Prioritizing the Health and Well-Being of Mothers and Children in Emergencies

Princess Sarah Zeid of Jordan relayed the following statistics in a statement at the side event on health and well-being in emergencies during the 68th World Health Assembly:

"Sixty per cent of maternal, 53 per cent of under-five and 45 per cent of new born mortality takes place in humanitarian and fragile settings. Of the more than 80 million people who were in need of humanitarian assistance, in 2014, over 75 per cent of them were women and children."

Medina Maternal Child Health, Somalia, 2013     Photo: AP/Ben Curtis

The side event focused on three aspects: (i) safety and health of health care workers; (ii) reproductive, maternal, neonatal, child, and adolescent health (RMNCAH); and (iii) mental health and psychosocial support in humanitarian emergencies. You can read more about the health and well-being of mothers and children in emergencies here. 

Update on an Assymetrical Conflict

As of today, the ongoing conflict between Israel and Gaza has resulted in an estimated 213 Palestinians dead versus one Israeli dead. As with other Israeli assaults on Gaza, the conflict is grossly asymmetrical. Canadian for Justice and Peace in the Middle East explains:

"Israel is a military superpower, with F-15 fighter jets, AH-64 Apache helicopters, sophisticated missiles, an anti-rocket defence system (and nuclear arms.) Hamas and other militant groups have primitive and ineffective – often “home made” – rockets." 

Indeed, Hamas rockets have killed one Israeli man who was delivering food to Israeli military personnel. But Israel seems to ignore the international law of proportionality, which permits countries to respond to threats, but the response must be proportional to the threat faced. If the rockets coming from Gaza have killed one person and Israel's response has killed over 200, then Israel's response should be questioned by the international community.

Of course, firing rockets from Gaza violates international law as well, for Hamas is certainly targeting civilians as well as military targets. And UNRWA found that Hamas stored 20 missiles inside an abandoned school in Gaza, which is also a violation of international law. But the brutal strikes on Palestinian civilian homes, cafes, and other civilian sites (whether or not Israel provided warnings to the inhabitants) violates international law too. For example, today, four young boys were killed by Israeli bombs while playing on a beach in Gaza. The New York Times photojournalist Tyler Hicks wrote a short piece about his experience photographing the event surrounding their deaths, noting

"A small metal shack with no electricity or running water on a jetty in the blazing seaside sun does not seem like the kind of place frequented by Hamas militants, the Israel Defense Forces’ intended targets. Children, maybe four feet tall, dressed in summer clothes, running from an explosion, don’t fit the description of Hamas fighters, either."

Below is a photo from the Middle East Children's Alliance of a Palestinian mother reacting to news that her son was among the four children killed on a Gaza beach. I don't usually like to post photos of such visceral pain and suffering, but I think it is important in this context, where Palestinians can be dehumanized through media reports and Israeli news conferences.

Photo: Ayman Mohyeldin

The fear/anger/sadness was also reported upon from another New York Times editorial written by Rula Salameh describing her experience in East Jerusalem, which has been threatened by long-range missiles from Hamas as well as other sites throughout Israeli.

The Increasingly Strong Connection Between Climate Change and Conflict

Tim McDonnell of Mother Jones magazine recently wrote an excellent piece connecting global warming and violent conflict. McDonnell cites a survey published in Science, which:

"...takes a first-ever 30,000-foot view of this research, looking for trends that tie these examples together through fresh analysis of raw data from 60 quantitative studies. It offers evidence that unusually high temperatures could lead to tens of thousands more cases of "interpersonal" violence—murder, rape, assault, etc.—and more than a 50 percent increase in "intergroup" violence, i.e. war, in some places."

There are many potential reasons for this connection between climate change and violence. There are obvious connections between climate change and natural disaster, which oftentimes goes hand-in-hand with violence. Some researchers claim that warm weather contributes to increased inner-city violence (cue: Spike Lee's Do the Right Thing), such as the recent increase in murders in Chicago. Another reason is exceptionally high and low rainfall impacting agricultural production, which in turn can lead to interpersonal and intergroup violence.

