British Medical Journal
28 August 2015 (vol 351, issue 8024)
http://www.bmj.com/content/351/8024

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Editorials
Europe’s refugee crisis: an urgent call for moral leadership
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4833 (Published 09 September 2015) Cite this as: BMJ 2015;351:h4833
Kamran Abbasi, international editor, The BMJ,
Kiran Patel, consultant cardiologist, Heart of England NHS Trust,
Fiona Godlee, editor in chief, The BMJ
Offering asylum is a minimum standard of civilised society
Europe’s refugee crisis is the greatest test of humanity faced by the world’s rich countries this century. It isn’t a new crisis. Nor was it difficult for politicians to anticipate. Refugees have fled to Europe since at least the premature optimism of the Arab Spring in 2011. Today, optimism is replaced by desperation, a promise of freedom overshadowed by death. Western nations rushed to support the democratic principles of the Arab Spring yet are reluctant to address the root causes and the consequences, which include civil war and state brutality, most notably in Syria. Oil rich Arab States have played their part by allowing political oppression and conflict to flourish in their region. A funding crisis in UN organisations is affecting the humanitarian effort in the Middle East, driving refugees to Europe in greater numbers.1 Ignoring injustice and inequity in poorer countries and in areas of conflict has not prevented the consequences reaching the shores and borders of the rich world…

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Research
Effect of bivalent human papillomavirus vaccination on pregnancy outcomes: long term observational follow-up in the Costa Rica HPV Vaccine Trial
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4358 (Published 07 September 2015) Cite this as: BMJ 2015;351:h4358
Orestis A Panagiotou, researcher1, Brian L Befano, senior programmer2, Paula Gonzalez, investigator34, Ana Cecilia Rodríguez, investigator3, Rolando Herrero, group head4, John T Schiller, senior investigator5, Aimée R Kreimer, investigator1, Mark Schiffman, senior investigator1, Allan Hildesheim, senior investigator1, Allen J Wilcox, senior investigator6, Sholom Wacholder, senior investigator1 on behalf of the Costa Rica HPV Vaccine Trial (CVT) Group (see end of manuscript for full list of investigators)
Abstract
Objective
To examine the effect of the bivalent human papillomavirus (HPV) vaccine on miscarriage.
Design
Observational long term follow-up of a randomized, double blinded trial combined with an independent unvaccinated population based cohort.
Setting S
ingle center study in Costa Rica.
Participants
7466 women in the trial and 2836 women in the unvaccinated cohort enrolled at the end of the randomized trial and in parallel with the observational trial component.
Intervention Women in the trial were assigned to receive three doses of bivalent HPV vaccine (n=3727) or the control hepatitis A vaccine (n=3739). Crossover bivalent HPV vaccination occurred in the hepatitis A vaccine arm at the end of the trial. Women in the unvaccinated cohort received (n=2836) no vaccination.
Main outcome measure
Risk of miscarriage, defined by the US Centers for Disease Control and Prevention as fetal loss within 20 weeks of gestation, in pregnancies exposed to bivalent HPV vaccination in less than 90 days and any time from vaccination compared with pregnancies exposed to hepatitis A vaccine and pregnancies in the unvaccinated cohort.
Results
Of 3394 pregnancies conceived at any time since bivalent HPV vaccination, 381 pregnancies were conceived less than 90 days from vaccination. Unexposed pregnancies comprised 2507 pregnancies conceived after hepatitis A vaccination and 720 conceived in the unvaccinated cohort. Miscarriages occurred in 451 (13.3%) of all exposed pregnancies, in 50 (13.1%) of the pregnancies conceived less than 90 days from bivalent HPV vaccination, and in 414 (12.8%) of the unexposed pregnancies, of which 316 (12.6%) were in the hepatitis A vaccine group and 98 (13.6%) in the unvaccinated cohort. The relative risk of miscarriage for pregnancies conceived less than 90 days from vaccination compared with all unexposed pregnancies was 1.02 (95% confidence interval 0.78 to 1.34, one sided P=0.436) in unadjusted analyses. Results were similar after adjusting for age at vaccination (relative risk 1.15, one sided P=0.17), age at conception (1.03, P=0.422), and calendar year (1.06, P=0.358), and in stratified analyses. Among pregnancies conceived at any time from bivalent HPV vaccination, exposure was not associated with an increased risk of miscarriage overall or in subgroups, except for miscarriages at weeks 13-20 of gestation (relative risk 1.35, 95% confidence interval 1.02 to 1.77, one sided P=0.017).
Conclusions
There is no evidence that bivalent HPV vaccination affects the risk of miscarriage for pregnancies conceived less than 90 days from vaccination. The increased risk estimate for miscarriages in a subgroup of pregnancies conceived any time after vaccination may be an artifact of a thorough set of sensitivity analyses, but since a genuine association cannot totally be ruled out, this signal should nevertheless be explored further in existing and future studies.
Trial registration
Clinicaltrials.gov NCT00128661 and NCT01086709.

Health Affairs
September 2015; Volume 34, Issue 9
http://content.healthaffairs.org/content/current

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Issue Theme: Noncommunicable Diseases: The Growing Burden
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Achieving Effective Universal Health Coverage And Diagonal Approaches To Care For Chronic Illnesses
Felicia Marie Knaul1,*, Afsan Bhadelia2, Rifat Atun3 and Julio Frenk4
Author Affiliations
1Felicia Marie Knaul (fknaul@gmail.com) is director of the Miami Institute for the Americas and professor at the Miller School of Medicine, University of Miami, in Florida. At the time this research was conducted, she was director of the Harvard Global Equity Initiative, in Boston, Massachusetts.
2Afsan Bhadelia is a research associate at the Harvard Global Equity Initiative.
3Rifat Atun is a professor of global health systems in the Department of Global Health and Population at the Harvard School of Public Health.
4Julio Frenk is president of the University of Miami, in Florida. At the time this research was conducted, he was dean of the Harvard School of Public Health.
*Corresponding author
Abstract
Health systems in low- and middle-income countries were designed to provide episodic care for acute conditions. However, the burden of disease has shifted to be overwhelmingly dominated by chronic conditions and illnesses that require health systems to function in an integrated manner across a spectrum of disease stages from prevention to palliation. Low- and middle-income countries are also aiming to ensure health care access for all through universal health coverage. This article proposes a framework of effective universal health coverage intended to meet the challenge of chronic illnesses. It outlines strategies to strengthen health systems through a “diagonal approach.” We argue that the core challenge to health systems is chronicity of illness that requires ongoing and long-term health care. The example of breast cancer within the broader context of health system reform in Mexico is presented to illustrate effective universal health coverage along the chronic disease continuum and across health systems functions. The article concludes with recommendations to strengthen health systems in order to achieve effective universal health coverage.

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Cardiovascular Disease Screening By Community Health Workers Can Be Cost-Effective In Low-Resource Countries
Thomas Gaziano1,*, Shafika Abrahams-Gessel2, Sam Surka3, Stephen Sy4, Ankur Pandya5,
Catalina A. Denman6, Carlos Mendoza7, Thandi Puoane8 and Naomi S. Levitt9
Author Affiliations
1Thomas Gaziano (tgaziano@partners.org) is an assistant professor in the Cardiovascular Division of Brigham and Women’s Hospital, in Boston, Massachusetts.
2Shafika Abrahams-Gessel is a research manager at the Center for Health Decision Science in the Harvard T. H. Chan School of Public Health, in Boston.
3Sam Surka is a researcher in the Chronic Diseases Initiative for Africa at Old Groote Schuur Hospital, in Cape Town, South Africa.
4Stephen Sy is a programmer at the Center for Health Decision Science in the Harvard T. H. Chan School of Public Health.
5Ankur Pandya is an assistant professor of health policy and management at the Harvard T. H. Chan School of Public Health.
6Catalina A. Denman is a professor in the Centro de Estudios en Salud y Sociedad at El Colegio de Sonora, in Hermosillo, Mexico.
7Carlos Mendoza is a coinvestigator at the Instituto de Nutricion de Centro America y Panama, in Guatemala City, Guatemala.
8Thandi Puoane is a professor in the School of Public Health at the University of the Western Cape, in Bellville, South Africa.
9Naomi S. Levitt is director of the Division of Diabetes and the Chronic Diseases Initiative for Africa, both at Old Groote Schuur Hospital.
*Corresponding author
Abstract
In low-resource settings, a physician is not always available. We recently demonstrated that community health workers—instead of physicians or nurses—can efficiently screen adults for cardiovascular disease in South Africa, Mexico, and Guatemala. In this analysis we sought to determine the health and economic impacts of shifting this screening to community health workers equipped with either a paper-based or a mobile phone–based screening tool. We found that screening by community health workers was very cost-effective or even cost-saving in all three countries, compared to the usual clinic-based screening. The mobile application emerged as the most cost-effective strategy because it could save more lives than the paper tool at minimal extra cost. Our modeling indicated that screening by community health workers, combined with improved treatment rates, would increase the number of deaths averted from 15,000 to 110,000, compared to standard care. Policy makers should promote greater acceptance of community health workers by both national populations and health professionals and should increase their commitment to treating cardiovascular disease and making medications available.

