Where do we work?
Africa: Central African Republic; Democratic Republic of Congo; Guinea; Liberia; Niger; Rwanda; Sierra Leone; Somalia; Somaliland; South Sudan; Sudan; Uganda
Asia: Bangladesh; Cambodia; Georgia; Myanmar; Nepal; Sri Lanka
Middle East: Afghanistan; Lebanon; Iraq; Syria; Yemen
COVID-19 and related public health threats in populations affected by crises: a multi-disciplinary, collaborative research programme
Crises due to armed conflicts, natural disasters and food insecurity result in excess mortality and mental health problems, especially when people are forcibly displaced. Public health information plays a potentially key role in informing resource allocation and the design and implementation of humanitarian responses. Epidemics are a particular threat in crisis settings and create specific information requirements. The COVID-19 pandemic’s health impact in crisis-affected populations is mostly unclear due to inadequate testing and surveillance for SARS-CoV-2, stigma and other societal factors, and limited measurement of the indirect effects of control measures on various thematic areas, including sexual and reproductive health, non-communicable diseases and mental health, for which programmatic adaptations are warranted.
The pandemic has also highlighted the importance of retrospective and prospective monitoring of mortality (already a common information gap in humanitarian responses) as a key metric of ultimate downstream impacts, and a basis for fitting realistic transmission dynamic models. COVID-19 control has also relied heavily on non-pharmaceutical interventions, including hygiene behaviour change, a historically underfunded area with outstanding evidence gaps to fill. Addressing the above evidence challenges must contend with a dearth of methodological expertise, shrinking humanitarian and researcher access to affected populations, and a post-colonial architecture that disempowers local actors. Against these challenges, we identify key capacity-strengthening and methodological innovation opportunities.
We have formed a consortium of academic and civil society organisations, funded by the US Centers for Disease Control, that proposes to work collaboratively and equitable to conduct research among crisis-affected and displaced populations in the context of COVID-19. This programme is a multi-disciplinary partnership, with LSHTM as the lead applicant, and partners in each of the research countries: the Université Catholique de Bukavu in DRC, SIMAD University in Somalia, the Bridge Network Organisation in South Sudan, and the Youth Peer Education Network (Y-Peer) in Sudan (who work under the umbrella of Adeela, a Sudanese civil society incubator NGO). Our partnership is committed to coproduction principles and will adopt a decolonial approach to research and humanitarian action. The LSHTM Principal Investigator is Francesco Checchi and LSHTM Research Manager is Lucy Bell.
This programme of research and capacity strengthening runs from February 2022 to September 2026, focused on four key crisis-affected countries (the Democratic Republic of Congo, Somalia, South Sudan and Sudan), but with flexibility to conduct data collection in new emergencies and other settings where existing collaborations facilitate this. This programme activities and studies are organised along three aims:
Aim 1: Establish or strengthen country-based, locally-led, multi-disciplinary humanitarian public health research units in the four key countries.
Aim 2: Explore novel cross-cutting methods based on community-led surveillance and data science methods.
Aim 3: Generate thematic evidence on the direct and indirect impacts of COVID-19 and other emergent public health threats, as per the following scientific objectives:
- Generate improved all-cause and cause-specific mortality estimates.
- Quantify transmission of SARS-CoV-2 and other epidemic infections.
- Explore changes to hygiene behaviours, improve monitoring of hygiene behaviours and evaluate alternative behaviour change interventions.
- Quantify and describe COVID-19’s secondary impacts on sexual and reproductive health.
- Quantify COVID-19’s impacts on non-communicable disease burden and mental health and test novel care models.
BRANCH Consortium (Bridging Research and Action in Conflict Settings for the Health of Women and Children)
A recent Save the Children report highlighted that some 357 million children, one in every six children in the world, currently live in a conflict zone. Almost half of them live in severe conflict settings. New estimates of the mortality burden are important given that the accuracy of commonly-cited crude estimates of maternal (and possibly child) deaths in such settings has been criticised. However, these new mortality figures do not capture the lasting impact that exposure to violence in war and conflict has on the mental health and developmental trajectories of children or the thousands of childhoods lost through conscription of child soldiers or through sexual and gender based violence in such settings.