The factors contributing to this connection is piquing the interest of researchers. Hopefully, new studies will draw stronger connections to causality, and perhaps suggest how violence can be lessened and even prevented.

[Photo: Medyan Dairieh/ZUMA Press]

The World's Displaced Population Reaches Record Levels

According to the Internal Displacement Monitoring Centre (IDMC), the wars in Syria and Democratic Republic of Congo (DRC) have caused the number of displaced people to increase dramatically, with the current world total at 28 million.

Here is some more information from an article in The Guardian (Photo: Kate Holt/Oxfam):

More than 6.5 million people were newly displaced within their own countries in 2012, almost twice as many as the year before, IDMC said in its annual report. Since these people have not crossed borders, they are not refugees and do not benefit from international protection.

The situation in Syria is particularly critical, as it is the world's largest and fastest evolving crisis in terms of new displacements. The number of Syrian internally displaced persons (IDPs) is now more than 3 million, of which 2.4 million were displaced last year.

"The crisis is in its third year and the escalation has gone beyond a tipping point," said Clare Spurrell, an IDMC spokeswoman. "Humanitarians can't save Syria, it has to be the politicians … what you are seeing are people who are utterly exhausted. The internally displaced are completely reliant on others, but host communities are themselves suffering from a lack of food, and diseases are breaking out."

The UN high commissioner for refugees, António Guterres, has described the Syrian civil war as the worst humanitarian disaster since the end of the cold war, and more brutal and destructive than the conflicts in Iraq and Afghanistan.

Until the conflict in Syria is resolved, internal displacement will continue to accelerate, said the IDMC, pointing out that this phenomenon has been seen in other countries with drawn-out conflicts.

Colombia has the largest number of IDPs in the world, followed by Syria and the DRC, which has the third largest IDP population. The region with the largest number of IDPs last year was sub-Saharan Africa, where there were 10.4 million IDPs by the end of 2012, almost a third of the world's internally displaced population.

About a million people fled their homes in DRC as a result of attacks from the rebel group M23. In November, 140,000 people fled the North Kivu capital of Goma in a single week as M23 forces entered the city. Conflict in Mali and increased violence in Nigeria from the radical Islamist group Boko Haram also caused large new displacements.

The report suggests that while a resolution to the conflict, particularly in Syria, is critical to dealing with an internal displacement crisis, so too is bridging the gap between emergency response and development.

"Ninety percent of the countries monitored by IDMC have IDPs living in protracted displacement, often for decades, while second and third generations are born into displacement,'' said Kate Halff, director of IDMC. She added: ''Governments are responsible for finding long-term solutions for their displaced citizens. However, they can only be realised when the governments and the international community recognise that people forced from their homes require not only a humanitarian response at the height of a crisis, but sustained engagement until a lasting solution is achieved."

African countries have emerged as pioneers in addressing the problem of IDPs. In December, the Kampala convention, the world's first legally binding instrument to outline the obligations of governments to protect and assist IDPs, came into force.

So far, the convention has been signed, although not necessarily ratified, by 37 of the 53 members of the African Union. It binds governments to provide legal protection for the rights and wellbeing of those forced to flee inside their own countries due to conflict, violence, natural disasters, or development projects. Under the convention, governments must gather data and identify IDPs to understand where they are and what they need, provide personal ID documents, trace families and help to reunite them, and consult IDPs in decisions on their needs.

57th Commission on the Status of Women

Worldwide, it is estimated that one in every three women has been beaten, coerced into sex or abused in some other way. Women and girls who have been displaced by conflict are at particular risk of gender-based violence (GBV). From the Democratic Republic of Congo to Syria, forms of GBV such as rape, sexual exploitation and forced prostitution turn women’s lives upside down, leaving lasting physical and emotional scars. GBV doesn't just affect women, but it has deep and lasting effects on families, communities, and societies.