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Overcoming Obstacles To Enable Access To Medicines For Noncommunicable Diseases In Poor Countries
Sandeep P. Kishore1,*, Kavitha Kolappa2, Jordan D. Jarvis3, Paul H. Park4, Rachel Belt5,
Thirukumaran Balasubramaniam6 and Rachel Kiddell-Monroe7
Author Affiliations
1Sandeep P. Kishore (sunny.kishore@gmail.com) is a fellow at Yale University, in New Haven, Connecticut, and president of the Young Professionals Chronic Disease Network, in Boston, Massachusetts.
2Kavitha Kolappa is a resident in psychiatry at Massachusetts General Hospital, in Boston, a and board member for the Young Professionals Chronic Disease Network.
3Jordan D. Jarvis is executive director of the Young Professionals Chronic Disease Network and a former postgraduate research fellow at the Harvard Global Equity Initiative, in Boston.
4Paul H. Park is director of noncommunicable diseases for Partners in Health—Rwanda and a member of Universities Allied for Essential Medicines, in Washington, D.C.
5Rachel Belt is a member of Universities Allied for Essential Medicines.
6Thirukumaran Balasubramaniam is a Geneva representative at Knowledge Ecology International, in Switzerland.
7Rachel Kiddell-Monroe is a special adviser for the Universities Allied for Essential Medicines, a board member for the Young Professionals Chronic Disease Network, and a member of the International Board for Médecins sans Frontières, in Geneva.
*Corresponding author
Abstract
The modern access-to-medicines movement grew largely out of the civil-society reaction to the HIV/AIDS pandemic three decades ago. While the movement was successful with regard to HIV/AIDS medications, the increasingly urgent challenge to address access to medicines for noncommunicable diseases has lagged behind—and, in some cases, has been forgotten. In this article we first ask what causes the access gap with respect to lifesaving essential noncommunicable disease medicines and then what can be done to close the gap. Using the example of the push for access to antiretrovirals for HIV/AIDS patients for comparison, we highlight the problems of inadequate global financing and procurement for noncommunicable disease medications, intellectual property barriers and concerns raised by the pharmaceutical industry, and challenges to building stronger civil-society organizations and a patient and humanitarian response from the bottom up to demand treatment. We provide targeted policy recommendations, specific to the public sector, the private sector, and civil society, with the goal of improving access to noncommunicable disease medications globally.

International Journal of Infectious Diseases
September 2015 Volume 38, In Progress
http://www.ijidonline.com/current

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Planning for the Next Global Pandemic
Allen G.P. Ross, Suzanne M. Crowe, Mark W. Tyndall
Corresponding Editor: Eskild Petersen, Aarhus, Denmark
DOI: http://dx.doi.org/10.1016/j.ijid.2015.07.016
Abstract
In order to mitigate human and financial losses as a result of future global pandemics, we must plan now. As the Ebola virus pandemic declines, we must reflect on how we have mismanaged this recent international crisis and how we can better prepare for the next global pandemic. Of great concern is the increasing frequency of pandemics occurring over the last few decades. Clearly, the window of opportunity to act is closing. This editorial discusses many issues including priority emerging and re-emerging infectious diseases; the challenges of meeting international health regulations; the strengthening of global health systems; global pandemic funding; and the One Health approach to future pandemic planning. We recommend that the global health community unites to urgently address these issues in order to avoid the next humanitarian crisis.

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Short Communications
Investigating the immunizing effect of the rubella epidemic in Japan, 2012-14
Hiroshi Nishiura, Ryo Kinoshita, Yuichiro Miyamatsu, Kenji Mizumoto
p16–18
Published online: July 13 2015

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Epidemiological features and trends of Ebola virus disease in West Africa
Ligui Wang, Guang Yang, Leili Jia, Zhenjun Li, Jing Xie, Peng Li, Shaofu Qiu, Rongzhang Hao, Zhihao Wu, Hui Ma, Hongbin Song
p52–53
Published online: July 24 2015

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Probable transmission chains of Middle East respiratory syndrome coronavirus and the multiple generations of secondary infection in South Korea
Shui Shan Lee, Ngai Sze Wong
p65–67

JAMA
September 8, 2015, Vol 314, No. 10
http://jama.jamanetwork.com/issue.aspx

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Editorial | September 8, 2015
Antenatal Iron Use in Malaria Endemic Settings: Evidence of Safety?
Parul Christian, DrPH, MSc1; Robert E. Black, MD, MPH2
Author Affiliations
JAMA. 2015;314(10):1003-1005. doi:10.1001/jama.2015.10032.
Extract
Anemia related to iron deficiency during pregnancy occurs in 19% of women worldwide and in 20% of women in sub-Saharan Africa.1 Findings from observational studies reveal a linear, inverse relationship between maternal anemia and risk of maternal mortality across the entire distribution of hemoglobin concentrations, although confounding may be an issue.2,3 Severe anemia in pregnancy may result in maternal death due to cardiac failure. The current World Health Organization (WHO) guideline is to provide 30 to 60 mg of elemental iron and 400 µg of folic acid daily throughout pregnancy. This recommendation is mainly based on the proven effects of supplementation in reducing maternal anemia, iron deficiency, and low birth weight.4 In addition, approximately 35 million pregnant women, nearly all of whom live in sub-Saharan Africa, are at risk of Plasmodium falciparum infection annually.5 Across Africa, the prevalence of infection among children aged 2 to 10 years has declined from 26% in 2000 to 14% in 2013.5 Still, in 2013, an estimated 437 000 malaria deaths occurred in children younger than 5 years, representing 83% of all deaths due to malaria in Africa.5

