Zimbabwe-South Africa border; and, secondly, among Venezuelan migrants and refugees in Colombia. This article describes the implementation of this innovative method for collecting quantitative retrospective data on mobility and health in the context of two humanitarian interventions. The results have proven the flexibility of the methodology, which generated detailed information on mobility trajectories and on the temporalities of migration in two different contexts. It also revealed how health outcomes are not only associated with the spatial dimensions of movement, but also with the temporalities of mobility trajectories.

797-P: Usability and Satisfaction of a New Affordable Insulin Pen for All: Positive Outcomes of Two Usability Studies

Globally, 13 million people (4 million in USA) inject insulin with single use disposable syringes daily. Compared to syringe and vials, pens are known to increase adherence and diabetes control and to reduce healthcare utilization costs. Yet, pens are largely unavailable to low-income groups, due to prohibitive cost. GO-Pen has designed a new affordable pen for use with vial insulin and conducted usability testing in collaboration with Médecins Sans Frontières (MSF) , an international medical humanitarian organization working to improve diabetes care for people living in difficult circumstances. Here we report the results of two usability studies conducted among insulin pen users (n=19, f/m: 11/8, age: 23-64) and syringe users (n=20, f/m: 10/10, age: 24-70) in refugee populations in Malaysia and Jordan. A convenience sample of the first 20 to accept enrollment was set up after informed consent. After a short introduction, participants were asked to demonstrate the use of the insulin pen in front of a camera, without revealing their faces or any identifying information, while an interviewer noted their correct use and confidence level. Injection was simulated in a sponge. 100% (n=19) of pen users and 75% (n=15) of syringe users performed >90% of the tasks correctly. Among pen users, the most common failed tasks were priming the needle (n=4) . Among syringe users, the most common failed tasks were failing to check the vial label (n=9) and priming the needle (n=6) . 5% (n=1) of pen users preferred the new insulin pen over the pen they were already familiar with. 75% (n=15) of syringe users preferred the new insulin pen over syringes. The most common complaint among pen users was that there were too many steps in the process. In conclusion, we find current pen users require little training and prefer the pen they are already familiar with. Syringe users who are unfamiliar with pen usage require more training than pen users, however, they have largely favorable attitudes towards this new insulin pen. Disclosure O.K.Nielsen: Stock/Shareholder; GO-Pen ApS. G.Huisman: None. J.A.Qasem: None. C.Eng: None. A.F.Jørgensen: None. M.Torrone: None. B.S.Larsen: None. A.Reddy: None.

“Not a free version of a broken system:” Medical humanitarianism and immigrant health justice in the United States

Medical humanitarian organizations are increasingly the primary healthcare providers for unauthorized migrants in high-income countries. Existing studies of medical humanitarianism in the Global North reveal tensions between principles of traditionally apolitical humanitarianism and human rights. In practice, these tensions translate into organizational debates about prioritizing direct service provision to meet immediate needs or advocacy to effect long-term systemic change. Informed by these debates, this paper asserts the importance of immigration and health policy contexts as central to shaping the relationship between healthcare provision and political advocacy within medical humanitarian NGOs. Drawing from twelve months of fieldwork with medical humanitarian NGOs in Arizona, I analyze data from ethnographic participant observation and interviews with volunteer healthcare providers at a medical humanitarian organization I call Community Clinic of Phoenix (CCP), a free clinic for uninsured, undocumented immigrants. I find that, in the context of Arizona's anti-immigrant rhetoric and policies, CCP employs medical humanitarianism as both a discourse and a model of care to challenge immigrants' exclusion from health coverage and criminalization through immigration enforcement. The clinic's emphasis on immigrant health justice shapes their critiques of the structural failures of U.S. immigration and health systems, their approach to providing equitable access to quality healthcare for uninsured immigrants, and their work to create broad social change for immigrant rights and health justice. Driven by their mission of “not replicating a free version of a broken system,” the clinic's healthcare provision amid a climate inhospitable to immigrants demonstrates the importance of both conceptualizing and practicing medical humanitarianism as healthcare advocacy.

How to bring residents' psychosocial well-being to the heart of the fight against Covid-19 in Belgian nursing homes-A qualitative study.

