Trends in Maternal Mortality: 1990 to 2015
Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Fund
Publication date: November 2015 :: 12 pages
WHO reference number: WHO /RHR/15.23
Full report pdf, 5 MB :: Executive summary pdf, 1 MB

Millennium Development Goal (MDG) 5 Target 5A called for the reduction of maternal mortality ratio by three quarters between 1990 and 2015. It has been a challenge to assess the extent of progress due to the lack of reliable and accurate maternal mortality data – particularly in developing-country settings where maternal mortality is high. As part of ongoing efforts, the WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division updated estimates of maternal mortality for the years 1990, 1995, 2000, 2005 and 2015.

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Joint news release
Maternal deaths fell 44% since 1990 – UN
Report from WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division highlights progress

12 NOVEMBER 2015 ¦ GENEVA ¦ NEW YORK – Maternal mortality has fallen by 44% since 1990, United Nations agencies and the World Bank Group reported today.
Maternal deaths around the world dropped from about 532 000 in 1990 to an estimated 303 000 this year, according to the report, the last in a series that has looked at progress under the Millennium Development Goals (MDGs). This equates to an estimated global maternal mortality ratio (MMR) of 216 maternal deaths per 100 000 live births, down from 385 in 1990.

Maternal mortality is defined as the death of a woman during pregnancy, childbirth or within 6 weeks after birth.

“The MDGs triggered unprecedented efforts to reduce maternal mortality,” said Dr Flavia Bustreo, WHO Assistant Director-General, Family, Women’s and Children’s Health. “Over the past 25 years, a woman’s risk of dying from pregnancy-related causes has nearly halved. That’s real progress, although it is not enough. We know that we can virtually end these deaths by 2030 and this is what we are committing to work towards.”

Achieving that goal will require much more effort, according to Dr. Babatunde Osotimehin, the Executive Director of UNFPA, the United Nations Population Fund. “Many countries with high maternal death rates will make little progress, or will even fall behind, over the next 15 years if we don’t improve the current number of available midwives and other health workers with midwifery skills,” he said. “If we don’t make a big push now, in 2030 we’ll be faced, once again, with a missed target for reducing maternal deaths.”
The analyses contained in Trends in Maternal Mortality: 1990 to 2015 – Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division are being published simultaneously in the medical journal The Lancet.

Ensuring access to high-quality health services during pregnancy and child birth is helping to save lives. Essential health interventions include: practising good hygiene to reduce the risk of infection; injecting oxytocin immediately after childbirth to reduce the risk of severe bleeding; identifying and addressing potentially fatal conditions like pregnancy-induced hypertension; and ensuring access to sexual and reproductive health services and family planning for women.

Uneven gains
Despite global improvements, only 9 countries achieved the MDG 5 target of reducing the maternal mortality ratio by at least 75% between 1990 and 2015. Those countries are Bhutan, Cabo Verde, Cambodia, Iran, Lao People’s Democratic Republic, Maldives, Mongolia, Rwanda and Timor-Leste. Despite this important progress, the MMR in some of these countries remains higher than the global average.

“As we have seen with all of the health-related MDGs, health system strengthening needs to be supplemented with attention to other issues to reduce maternal deaths,” said UNICEF Deputy Executive Director, Geeta Rao Gupta. “The education of women and girls, in particular the most marginalized, is key to their survival and that of their children. Education provides them with the knowledge to challenge traditional practices that endanger them and their children.”

By the end of this year, about 99% of the world’s maternal deaths will have occurred in developing regions, with Sub-Saharan Africa alone accounting for 2 in 3 (66%) deaths. But that represents a major improvement: Sub-Saharan Africa saw nearly 45% decrease in MMR, from 987 to 546 per 100 000 live births between 1990 and 2015.

The greatest improvement of any region was recorded in Eastern Asia, where the maternal mortality ratio fell from approximately 95 to 27 per 100 000 live births (a reduction of 72%). In developed regions, maternal mortality fell 48% between 1990 and 2015, from 23 to 12 per 100 000 live births.