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Original Investigation | September 8, 2015
Effect of Daily Antenatal Iron Supplementation on Plasmodium Infection in Kenyan Women: A Randomized Clinical Trial
Martin N. Mwangi, PhD1,2; Johanna M. Roth, MSc1,3; Menno R. Smit, MD1; Laura Trijsburg, MSc1; Alice M. Mwangi, PhD4; Ayşe Y. Demir, MD, PhD5; Jos P. M. Wielders, PhD5; Petra F. Mens, PhD3; Jaco J. Verweij, PhD6; Sharon E. Cox, PhD7,8; Andrew M. Prentice, PhD, FMedSci7,8; Inge D. Brouwer, PhD9; Huub F. J. Savelkoul, PhD1; Pauline E. A. Andang’o, PhD2; Hans Verhoef, PhD1,7,8
Author Affiliations
JAMA. 2015;314(10):1009-1020. doi:10.1001/jama.2015.9496.
Abstract
Importance
Anemia affects most pregnant African women and is predominantly due to iron deficiency, but antenatal iron supplementation has uncertain health benefits and can increase the malaria burden.
Objective
To measure the effect of antenatal iron supplementation on maternal Plasmodium infection risk, maternal iron status, and neonatal outcomes.
Design, Setting, and Participants
Randomized placebo-controlled trial conducted October 2011 through April 2013 in a malaria endemic area among 470 rural Kenyan women aged 15 to 45 years with singleton pregnancies, gestational age of 13 to 23 weeks, and hemoglobin concentration of 9 g/dL or greater. All women received 5.7 mg iron/day through flour fortification during intervention, and usual intermittent preventive treatment against malaria was given.
Interventions Supervised daily supplementation with 60 mg of elemental iron (as ferrous fumarate, n = 237 women) or placebo (n = 233) from randomization until 1 month postpartum.
Main Outcomes and Measures
Primary outcome was maternal Plasmodium infection at birth. Predefined secondary outcomes were birth weight and gestational age at delivery, intrauterine growth, and maternal and infant iron status at 1 month after birth.
Results
Among the 470 participating women, 40 women (22 iron, 18 placebo) were lost to follow-up or excluded at birth; 12 mothers were lost to follow-up postpartum (5 iron, 7 placebo). At baseline, 190 of 318 women (59.7%) were iron-deficient. In intention-to-treat analysis, comparison of women who received iron vs placebo, respectively, yielded the following results at birth: Plasmodium infection risk: 50.9% vs 52.1% (crude difference, −1.2%, 95% CI, −11.8% to 9.5%; P = .83); birth weight: 3202 g vs 3053 g (crude difference, 150 g, 95% CI, 56 to 244; P = .002); birth-weight-for-gestational-age z score: 0.52 vs 0.31 (crude difference, 0.21, 95% CI, −0.11 to 0.52; P  = .20); and at 1 month after birth: maternal hemoglobin concentration: 12.89 g/dL vs 11.99 g/dL (crude difference, 0.90 g/dL, 95% CI, 0.61 to 1.19; P < .001); geometric mean maternal plasma ferritin concentration: 32.1 µg/L vs 14.4 µg/L (crude difference, 123.4%, 95% CI, 85.5% to 169.1%; P < .001); geometric mean neonatal plasma ferritin concentration: 163.0 µg/L vs 138.7 µg/L (crude difference, 17.5%, 95% CI, 2.4% to 34.8%; P = .02). Serious adverse events were reported for 9 and 12 women who received iron and placebo, respectively. There was no evidence that intervention effects on Plasmodium infection risk were modified by intermittent preventive treatment use.
Conclusions and Relevance
Among rural Kenyan women with singleton pregnancies, administration of daily iron supplementation, compared with administration of placebo, resulted in no significant differences in overall maternal Plasmodium infection risk. Iron supplementation led to increased birth weight.
Trial Registration clinicaltrials.gov Identifier: NCT01308112

JAMA Pediatrics
September 2015, Vol 169, No. 9
http://archpedi.jamanetwork.com/issue.aspx

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Editorial
Human Trafficking of Children and Adolescents
Abigail English, JD
Extract
Human trafficking has severe adverse effects on the health, development, well-being, and human rights of vulnerable young people globally and in the United States. Awareness of human trafficking—once hidden in the shadows—is growing. Although precise estimates are not available of how many children and adolescents are affected, there is little doubt that young people everywhere have experienced physical and sexual violence from being trafficked and millions worldwide are at risk. Despite the increased awareness, significant gaps remain in evidence-based knowledge about the causes, consequences, and responses; the gaps are particularly noteworthy with respect to the health implications of human trafficking and the appropriate role of health care professionals.

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Original Investigation
Exploitation, Violence, and Suicide Risk Among Child and Adolescent Survivors of Human Trafficking in the Greater Mekong Subregion ONLINE ONLY
Ligia Kiss, PhD; Katherine Yun, MD; Nicola Pocock, MSc; Cathy Zimmerman, PhD
Abstract
Importance
Human trafficking and exploitation of children have profound health consequences. To our knowledge, this study represents the largest survey on the health of child and adolescent survivors of human trafficking.
Objective
To describe experiences of abuse and exploitation, mental health outcomes, and suicidal behavior among children and adolescents in posttrafficking services. We also examine how exposures to violence, exploitation, and abuse affect the mental health and suicidal behavior of trafficked children.
Design, Setting, and Participants
A survey was conducted with 387 children and adolescents aged 10 to 17 years in posttrafficking services in Cambodia, Thailand, or Vietnam, which along with Laos, Myanmar, and Yunnan Province, China, compose the Greater Mekong Subregion. Participants were interviewed within 2 weeks of entering services from October 2011 through May 2013.
Main Outcomes and Measures Depression, posttraumatic stress disorder, anxiety, suicidal ideation, self-injury, and suicide attempts.
Results
Among the 387 children and adolescent study participants, most (82%) were female. Twelve percent had tried to harm or kill themselves in the month before the interview. Fifty-six percent screened positive for depression, 33% for an anxiety disorder, and 26% for posttraumatic stress disorder. Abuse at home was reported by 20%. Physical violence while trafficked was reported by 41% of boys and 19% of girls. Twenty-three percent of girls and 1 boy reported sexual violence. Mental health symptoms were strongly associated with recent self-harm and suicide attempts. Severe physical violence was associated with depression (adjusted odds ratio [AOR], 3.55; 95% CI, 1.64-7.71), anxiety (AOR, 2.13; 95% CI, 1.12-4.05), and suicidal ideation (AOR, 3.68; 95% CI, 1.77-7.67). Sexual violence while trafficked was associated with depression (AOR, 2.27; 95% CI, 1.22-4.23) and suicidal ideation (AOR, 3.43; 95% CI, 1.80-6.54).
Conclusions and Relevance
Children and adolescents in posttrafficking care showed high symptom levels of depression, anxiety, and posttraumatic stress disorder, which are strongly associated with self-harm or suicidal behaviors. Mental health screening and reintegration risk assessments are critical components of posttrafficking services, especially in planning for family reunification and other social integration options.

Journal of International Development
August 2015 Volume 27, Issue 6 Pages 717–880
http://onlinelibrary.wiley.com/doi/10.1002/jid.v27.6/issuetoc

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Special Issue: The Post-2015 Moment: Towards Sustainable Development Goals and a New Global Development Paradigm
Introduction
The Post-2015 Moment: Towards Sustainable Development Goals and a New Global Development Paradigm
Charles Gore*
Article first published online: 5 AUG 2015
DOI: 10.1002/jid.3109
Abstract
The post-2015 moment is a moment in time in which multiple efforts are being made to envision a better long-term future for humanity and to forge, post-2015, a new and different global development trajectory. There is a need for not only new global goals but also a new global development paradigm. The papers in this special issue assess the Sustainable Development Goals in the making and offer constructive suggestions to further a paradigm shift that would bring the post-2015 development agenda to life in a transformative way rather than sustain business as usual.

The Lancet
Sep 12, 2015 Volume 386 Number 9998 p1013-1108
http://www.thelancet.com/journals/lancet/issue/current

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Comment
Diaspora engagement in humanitarian emergencies and beyond
Neeraja Nagarajan, Blair Smart, Joseph Nwadiuko
DOI: http://dx.doi.org/10.1016/S0140-6736(15)00071-9
Summary
Migration of health workers from low-income and middle-income countries (LMICs) to high-income countries continues unabated, with substantial effects on the development of health systems in LMICs.1–3 WHO estimates that an additional 4·3 million health-care workers are needed to meet global health-care needs, with acute shortages in LMICs.4 Yet almost 25% of physicians in high-income countries such as the USA, UK, Australia, and Canada are foreign-born and from the very LMICs that face shortages in health-care workforces.