Violence against women can and should be prevented. Also, survivors of GBV must be able to access the care and services that they need, including medical and mental health services.

Today, non-governmental organizations and activists are gathering at the United Nations for the first day of the 57th Commission on the Status of Women. As one of the participants in the Commission, the Women's Refugee Commission is also starting a social media initiative called "Power of Prevention: Ending Violence Against Women and Girls in Crises", which aims to raise awareness about the prevention of GBV in crisis settings and highlight tools and resources to help make displaced women and girls safer.

Study Finds Group Interpersonal Psychotherapy Reduces Symptoms of Depression Among Adolescent Girls Affected by War in Northern Uganda

Prior research indicates that war-affected youth are at increased risk of mental health issues, and many humanitarian organizations have been implementing interventions to ameliorate these problems. Yet, few rigorous evaluations have been conducted and even fewer have implemented a randomized control design. Using a randomized control design, Bolton et al. (2007) examined the effectiveness of a group interpersonal psychotherapy intervention (IPT-G) and a creative play intervention (CP), as compared to a wait-list control group, in decreasing depression symptoms, anxiety symptoms, and conduct problems among war-affected adolescents. The authors first developed locally derived measures for depression, anxiety, conduct problems, and functioning to create the Acholi Psychosocial Assessment Instrument (APAI), which was found to have strong test-retest reliability and criterion validity. Stage one of the screening asked community leaders, teachers, community workers, and adolescents to create a list of 14 to 17-year-olds who exhibited at least one of the locally-derived depression symptoms. Stage two of the screening process administered the locally derived instrument to community-identified children to determine who should be included in the study. The study employed a pretest-posttest control group design, with participants randomly assigned to one of the three groups. The authors found that all three groups experienced decreased symptoms of depression. However, only girls experienced statistically significant reductions in their depressive symptoms after participating in IPT-G. Neither IPT-G nor CP were associated with improvement in anxiety, conduct problems, or functioning.

Based on previous RCTs in sub-Saharan populations, the authors recognized that attrition could pose a threat to the study’s validity by decreasing sample size and power and compromising the integrity of the random assignment. To address this, the authors employed intent-to-treat analysis, using pretreatment data from subjects who have dropped out as both pre- and post-test data. Intent-to-treat analysis also provided a conservative test of the hypothesis, making the effect of IPT-G all the more compelling. To decrease attrition further, the experimenters used a unique method of obtaining informed consent from the sample, both before the administration of the pre-intervention measure and after random assignment to one of the three groups. This study contributes to the growing knowledge base about ways to address the effects of war among adolescents, and proves that randomized control study designs can be implemented in difficult contexts with vulnerable populations.

Reference:
Bolton, P., Bass, J., Betancourt, T., Speelman, L., Onyango, G., Clougherty, K.F., Neugebauer, R., Murray, L., and Verdeli, H. (2007). Interventions for depression symptoms among adolescent survivors of war and displacement in Northern Uganda: A randomized control trial. Journal of the American Medical Association, 298(5), 519-527

Behavior, Development, and Society

In his sixth chapter of Introductory Lectures on Psychoanalysis, Freud focuses on the interpretation of cultural phenomena. Using analysis of the dream world as the basis of interpretation, he suggests “We want something that is sought for in all scientific work – to understand the phenomena” (p. 129). In exploring phenomena, Freud’s writings seem wholly focused on the individual as a singular entity to explore through analysis. Nevertheless, Freud expounds upon the contradictory demands of the individual and society; the interpretation, translation, and analysis of cultural phenomena are associated with the clash between the individual and society.