BackgroundNursing homes (NH) for the elderly have been particularly affected by the Covid-19 pandemic mainly due to their hosted vulnerable populations and poor outbreak preparedness. In Belgium, the medical humanitarian organization Médecins Sans Frontières (MSF) implemented a support project for NH including training on infection prevention and control (IPC), (re)-organization of care, and psychosocial support for NH staff. As psychosocial and mental health needs of NH residents in times of Covid-19 are poorly understood and addressed, this study aimed to better understand these needs and how staff could respond accordingly.MethodsA qualitative study adopting thematic content analysis. Eight focus group discussions with direct caring staff and 56 in-depth interviews with residents were conducted in eight purposively and conveniently selected NHs in Brussels, Belgium, June 2020.ResultsNH residents experienced losses of freedom, social life, autonomy, and recreational activities that deprived them of their basic psychological needs. This had a massive impact on their mental well-being expressed in feeling depressed, anxious, and frustrated as well as decreased meaning and quality of life. Staff felt unprepared for the challenges posed by the pandemic; lacking guidelines, personal protective equipment and clarity around organization of care. They were confronted with professional and ethical dilemmas, feeling ‘trapped’ between IPC and the residents’ wellbeing. They witnessed the detrimental effects of the measures imposed on their residents.ConclusionThis study revealed the insights of residents’ and NH staff at the height of the early Covid-19 pandemic. Clearer outbreak plans, including psychosocial support, could have prevented the aggravated mental health conditions of both residents and staff. A holistic approach is needed in NHs in which tailor-made essential restrictive IPC measures are combined with psychosocial support measures to reduce the impact on residents’ mental health impact and to enhance their quality of life.

P0276 / #811: THE USE OF NEONATAL EARLY WARNING SCORING SYSTEMS (NEWS) IN RESOURCE-LIMITED SETTINGS

Aims & Objectives: Early warning score systems have proven its place in adult and pediatric wards to identify at risk patients and intervene early before a serious adverse event takes place. These scoring systems allow for better resource allocations in inpatient settings. Often pediatric scores are used for newborns, while there exists a different physiopathology. In resource-limited settings, where newborn mortality is very high, and the availability and technical expertise of medical staff is limited, an adapted scoring system could be useful. Methods: A literature research was performed for validation of NEWS systems and their effects on morbidity and mortality in maternity and neonatal wards using Pubmed, Web of Science, CINAHL and google scholar. An online research and contact with medical humanitarian organizations for non-validated scores was also executed. Results: Research showed very limited studies validating NEWS and even less for humanitarian settings. Different scores are being used in high resource countries, but with lack of standardization. Few scores are being used in humanitarian settings Based upon literature research we made an adapted NEWS for low-resource settings. In a second time we propose the validation of this tool in a prospective study in high and resource-limited settings. Conclusions: NEWS could be a useful tool in maternity and neonatal wards to prevent adverse events and reduce mortality as well as helping resource allocation for sick newborns. There are no validated adapted scores for resource-limited settings. We strongly advocate for further research to adapt and validate NEWS for resource-limited settings.

Doctors Without Borders Lends a Gloved Hand to U.S. Nursing Homes

Doctors Without Borders Lends a Gloved Hand to U.S. Nursing Homes

Interpreting for EFL Speakers in Humanitarian Organizations (MSF- Jordan): Roles and Challenges

This paper sheds light on the subjective experiences of interpreters who work with an international, medical humanitarian organization, namely MSF-Jordan. The paper seeks to explore the role/s that interpreters identify themselves as performing when working with MSF-Jordan, the challenges they encounter when working for such organizations where most of the officials are EFL speakers, and the strategies they adopt to overcome the challenges. The study uses a qualitative method through conducting interviews in the form of a questionnaire that was sent to seventeen interpreters who worked or still working with MSF-Jordan between 2011-2019. The questionnaire used in this study was developed by Stahuljak and its selection is based on its suitability for the purposes of the current study. Eleven interpreters responded, and the data was analyzed considering the research questions. The results show that interpreters identify themselves as performing the roles of conduits, culture brokers, and other. The interpreters identified challenges related to their lack of experience specifically in specialized terminologies, officials' accents, officials’ speaking pace, their feel of lack of recognition, too much work and having additional tasks other than interpreting. The study further shows that interpreters opt for various strategies to overcome the challenges such as asking for help in relevance to lack of knowledge, asking officials to repeat, guessing, and asking the officials to write down what they say to overcome the impediment of EFL.

Knowledge, attitudes, and Expectations of Medical Staff Toward Medical Error Management Policies in Humanitarian Medicine: A Qualitative Study.