Working towards ending preventable maternal deaths
A new Global Strategy for Women’s, Children’s and Adolescents’ Health, launched by the UN Secretary General in September 2015, aims to help achieve the ambitious target of reducing maternal deaths to fewer than 70 per 100,000 live births globally, as included in the Sustainable Development Goals (SDGs). Reaching that goal will require more than tripling the pace of progress – from the 2.3% annual improvement in MMR that was recorded between 1990 and 2015 to 7.5% per year beginning next year.

The Global Strategy highlights the need to reinforce country leadership by mobilizing domestic and international resources for women’s, children’s and adolescents’ health. It will be important to strengthen health systems so they can provide good quality care in all settings, promote collaboration across sectors, and support individuals and communities to make informed decisions about their health and demand the quality care they need. The strategy emphasizes that special attention is imperative during humanitarian crises and in fragile settings, since maternal deaths tend to rise in these contexts.

“The SDG goal of ending maternal deaths by 2030 is ambitious and achievable provided we redouble our efforts,” said Dr Tim Evans, Senior Director of Health, Nutrition and Population at the World Bank Group. “The recently launched Global Financing Facility in Support of Every Woman Every Child, which focuses on smarter, scaled and sustainable financing, will help countries deliver essential health services to women and children.”

Need for better data
The 2015 maternal mortality estimates present the tremendous progress achieved towards the Millennium Development Goal 5 on maternal mortality reduction. They show a strong trend of reduction over the years. At the same time, we have seen more and better data coming from various countries, enhancing the accuracy of the absolute numbers reported.

Efforts to strengthen data and accountability especially over the past years have helped fuel this improvement. However, much more needs to be done to develop complete and accurate civil and vital registration systems that include births, deaths and causes of death.

Maternal death audits and reviews also need to be implemented to understand why, where and when women die and what can be done to prevent similar deaths. Since 2012, WHO, UNFPA and partners have developed Maternal Death Surveillance and Response for identification and timely notification of all maternal deaths, followed by review of their causes and the best methods of prevention. An increasing number of low- and middle-income countries are now implementing this approach.

BMC Health Services Research
http://www.biomedcentral.com/bmchealthservres/content
(Accessed 21 November 2015)

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Research article
The cost of dialysis in low and middle-income countries: a systematic review
Lawrencia Mushi, Paul Marschall, Steffen Fleßa BMC Health Services Research 2015, 15:506 (12 November 2015)
Abstract
Background
The cost of dialysis in low and middle-Income countries has not been systematically reviewed. The objective of this article is to systematically review peer-reviewed articles on the cost of dialysis across low and middle-income countries.
Methods
PubMed and Embase databases were searched for the year 1998 to March 2013, and additional studies were added from Google Scholar search. An article was included if two reviewers agreed that it had reported cost of dialysis from low and middle-Income countries.
Results
The annual cost per patient for hemodialysis (HD) ranged from Int$ 3,424 to Int$ 42,785, and peritoneal dialysis (PD) ranged from Int$ 7,974 to Int$ 47,971. Direct medical cost especially drugs and consumables for HD and dialysis solutions and tubing for PD were the main cost drivers.
Conclusion
The number of studies on the economics of dialysis in low and middle-income countries is limited. Few papers indicate that dialysis is an expensive form of treatment for the population of these countries and that the poorer countries have an over-proportional burden to finance dialysis services. Further research is needed to determine the cost of dialysis based on a standard methodology grounded on existing economic guidelines and to address the question whether dialysis should be an element of the essential package of health in resource-poor countries. Used data should be as complete as possible. In case of missing data, proxies can be used. In case of developing countries, expert interviews are often used for estimating missing information.