Maternal and Child Health Journal
Volume 19, Issue 9, September 2015
http://link.springer.com/journal/10995/19/9/page/1

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Original Paper
Decentralizing Maternity Services to Increase Skilled Attendance at Birth and Antenatal Care Utilization in Rural Rwanda: A Prospective Cohort Study
Lisa M. Nathan, Quihu Shi, Kari Plewniak…

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Original Paper
Integrating Vitamin A Supplementation at 6 months into the Expanded Program of Immunization in Sierra Leone
Mary H. Hodges, Fatmata F. Sesay, Habib I. Kamara…

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Review Paper
Impact of Male Partner Antenatal Accompaniment on Perinatal Health Outcomes in Developing Countries: A Systematic Literature Review
Carolina Aguiar, Larissa Jennings

New England Journal of Medicine
September 10, 2015 Vol. 373 No. 11
http://www.nejm.org/toc/nejm/medical-journal

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Perspective
Creating a Global Health Risk Framework
Victor J. Dzau, M.D., and Judith Rodin, Ph.D.
N Engl J Med 2015; 373:991-993 September 10, 2015 DOI: 10.1056/NEJMp1509136

The Ebola outbreak in West Africa tragically illustrated the shortcomings of the global health system. Dysfunctional governance structures — within and among institutions and sectors — hindered response efforts. Financial and human resources were slow to arrive and insufficient,1 as they often are during humanitarian crises. Surveillance and other information systems were not up to the task. Health care personnel risked their lives to provide care, and many died. Local culture was not respected, and mistrust of the health system was rampant.2 Private industry had little incentive to proactively develop lifesaving products, and when it nevertheless did so, regulatory barriers and poor coordination hindered testing and deployment.3 The list goes on. As a result, the Ebola outbreak has had catastrophic health, economic, and social effects on Guinea, Liberia, Sierra Leone, and beyond.

Clearly, a unifying framework for managing global public health events is needed. Although previous globally significant outbreaks, such as those of the human immunodeficiency virus, influenza, and the severe acute respiratory syndrome (SARS), highlighted many of these weaknesses, the political will needed to reform the global public health framework has failed. As a result, countless lives have been lost and billions of dollars in economic damage has been incurred. The situation urgently needs to be fixed, and that requires leadership from the highest levels. We can’t allow another epidemiologic crisis to become a full-fledged catastrophe. An independent, multinational Commission on a Global Health Risk Framework for the Future has been established to recommend a more effective global architecture for mitigating the threat of epidemic infectious diseases.4 The U.S. National Academy of Medicine (formerly the Institute of Medicine) is the secretariat for this commission.

The Global Health Risk Framework (GHRF) initiative will build on lessons from the current Ebola outbreak and other major outbreaks to develop a comprehensive framework for improving our response to future global public health threats. The Commission will rigorously analyze options for improving governance, finance, health system resilience, and research and development for global health security. To foster trust internationally with various levels of government, civil society, academia, and industry, the Commission intends to keep the framework from being influenced by politics or the interests of any one country or organization.

The 18 Commission members have expertise in global health governance; workforce mobilization; global financing, including reinsurance business, economics, and public–private partnerships; information management and disease surveillance; humanitarian and pandemic response; and research, development, acquisition, and distribution. Because preparing for and responding to outbreaks requires more than medical expertise, the Commission also includes lawyers, bankers, mining executives, and others. To ensure the group’s independence, the commissioners were screened for conflicts of interest, their evidence collection and analysis will be transparent, and their report will be rigorously peer reviewed.

An international oversight group will steer the initiative and determine the scope of the study, approve the Commission slate and the initiative processes, develop guidelines for the report review process, and assist with dissemination. The initiative also includes workstream planning groups that will oversee preparations for four public information-gathering workshops, involving experts to address governance for global health, financing for public health emergencies, resilient health systems, and research and development of medical products.

The governance-for-global-health workstream will begin with a review of the current responsibilities and constraints of countries, regional institutions, the World Health Organization (WHO), and other relevant United Nations (UN) agencies, as well as the International Health Regulations (IHR), and assessment of potential changes to international governance frameworks that would ensure a robust response capability regardless of the environmental contexts. Possible ways to reform or empower the WHO and the UN system to more effectively respond to public health emergencies — such as developing guidelines for roles of non–health-focused organizations, establishing mechanisms for mobilizing a global health workforce, developing strong regional networks that share information and coordinate responses, and creating national command centers — may also be considered.

The financing workstream will start with an examination of how global funding for response to pandemic threats can be set aside in advance or rapidly mobilized, where the money should come from, and how it should be spent. The workstream group will evaluate the role of the World Bank’s proposed Pandemic Emergency Financing Facility, which will coordinate international financial response to pandemics — in particular, how the facility might ensure rapid deployment and prompt remuneration of health workers and minimize transaction times on other expenses. Vital to this discussion will be the roles to be played by the private sector, especially the reinsurance industry, in pooling risk for global emergencies. The financing workshop will explore possible underwriting functions of banks, insurers, and investment houses and analyze how they could ease the financial shock of an epidemic and control the costs of response, including the cost of developing new drugs and vaccines. The financing of surveillance systems to comply with the IHR will also be considered.

In the workstream focused on resilient health systems, optimal approaches to achieving effective, resilient, and sustainable health systems in individual countries will be considered. Multiple components of health systems will be examined, including surveillance and health information systems; universal health coverage; workforce capacity; health systems infrastructure; community, regional, and global partner engagement; supply-chain coordination and management; and how these components are connected and coordinated to form a resilient health system. Other considerations include options for enhancing connections among the health sector, other sectors (such as agriculture, education, and commerce), and the community; strengthening syndromic surveillance systems to permit early reporting and response; enhancing education and training for health care workers, community leaders, and the public; and leveraging existing systems and resources to address surge needs and capabilities. These issues will be explored in the context of other efforts including the IHR, the Post-2015 Hyogo Framework for Disaster Risk Reduction, the Global Health Security Agenda, Health in All Policies initiatives, and the Sustainable Development Goals.

In the workstream for medical-product research and development, participating experts will examine issues surrounding ensuring global capacity for relevant research and development, acquisition, and dispensing of countermeasures and diagnostics. They may explore the need for a global plan to harmonize and strengthen regulatory systems, processes, and standards; models for public–private partnerships and nongovernmental organizations to support rapid research and development and complement and reinforce private-sector mechanisms; global financing models that provide incentives for research and development; frameworks for ethical and methodologic standards for product safety and efficacy; and investments in regulatory science and multiuse platforms to support rapid development and deployment.

In each workstream, expert participants will gather diverse perspectives on various policy options, which will be captured in written workshop summaries. The Commission will integrate the evidence from these workshops, synthesizing the expertise of more than 100 leaders in health and related areas. It will then develop a comprehensive set of recommendations based on the available evidence, with the ultimate aim of strengthening systems, reducing suffering, and saving lives. The Commission will also use information collected through expert consultations, literature reviews, and public input to propose a preparedness-and-response plan that will build on and be coordinated with other efforts in this area. This plan will be captured in a final report expected to be released by December 2015.

To be effective, the report will have to be positioned to encourage global health leaders to act on its recommendations. The International Oversight Group is working closely with decision makers to coordinate dissemination of the report. The plan is to feature the Commission’s work at major events of the UN, the World Health Assembly, and the G7 and G20 groups of countries, aiming for effect well beyond the health sphere. Ultimately, world leaders’ actions will determine international preparedness for future pandemics and medical disasters. This GHRF initiative should provide sound, evidence-based guidance for their decisions.

A world health crisis such as the Ebola outbreak should never happen again. If we prepare now, we can avoid devastation when the next outbreak occurs.

New England Journal of Medicine
September 10, 2015 Vol. 373 No. 11
http://www.nejm.org/toc/nejm/medical-journal

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Perspective
Combating Emerging Threats — Accelerating the Availability of Medical Therapies
Luciana Borio, M.D., Edward Cox, M.D., M.P.H., and Nicole Lurie, M.D., M.S.P.H.
N Engl J Med 2015; 373:993-995 September 10, 2015 DOI: 10.1056/NEJMp1508708

Life-threatening emerging or reemerging infectious diseases increasingly inspire demands for access to novel, often untested therapies. Recent concern about transmission of the Middle East respiratory syndrome coronavirus (MERS-CoV) in Asia underscores the need to rapidly evaluate investigational therapies during outbreaks, identify those that actually benefit patients, and protect against those that cause harm. Although a traditional sequence of studies in animals followed by phased clinical trials works well for many therapeutics, that process may be too slow during public health emergencies. We propose establishing a new paradigm for accelerating evaluation of investigational therapies during public health emergencies so that therapies shown to be safe and effective can reach patients as soon as possible.