Patient safety, a major component of quality of care, is now an attribute of health care systems in developed countries at least. Although there is ever more research on this subject in developed countries, humanitarian medicine, mainly implemented in resource-poor countries, has yet to structure its own set of policies and strategies on patient safety and the management of medical errors. We assessed the knowledge, attitudes, and expectations of medical humanitarian staff regarding the development of policies and strategies related to patient safety and medical error management in medical humanitarian action. We conducted 36 semistructured interviews with international medical and paramedical staff active in 6 medical humanitarian organizations after having interviewed the medical directors or the person in charge of quality of care and the legal advisors. Interviews were transcribed verbatim and subjected to a thematic analysis. The interviews confirmed the current absence of clear investments in dealing with safety risks in the selected medical humanitarian organizations. The difficulties experienced by medical staff in reporting medical errors such as blame culture, lack of training, and absence of leadership committed on patient safety are nonspecific. Other arguments are related to the specific conditions of humanitarian settings: coexistence of different medical culture, absence of international or local regulations or external pressures, and great diversity of activities and contexts. Interviewed staff expressed high expectations of receiving guidance from their organizations and support to adopt clear patient safety and medical error management policies adapted to their complex operational and clinical realities.

The value of case reports in democratising evidence from resource-limited settings: results of an exploratory survey

BackgroundFollowing a knowledge management analysis, Médecins Sans Frontières (MSF) – a medical humanitarian non-governmental organisation (NGO) – identified significant loss of medical knowledge from the field, owing primarily to the absence of a platform on which to share clinical lessons learned in humanitarian and resource-limited settings (HRLS). Wishing to address these missed opportunities to retain important scientific and pragmatic knowledge, the NGO has begun to actively encourage its clinicians to publish case reports/series that bring new and/or practical insights of benefit to patients and population groups. In parallel, we wished to obtain a clearer understanding of how case reports (CRs)/series can best play their role as ‘first-line evidence’ from HRLS, especially in areas suffering from a significant lack of data.MethodsWe developed a survey with closed and open questions on ‘The value of CRs from HRLS’ to explore primarily (1) the reasons why this form of evidence from HRLS is often lacking, (2) what makes a case report/series worth sharing with the wider global health community, and (3) how we can ensure that published case reports/series reach their target audience.ResultsOver a 6-month period, 1115 health professionals responded to the survey. Participants included clinicians and public health specialists from all over the world, with a majority based in Africa. The main reason cited for the dearth of CRs from HRLS was that practitioners are simply not writing and/or submitting reports (as versus having their papers rejected) due mainly to (1) a lack of skills and (2) time constraints. A large majority of respondents felt the CRs are a valuable tool for HRLS given their ability to discuss how cases are managed with rudimentary means as well as to draw attention to emerging or underestimated public health problems and neglected populations.ConclusionWe conclude that the clinical knowledge gained in resource-challenged settings is being underutilised in the interest of patients and global health. Consequently, clinicians in HRLS need greater access to basic training in scientific investigation and writing in addition to awareness as to the potential value of sharing their clinical experience with a view to broadening evidence production from high-income to low-income settings.

Twenty years on: International humanitarian law and the protection of civilians against the effects of cyber operations during armed conflicts

AbstractThe use of cyber operations during armed conflicts and the question of how international humanitarian law (IHL) applies to such operations have developed significantly over the past two decades. In their different roles in the Legal Division of the International Committee of the Red Cross (ICRC), the authors of this article have followed these developments closely and have engaged in governmental and non-governmental expert discussions on the subject. In this article, we analyze pertinent humanitarian, legal and policy questions. We first show that the use of cyber operations during armed conflict has become a reality of armed conflicts and is likely to be more prominent in the future. This development raises a number of concerns in today's increasingly cyber-reliant societies, in which malicious cyber operations risk causing significant disruption and harm to humans. Secondly, we present a brief overview of multilateral discussions on the legal and normative framework regulating cyber operations during armed conflicts, looking in particular at various arguments around the applicability of IHL to cyber operations during armed conflict and the relationship between IHL and the UN Charter. We emphasize that in our view, there is no question that cyber operations during armed conflicts, or cyber warfare, are regulated by IHL – just as is any weapon, means or methods of warfare used by a belligerent in a conflict, whether new or old. Thirdly, we focus the main part of this article on how IHL applies to cyber operations. Analyzing the most recent legal positions of States and experts, we revisit some of the most salient debates of the past decade, such as which cyber operations amount to an “attack” as defined in IHL and whether civilian data enjoys similar protection to “civilian objects”. We also explore the IHL rules applicable to cyber operations other than attacks and the special protection regimes for certain actors and infrastructure, such as medical facilities and humanitarian organizations.

A Call for the Application of Patient Safety Culture in Medical Humanitarian Action: A Literature Review.