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Research article
Equity in access to health care among asylum seekers in Germany: evidence from an exploratory population-based cross-sectional study
Kayvan Bozorgmehr, Christine Schneider, Stefanie Joos BMC Health Services Research 2015, 15:502 (9 November 2015)
Abstract
Background
Research on inequities in access to health care among asylum-seekers has focused on disparities between asylum-seekers and resident populations, but little attention has been paid to potential inequities in access to care within the group of asylum-seekers. We aimed to analyse the principles of horizontal equity (i.e., equal access for equal need irrespective of socioeconomic status, SES) and vertical equity (higher allocation of resources to those with higher need) among asylum-seekers in Germany.
Methods
We performed a secondary exploratory analysis on cross-sectional data obtained from a population-based questionnaire survey among all asylum-seekers (aged 18 or above) registered in three administrative districts in Germany during the three-month study period (N = 1017). Data were collected on health care access (health care utilisation of four types of services and unmet medical need), health care need (approximated by sex, age and self-rated health status), and SES (highest educational attainment and subjective social status, SSS). We calculated odds ratios and 95 % confidence intervals (CI) in multiple logistic regression models to analyse associations between SES indicators and access to health care under control of need.
Results
We contacted 60.4 % (614) of the total asylum-seekers population, of which 25.4 % (N = 156) participated in the study. Educational attainment showed no significant effect on health care access in crude models, but was positively associated with utilisation of psychotherapists and hospital admissions in adjusted models. Higher SSS was positively associated with health care utilisation of all types of services. The odds of hospitals admissions for asylum-seekers in the medium and highest SSS category were 3.18 times [1.06, 9.59] and 1.6 times [0.49, 5.23] the odds of those in the lowest SSS category. After controlling for need variables none of the SES indicators were significantly associated with measures of access to care, but a positive association remained, indicating higher utilisation of health care among asylum-seekers with higher SES. Age, sex or general health status were the only significant predictors of health care utilisation in fully adjusted models. The adjusted odds of reporting unmet medical needs among asylum-seekers with “fair/bad/very bad” health status were 2.16 times [0.84, 5.59] the odds of those with “good/very good” health status.
Conclusion
Our findings revealed that utilisation of health services among asylum-seekers is associated with higher need (vertical equity met). Horizontal equity was met with respect to educational attainment for most outcomes, but a social gradient in health care utilisation was observed across SSS. Further confirmatory research is needed, especially on potential inequities in unmet medical need and on measurements of SES among asylum-seekers.

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Research article
Exploring providers’ perspectives of a community based TB approach in Southern Ethiopia: implication for community based approaches
Daniel Datiko, Mohammed Yassin, Olivia Tulloch, Girum Asnake, Tadesse Tesema, Habiba Jamal, Paulos Markos, Luis Cuevas, Sally Theobald BMC Health Services Research 2015, 15:501 (9 November 2015)

BMC Medical Ethics
http://www.biomedcentral.com/bmcmedethics/content
(Accessed 21 November 2015)

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Correspondence
Enhancing quality and integrity in biomedical research in Africa: an international call for greater focus, investment and standardisation in capacity strengthening for frontline staff
Francis Kombe, Participants of an International Workshop in Kenya on the Role of Frontline Staff in Biomedical Research, July 2014 BMC Medical Ethics 2015, 16:77 (13 November 2015)

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Debate
Informed consent instead of assent is appropriate in children from the age of twelve: Policy implications of new findings on children’s competence to consent to clinical research
Irma Hein, Martine De Vries, Pieter Troost, Gerben Meynen, Johannes Van Goudoever, Ramón Lindauer BMC Medical Ethics 2015, 16:76 (9 N
Abstract
Background
For many decades, the debate on children’s competence to give informed consent in medical settings concentrated on ethical and legal aspects, with little empirical underpinnings. Recently, data from empirical research became available to advance the discussion. It was shown that children’s competence to consent to clinical research could be accurately assessed by the modified MacArthur Competence Assessment Tool for Clinical Research. Age limits for children to be deemed competent to decide on research participation have been studied: generally children of 11.2 years and above were decision-making competent, while children of 9.6 years and younger were not. Age was pointed out to be the key determining factor in children’s competence. In this article we reflect on policy implications of these findings, considering legal, ethical, developmental and clinical perspectives.
Discussion
Although assessment of children’s competence has a normative character, ethics, law and clinical practice can benefit from research data. The findings may help to do justice to the capacities children possess and challenges they may face when deciding about treatment and research options. We discuss advantages and drawbacks of standardized competence assessment in children on a case-by-case basis compared to application of a fixed age limit, and conclude that a selective implementation of case-by-case competence assessment in specific populations is preferable. We recommend the implementation of age limits based on empirical evidence. Furthermore, we elaborate on a suitable model for informed consent involving children and parents that would do justice to developmental aspects of children and the specific characteristics of the parent-child dyad.
Summary
Previous research outcomes showed that children’s medical decision-making capacities could be operationalized into a standardized assessment instrument. Recommendations for policies include a dual consent procedure, including both child as well as parents, for children from the age of 12 until they reach majority. For children between 10 and 12 years of age, and in case of children older than 12 years in special research populations of mentally compromised patients, we suggest a case-by-case assessment of children’s competence to consent. Since such a dual consent procedure is fundamentally different from a procedure of parental permission and child assent, and would imply a considerable shift regarding some current legislations, practical implications are elaborated.

