0 comments on “Ethics and Unmet Promises: Syrian refugees healthcare in Lebanon”

Ethics and Unmet Promises: Syrian refugees healthcare in Lebanon

The New York Declaration for Refugees and Migrants, adopted by the United Nations GEneral Assembly in September 2016, stresses that root causes should be addressed “through the prevention and peaceful resolution of conflict, greater coordination of humanitarian, development and peace-building efforts, the promotion of the rule of law at the national and international levels and the protection of human rights”. The international community has thus recognized “a shared responsibility to manage large movements of refugees and migrants in humane, sensitive, compassionate and people-centered manner”.

UN Document A/71/L.1. (paragraph 11)

Refugees & Migrants and Ethical Responsibility for their Health Care:

  • It is more than simple generosity, simple charity.
  • It aims to build spaces of normalcy in the midst of what is abnormal.
  • More than offering material assistance, we aim to enable individuals to regain their rights and dignity as human beings.

Nobel Lecture by James Orbinski, Médecins Sans Frontières, Oslo, December 10, 1999

The Context

Since the start of the Syrian conflict in 2011, Lebanon has been host to incoming refugees. The UNHCR estimates 1,050,877 Syrians are now in Lebanon, amounting to 25% of the Lebanese population. Refugees are concentrated in the North and Bekaa regions, host communities that are already poor, underserved and vulnerable.[1]

The Issue

The large and constant influx of Syrian refugees into Lebanon has greatly strained the Lebanese healthcare system and economy. Many local and international NGOs, humanitarian organizations and governmental agencies are involved in providing humanitarian assistance and health services to Syrian refugees. Yet, there remain existing structures that limit refugee access to essential health care services, including poor coordination between them. The result is a rise in communicable diseases, increased risk of epidemics, suboptimal control of chronic diseases, and other health related matters.[2]

How can the Lebanese MOPH and other stakeholder organizations secure better access to essential and urgent healthcare needs of Syrian refugees?

Current Health Situation of Syrian Refugees in Lebanon

Access to Healthcare by Syrian Refugees in Lebanon

Roles and Responsibilities of the Lebanese Ministry of Public Health (MoPH)

Conclusion

It is important to promote access to Essential Health Care Services for Syrian Refugees in Lebanon and to recognize the severe shortage in financing and unmet promises by the international community. An immediate action and far greater support from the international community is needed to address the needs of refugees in Lebanon.

Recommendations for the MOPH and international aid agencies:

  1. Develop an essential package of healthcare services for Syrian refugees and Lebanese people.
  2. Develop a mechanism at the level of the government to raise funds to finance the delivery of the essential package.
  3. Expand the number of primary healthcare centers, and hospitals that are within the humanitarian sector.
  4. Developing refugee health information system through:
    • Identifying priority data needs and requirements;
    • Developing guidelines for data collection, and data use;
    • Establishing a mechanism for data monitoring, data sharing between all stakeholders including the private sector.
  5. Invest in building capacities of local infrastructure and local government (municipalities) to handle crisis situations.
  6. Explore mechanisms to increase transparency in the work including resource allocation of NGOs and other agencies in delivering health interventions.
  7. Invest in decentralizing decision making capacity at the level of the government departments to match interventions and aid to the needs of the local community.
  8. Identify research priorities on refugee health.
  9. Strengthen the stewardship function of governmental departments and having a lead organization that is capable to play a major role by coordinating and establishing effective partnerships with local and international agencies.

About the Author:

Michel Daher, MD, FACS
Professor of Surgery, Univ of Balamand
Secretary General, Lebanese National Ethics Committee
Vice-Chair, National Committee for Palliative Care
Saint George Hospital-UMC, Beirut- Lebanon
mndaher@inco.com.lb

 

Photo Credit: One-month-old baby boy, Walid, is comforted by his mother after a check-up provided by UK aid at a Save the Children clinic in Lebanon’s Bekaa Valley. Walid’s mum was worried about him but the diagnosis was just that’s he suffering from colic, which will hopefully get better by itself in time. The UK is supporting Save the Children to provide access to primary healthcare for thousands of Syrian refugee children in Lebanon, as well as ensuring that hundreds of pregnant Syrian women have access to anti-natal care. To find out more about how the UK is responding to the humanitarian crisis in Syria and its neighbouring countries, please see:www.gov.uk/government/news/syria-the-latest-updates-on-uk… Picture: Russell Watkins/Department for International Development

 

[1] (UNHCR, 2014 – WB&UN, 2013; UNHCR. 2015. Syria Regional Refugee Response http://data.unhcr.org/syrianrefugees/regional.php)

[2] (Refaat & Mohanna, 2013)

1 comment on “From Boston to Nepal: How to treat suffering without medical resources”

From Boston to Nepal: How to treat suffering without medical resources

One never gets used to the idea that there is nothing one can do.