The aims of the study were to assess lessons learned on patient safety in Organization for Economic Cooperation and Development (OECD) countries and to assess whether they are applied or can be applied to the humanitarian medicine. This is (a) a 2013-2018 rapid literature review of reviews and systematic reviews articles (PubMed database) on "patient safety" and "medical error" to look for lessons learned regarding patient safety in OECD countries and (b) a rapid literature review (PubMed and Embase databases) on "humanitarian medicine" and "patient safety," from their creation to 2018, to find any articles related to patient safety in humanitarian medicine. In both reviews were excluded articles specifically related to one device, disease, or medical act. These reviews were complemented by a Google search. Of the 245 references retrieved, 104 met the inclusion criteria. Of 308 references, 39 respected the inclusion criteria. In OECD countries, patient safety comprises correlated measures taken at three levels. The micro level focuses on individual staff involved in healthcare provision or management; the meso level focuses on medical institutions; the macro level focuses on national healthcare systems. Only one reference mentioned the implementation of a medical error reporting and analysis system in medical humanitarian organization. The adoption of strategies and a culture of safety will need to be adapted to address the variety of intervention contexts and to respond first to the fears and expectations of humanitarian staff. Medical humanitarian organizations, in the absence of an overarching authority for the sector, have a major responsibility in the development of a general patient safety policy applicable in all their operations.

Challenging traditional energy settings in the humanitarian aid: experiences from Doctors Without Borders

Energy is essential to the provision of humanitarian aid, from operating medical and non-medical equipment, to storing vaccines and drugs. In the last decades, the contexts of intervention of humanitarian actors are getting more complex and volatile, sometimes leading to longer project lifespans. To respond to this evolving context, and at the same time to try to cope with the global ecological crisis, humanitarian actors are proposing new strategies toward more sustainable energy solutions in their operations. However, there is a lack of reflection regarding how energy is conceived and used in the humanitarian response. With the aim of shedding light on these issues, we take the case of Médecins Sans Frontières, a medical humanitarian organization who is rethinking its traditional logics of energy planning. The results reveal that even if some transformative approaches to energy are emerging in the humanitarian field, they face several challenges when putting them into practice. Challenges related to effectiveness and flexibility, core concerns of the humanitarian aid. The work invites to a deeper look at the plurality of those challenges, aiming to gain better understanding on the relationship between energy and society and its operational impact.

Seven years of telemedicine in Médecins Sans Frontières demonstrate that offering direct specialist expertise in the frontline brings clinical and educational value.

BackgroundMédecins Sans Frontières (MSF), a medical humanitarian organization, began using store-and-forward telemedicine in 2010. The aim of the present study was to describe the experience of developing a telemedicine service in low-resource settings.MethodsWe studied the MSF telemedicine service during the period from 1st July 2010 until 30th June 2017. There were three consecutive phases in the development of the service, which we compared. We also examined the results of a quality assurance program which began in 2013.ResultsDuring the study period, a total of 5646 telemedicine cases were submitted. The workload increased steadily, and the median referral rate rose from 2 to 18 cases per week. The number of hospitals submitting cases and the number of cases per hospital also increased, as did the case complexity. Despite the increased workload, the allocation time reduced from 0.9 to 0.2 hours, and the median time to answer a case decreased from 20 to 5 hours. The quality assurance scores were stable. User feedback was generally positive and more than 90% of referrers who provided a progress report about their case stated that it had been sent to an appropriate specialist, that the response was sufficiently quick and that the teleconsultation provided an educational benefit. Referrers noted a positive impact of the system on patient outcome in 39% of cases.ConclusionsThe quality of the telemedicine service was maintained despite rising caseloads. The study showed that offering direct specialist expertise in low-resource settings improved the management of patients and provided additional educational value to the field physicians, thus bringing further benefits to other patients.

Governing Ebola: between global health and medical humanitarianism

ABSTRACTMedical humanitarianism and global health are two distinct but co-dependent spheres of global health security. Their actors differ in their units of analysis, understanding of neutrality, and organizational capacities. While health underpins the normative principles of humanitarian action, humanitarian ideas, and notably medical humanitarian organizations, are absent from global health security planning. This article develops the work of Lakoff [‘Two regimes of global health’, Humanity, 1(1), 59–79 (2010)], distinguishing between these two governance spheres and how this had stark consequences in the 2014/15 Ebola outbreak in Liberia and Sierra Leone, framed as a problem of global health but which rapidly became a humanitarian crisis. Such a frame excluded medical humanitarian organizations from the initial global strategy and resulted in the creation of a new organization (UMMEER – United Nations Mission for Ebola Emergency Response) and the involvement of militaries to bridge the health-humanitarian divide. Reconciling the distinct but co-dependent relationship between medical humanitarianism and global health is fundamental to effective delivery of global health security.