BMC Pregnancy and Childbirth
http://www.biomedcentral.com/bmcpregnancychildbirth/content
(Accessed 21 November 2015)

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Research article
Demand-side interventions for maternal care: evidence of more use, not better outcomes
Taylor Hurst, Katherine Semrau, Manasa Patna, Atul Gawande, Lisa Hirschhorn
BMC Pregnancy and Childbirth, 2015, 15:294 (11 November 2015)

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Research article
Fertility desires, family planning use and pregnancy experience: longitudinal examination of urban areas in three African countries
Ilene Speizer, Peter Lance
BMC Pregnancy and Childbirth 2015, 15:294 (11 November 2015)

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Research article
The triple threat of pregnancy, HIV infection and malaria: reported causes of maternal mortality in two nationwide health facility assessments in Mozambique, 2007 and 2012
Patricia Bailey, Emily Keyes, Allisyn Moran, Kavita Singh, Leonardo Chavane, Baltazar Chilundo BMC Pregnancy and Childbirth 2015, 15:293 (9 November 2015)

Eurosurveillance
Volume 20, Issue 45, 12 November 2015
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

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Editorial
Refugee crisis demands European Union-wide surveillance!
M Catchpole 1 , D Coulombier 1
1. European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
The conflicts in the Middle-East and instability in Libya and some parts of Asia and Africa have resulted in a dramatic influx of refugees to the European Union (EU) in recent years. In the first nine months of 2015, more than 600,000 applications for asylum were filed in the EU [1]. With no prospect of change of the international context in the near future, it is likely that the influx of refugees into the EU will continue and may even increase in coming months.

We have witnessed numerous large displacements of populations in recent years and ‘Refugee health’ has become an area of concern for national and international, governmental and non-governmental organisations. Much has been learned from responding to these humanitarian crises.

Although refugees are facing a similar spectrum of non-communicable diseases to those experienced by the indigenous population of their countries of origin, trauma and injuries, sexual and reproductive health issues, violence and psychosocial disorders are among the most frequent health problems refugees encounter. Disruption of healthcare delivery systems in their countries of origin and limited access to healthcare during their journey result in the interruption of treatments often required for the control of chronic diseases [2].

Refugee populations entering the EU/European Economic Area (EEA), and particularly children, are at risk of exposure to infectious diseases in the same way as other EU residents, and in some cases may be more vulnerable because of the interruption of public health programmes, notably for immunisation, in their country of origin, as well as through various barriers to access healthcare such as language, culture etc. It is therefore important that they benefit from protection from infectious diseases, including those prevented through routine vaccinations. In addition, these refugees may be at specific risk for certain infectious diseases in relation to their country of origin, countries traversed during their migration, and the conditions they experienced during their mostly difficult journeys.

