Neglected Diseases, Civil Conflicts, and the Right to Health INSTITUTE OF MEDICINE September 22nd, 2010 Chris Beyrer MD, MPH Director, Center for Public Health and Human Rights Johns Hopkins Bloomberg SPH

Key Themes • NTDs are diseases of neglected peoples-conflicts fuel neglect • Conflict, post-conflict, and other settings of chronic rights abuses can aid and abet NTDs through direct and indirect pathways • Interventions for NTDs in conflict settings are challenging, but can have measurable impacts

The Challenge “In addition to understanding possible explanations for observed results, it is also important to recognize the limitations of the survey, due, in part, to the difficult context of operating in ______. First, the lack of up-todate census data and a geo-referenced village database – due to longstanding civil war – meant that villages could not be selected entirely at random from within areas identified to be at risk of ______.”

Outline • Introduction • Mechanisms • Cases – HAT in Central Africa – Parasites and displacement

• Interventions – De-worming and Malaria control: Eastern Burma – Other ways forward

• Discussion and conclusions

NTDs and Conflict Recent reports on high burden of NTDs in conflict settings (blue = negative findings) HAT in Africa (6 States)

Berrang-Ford

SSM

2010

All NTDs, S S Africa

Hotez

PLoS NTDs

2009

NTDs + Malaria, review

Furst

PloS NTDs

2009

Buruli Ulcer, DRC

Suykerbuyk

Am J T M H

2009

Leishmania, Sudan

Bern

PLoS NTDs

2008

Parasites, stunting, Sri Lanka

Chandrasena

Trop Doc

2007

NTDs, Burma & Colombia

Beyrer

Lancet

2007

Blindness (CT), Sudan

Ngondi

Bull WHO

2005

Blindness (CT), Rwanda

Mathenge

PLoS Med

2007

How do conflicts increase vulnerability to NTDs? • Increased Exposure – Displacement, overcrowding in camps, resettlement areas, forest/bush encampments

• Increased Acquisition and Transmission – Treatment delays or gaps, barriers to access, lack of access to water, hygiene, food

• Increased morbidity and mortality – Barriers to access treatment, care

How do conflicts/terror regimes increase neglect of NTDs? • Impacts on health care systems, surveillance, delivery systems • Impacts on providers • Impacts on research

Conceptual framework: direct and indirect effects of an armed conflict on health status of households.

Furst et al. PLoS NTD 2009

Estimated fraction of the adult population displaced in Cote d’Ivoire’s armed conflict in 2002

Study Area

Estimated adult population size in 2001

North

552,686

25

414,515

Central

802,325

40

481,395

West

1,075,731

55

484,079

Source: Betsi , N. et al., AIDS Care, 18:4,356-365

Estimated % of adult population displaced

Estimated adult population size in April/May 2004

Number of health staff before and after Cote d’Ivoire’s 2002 conflict # of health staff in Central Cote d’Ivoire

# of health staff in North Cote d’Ivoire

Qualification

2001

2004

Reduction (%)

2001

Medical doctor

127

3

124 (98)

38

2

36 (95)

69

6

63 (91)

Nurse

471

67

404 (86)

257

82

175 (68)

310

42

268 (86)

Qualified midwife

184

26

158 (86)

65

9

56 (86)

90

6

84 (93)

Nurses’ aid

42

6

36 (86)

23

5

18 (78)

10

1

9 (90)

Laboratory technologist

88

12

76 (86)

51

10

41 (80)

54

7

47(87)

912

114

798 (88)

108

108

326 (75)

533

62

471(88)

Total

Source: Betsi , N. et al., AIDS Care, 18:4,356-365

Reduction (%)

# of health staff in West Cote I’voire

2004

2001

Reduction (%)

2004

Total Number of Cases of STIs Recorded by Health Staff and NGOs Baseline situation in 2001