The primary approach to containing outbreaks of emerging infectious diseases involves standard public health measures, such as identifying and isolating infected persons, tracing their contacts to detect secondary infections, and protecting contacts and health care workers from exposure. General supportive medical care for anyone who becomes infected is essential, in addition to use of any proven specific treatments. When such treatments are lacking, clinicians commonly try therapies on the basis of experience with other diseases (usually on the basis of a postulated mechanism of action) in the hope of improving outcomes. For example, during the 2003 epidemic of the severe acute respiratory syndrome (SARS), several small observational studies examined the use of interferon, ribavirin, steroids, and convalescent plasma.1 Unfortunately, the inability to implement properly designed trials precluded any clear demonstration of benefit, and some evaluations suggested possible harm.

During the 2009 H1N1 influenza pandemic, it was considered infeasible to establish a multisite clinical study for an investigational therapy during a public health emergency. Peramivir, an intravenously administered influenza antiviral drug under clinical development, was made available in the United States under Emergency Use Authorization (EUA) to treat certain hospitalized patients. Demand was brisk — nearly 1300 seriously ill patients received the drug.2 Unfortunately, no reliable data on effectiveness were derived from this use. Some analyses suggested that mortality was increased among patients receiving peramivir, although that finding could have represented channeling bias (if patients receiving peramivir were already “sicker” in ways that could not be readily measured). A subsequent randomized clinical trial did not demonstrate either benefit or increased mortality associated with peramivir in patients hospitalized with influenza.3 Demand for this investigational drug drove its use under EUA, but any imperative to get demonstrably effective products to people in need as quickly as possible was not fulfilled. This experience showed that a reasonable expectation of benefit doesn’t always pan out, data derived from uncontrolled use may not be interpretable, and use outside a properly designed clinical trial can delay product assessment.

In early August 2014, two Americans who became infected with Ebola virus in West Africa were evacuated to the United States for medical care. They received various interventions, including ZMapp, an investigational monoclonal antibody cocktail in early development, not previously tested in humans. Their survival from what had been considered a highly fatal disease was followed by widespread demand for access to early-stage investigational therapies for Ebola. A World Health Organization ethics panel opined that although it was ethical to offer interventions with as-yet-unknown efficacy and adverse effects as potential treatment or prevention, there was a moral imperative to determine as quickly as possible which therapies worked.4
The international medical research community rushed to conduct clinical trials of several investigational products, but trial infrastructure took some time to establish. Meanwhile, initial doses of investigational drugs, some of which existed in very limited quantities, were administered to a few patients outside a clinical trial through so-called compassionate use. In some countries, such use continued even after clinical trials were established, despite the knowledge that it could delay the gathering of high-quality evidence to identify beneficial drugs or prolong the use of harmful ones.

Moreover, substantial disagreement emerged about the types of clinical trial designs that were appropriate for rapidly evaluating unproven therapies. Some investigators argued that randomized, controlled studies comparing an investigational therapy with available supportive medical care would be unethical,5 even when a drug’s limited supply meant that some patients would receive it while others couldn’t; others argued that early randomized trials should take priority both ethically and scientifically. Several uncontrolled studies were implemented, but their design makes them unlikely to provide reliable efficacy data or adequately protect patients by detecting serious adverse effects.

In early 2015, the National Institutes of Health, in partnership with U.S. and West African academic institutions and health authorities in Liberia, Sierra Leone, and later, Guinea, implemented a common protocol in which multiple therapies, even those at very early stages of development, could be simultaneously evaluated against a shared control group in an adaptive randomized trial. In this design, the shared control group is initially given the best available supportive care until a drug is identified that improves outcomes. Once a drug is proven effective, it’s incorporated into the supportive care that all trial patients receive, and the study may continue in order to evaluate the added benefit of other investigational drugs.

The first drug being evaluated under this protocol, ZMapp, advanced more rapidly than usual to a clinical trial designed to assess both safety and efficacy (typically, efficacy trials occur much later in development). The study is very efficient because it includes frequent prespecified interim evaluations of the accruing data, employing Bayesian analytic techniques, to identify a winner or a harmful drug as early as possible. If proven effective, ZMapp will be incorporated in the control group against which other therapies are tested. This protocol is being used in both high- and low-resource settings, providing equity of access to the study drug.

The critical need for rapid availability of effective new therapies coupled with advances in product development, manufacturing, and clinical trial design create new opportunities for efficient, scientifically sound evaluation of investigational therapies during public health emergencies. The serious impact of these emergencies and the lack of effective therapies warrant moving forward with clinical testing as soon as possible. The Ebola experience indicates that the usual phased development approach can be accelerated and abridged on the basis of what’s known about the candidate product, the severity and acuteness of the disease, and the limited window of opportunity for study. In such emergency settings, it may be appropriate to accept greater-than-usual degrees of uncertainty and risk in order to move rapidly to clinical trials, with the goal of getting safe, effective therapies to patients sooner.

The common protocol launched during the Ebola epidemic could serve as a model for rapidly evaluating promising but unproven therapies in the current MERS-CoV outbreak and future epidemics. Such an approach would allow earlier clinical testing of investigational drugs to accelerate identification of safe, effective therapies and thereby make them available to patients sooner. To succeed, this model requires close cooperation among clinical researchers, product developers, and public health and regulatory authorities globally.

Public health leaders need to take action before the next new threatening infectious disease emerges. One high-priority action will be the development and prepositioning of scientifically sound and widely accepted protocols by global public health authorities, to have them ready for use at the onset of a deadly outbreak wherever it strikes. In addition, work is needed to augment global clinical trial infrastructure, streamline processes for careful ethical review of multisite international studies, and establish model agreements for managing data and addressing intellectual property issues. If we are to act on lessons learned, there is no time to waste in getting this work done.

PLoS Medicine
http://www.plosmedicine.org/
(Accessed 12 September 2015)

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Equity and Noncommunicable Disease Reduction under the Sustainable Development Goals
Harald Schmidt, Anne Barnhill
Essay | published 08 Sep 2015 | PLOS Medicine
10.1371/journal.pmed.1001872
Summary Points
:: Currently proposed Sustainable Development Goals (SDGs) include a timely call to significantly reduce the burden of noncommunicable diseases (NCDs).
:: Existing policy guidance highlights cost-effective interventions for NCDs, but focusing just on cost-effectiveness risks exacerbating socioeconomic and health inequalities rather than reducing them.
:: In implementing the SDGs, targets and interventions that benefit the worst off should be prioritized.
:: The United Nations should develop practical guidance to assist policy makers at the country level with incorporating equity considerations.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 12 September 2015)

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Financial and Economic Costs of the Elimination and Eradication of Onchocerciasis (River Blindness) in Africa
Young Eun Kim, Elisa Sicuri, Fabrizio Tediosi
Research Article | published 11 Sep 2015 | PLOS Neglected Tropical Diseases
10.1371/journal.pntd.0004056

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Antivenoms for Snakebite Envenoming: What Is in the Research Pipeline?
Emilie Alirol, Pauline Lechevalier, Federica Zamatto, François Chappuis, Gabriel Alcoba, Julien Potet
Viewpoints | published 10 Sep 2015 | PLOS Neglected Tropical Diseases
10.1371/journal.pntd.0003896