–Connie Willis, The Doomsday Book, 1992

by Annekathryn Goodman, MD

I was deployed to Nepal for three weeks after the April 2015 Earthquake as part of a first responder mobile medical team of the International Medical Corps. My 12-person team was helicoptered into remote, inaccessible mountain villages that had been devastated by the earthquake. We would set up a clinic, treat acute injuries, collect data on impending infectious disease epidemics, and triage severely injured earthquake victims for helicopter evacuation to Kathmandu. It was during this journey that I was confronted with the dilemmas of how to care for actively dying people when resources were not available.

The challenges after a natural disaster are complex and nuanced.  There is a loss of civic infrastructure. Scarce resources include among others: medications, health facilities, and providers. There is also the terrible loss of family, food scarcity, and a lack of water and electricity.

The goals of first responders shift to acute care and includes saving lives, stabilizing injuries, and offering definitive therapy when possible. When a victim cannot survive, palliation of symptoms would be ideal if it is possible to do so. There is the tough business of triaging patients in this setting by whether or not they can be saved. The categories of triage range from immediate (immediate intervention will save the life), delayed (the injuries are not life threatening and can be treated later), minimal, and expectant. The expectant category is reserved for patients with devastating injuries where they will not survive or where the resources to help them are greater than what is available and even with the best care, their chance of pulling through is minimal.

In contrast to a disaster-restricted setting, tremendous expense is routinely spent for ill cancer patients in the hopes of giving them an extra 3 to 6 months of life. In addition, early palliative care intervention in a non-disaster setting hopes to improve symptoms, relieve suffering, and help patients with advanced and incurable cancers to transition in a gentler and more gradual way towards the inevitable end of their lives. During a mass casualty event, palliative care services directly compete with definitive or life-saving care. This leads to an altered standard of palliative care where pain-control and sedation is the main goal.

Durbarsquare_after_earthquake_3
Damage in the Basantpur Durbar Square. Photo from Wikipedia.

Nepal, a country of 31.5 million people where the average age is 22 years is an agrarian society and among the poorest countries in the world. Pre-earthquake, prescribing narcotics was illegal and palliative care was not a widely known medical concept. On 25 April 2015, a 7.8 earthquake rocked the country. A second 6.8 earthquake followed on 12 May. These earthquakes and the subsequent hundreds of severe aftershocks led to deaths, landslides, displacement, homelessness, and crop failure and food insecurity.

In this setting, my mobile medical unit treated over 2000 people during our three-week rotation. There were many cases of respiratory illness, dehydration, diarrheal diseases, pain, rashes, urinary symptoms, lacerations, fractures, pregnancy and gender based violence.

It was during one chaotic day that I met a 55-year-old gentleman whom I had to triage to the expectant category. I was in the middle of suturing a laceration when looking up I saw a group of people carrying a man down the mountainside in a large grain basket. Two years before, he had been treated in Kathmandu for bladder cancer and had undergone a pelvic exenteration, radiation, and chemotherapy. His family wanted him evacuated to Kathmandu. On examination there were multiple sites of tumor growing through the abdominal wall and he had developed a high output enterocutaneous fistula. His clothes were saturated by the fistulous output, and he was in obvious, tremendous pain. His family had been walking for two days to get to us.

It was an awful moment. I gently tried to explain through an interpreter that he probably would not last more than a few days and we could not send him to Kathmandu. His son and I bathed him and wrapped him in some chux pads that we had on hand. The family was incredulous and angry.

There are guidelines for the ethical approach to allocation of scarce resources and triage. The concepts to consider include accountability, transparency, consistency, and proportionality. There is the issue of fairness—to be inherently just to all people. And there is the public health concept of the duty to obtain the best outcome for the greatest number of patients with available resources. These issues confronted me with this poor gentleman and his family. I could not even offer adequate palliation of his and his family’s suffering.

I will always remember this patient and I bring back to our resource rich country some important concepts to consider in our care of cancer patients. The inability to give good care and alleviate suffering leads to moral distress among the providers. There is a balance of care and we must be thoughtful with treatment choices. On the one hand, we can cause harm with overly aggressive care that may be futile. In addition, beyond the individual patient, the inappropriate use of health care resources harms others who may not be able to receive care. However, the inability to at least manage symptoms is unacceptable.

AK_Nepal
Caption: “I am inspired by how children cope in disasters,
they are so resilient:
Laughing, figuring out how to make play out of the rubble and destruction.
So in that scene, I pulled out my notebook and asked them to draw pictures for me.
They loved it.
Got lots of drawings.
And then they loved looking at each other’s drawings.
There was lots of feedback and analysis all in Nepali.
And they loved leaning over and poking at me:
Lots of dirty fingers in my ears.”