Situation in the period between April ’03 – April ‘04

T otal # of STIs

# of STIs per 1,000 adults

T otal # of STIs

Number of STIs per 1,000 adults

Central

9,629

12

6,708

13.9

North

2,697

4.9

2,748

6.6

West

12,310

11.4

20,232

41.8

Total

24,636

10.1

29,688

21.5

Study Area

Source: Betsi , N. et al., AIDS Care, 18:4,356-365

10 0

5

Studies

15

20

HIV/AIDS Studies Initiated, DRC, 1982-2004

1980

1985

1990

1995

Year Lowess smoothed curve with bandwidth 0.3

Source: Beyrer , C. et al. Civil conflict and health information: The Case of DR Congo. Public Health & Human Rights: Evidence Based Approaches , 2007

2000

2005

10 5 0

Studies

15

20

Figure 3. Malaria studies initiated, Democratic Republic of Congo, 1980 - 2004

1980

1985

1990

1995

2000

2005

Year Lowess smoothed curve with bandwidth 0.3 Source: Beyrer , C. et al. Civil conflict and health information: The Case of DR Congo. Public Health & Human Rights: Evidence Based Approaches, 2007

Case Example Human African Trypanosomiasis and conflict in Central Africa

HAT History in DRC •

Ekwanzala et al, in a 1996 study of the re-emergence of human African trypanosomiasis (HAT) as a result of the civil conflict in then Zaire

•

HAT cases peaked at over 30,000/year in 1930, and had declined to some 1,000/year at independence in 1960

•

During the corrupt and violent decades of the Mobutu dictatorship, cases rose to over 10,000/year by 1990

•

During social chaos which prevailed between 1991-1994, the HAT incidence peaked at 34,400 cases, the highest rate reported in the 20th century

•

“The neglect brought about an increase in the number of infectious people, an increase in transmission, and a higher cost and toxicity of treatment due to an increase in late-stage HAT cases.”

Trypanosomiasis and African conflicts Country

Years

RR

Lag

DRC

1994-2000

13.3

Unknown

Angola

1996-2002

10.2

10

Uganda

1978- 1981

10.5

5-10

CAR

1995-2001

5.4

Cameroon

1982-1985

3.9

Sudan

2002e03

2.1

7-12

Berrang et al Social Science and Medicine 2010

Map of the distribution and incidence of sleeping sickness in Africa (1976 -2004).

Black circles identify clusters of incidence in space-time . Cluster years are shown for each circle, with annual incidence during the cluster years included in brackets; circle size is proportional to annual incidence during the cluster period.

Berrang-Ford et al. Social Science and Medicine 2010

cases per year

Average HAT cases per year (1976 – 2004)

Conflict severity Berrang-Ford et al. Social Science and Medicine 2010

cases per year

Average HAT cases per year (1976 – 2004)

Political terror scale Berrang-Ford et al. Social Science and Medicine 2010

(Buruli Ulcer) in Kasongo Territory, the Democratic Republic of Congo

Suykerbuyk et al Am. J. Trop. Med. Hyg 2009

Case Example Parasites and displacement

Displacement camps and intestinal helminths • Displacement camps are ideal locations for transmission of intestinal protozoan and helminth parasites • Due to poor sanitation and hygeine • Studies from Sierra Leone, Sri Lanka, show the association

Chandrasena 2007 Trop Doctor, Gbakami 2007, Af J med science

Interventions MOM Project: malaria control, de-worming, for IDP women in conflict zones

Mobile Obstetric Medics (MOM) Providing health services in the conflict zones in Eastern Burma Karen, Karenni, Mon, Shan ethnic teams, Mae T ao Clinic (Dr. Cynthia Maung), Hopkins, UCLA Cross border MCH program – Family planning, ANC care, attended deliveries, BEOC, TBA training – malaria screening in pregnancy (heat stable rapid test Paracheck) – Mass deworming to treat maternal anemia Supported by Bill & Melinda Gates Institute for Population and Reproductive Health at Johns Hopkins

Map of Eastern Burma showing the MOM Project Communities

Mullany et al., PLoS Med 2010

Backpack supply teams carrying medical supplies to IDP Communities, Eastern Burma. The Mobile Obstetric Medic Project