Whereas Freud emphasizes the conflict between the interests of society and the demands of the individual, Parsons (1954) highlights that these elements are independent, as well as interactive with each other. In other words, the individual supports society, just as society supports the individual. With an emphasis on order and cohesion, Parsons, like Freud, also believes that social phenomena can be described, analyzed, and explained. Parsons’ four-factor model of social system dimensions – adaptation, goal attainment, pattern maintenance, integration – can be used as a model for analyzing any kind of relationship. In beginning to outline his concept of structural-functionalism, Parsons proposes a theory of social action, depicting human action as a system. This system is composed of four interdependent and interaction units making up “a body of logically interdependent generalized concepts of empirical reference” (p. 212): individual, personality, social system, and culture. In Parsons’ world, theory’s purpose is to facilitate description and analysis. By description, he refers to determining verifiable answers to all the scientifically important questions. By analysis, he refers to ensuring that the conceptual structure is delineated through propositions, or building larger concepts upon smaller ones.

Erikson’s (1997) “Major Stages of Psychosocial Development” illustrates Parsons’ concept of propositions, with one stage building upon another like a developmental ladder. Erikson provides an outline of his theoretical system, from infancy through old age, as the individual “gradually becoming what one has caused to be, one eventually will be what one has been” (p. 79). At first glance, the stages alone do not seem to take into account contextual variation among individuals. Yet, the fact that the stages are general and not stringently outlined, makes it more applicable to various contexts. Erikson’s framework of psychosocial development is particularly mindful of the cultural location of the developmental tasks and of the ways in which the natural movement through development may be distorted by external forces. As a powerful external force, armed conflict disrupts the developmental processes of the individual, family, and community. In particular, the role of caregivers is compromised, as they face increasing external demands that prioritize safety and survival. As a result, developmental needs of children are compromised and movement between stages is stalled.

Are the theoretical concepts of Freud, Parsons, and Erikson relevant today? In order to address issues of human development in today’s society, culture must be considered. All individuals are participants in cultural communities, engaging with others in shared endeavors and building upon cultural practices of previous generations. Human development is a process of participation in society, while society represents the culmination of various individuals interacting with others. External forces, such as global crises, create another contextual layer through which the individual must interact and contend with.

References:
Erikson, E. (1997). The Life Cycle Completed. New York, NY: W.W. Norton.
Freud, S. (1991). Introductory Lectures in Psychoanalysis. London, UK: Penguin Books.
Parsons, T. (1954). Essays in Sociological Theory. New York, NY: Macmillan Company.

Mind-Body Skills Intervention Decreases Symptoms of Post-Traumatic Stress Disorder in Postwar Kosovar Adolescents

Incidence of post-traumatic stress disorder (PTSD) has been reported among war-affected children and adolescents. Yet few studies have evaluated the effectiveness of PTSD treatment programs for this population. Gordon, et al. (2009) conducted a randomized control trial to determine the effectiveness of an intervention aimed at ameliorating the effects of PTSD in adolescents. All children in Jeta e Re (“New Life”) High School in Kosovo were screened to participate in the study. Eighty-two students met the criteria for PTSD and were randomly assigned to two groups: (a) intervention group and (b) delayed intervention group. The intervention group participated in a comprehensive mind-body skills group program, a 12-session program consisting of meditation, guided imagery, breathing exercises, relaxation activities, therapeutic discussion, and art therapy. The delayed intervention group received the same intervention once the intervention group had completed the program, approximately 6 weeks later. The study shows that students receiving the mind-body skills group program had significantly reduced levels of PTSD symptoms as compared to the delayed intervention control group.

This study is the first randomized control study to examine the effects of a therapeutic intervention on war-affected adolescents. The study design overcomes the ethical dilemma of withholding promising treatment from the control group by providing treatment to the control group after the intervention group has completed post-intervention interviews. Nevertheless, expectation bias poses a threat to the study’s internal validity, because the results of the improved outcomes may be due to the participants’ expectations that the intervention would be effective. This threat to internal validity is supported by the fact that the intervention was piloted in the school prior to the study, building even more anticipation, as students are bound to share their experiences with other students. This is also be related to the process of testing, which could be a threat to internal validity, because students may become familiar with the measures being used. Because teachers both facilitated the intervention and administered the measures, unintentional expectancy effects pose a threat to the study’s construct validity. In this case, teachers may have subconsciously expected students to show fewer PTSD symptoms in the post-test. Similarly, the students may have wanted to please the facilitators by showing improvements in the post-test. Despite the authors’ explanation that these students would only be comfortable speaking with a familiar adult, future studies should utilize external experimenters to administer the pre- and post-test, because they will be naïve to which students received the intervention and will have no vested interest in the outcome of the intervention.