It is important to note that refugees should not be seen as representing a threat to Europeans regarding infectious diseases, but rather as being themselves vulnerable for such diseases. For example, poor living conditions and close contact in crowded shelters and refugee camps may increase the risk for the spread of lice and/or fleas, which in rare cases can carry diseases such as louse-borne diseases (relapsing fever due to Borrelia recurrentis, trench fever due to Bartonella quintana, epidemic typhus due to Rickettsia prowazekii), murine typhus and mites (scabies). In recent months, sporadic cases of louse-borne relapsing fever (LBRF) have been reported in Belgium, Finland, Germany and the Netherlands among migrants from Eritrea, Somalia and Sudan [3-5]. LBRF is a disease transmitted by body lice that caused major epidemics in the first half of the 20th century in Europe [6,7] and is known to have occurred occasionally among homeless people in recent years, without spreading to the general population [8]. Recent reports from Italy indicate that transmission of LBRF is likely to have occurred in shelters for refugees in the EU, resulting in the risk of cross-border spread as refugees are frequently moving to other countries [9,10]. Media are reporting outbreaks of scabies and diarrhoea, notably in Calais, France, in relation to poor housing and hygiene conditions [11].

Meningococcal disease outbreaks have been associated with overcrowding overall and in refugee settings. Contributing factors include sharing dormitories, poor hygiene, and limited access to medical care [12] and that meningococcal carriage rates have been shown to be higher in individuals in overcrowded settings. Most cases are acquired through exposure to asymptomatic carriers [13]. Meningococcal disease has usually been reported in children, but is still a leading cause of both meningitis and sepsis in adolescents, young adults and adults. In addition, overcrowding has been associated with increased transmission of measles, varicella and influenza.

As we are approaching winter, the travelling and living conditions for refugees in transit to Europe or in reception centres after their arrival is likely to deteriorate, with even more overcrowding in shelters with insufficient hygiene and therefore increased risk of transmission of communicable diseases. With the start of the influenza season, there is obviously a risk of increased influenza transmission.

Given the numbers and mobility of the refugee populations, the infectious disease risk can only be contained through a coordinated response at the EU level. That includes (i) raising awareness of the risks and types of infection that refugees may have been exposed to and may continue to be exposed to in reception centres, (ii) providing appropriate hygienic and medical countermeasures and (iii) ensuring ready access to medical diagnosis and treatment services. However, such a response will require that Europe has good information on the health situation of the refugees on the move in the EU.

Currently, the basic information that would allow a competent assessment of the situation is not available. The exact number of refugees is not known, and its assessment is hampered because refugees may avoid registration in fear of being sent back [14] and because they continue to move through different European countries. No comprehensive surveillance data is currently being gathered and only sporadic reports by organisations and institutions providing care for these populations are available.

Refugees are not currently a threat for Europe with respect to communicable diseases, but they are a priority group for communicable disease prevention and control efforts because they are more vulnerable.

The scale of the current influx of refugees is inevitably putting pressure on public health systems in frontline receiving countries. Protecting the health of this vulnerable group is complicated further by the potential occurrence of communicable diseases that have not been commonly or widely seen within Europe, creating challenges in terms of recognition and case management. It is vital to ensure that public health authorities have the right information to target resources and provide appropriate measures.

Given these challenges, the European Centre for Disease Prevention and Control (ECDC) will continue to work with its partners in Europe, including public health authorities in the Member States and the European Commission, to strengthen the evidence base guiding prevention and control measures and adding to the current evidence which pinpoint adequate hygiene conditions and vaccination services as the most immediate needs. Strengthening and coordinating surveillance will require continuing efforts to improve the quantity and quality of surveillance data collected through a EU-wide surveillance scheme. It will allow to ensure that interventions aimed at improving health of the refugees are relevant, proportionate, appropriately targeted and coordinated.
[References available at title link]

Globalization and Health
http://www.globalizationandhealth.com/
[Accessed 21 November 2015]

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Commentary
Mitigation of non-communicable diseases in developing countries with community health workers
Mishra SR, Neupane D, Preen D, Kallestrup P and Perry HB Globalization and Health 2015, 11:43 (10 November 2015)
Abstract
Non-communicable diseases (NCDs) are rapidly becoming priorities in developing countries. While developed countries are more prepared in terms of skilled human resources for NCD management, developing the required human resources is still a challenge in developing countries. In this context, mobilizing community health workers (CHWs) for control of NCDs seems promising. With proper training, supervision and logistical support, CHWs can participate in the detection and treatment of hypertension, diabetes, and other priority chronic diseases. Furthermore, advice and support that CHWs can provide about diet, physical activity, and other healthy lifestyle habits (such as avoidance of smoking and excessive alcohol intake) have the potential for contributing importantly to NCD programs. This paper explores the possibility of involving CHWs in developing countries for addressing NCDs.