There is a movement to develop a crisis standard of care during disasters. These standards are also worthy of consideration in a non-disaster situation. Critical resources go to those who will benefit the most. We must prevent hoarding and overuse of limited resources. Limited resources must be conserved so more people can get the care they need. We must minimize discrimination against vulnerable groups who cannot advocate for themselves such as the poor, the minorities, the elderly, and immigrants.

Ultimately, regardless of the context we must maintain the basic human values of compassion, empathy, and respect for the dignity of others and to maintain professional codes of conduct.

Dr. Annekathryn Goodman is a Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School and practices as a gynecologic oncologist at Massachusetts General Hospital in Boston. She is a member of the national Trauma and Critical Care Team  a branch of the US department of Health and Human Services and has deployed to various international disasters including Bam, Iran 2004, Banda Aceh 2005, Haiti 2010, the Philippines 2014, and Nepal 2015.  Since 2008, she has been consulting in Bangladesh on cervical cancer prevention and the development of medical infrastructure to care for women with gynecologic cancers. 

0 comments on “Call now open for GFBR 2017”

Call now open for GFBR 2017

The Global Forum on Bioethics in Research will hold a two-day meeting in Bangkok, Thailand, on 28-29 November 2017 on the theme of: the ethics of alternative clinical trial designs and methods in low- and middle- income country research.

The CALL IS NOW OPEN for:

  1. CALL FOR CASE STUDIES
  2. CALL FOR PROPOSALS ON GUIDANCE AND POLICY ISSUES
  3. CALL FOR PARTICIPANTS

See the following link for more details and information:

http://www.gfbr.global/news/call-now-open-2017-gfbr/

If you have any questions about this call please email gfbr@wellcome.ac.uk.

All applications should be sent to gfbr@wellcome.ac.uk by 21.00 BST on Tuesday 30 May 2017, in English. Please specify in the subject line whether you are applying to attend, present a case study or present on guidance or a policy issue. Applications received after the deadline will not be considered.

0 comments on “Geneva & Back Again – Julia Pemberton’s Reflections on Interning at the WHO”

Geneva & Back Again – Julia Pemberton’s Reflections on Interning at the WHO

Julia Pemberton, PhD candidate
Health Research Methodology Program, Field of Interest: Global Health
pemberj@mcmaster.ca

img_8967This past summer I had the incredible opportunity to join the World Health Organization (WHO) as a Research Intern for three months. At WHO I joined the Global Health Ethics Unit, which is part of the larger Research, Ethics, Knowledge Management Department. The majority of my internship focused on the creation and execution of a qualitative descriptive research study. Entitled “Ethical Issues Associated with Implementation Research: A Descriptive Qualitative Analysis of the WHO Experience from 2005-2015,” this study consists of a document analysis followed by two focus group sessions, one with WHO Technical Officers, and one with past and present WHO Ethics Research Committee (ERC) members. The purpose of this study is to identify and understand the ethical issues identified by the WHO ERC in its review of  Implementation Research (IR) projects submitted for ethical review at WHO. The results from this study will be used to raise awareness on the ethical issues arising in IR and to build capacity of researchers and ethics committees involved in the conduct and review of IR, respectively. The results will also potentially be used to inform a global guidance document on ethical review of IR. In addition to this research project I also was a member of the WHO Intern Board as an Intern Advocate, where I helped connect interns with WHO staff to engage in professional development and networking opportunities. Finally, I was also responsible for the creation of an Intern Alumni platform for the Global Health Ethics Unit, as well as the Global Health Ethics newsletter. In summary, I used my time in Geneva to expand my professional network, and had productive meetings with the International Committee of the Red Cross, Médecins sans frontières, the Council on Health Research and Development (COHRED), and the Geneva Centre for Education and Research in Humanitarian Action (CERAH).

The research activities described above directly relate to my doctoral work. The topic of my dissertation is global health research governance. Governance, or the way political, ethical, administrative, and financial authority applies to a health research system, is an important part

of how these systems are organized and managed, and how they perform. The purpose of my doctoral thesis is to examine how global health research governance is being understood, developed and currently used in the Canadian national health research system. Briefly, my thesis will generate an inductively derived, reflexive, global health research governance model for Canada. Through this work I intend to identify specific value criteria that are indicative of good global health research governance. Foregrounded will be the contribution of global health research ethics to governance beyond research ethics review, and discerning how values are known and reflected in the governance of national health research systems. Once this model of Canadian global health research governance is known, I will be conducting a case study of a global health research partnership (Canada and Zambia) to determine the current reflexivity of the Canadian model and determine what, if any, recommendations for policy and health systems strengthening could be made.

Julia Pemberton is a 3rd year student in the Health Research Methodology PhD at McMaster University, a CIHR Banting & Best Canadian Graduate Scholar, and a recipient of both the CIHR Douglas Kinsella Award in Bioethics and the CIHR Michael Smith Foreign Study Supplement Award.