Reference:
Gordon, J.S., Staples, J.K., Blyta, A., Bytyqi, M., and Wilson, A.T. (2008). Treatment of posttraumatic stress disorder in postwar Kosovar adolescents using mind-body skills groups: A randomized controlled trial. Journal of Clinical Psychiatry, 69(9), 1469-1476.

Combination of Education and Trauma Healing Activities Decreases Trauma Symptoms in War-Affected Children in Sierra Leone

Though research indicates that higher levels of traumatic events among war-affected children leads to greater incidence of negative mental health outcomes, there is little evidence about the effectiveness of psychosocial interventions to mitigate these consequences. Gupta and Zimmer (2008) focus on determining the effectiveness of a psychosocial intervention study among children affected by the conflict in Sierra Leone. The sample was randomly drawn from school registration lists provided by the Ministry of Education, which contains all school-age children residing in the Grafton and Trade Center camps for internally displaced persons. The sample focused on an equal number of boys and girls ages 8-17, for a total sample size of 315 children. The Rapid-Ed intervention consisted of an education module enhanced with eight sessions of structured trauma healing activities and unstructured recreation activities. Children were interviewed for the pre- and post-test by trained camp teachers using a semi-structured questionnaire, which was translated and back-translated into the local language (Creole). The pre-test was administered approximately 9-12 months after the start of armed conflict, and the post-test was administered 4-6 weeks after participants completed the intervention. Results show that 96% of children reported a significant reductions in concentration problems, sleep disturbances, bad dreams, and intrusive images after participating in the Rapid-Ed intervention. The study also found that there was a slight increase in avoidance symptoms after the intervention.

The study addresses selection bias by randomly selecting children from the target communities. Also, the low attrition rate (3%) was a strength, and most likely due to the accessibility and reliability of finding the students in formal schooling programs. However, the results of this study would be strengthened with the addition of a control group. Use of a control group would indicate whether it was the intervention that caused the decreased psychological distress or whether other factors were responsible. Firstly, maturation poses a threat to the internal validity, because the study is unable to discern whether the intervention was the cause of improved psychosocial outcomes or whether it was due to the subjects’ internal healing processes. Secondly, statistical regression may pose a threat to the internal validity, because the change due to the intervention cannot be distinguished from the effect of scores reverting toward the mean. A control group would have addressed these concerns and greatly improved the study’s internal reliability. However, the sensitive context creates ethical challenges in regards to whether one group can receive the intervention and the other one doesn’t.

Reference:
Gupta, L. and Zimmer, C. (2008). Psychosocial intervention for war-affected children in Sierra Leone. The British Journal of Psychiatry, 192, 212-216.

Study in Afghanistan Finds Trauma Exposure and Caregiver Mental Health Predict Risk of Negative Mental Health Outcomes in War-Affected Youth

Research conducted in war-affected situations has found an association between exposure to traumatic events and mental health outcomes. However, there have been few studies focusing on the mental health outcomes of children and adolescents affected by war. Panter-Brick, et al. (2009) conducted a study aimed at determining a causal relationship between war and mental health problems, specifically looking at associations related to gender, traumatic events, caregiver mental health, and socio-demographic characteristics. The sample targeted children ages 11 to 16, who were randomly drawn from randomly selected schools in three purposively chosen regions of Afghanistan. Data were gathered from three informants (children, caregivers, and teachers), who were interviewed with a variety of brief measures. Measures were chosen because they had high reliability in other contexts of instability. To increase instrument diagnostic validity, measures were translated, back-translated, and reviewed by a multi-disciplinary team. The research found that the variables of exposure to multiple trauma and caregiver mental health were predictive of psychopathology for in-school Afghan adolescents. Previous research corroborates this finding and adds to the study’s external validity. Furthermore, the study found that girls were more likely than boys to develop poor mental health outcomes, such as depression.

