Global Health Research in Humanitarian Crises

Written by Nivedita Poola

Edited by Wesley Chan

The rise in humanitarian crises including natural disasters, pandemics, or political conflicts, has taken a significant toll on global, national, and individual health around the world and demands a robust response from the international community. In July 2021, the International Emergency Medicine Mini-Fellowship discussed three articles on the challenges and lessons learned in global health research during humanitarian crises.

Introduction to collection: confronting the challenges of health research in humanitarian crises [1]

The discussion started with this introductory article by Mistry et al. which addresses, in broad strokes, the dearth of research available to reference when acting in humanitarian crises. Specifically, this paper comments on a collection of 18 articles commissioned by the Fogarty International Center of the US National Institutes of Health. Per the authors of this paper, this case analysis addressed two of the three objectives initially outlined for this collection: to “highlight common challenges and share strategies for overcoming the difficulties of conducting health research in humanitarian crises” and to “demonstrate the feasibility and importance of health research in humanitarian crises.

The authors highlighted three themes common in these various studies. Firstly, due to ongoing challenges in research, including ethical issues, security concerns, and logistical difficulties, there is an obvious need for more humanitarian research. Second, local community engagement is significant to the research process and benefits the community. Finally, partnerships with other humanitarian players are important to addressing the challenges of conducting research.  

A case analysis of partnered research on palliative care for refugees in Jordan and Rwanda [2]

This case analysis by Laat et al., addresses the lessons and challenges of transnational partnerships while researching conflict-induced, refugee situations. Conducted by the Humanitarian Health Ethics Research Group, the research focused on providing palliative care to refugees in Jordan and Rwanda with poor clinical prognoses. The initial research plans were initiated in Canada, but the study objectives were developed with local players including health care providers, NGOs, and international aid agencies in each location. The authors recognized that these partnerships were “essential to inform [the] research strategies, ensure that study approaches were acceptable and ethically sound, complete the study, and to understand the context, needs, and opportunities for service providers and the populations they serve”. While the results of the primary study are not included, this article focuses primarily on three main challenges of building strong partnerships:

1. 1. Building, nurturing, and sustaining respectful and equitable research partnerships: The authors recognized the early decision-making was “lopsided” until local partnerships were made. A notable initial challenge was buy-in from local players, with a broader challenge regarding the historical power differentials and possible racial hierarchies that introduced concerns of distrust and exploitation.
2. 2. Ethics review and challenges of responding to local decision-makers’ research needs: While initial ethic approvals were done in Canada, modifications to fit local needs and culture were expected. The authors recognized the challenges of collaborating with “cultural navigators” and multiple other project members to ensure local ethics review was thoroughly completed.
3. 3. Equity and fairness towards vulnerable populations: In both Jordan and Rwanda, discussions about death and dying are considered a cultural taboo. The authors noted the challenges of addressing these cultural norms and providing fair and culturally appropriate compensation for participation. Additionally, the authors noted the challenge of interviewing refugees, a vulnerable population, that required training with refugee care professionals and scholars skilled in crisis-setting.

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 [3]

The final article discussed, by Gaffey et al., outlines the research challenges and strategies employed by researchers in Somalia, Mali, Pakistan, and Afghanistan during armed conflicts. As part of a larger group of case studies through the BRANCH Consortium, the researchers aimed to provide evidence for effective interventions for women and children’s health and nutrition. The authors of this article elaborate on the challenges, both anticipated and unexpected, due to insecurity, socio-political complexity, and data acquisition.

1. 1. Insecurity: Safety was an important consideration in all four studies given that each study occurred in the setting of armed conflict. Infrastructure, armed violence, and challenging terrains are amongst the many problems limiting access to study participants as well as interactions between team members. These barriers required investigators to prepare for and rely on multiple modes of communication, including videoconference and instant messaging. Data collection teams and local/non-local team members would maximize limited windows of time to meet study participants or hold meetings. The authors also recognized the need for investigators to negotiate with non-state actors and to adjust data collection protocols to protect at-risk study participants.
2. 2. Navigating local sociopolitical contexts: Because an objective was to understand the effect of conflict on the humanitarian health response for women and children, investigators relied heavily on local partners to identify appropriate study areas, stakeholders, and study participants and ensure culturally appropriate study methods and tools. While some local and international partnerships proved to be difficult or impossible, the authors concluded leveraging local partners’ knowledge was key to navigating the local social and political practices.
3. 3. Lack of reliable intervention coverage and other quantitative data: High-quality data collection in these conflict settings proved to be difficult. For example, achieving a representative sample, accessing complete records, and analysis of such data are all challenging steps in the study. Investigators attempted to analyze data stratified by conflict intensity. Per the authors, solutions in this area of research remain unclear and an area they suggested requires more methodologic research.
4. 4. Maintaining consistency across studies: Across these four studies, while initial protocols were made, investigators had to adjust plans to the local conditions. The consortium was aware of this likelihood and evaluated for trends and common elements.

Discussion:

The group discussion revolved around the desire for more specifics within each of these research articles. For example, it is mentioned that the research teams developed strategies to overcome challenges or found avenues to engage communities, but concrete examples were not provided. While solutions would be context-specific, providing examples of the discussions and trainings mentioned could help the readers brainstorm for their challenges with collaborators and partners. That said, the articles provided context to know what challenges to expect, especially for those new to working in humanitarian settings. These articles provided insight into how challenges in multiple humanitarian crises may be handled, highlighting the importance of the networks for those who have worked internationally. Per some participants with international experience, local partnerships and the networks that were made were key to everything from developing projects, learning what is needed, and even making complete adjustments to projects based upon the changing political and social climate (i.e. political instability, COVID pandemic, etc.).  

Take away points:

1. 1. Perhaps an obvious point, but one not to underestimate: the scope of “global health” is broad. As emergency medicine professionals or professionals in truly any area of health care, there is much to research and much to do.
2. 2. In any project we hope to pursue, we cannot and should not forget to, in good faith, find local partners who will likely be more finely attuned to the needs of their community.
3. 3. Networking is key: The networks we make, both with local, national, and international actors, are vital to the development of research and ensuring we can overcome the challenges we face.

References

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• Global Health Research in Humanitarian Crises - September 30, 2021