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An Estimation of Private Household Costs to Receive Free Oral Cholera Vaccine in Odisha, India
Vittal Mogasale, Shantanu K. Kar, Jong-Hoon Kim, Vijayalaxmi V. Mogasale, Anna S. Kerketta, Bikash Patnaik, Shyam Bandhu Rath, Mahesh K. Puri, Young Ae You, Hemant K. Khuntia, Brian Maskery, Thomas F. Wierzba, Binod Sah
Research Article | published 09 Sep 2015 | PLOS Neglected Tropical Diseases
10.1371/journal.pntd.0004072
Abstract
Background
Service provider costs for vaccine delivery have been well documented; however, vaccine recipients’ costs have drawn less attention. This research explores the private household out-of-pocket and opportunity costs incurred to receive free oral cholera vaccine during a mass vaccination campaign in rural Odisha, India.
Methods
Following a government-driven oral cholera mass vaccination campaign targeting population over one year of age, a questionnaire-based cross-sectional survey was conducted to estimate private household costs among vaccine recipients. The questionnaire captured travel costs as well as time and wage loss for self and accompanying persons. The productivity loss was estimated using three methods: self-reported, government defined minimum daily wages and gross domestic product per capita in Odisha.
Findings
On average, families were located 282.7 (SD = 254.5) meters from the nearest vaccination booths. Most family members either walked or bicycled to the vaccination sites and spent on average 26.5 minutes on travel and 15.7 minutes on waiting. Depending upon the methodology, the estimated productivity loss due to potential foregone income ranged from $0.15 to $0.29 per dose of cholera vaccine received. The private household cost of receiving oral cholera vaccine constituted 24.6% to 38.0% of overall vaccine delivery costs.
Interpretation
The private household costs resulting from productivity loss for receiving a free oral cholera vaccine is a substantial proportion of overall vaccine delivery cost and may influence vaccine uptake. Policy makers and program managers need to recognize the importance of private costs and consider how to balance programmatic delivery costs with private household costs to receive vaccines.
Author Summary
The price of vaccine and the costs of its delivery are two important economic measures considered by governments and various international organizations in their decisions on the use of a new vaccine. However, the costs to the vaccine recipients resulting from their travel, time and wage loss are hardly considered and rarely documented. Even if the vaccine is provided for free, the costs borne by vaccine recipients could be sufficient enough to be a hurdle for taking vaccine. We elucidate this less explored angle of “vaccine recipient cost” in the context of oral cholera vaccine mass campaign in Odisha, India. Our research shows that the potential loss of income for individuals for receiving oral cholera vaccine ranged from 25% to 38% of overall vaccine delivery costs. We believe our findings have global implications on future decisions and policy making on vaccine introduction in balancing programmatic delivery costs with private household costs to receive vaccines.

PNAS – Proceedings of the National Academy of Sciences of the United States of America
http://www.pnas.org/content/early/
(Accessed 12 September 2015)

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Impact of human mobility on the emergence of dengue epidemics in Pakistan
Amy Wesolowskia,b, Taimur Qureshic, Maciej F. Bonid,e, Pål Roe Sundsøyc, Michael A. Johanssonb,f, Syed Basit Rasheedg, Kenth Engø-Monsenc, and Caroline O. Buckeea,b,1
Author Affiliations
Edited by Burton H. Singer, University of Florida, Gainesville, FL, and approved August 6, 2015 (received for review April 2, 2015)
Significance
Dengue virus has rapidly spread into new human populations due to human travel and changing suitability for the mosquito vector, causing severe febrile illness and significant mortality. Accurate predictive models identifying changing vulnerability to dengue outbreaks are necessary for epidemic preparedness and containment of the virus. Here we show that an epidemiological model of dengue transmission in travelers, based on mobility data from ∼40 million mobile phone subscribers and climatic information, predicts the geographic spread and timing of epidemics throughout the country. We generate fine-scale dynamic risk maps with direct application to dengue containment and epidemic preparedness.
Abstract
The recent emergence of dengue viruses into new susceptible human populations throughout Asia and the Middle East, driven in part by human travel on both local and global scales, represents a significant global health risk, particularly in areas with changing climatic suitability for the mosquito vector. In Pakistan, dengue has been endemic for decades in the southern port city of Karachi, but large epidemics in the northeast have emerged only since 2011. Pakistan is therefore representative of many countries on the verge of countrywide endemic dengue transmission, where prevention, surveillance, and preparedness are key priorities in previously dengue-free regions. We analyze spatially explicit dengue case data from a large outbreak in Pakistan in 2013 and compare the dynamics of the epidemic to an epidemiological model of dengue virus transmission based on climate and mobility data from ∼40 million mobile phone subscribers. We find that mobile phone-based mobility estimates predict the geographic spread and timing of epidemics in both recently epidemic and emerging locations. We combine transmission suitability maps with estimates of seasonal dengue virus importation to generate fine-scale dynamic risk maps with direct application to dengue containment and epidemic preparedness.

Qualitative Health Research
October 2015; 25 (10)
http://qhr.sagepub.com/content/current

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Refugees, Post-Migration Stress, and Internet Use
A Qualitative Analysis of Intercultural Adjustment and Internet Use Among Iraqi and Sudanese Refugees to the United States
Jude P. Mikal1, Braden Woodfield1
1University of Utah, Salt Lake City, Utah, USA
Jude P. Mikal, University of Utah, Orson Spencer Hall, 260 S. Central Campus Dr., Rm. 205, Salt Lake City, UT 84112, USA. Email: mikal@csbs.utah.edu
Abstract
Post-migration stressors represent significant obstacle to refugee adjustment, and continued exposure to post-migration stressors can negatively affect mental and physical health. Communities of support maintained over the Internet may provide a sense of constancy and reliability that may insulate against the negative effects of stress. We conducted five focus group interviews with Iraqi and Sudanese refugees to understand how refugees use the Internet to access support in their daily lives. Four trends were observed: (a) Internet use was related to culture of origin, (b) refugees were reluctant to explore online, (c) children served as brokers of online knowledge, and (d) limited Internet access is associated with increased time and financial obligations. This study aims to contribute to theory on Internet-mediated social support and to refugee health by creating smoother pathways to self-sufficiency and allowing refugees to exhibit agency in constructing and maintaining online networks of support.

Social Science & Medicine
Volume 140, Pages 1-146 (September 2015)
http://www.sciencedirect.com/science/journal/02779536/140

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Paid maternity leave and childhood vaccination uptake: Longitudinal evidence from 20 low-and-middle-income countries
Original Research Article
Pages 104-117
Mohammad Hajizadeh, Jody Heymann, Erin Strumpf, Sam Harper, Arijit Nandi
Abstract
The availability of maternity leave might remove barriers to improved vaccination coverage by increasing the likelihood that parents are available to bring a child to the clinic for immunizations. Using information from 20 low-and-middle-income countries (LMICs) we estimated the effect of paid maternity leave policies on childhood vaccination uptake. We used birth history data collected via Demographic and Health Surveys (DHS) to assemble a multilevel panel of 258,769 live births in 20 countries from 2001 to 2008; these data were merged with longitudinal information on the number of full-time equivalent (FTE) weeks of paid maternity leave guaranteed by each country. We used Logistic regression models that included country and year fixed effects to estimate the impact of increases in FTE paid maternity leave policies in the prior year on the receipt of the following vaccines: Bacillus Calmette-Guérin (BCG) commonly given at birth, diphtheria, tetanus, and pertussis (DTP, 3 doses) commonly given in clinic visits and Polio (3 doses) given in clinic visits or as part of campaigns. We found that extending the duration of paid maternity leave had a positive effect on immunization rates for all three doses of the DTP vaccine; each additional FTE week of paid maternity leave increased DTP1, 2 and 3 coverage by 1.38 (95% CI = 1.18, 1.57), 1.62 (CI = 1.34, 1.91) and 2.17 (CI = 1.76, 2.58) percentage points, respectively. Estimates were robust to adjustment for birth characteristics, household-level covariates, attendance of skilled health personnel at birth and time-varying country-level covariates. We found no evidence for an effect of maternity leave on the probability of receiving vaccinations for BCG or Polio after adjustment for the above-mentioned covariates. Our findings were consistent with the hypothesis that more generous paid leave policies have the potential to improve DTP immunization coverage. Further work is needed to understand the health effects of paid leave policies in LMICs.

Sustainability
Volume 7, Issue 7 (July 2015), Pages 8051-9752
http://www.mdpi.com/2071-1050/7/7

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Editorial
A New Urban Agenda: Introduction to the Special Issue on “Sustainable Urban Development”
by Steffen Lehmann
Sustainability 2015, 7(8), 10000-10006; doi:10.3390/su70810000
Received: 20 July 2015 / Revised: 21 July 2015 / Accepted: 21 July 2015 / Published: 24 July 2015
Abstract:
Since the start of the 21st century, humanity has been a predominantly urban species. This Special Issue is about the future of cities and how urbanization will develop when based on principles of sustainability. It explores the underlying dimensions of the transformation of existing cities and the design of low carbon green precincts and their urban systems. The view of the papers presented in this Special Issue is holistic and takes questions of social sustainability into account. This editorial highlights the contents and methodologies of 13 selected papers, while presenting diverse issues in strategies, concepts and policies for sustainable urban development.