The authors explore the quality of traumatic events to include not just war-related events, but accidents, corporal punishment, illness, death of a relative. The quality of the particular incident is not indicative of predicting poor mental health, but rather the accumulation of traumatic events contribute to risk factors for mental health problems. The study includes a few threats to validity. By only sampling school children, the study neglects out-of-school youth, who may be at high risk of developing psychopathology. Furthermore, even though the sample of in-school youth was stratified to include accurate proportions of boys and girls, the focus on in-school youth disproportionately excludes girls, because boys are more likely to attend school than girls. The school samples were restricted to three urban areas, affecting external validity and indicating that future research might consider including a sample from a rural setting. Despite its limitations, this study indicates the value of working within the school system to assess children’s mental health needs and proves the value of school-based mental health services. Furthermore, the findings contribute to the small but much needed knowledge base about the mental health of war-affected children.

Reference:
Panter-Brick, C., Eggerman, M., Gonzalez, V., and Safdar, S. (2009). Violence, suffering, and mental health in Afghanistan: a school-based survey. The Lancet, 374, 807-816.

The Spirit Catches You and You Fall Down

Anne Fadiman's excellent examination of the clash of two cultures - one the Hmong refugees, and the other, Western medicine - not only proves the importance of holistic child development and a family-centered approach, but also draws attention to the struggle many families in forced displacement must face. The following passage, describing how families with young children coped during their flight, is horrifying, yet still (unfortunately) within the boundaries of comprehension in the context of armed conflict.

"Many people carried children on their backs. The babies presented a potentially fatal problem: they made noise. Silence was so essential that one Hmong woman, now living in Wisconsin, recalled that her son, who was a month old when the family left their home village, didn't know a single word when they arrived in Thailand two years later, because no one had talked that entire period except in occasional whispers. Nearly every Hmong family I met in Merced had a story to tell about a baby - a relative's child, a neighbor's child, a member of the group they escaped with - who had been drugged with opium. 'When the babies would cry,' a young mother named Yia Thao Xiong told me, 'we would mix the opium in the water in a cup and give it to them so they would be quiet and the soldiers would not hear, because if they heard the babies, they would kill all of us. Usually the baby just went to sleep. But if you give too much by mistake, the baby dies. That happened many, many times.' When I heard these stories, I recalled something I had once read about an Israeli child, hiding from Palestinian terrorists, who, when she began to cry, was accidentally smothered to death by her mother. That death, in 1979, was said to have driven the entire Israeli nation into mourning. The horror of the opium overdoses was not only that such things happened to the Hmong, but that they happened so frequently that, far from driving a nation into mourning, they never made headlines, never caught the world's ear, never reached beyond a community of families that numbly accepted them as a fact of life" (p. 162).

Rethinking ECD

I had an interesting conversation with a colleague about the direction that the Early Childhood Development (ECD) community is heading, especially in light of increased emphasis on ECD in emergency settings. Because the roots of ECD are grounded in development, it is a difficult transition to examine the non-developmental aspects of ECD in emergencies. Yes, one of the most important issues affecting very young children in crisis-affected settings is the impact on their development (from stimulation, separation from caregiver, etc.) because this has such long-term implications for young children as they transition into adolescence and adulthood and even greater implications for the development of nations and future investments in populations. However, in emergencies, there should be an equal importance placed on safety and protection issues, such as addressing the fact that young children are disproportionately affected by natural disasters. It is necessary to rethink ECD through multiple lenses.