We still lack the knowledge and tools required to effectively restore, protect, and promote the health and wellbeing of women and children affected by conflict. We know which health interventions and services work in development settings, and often how best to implement them, but our understanding and appreciation of what more can be done for women and children affected by conflict remains limited. Guidelines and guidance on prioritising and implementing child health and nutrition interventions in conflict settings remain sparse. Existing handbooks and manuals are constrained by a general focus on broader humanitarian settings or by a paucity of evidence to underpin or inform maternal and child health recommendations.
Led by the The Hospital for Sick Children in Canada, with co-investigators from Harvard T.H. Chan School of Public Health, Johns Hopkins School of Public Health, George Washington University, Stanford University and LSHTM (Karl Blanchet and Neha Singh), the BRANCH consortium (Bridging Research and Action in Conflict Settings for the Health of Women and Children) aims to learn more about how best to reach women, children and adolescents affected by conflict and how best to provide them with optimal care. Fortunately, primary research in this area is growing. Multiple funding initiatives now explicitly support rigorous, ethical testing of strategies for delivering child focused interventions in conflict settings. Our consortium aims to consolidate and interpret research findings in relation to the whole body of evidence.
Later this year, The Lancet, BMJ and Conflict and Health journals will publish a series of papers by the BRANCH Consortium that critically assess the delivery of health and nutrition interventions to women, children and adolescents in the context of armed conflict. Neha Singh and Karl Blanchet have also led a mixed-methods study of coordination, decision-making, and health service delivery among humanitarian actors in 10 countries affected by conflict, which is due to be published in The Lancet in November 2019. We hope that the BRANCH consortium's outputs will amplify the urgent need and global call for better evidence, better care, and better outcomes for women, children and adolescents affected by conflict.
ACCESS: Approaches in Complex and Challenging Environments for Sustainable SRHR
The London School of Hygiene & Tropical Medicine is to play a leading role in a new UK Government funded consortium that aims to boost global sexual and reproductive health and rights (SRHR). Centre Director Karl Blanchet is a co-investigator and Deputy Director Neha Singh will also be working on the project.
Contraception and safe abortion care services, HIV/STI prevention, treatment and care, and comprehensive sexuality education are extremely poor for marginalised groups in many parts of the world. Announced by the UK Department for International Development, Approaches in Complex and Challenging Environments for Sustainable SRHR (ACCESS) Consortium seeks to create innovative solutions in complex and challenging environments to ensure that marginalised groups such as young people, disabled people and refugees are not left behind.
Read more about the project here.
Anatomy of therapeutic itineraries: ethnographic insights on Syrian health professionals-led initiatives in Lebanon
Principal Investigator: Karl Blanchet (LSHTM)
Collaborators: Diane Duclos (LSHTM), Jennifer Palmer (LSHTM), Fouad M. Fouad (AUB)
Seed funding was granted by the Wellcome Trust to conduct a feasibility study exploring to what extent humanitarian agencies can build on initiatives led by refugee health professionals to pilot public health interventions for refugees (registered and unregistered) in Lebanon.
The research objectives include:
- To identify the humanitarian initiatives led by Syrian displaced health professionals to meet refugee’s health needs in Lebanon
- To understand how refugees make decisions about their health providers and determine whether identified humanitarian initiatives could benefit from international support to implement public health interventions.
We are conducting an ethnographic study in the Bekaa Valley which is the home of the vast majority of Syrian refugees in Lebanon. We will explore encounters between displaced patients and displaced health professionals, and account for complex therapeutic itineraries at the intersection between formal and informal sectors. This study provides critical insight on humanitarian spaces by looking at how narratives and lived experiences of health seeking intersect with or challenge the humanitarian response developed to meet refugees’ health needs.
This project is a collaboration between LSHTM and the American University of Beirut.
Improving handwashing promotion in humanitarian crises
Principal Investigator: Sian White (LSHTM)
Collaborators: Jean Lapegue (ACF), Melinda Foran (CAWST), Val Curtis and Karl Blanchet (LSHTM)
In stable settings, handwashing with soap is known to be one of the most cost-effective public health interventions, reducing diarrhoeal disease up to 48% and contributing to the reduction of undernutrition. When a humanitarian crisis occurs, whether it be a disease outbreak, a natural disaster or a protracted conflict, the social and physical environments of the affected population are disrupted. These disruptions result in behavioural shifts, including to behaviours of public health significance, such as handwashing with soap. There is a dearth of literature on hygiene behaviour and its determinants in emergencies. This is a significant issue for crisis-affected populations whose disease risk increases in the wake of an emergency. It is also an issue for emergency responders. While this evidence remains lacking it will impede the development of effective hygiene programs. The proposed research will map the determinants of hygiene behaviour and understand the constraints of hygiene programming within these crises settings. It will involve a multi-stage literature review, a policy analysis and a multi-country qualitative case study, with the aim of drawing recommendations for practitioners.