International Health
Volume 7 Issue 6 November 2015
http://inthealth.oxfordjournals.org/content/current

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Improving surgical systems in low- and middle-income countries: an inclusive framework for monitoring and evaluation
Peter G. Bendix, Jamie E. Anderson, John A. Rose, Emilia V. Noormahomed, and Stephen W. Bickler
Int. Health (2015) 7 (6): 380-383 doi:10.1093/inthealth/ihv054
Corresponding author: E-mail: jeanderson@ucdavis.edu
Abstract
High disease burden and inadequate resources have formed the basis for advocacy to improve surgical care in low- and middle-income countries (LMICs). Current measures are heavily focused on availability of resources rather than impact and fail to fully describe how surgery can be more integrated into health systems. We propose a new monitoring and evaluation framework of surgical care in LMICs to integrate surgical diseases into broader health system considerations and track efforts toward improved population health. Although more discussion is required, we seek to broaden the dialogue of how to improve surgical care in LMICs through this comprehensive framework.

International Health
Volume 7 Issue 6 November 2015
http://inthealth.oxfordjournals.org/content/current

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Screening for psychological difficulties in young children in crisis: complementary cross-cultural validation
Caroline Marquer, Caroline Barry, Yoram Mouchenik, Douma M. Djibo, Mahamane L. Manzo,
Elena Maria Trujillo Maza, Sandra Githaiga, German Casas, Béatrice W. Kirubi, Héloïse Marichez,
Bruno Falissard, Marie-Rose Moro, and Rebecca F. Grais
Int. Health (2015) 7 (6): 438-446 doi:10.1093/inthealth/ihv006
Abstract
Background Detection of children’s psychological difficulties in crises and low resource settings is challenged by the lack of a validated, rapid and simple tool. We present the results of two confirmatory validations of the Psychological Screening for Young Children aged 3 to 6 years (PSYCa 3–6) scale.
Methods We performed cross-cultural validations, assessing the performance of the scale in different contexts. These were conducted in Mathare, Nairobi, Kenya and Buenaventura, Colombia between December 2009 and February 2012. External validity was assessed comparing the PSYCa 3–6 against a clinical interview and the Clinical Global Impression Severity scale (CGI).
Results A total of 160 mothers or caregivers of children 3 to 6 years old in Mathare and 148 in Buenaventura were included in the study. Both demonstrated good concurrent validity (Buenaventura ρ=0.49, p<0.0001; Mathare ρ=0.41, p<0.0001). Inter-rater reliability was found to be acceptable in Buenaventura (intraclass correlation [ICC]=0.69 [0.4–0.84]) and high in Mathare (0.87 [0.75–0.94]).
Conclusions As shown by its validation in diverse contexts, use in other populations may help improve the delivery of mental health care to children in crises and low-resource settings. Additional research on the design and delivery of intervention models for crises remains essential.

International Health
Volume 7 Issue 6 November 2015
http://inthealth.oxfordjournals.org/content/current

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When free healthcare is not free. Corruption and mistrust in Sierra Leone’s primary healthcare system immediately prior to the Ebola outbreak
Pieternella Pieterse and Tom Lodge
Int. Health (2015) 7 (6): 400-404 doi:10.1093/inthealth/ihv024
Abstract
Introduction
Sierra Leone is one of three countries recently affected by Ebola. In debates surrounding the circumstances that contributed to the initial failure to contain the outbreak, the word ‘trust’ is often used: In December 2014, WHO director Margret Chan used ‘lack of trust in governments’; The Lancet’s Editor-in-Chief, wrote how Ebola has exposed the ‘… breakdown of trust between communities and their governments.’ This article explores the lack of trust in public healthcare providers in Sierra Leone, predating the Ebola outbreak, apparently linked to widespread petty corruption in primary healthcare facilities. It compares four NGO-supported accountability interventions targeting Sierra Leone’s primary health sector.
Methods
Field research was conducted in Kailahun, Kono and Tonkolili Districts, based on interviews with health workers and focus group discussions with primary healthcare users.
Results
Field research showed that in most clinics, women and children entitled to free care routinely paid for health services.
Conclusions
A lack of accountability in Sierra Leone’s health sector appears pervasive at all levels. Petty corruption is rife. Understaffing leads to charging for free care in order to pay clinic-based ‘volunteers’ who function as vaccinators, health workers and birth attendants. Accountability interventions were found to have little impact on healthworker (mis)behaviour.