Benznidazole treatment safety: the Médecins Sans Frontières experience in a large cohort of Bolivian patients with Chagas' disease.

Up to half of patients with Chagas' disease under benznidazole treatment present adverse drug reactions (ADRs) and up to one-third do not complete standard treatment. To verify the incidence and possible factors associated with the suspension of benznidazole treatment in a large cohort of patients. We included 2075 patients treated with benznidazole during the projects managed by the medical humanitarian organization Doctors Without Borders (Médecins Sans Frontières) in Bolivia from 2009 to 2013. Benznidazole treatment was provided two or three times per day for ∼60 days at 5-7.5 mg/kg/day. A multiple logistic regression model was developed to evaluate the factors associated with permanent suspension of benznidazole treatment. Permanent benznidazole treatment suspension occurred in 211 patients (10.2%) and the average time until permanent treatment suspension was 23 days. Multifactorial analysis revealed that female sex (adjusted OR = 1.70), moderate ADRs (adjusted OR = 10.57), mild ADRs (adjusted OR = 1.69) and skin disorders (adjusted OR = 4.18) were significantly associated with the permanent suspension of benznidazole treatment. Women with mild or moderate skin ADRs presented a probability of treatment interruption of 18.6% and 59.0%, respectively. Benznidazole treatment was safe and a large proportion of patients were able to complete a full course of benznidazole treatment under close treatment surveillance. Female sex, skin disorders and mild and moderate ADRs were independently associated with the permanent suspension of benznidazole treatment. In particular, women with moderate skin ADRs had the highest risk of benznidazole treatment interruption.

The health of migrants passing through Serbia: The threat of the sick “other”?

With the gaining influence of securitarian discourses, migrants in Serbia are increasingly presented as a threat to the health of the general population. The media and local authorities often present them as carriers of contagious diseases and use their poor health condition as a justification for repressive measures against them. But are the public concern and (an almost exclusive) focus on the ways the health of migrants influences public health really appropriate? Have migrants been a threat to the health of the general population? In this article, I present some observations from seven months of participant observation I conducted in Serbia as a Persian and French translator during medical consultations for migrants (both in a center for asylum seekers and in the setting of the medical humanitarian organization providing primary healthcare to illegalized migrants). The attention to ethnographic data reveals that migrants have not been the carriers of diseases “from far away”, which would endanger the population, but that rather their health problems stem from the risk environment and conditions of structural violence they find themselves in.

A Retrospective Analysis of Pediatric Cases Handled by the MSF Tele-Expertise System.

We conducted a retrospective analysis of all pediatric cases referred by Médecins Sans Frontières (MSF) field doctors via the MSF telemedicine system during a 4-year period from April 2010. A total of 467 pediatric cases were submitted, representing approximately 40% of all telemedicine cases. The median age of the patients was 4 years. The median response time (i.e., the interval between the case being submitted and the first response from a specialist) was 13 h (interquartile range 4–32 h). We selected a random sample of 12 pediatric cases in each of four age categories for detailed analysis by an experienced MSF pediatrician. In the 48 randomly selected cases, the mean rating for the quality of information provided by the referrer was 2.8 (on a scale from 1 = very poor to 5 = very good), and the mean rating for the appropriateness of the response was 3.3 (same scale). More than two-thirds of the responses were considered to be useful to the patient, and approximately three-quarters were considered to be useful to the medical team. The usefulness of the responses tended to be higher for the medical team than for the patient, and there was some evidence that usefulness to both groups was lower in newborns and adolescent patients. The telemedicine system allows the quality of the medical support given to medical teams in the field to be controlled objectively as there is a record of all cases and answers. Telemedicine has an important role in supporting the aims of medical humanitarian organizations such as MSF.

Ambulatory tuberculosis treatment in post-Semashko health care systems needs supportive financing mechanisms.

The tuberculosis (TB) control strategy in the Republic of Karakalpakstan, Uzbekistan, is being changed to decentralised out-patient care for most TB patients by the Government of Uzbekistan, in collaboration with the international medical humanitarian organisation Médecins Sans Frontières. Ambulatory treatment of both drug-susceptible and drug-resistant TB from the first day of treatment has been recommended since 2011. Out-patient treatment of TB from the beginning of treatment was previously prohibited. However, the current Uzbek health financing system, which evolved from the Soviet Semashko model, offers incentives that work against the adoption of ambulatory TB treatment. Based on the 'Comprehensive TB Care for All' programme implemented in Karakalpakstan, we describe how existing policies for the allocation of health funds complicate the scale-up of ambulatory-based management of TB.