Table 1. Survey sampling frame, coverage and response rate, and household size. Sample characteristic

Karen

Karenni

Shan

Mon

Overall

Estimated population in pilot areas

44700

7257

4959

4228

61114

Estimated reproductiveaged women

8953

1453

992

845

12223

Intended clusters

160

40

N/A

N/A

175 (87.5%)

Surveys conducted

1,380 (86.3%)

367 (91.8%)

337 (100.0%)

400 (100.0% )

2,484 (88.7%)

Agreed to participate

1,339 (97.0%)

367 (100.0%)

337 (100.0%)

399 (99.8%)

2,442 (98.3%)

Total sample within participating households

7,568

1,412

1,497

1,975

12,452

Mean household size (SD)

5.7 (2.1)

3.8 (1.9)

4.4 (1.7)

4.9 (1.9) 5.1 (2.1)

Mullany et al. PLoS Medicine 2010

Cross-Border Medical Obstetric Medic in Eastern Burma, 2007

Table 3. Changes in coverage of antenatal and postnatal interventions. Service Provided

Baseline (n = 2,252)

Endline (n = 1,531) PRR (95% CI)

>1 ANC visits

39.3%

71.8%

1.83 (1.64–2.04)*

>4 ANC visits

16.7%

34.4%

2.06 (1.72–2.47)*

Blood pressure measured

43.1%

72.9%

1.69 (1.51–1.89) *

Urine tested

15.7%

42.4%

2.69 (2.05–3.54)*

Malaria test done

21.9%

55.5%

2.53 (2.01–3.18)*

Positive rate

36.7%

11.8%

0.32 (0.24–0.43)*

90 d Fe/Folic Acid

11.8%

41.3%

3.49 (2.80–4.35)*

De-worming treatment

4.1%

58.2%

14.18 (10.76–18.71)*

Presumptive antimalarial provided

9.8%

12.5%

1.27 (0.93–1.75)

Antenatal visit coverage

Antenatal interventions

Mullany et al. PLoS Medicine 2010

Table 3. Changes in coverage of antenatal and postnatal interventions. Service Provided

Baseline (n = 2,252)

Endline (n = 1,531) PRR (95% CI)

Antenatal interventions, continued Used insecticide treated 21.6% net

59.3%

2.75 (2.19–3.45)*

Tetanus toxoid >1 dose

22.4%

15.6%

0.69 (0.47–1.03)

>2 doses

14.3%

6.5%

0.46 (0.20–1.03)

PNC visit within 7 d

33.7%

69.8%

2.07 (1.81–2.37)*

Skin-to-skin care given

10.1%

27.2%

2.70 (1.93–3.78)*

Maternal post partum Vitamin A

12.3%

63.4%

5.17 (4.17–6.43)*

Breastfeeding initiated within 24 h

93.7%

95.8%

1.02 (0.99–1.05)

Postnatal interventions

Mullany et al. PLoS Medicine 2010

Responses: NTDs in Conflict • Innovative delivery: Cross-border into conflict • Train and empower local ethnic health workers • Communities based groups can access areas and populations others cannot • Meets the “responsibility to protect.” R2P , imperative

Ways forward: example malaria control 2

•

Successful malaria control in IDP camp in Timor-Leste during conflict

Martins et al Malaria Journal 2009

State Responsibilities Signatory States must not violate these rights Commit to measurable progress to: Respect Protect Fulfill

Forced Migration: Operation Murambatsvina or “Clear the filth” Porta Farm, Zimbabwe

June 22, 2002

Source : © Digital Globe, Inc., Amnesty International 2006

April 6, 2006

There are no illegal human beings

Archbishop Desmond Tutu

Acknowledgements Johns Hopkins – Stefan Baral – Sonal Singh – Voravit Suwanvanichkij – Darshan Sudarshi (Oxford) – Lea Berrang-Ford Mcgill Univ. – Juerg Utzinger Univ. Basel