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Prevalence of pneumonia and associated factors among indigenous children in Brazil: results from the First National Survey of Indigenous People’s Health and Nutrition
Andrey M. Cardoso, Bernardo L. Horta, Ricardo V. Santos, Ana L. Escobar, James R. Welch,
and Carlos E. A. Coimbra, Jr.
Int. Health (2015) 7 (6): 412-419 doi:10.1093/inthealth/ihv023

The Lancet
Nov 14, 2015 Volume 386 Number 10007 p1917-2028 e36-e44
http://www.thelancet.com/journals/lancet/issue/current

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Comment
HPV vaccination for victims of childhood sexual abuse
Suzanne M Garland, Asvini K Subasinghe, Yasmin L Jayasinghe, John D Wark, Anna-Barbara Moscicki, Albert Singer, Xavier Bosch, Karen Cusack, Margaret Stanley
DOI: http://dx.doi.org/10.1016/S0140-6736(15)00757-6

Health authorities around the world, including WHO, recommend starting cervical screening at age 25 years or older, thus excluding young women from population screening.1 This guidance was developed on the basis of numerous investigations documenting high rates of human papillomavirus infection in the general population of young women, with very low rates of cervical cancer.2 Although human papillomavirus infection is common, occurring shortly after sexual debut, it is largely transient and asymptomatic. Cervical cancer has decreased greatly owing to cervical cytology screening for and treatment of precursor lesions.3 However, the data from cervical cytology screening are from birth cohorts whose age of sexual debut was 5–10 years later than that of the present generation. An earlier age of sexual debut creates a wider gap between initial contact with human papillomavirus and the present recommendations for age of onset for screening.4 This generational change in sexual behaviour has the potential to increase the population risk for cervical cancer, an outcome that can be offset by human papillomavirus vaccination before sexual debut.

Less than 2% of women worldwide receive human papillomavirus vaccination, despite vaccines being licenced in 129 countries, with 64 countries having such vaccines in their national immunisation programmes.5 Few countries achieve wide vaccine coverage, although even in those with low coverage—such as the USA—the prevalence of vaccine-targeted human papillomavirus genotypes is low. Although delayed screening will not pose a risk to the vast majority of women, it could lead to otherwise preventable cervical cancers among high-risk women younger than 25 years of age in countries with poor vaccine coverage. Young women who have experienced childhood sexual abuse might fall into this category.

According to WHO, childhood sexual abuse is defined as the involvement in sexual activity of a child under the age of 18 years who did not give informed consent or is not developmentally prepared.6 The global prevalence of childhood sexual abuse is estimated to be 8–31% for girls and 3–17% for boys.7 According to a review published in 2004, parents were the perpetrators of about 45% of cases of childhood sexual abuse in the USA, and other relatives were responsible for 19%.8 Additionally, perpetrators can be trusted authority figures in society such as priests and teachers.8 Consequently, survivors of such abuse are often hesitant to report such incidents because of shame and fear of retribution. Thus, the incidence and prevalence of childhood sexual abuse is almost certainly underestimated.