Tropical Medicine & International Health
October 2015 Volume 20, Issue 10 Pages 1257–1404
http://onlinelibrary.wiley.com/doi/10.1111/tmi.2015.20.issue-7/issuetoc

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Roles and responsibilities in newborn care in four African sites (pages 1258–1264)
R. Iganus, Z. Hill, F. Manzi, M. Bee, Y. Amare, D. Shamba, A. Odebiyi, E. Adejuyigbe, B. Omotara and J. Skordis-Worrall
Article first published online: 17 JUN 2015 | DOI: 10.1111/tmi.12550
Abstract
Objectives
To explore roles and responsibilities in newborn care in the intra- and postpartum period in Nigeria, Tanzania and Ethiopia.
Methods
Qualitative data were collected using in-depth interviews with mothers, grandmothers, fathers, health workers and birth attendants and were analysed through content and framework analyses.
Results
We found that birth attendants were the main decision-makers and care takers in the intrapartum period. Birth attendants varied across sites and included female relatives (Ethiopia and Nigeria), traditional birth attendants (Tanzania and Nigeria), spiritual birth attendants (Nigeria) and health workers (Tanzania and Nigeria). In the early newborn period, when the mother is deemed to be resting, female family members assumed this role. The mothers themselves only took full responsibility for newborn care after a few days or weeks. The early newborn period was protracted for first-time mothers, who were perceived as needing training on caring for the baby. Clear gender roles were described, with newborn care being considered a woman’s domain. Fathers had little physical contact with the newborn, but played an important role in financing newborn care, and were considered the ultimate decision-maker in the family.
Conclusion
Interventions should move beyond a focus on the mother–child dyad, to include other carers who perform and decide on newborn care practices. Given this power dynamic, interventions that involve men have the potential to result in behaviour change.

The Sentinel

Human Rights Action :: Humanitarian Response :: Health ::
Holistic Development :: Sustainable Resilience
__________________________________________________
Week ending 5 September 2015

This weekly digest is intended to aggregate and distill key content from a broad spectrum of practice domains and organization types including key agencies/IGOs, NGOs, governments, academic and research institutions, consortia and collaborations, foundations, and commercial organizations. We also monitor a spectrum of peer-reviewed journals and general media channels. The Sentinel’s geographic scope is global/regional but selected country-level content is included. We recognize that this spectrum/scope yields an indicative and not an exhaustive product. Comments and suggestions should be directed to:

David R. Curry
Editor &
Founding Managing Director
GE2P2 – Center for Governance, Evidence, Ethics, Policy, Practice
david.r.curry@ge2p2center.net

pdf version: The Sentinel_ week ending 5 September 2015

blog edition: comprised of the 35+ entries to be posted below on 6 September 2015

Refugees/Migrants/IDPs [to 5 September 2015]

Editor’s Note:
The growing, multiple crises across the globe involving refugees, migrants and internally-displaced persons – especially in the EU context – received comment and calls-to-action by many agencies and INGOs [see the Watch sections in this edition]. We present the full-text of UNHCR and UNICEF statements and a New York Times editorial.

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UNHCR praises Austrian, German Leadership and Civil Society Response
Press Releases, 5 September 2015
UNHCR welcomes the decision of Austria and Germany to receive thousands of refugees and migrants who crossed the border last night from Hungary. This is political leadership based on humanitarian values.

UNHCR also praises the civil society groups and individuals of Austria and Germany who are mobilizing in large numbers to welcome and provide aid to people as they enter. All over Europe, UNHCR is witnessing a remarkable outpouring of public response, including from faith-based organizations, NGOs and individuals, in many cases driving governments to change policies and rhetoric.

However, the current concentration of refugees and migrants in a small number of countries willing to receive them is not a sustainable solution. There is clearly an urgent need to put in place an emergency plan to manage the refugee crisis. The High Commissioner for Refugees, António Guterres, us putting forward concrete proposals to respond ahead of key meetings of European leaders. They are outlined here: http://www.unhcr.org/55e9793b6.html

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Statement by UN High Commissioner for Refugees, António Guterres on refugee crisis in Europe
Press Releases, 4 September 2015
The European Union is preparing key emergency meetings to take decisions in its response to the present refugee and migration crisis. The situation requires a massive common effort that is not possible with the current fragmented approach.

Europe is facing its biggest refugee influx in decades. More than 300,000 people have risked their lives to cross the Mediterranean Sea so far this year. Over 2,600 didn’t survive the dangerous crossing, including three-year-old Aylan, whose photo has just stirred the hearts of the world public. After arriving on Europe’s shores and borders, they continue their journey – facing chaos and suffering indignity, exploitation and danger at borders and along the way.

The selfless generosity of private citizens and civil society organizations reaching out to welcome and help the new arrivals is truly inspiring. And there has been exemplary political and moral leadership from a number of countries. But overall, Europe has failed to find an effective common response, and people have suffered as a result. To address this untenable situation, we all must keep in mind a number of fundamental points:

1. This is a primarily refugee crisis, not only a migration phenomenon. The vast majority of those arriving in Greece come from conflict zones like Syria, Iraq or Afghanistan and are simply running for their lives. All people on the move in these tragic circumstances deserve to see their human rights and dignity fully respected, independently of their legal status. But we cannot forget the particular responsibility all states have vis a vis refugees, in accordance with international law.

2. Europe cannot go on responding to this crisis with a piecemeal or incremental approach. No country can do it alone, and no country can refuse to do its part. It is no surprise that, when a system is unbalanced and dysfunctional, everything gets blocked when the pressure mounts. This is a defining moment for the European Union, and it now has no other choice but to mobilize full force around this crisis. The only way to solve this problem is for the Union and all member states to implement a common strategy, based on responsibility, solidarity and trust.

3. Concretely, this means taking urgent and courageous measures to stabilize the situation and then finding a way to truly share responsibility in the mid to longer term. The EU must be ready, with the consent and in support of the concerned governments – mainly Greece and Hungary, but also Italy – to put in place immediate and adequate emergency reception, assistance and registration capacity. The European Commission should mobilize the EU asylum, migration and civil protection agencies and mechanisms for this purpose, including the resources of member states and with the support of UNHCR, IOM and civil society. From our side, UNHCR is fully committed to step up its efforts. It is essential that refugee families that disembark in Europe after having lost everything are welcomed into a safe and caring environment.

4. People who are found to have a valid protection claim in this initial screening must then benefit from a mass relocation programme, with the mandatory participation of all EU member states. A very preliminary estimate would indicate a potential need to increase relocation opportunities to as many as 200,000 places. This can only work if it goes hand in hand with adequate reception capacities, especially in Greece. Solidarity cannot be the responsibility of only a few EU member states.

5. Those who are found not to be in need of international protection and who cannot benefit from legal migration opportunities should be helped to return quickly to their home countries, in full respect of their human rights.

6. The only ones who benefit from the lack of a common European response are the smugglers and traffickers who are making profit from people’s desperation to reach safety. More effective international cooperation is required to crack down on smugglers, including those operating inside the EU, but in ways that allow for the victims to be protected. But none of these efforts will be effective without opening up more opportunities for people to come legally to Europe and find safety upon arrival. Thousands of refugee parents are risking the lives of their children on unsafe smuggling boats primarily because they have no other choice. European countries – as well as governments in other regions – must make some fundamental changes to allow for larger resettlement and humanitarian admission quotas, expanded visa and sponsorship programmes, scholarships and other ways to enter Europe legally. Crucially, family reunification has to become a real, accessible option for many more people than is currently the case. If these mechanisms are expanded and made more efficient, we can reduce the number of those who are forced to risk their lives at sea for lack of alternative options.

Beyond the immediate response, it is clear that this situation will require us to reflect seriously about the future. This massive flow of people will not stop until the root causes of their plight are addressed. Much more must be done to prevent conflicts and stop the ongoing wars that are driving so many from their homes. The countries neighbouring war zones, which shelter 9 in 10 refugees worldwide, must be supported more strongly, along with the funding required. At the same time, it is also essential that development cooperation policies are reoriented with the objective of giving people the opportunity to have a future in their own countries.