The objectives of this research will be:
To develop a deep understanding of the determinants of hand hygiene in emergency settings so as to contribute to the development of rapid and effective behaviour change intervention tools.
The field work for this research will take place in Kurdistan, Iraq and the Kivus, and the Democratic Republic of Congo (DRC). In Kurdistan, we will assess the determinants of behaviour among Internally Displaced Persons (IDPs) living in and outside camps during a protracted conflict. DRC is regularly affected by cholera outbreaks and will act as a case study of how people behave in a disease outbreak. We will assess the determinants of behaviour before and during a cholera outbreak.
This research brings together the expertise of Action Contre la Faim (ACF), the London School of Hygiene and Tropical Medicine (LSHTM) and the Centre for Affordable Water and Sanitation Technology (CAWST). The study is funded by the US Office of Foreign Disaster Assistance (OFDA).
Establishing real-time evaluations of WASH interventions on disease outbreaks in emergency settings
Principal Investigator: Oliver Cumming
Collaborators: Lauren D’Mello-Guyett (LSHTM), Peter Maes (MSF), Rafael Van den Bergh (MSF)
The role of water, sanitation and hygiene (WASH) interventions as a means to both preventing and controlling infectious disease outbreaks is well established. However, at a practice and policy level, there have been numerous recent calls to address a perceived evidence gap as to how WASH interventions can be best mobilized, and to what impact, during outbreak responses.
More rigorous research that identifies interventions and approaches that optimize the contribution of WASH, in health facilities and in the community in low and middle income countries, to outbreak control strategies, may improve the efficiency of investments and yield significant public health benefits. There are numerous guidance manuals on the management of WASH in outbreaks and other emergencies, produced by different international agencies involved in emergency humanitarian relief, but with often divergent or conflicting messages. This lack of convergence further illustrates the need for better evidence that might inform future guidelines and improve the cohesion and coordination of multi-agency responses.
This research study will aim to:
Evaluate the outbreak response of a chosen humanitarian agency, using an appropriate study design Measure the impact and outcome of WASH interventions on secondary transmission of disease in a humanitarian crisis in low and middle income countries. And, to strengthen the evidence base for chosen interventions and how they maximise and contribute to control and prevention of disease in crises-affected populations.
This research brings together the operational expertise of Médecins Sans Frontières (MSF), the London School of Hygiene and Tropical Medicine (LSHTM) and the UK Rapid Support Team (UKRST). The study is funded by the MSF and the UKRST.
RECAP – Research capacity building and knowledge generation to support preparedness and response to humanitarian crises and epidemics
Principal Investigator: Bayard Roberts
Collaborators: John Edmunds (LSHTM), Melissa Parker (LSHTM), Francesco Checchi (LSHTM), Jo Borghi, Karl Blanchet (LSHTM)
In the thick of natural disasters or war, relief agencies work through the chaos to bring basic services – and dignity – to the victims. In such a challenging environment it is hard to stand back and study what is going on, collect data and assess whether and how aid could be delivered more effectively. Yet it is vital to find a way of examining it critically, if responses are to improve and the health of those caught up in crises is to be protected.
Involving Crises Centre members from all faculties of LSHTM with funding from the UK’s Global Challenges Research Fund, the RECAP project will create a network of academics and agencies to tackle this research problem. The network will include leading organisations in the UK, as well as the American University of Beirut, in Lebanon, and the University of Sierra Leone. Working with Médecins sans Frontières, the International Rescue Committee, and the largest NGO in the world – Bangladesh’s BRAC – we are going to build research skills and conduct studies in some of the world’s hotspots. The result should be better research methods and strong links between all the organisations, leading, in turn, to improved humanitarian policies – and, ultimately, the safeguarding of populations’ health.
Partners include the University of Sierra Leone, American University of Beirut, Oxford University, Refugee Law Initiative at the School of Advanced Studies, LSE, MSF, International Rescue Committee, Save the Children. BRAC Funder: Global Challenges Research Fund.