Europe is facing a moment of truth. This is the time to reaffirm the values upon which it was built.

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United action needed now for child refugees: UNICEF
NEW YORK/GENEVA, 5 September 2015 – Europe has a brief window of opportunity, before winter approaches, to protect and care for the tens of thousands of children seeking refuge, UNICEF said today.

About a quarter of those seeking refuge in Europe this year are children. More than 106,000 children have claimed asylum within the first half of 2015, up 75 per cent from last year.
Many refugee and migrant children in Europe are living in overcrowded and inadequate conditions, where they are at risk of violence, exploitation and abuse. Many are sleeping out in the open air; as winter approaches, the health of young children is especially at risk, including from the threat of diseases like pneumonia. Only concerted action to accommodate and care for children now will prevent more deaths and suffering in the months ahead.

With the growing numbers of children making perilous journeys into and across Europe, collective action with a fair distribution of responsibility across the European Union is essential. This should include putting in place a number of immediate safeguards for children and their families:
:: Safe, child-friendly reception facilities as children arrive, with access to health care, psychosocial support, recreation and schooling.
:: More resettlement places across Europe and humanitarian visas for children and their families. The processing of asylum cases should be timely, and always focus on the best interests of the children.
:: Stronger commitment to resettlement of refugees from countries in conflict to reduce the likelihood that refugees resort to unsafe routes and people smuggling.
:: Stepped-up search and rescue operations at sea and on land.
:: Speeding up family reunification programmes for separated and unaccompanied children.
:: Adequate numbers of trained child welfare specialists to care for and counsel children and families.

Such care is enshrined in the Convention on the Rights of the Child, which provides for the protection of all children – whether on the move from their homes, on the seas, over land, or on the shores of destination countries.

UNICEF urges the international community to address the root causes of this huge movement of desperate children through more vigorous diplomatic efforts to end conflicts, and to provide the required development and humanitarian support in countries of origin.

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Editorial: Piercing the Denial on Refugees
New York Times, SEPT. 4, 2015
By THE EDITORIAL BOARD

Photographs of a lifeless little boy, dressed in a red shirt and dark shorts, lying face down on a beach, and then, minutes later, cradled in the arms of a police officer, have taken the world by storm. These heartbreaking images of 3-year-old Aylan Kurdi, who drowned when the rubber dinghy that was to carry him and his Syrian family to safety in Greece capsized off the coast of Turkey on Wednesday, have succeeded, finally, in bringing home the terrible human cost of Europe’s failure to deal with a surging refugee crisis.

Reaction to the photos has been swift: Chancellor Angela Merkel of Germany and President François Hollande of France issued a joint statement on Thursday calling for “a permanent and obligatory mechanism” to allocate refugees among the 28 member states of the European Union and for new reception centers in Italy and Greece. Prime Minister David Cameron of Britain, whose government has balked at allowing in any refugees from the Continent, said Friday that Britain would take in “thousands” of refugees from camps near the fighting in Syria. The Austrian chancellor, Werner Faymann, said his country would now accept the refugees who have been stuck in Budapest. Meanwhile, ordinary European citizens pledged to open their homes to Syrians.

The photos provoked reaction across the Atlantic as well. Canada, where the Kurdi family had sought refugee status, is looking into its own policies, and the United States pledged to intensify the clearing process for accepting refugees from Syria.

But this drama is unfolding in Europe, and it is far from clear that the European Union will be able to overcome the stark divisions the crisis has provoked among member states. Prime Minister Viktor Orban of Hungary blames Germany, which is expecting to take in 800,000 refugees this year, for the surge of people entering Hungary on their way north. Slovakia and Poland are refusing to accept refugees who are not Christian.

More than 300,000 people have crossed the Mediterranean to Europe this year, and about 2,500 others have died trying. Thousands are making a harrowing journey overland through Greece, Macedonia, Hungary, Austria and Serbia in search of refuge, mostly in Germany. And until there is peace in the Middle East and Africa, more people will flee to Europe.

On Friday, the United Nations called on the European Union to take in 200,000 people under a binding emergency relocation program, and to set up large reception camps in Italy, Greece and Hungary. The European Commission must act swiftly to ensure that ministers meeting in Brussels on Sept. 14 to deal with the crisis respond to these demands — before the emotions triggered by the photos fade and more people die.

Post-2015 Summit to chart a new era for sustainable development
25 Aug 2015 – More than 150 world leaders are expected to attend the UN Sustainable Development Summit from September 25-27 at UN headquarters in New York to formally adopt an ambitious new sustainable development agenda. Secretary-General Ban Ki-moon has said that the summit “will chart a new era of sustainable development in which poverty will be eradicated, prosperity shared and the core drivers of climate change tackled”.

The Summit will be the climax of a negotiating process that has spanned more than two years, involved all 193 member states of the United Nations and has featured the unprecedented participation of major groups of society and other stakeholders. On 2 August 2015, Member States reached agreement on the outcome document for the summit with the title ‘Transforming our world: the 2030 Agenda for Sustainable Development’, which includes 17 new sustainable development goals.

The Secretary-General said that this agreement, to be formally adopted at the summit, “encompasses a universal, transformative and integrated agenda that heralds an historic turning point for our world. This is the people’s agenda, a plan of action for ending poverty in all its dimensions, irreversibly, everywhere and leaving no one behind. It seeks to ensure peace and prosperity and forge partnerships with people and planet at the core. The integrated, interlinked and indivisible 17 sustainable development goals are the people’s goals and demonstrate the scale, universality and ambition of this new agenda.”

Six interactive dialogues
The Summit will feature six interactive dialogues with the following themes: Ending poverty and hunger; Tackling inequalities, empowering women and girls and leaving no one behind; Fostering sustainable economic growth, transformation and promoting sustainable consumption and production; Protecting our planet and combatting climate change; Building effective, accountable and inclusive institutions to achieve sustainable development; Delivering on a revitalised Global Partnership.

It is envisaged that each dialogue will address the three dimensions of sustainable development. There will also be scope to address in each dialogue issues such as gender equality and the empowerment of women and girls, prioritising the needs of all vulnerable groups including children, older persons, persons with disabilities, indigenous peoples and migrants and ensuring implementation at all levels.

Core Elements of the new sustainable development agenda
The new sustainable development agenda to be adopted in September highlights poverty eradication as the overarching goal of the new agenda and has at its core the integration of the economic, social and environmental dimensions of sustainable development. The emerging agenda is unique in that it calls for action by all countries, poor, rich and middle-income.

Member States pledge that as they embark on this collective journey, no one will be left behind. The “five Ps” — people, planet, prosperity, peace and partnership — capture the broad scope of the agenda.

The 17 goals and 169 targets aim at tackling key systemic barriers to sustainable development such as inequality, unsustainable consumption and production patterns, inadequate infrastructure and lack of decent jobs.

The means of implementation outlined in the outcome document match its ambitious goals and focus on finance, technology and capacity development. In addition to a stand-alone goal on the means of implementation for the new agenda, specific means are tailored to each of the goals.

Member States stressed that the desired transformations will require a departure from “business as usual” and that intensified international cooperation on many fronts will be needed. The agenda calls for a revitalized, global partnership for sustainable development, including for multi-stakeholder partnerships. It also calls for increased capacity-building and better data and statistics to measure sustainable development.

An effective follow-up and review architecture — a core element of the outcome document — will be critical to support the implementation of the new agenda. The High Level Political Forum on Sustainable Development, set up after the Rio+20 Conference, will serve as the apex for follow-up and review and will thus play a central role. The General Assembly, the Economic and Social Council and specialized agencies will also be engaged in reviewing progress in specific areas.

Based on the outcome document, the agenda will include a Technology Facilitation Mechanism to support the new goals, based on multi-stakeholder collaboration between Member States, civil society, business, the scientific community and the United Nations system of agencies. The Mechanism, which was agreed at the Addis Conference in July, will have an inter-agency task team, a forum on science, technology and innovation and an online platform for collaboration.