Results of a study in Australia9 suggest unwanted sexual experiences with genital contact in adolescence increase the risk of cervical cancer. Moreover, early onset of sexual activity is a strong risk factor for cervical cancer. This effect could be due to the greater risk of prolonged carriage of high-risk human papillomavirus as a result of earlier genital contact in these young women, or a specific vulnerability of the cervical epithelium during a critical developmental period. Globally, around 5–10% of girls and 1–5% of boys are exposed to penetrative childhood sexual abuse.10 Preliminary data from questionnaires from 398 women aged 16–25 years in Victoria, Australia, who had experienced childhood sexual abuse showed that penile–genital contact at the time of the abuse was common (32%)—the mean age at time of abuse was 12 years.11 Certainly, cervical or vaginal trauma resulting from forced intercourse places these women at high risk of infection. In addition, the epithelial vulnerability of immature cervixes could accelerate human papillomavirus acquisition and persistent human papillomavirus carriage.12
People who have experienced childhood sexual abuse are more likely to engage in risky behaviours associated with cervical cancer, such as an increased number of sexual partners, sex work, and cigarette smoking.13 Drug and alcohol use and depression are also more common in victims of childhood sexual abuse.14 Most childhood sexual abuse (70%) occurs at a mean age of 10–11 years, which is younger than the age at which human papillomavirus vaccinations are administered.15 Early virus exposure thus reduces later human papillomavirus vaccine efficacy. Hence, it would be intuitive to administer human papillomavirus vaccine as soon as childhood sexual abuse is reported because of the risk of ongoing exposures due to maladaptive coping, including potential disengagement with mainstream education and health services.

We believe that male and female victims of childhood sexual abuse should not only be screened for sexually transmitted infections (and offered appropriate treatment), but also be offered human papillomavirus vaccination. Moreover, although cervical cancer screening from age 25 years is appropriate for the general female population, policy makers should consider options for screening from 18 years when clinicians are concerned about individual risk. Early human papillomavirus vaccination, and cervical screening for women younger than 25 years who have experienced childhood sexual abuse, should help to reduce the burden of human papillomavirus-related disease in this high-risk population.

Women treated for cervical cancer are at increased risk of developing human papillomavirus-related anogenital cancers16 and need lifelong surveillance.17
[References at title link]

SMG has received research funding from Merck, GlaxoSmithKline, and bioCSL; non-financial support from Merck; and speaking fees from Merck Sharp & Dohme and Sanofi Pasteur MSD. YLJ has received the Novartis Scholarship from the Royal Australasian College of Physicians. AS has received personal fees from IBC Medical Services. XB has received research funding and personal fees from Merck Sharp & Dohme, GlaxoSmithKline, Sanofi Pasteur MSD, and Qiagen; and personal fees from Roche Molecular Systems. MS has received personal fees from GlaxoSmithKline Biologicals, MSD Merck, and Sanofi Pasteur MSD. A-BM has received personal fees from Merck. AKS, JDW, and KC declare no competing interests.

The Lancet Commissions
The Rockefeller Foundation–Lancet Commission on planetary health
Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health
Sarah Whitmee, Andy Haines, Chris Beyrer, Frederick Boltz, Anthony G Capon, Braulio Ferreira de Souza Dias, Alex Ezeh, Howard Frumkin, Peng Gong, Peter Head, Richard Horton, Georgina M Mace, Robert Marten, Samuel S Myers, Sania Nishtar, Steven A Osofsky, Subhrendu K Pattanayak, Montira J Pongsiri, Cristina Romanelli, Agnes Soucat, Jeanette Vega, Derek Yach
Summary
Far-reaching changes to the structure and function of the Earth’s natural systems represent a growing threat to human health. And yet, global health has mainly improved as these changes have gathered pace. What is the explanation? As a Commission, we are deeply concerned that the explanation is straightforward and sobering: we have been mortgaging the health of future generations to realise economic and development gains in the present. By unsustainably exploiting nature’s resources, human civilisation has flourished but now risks substantial health effects from the degradation of nature’s life support systems in the future.

New England Journal of Medicine
November 12, 2015 Vol. 373 No. 20
http://www.nejm.org/toc/nejm/medical-journal

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Review Article
Elder Abuse
Edward W. Campion, M.D., Editor
Mark S. Lachs, M.D., M.P.H., and Karl A. Pillemer, Ph.D.
N Engl J Med 2015; 373:1947-1956 November 12, 2015 DOI: 10.1056/NEJMra1404688

Although it has probably existed since antiquity, elder abuse was first described in the medical literature in the 1970s.1 Many initial attempts to define the clinical spectrum of the phenomenon and to formulate effective intervention strategies were limited by their anecdotal nature or were epidemiologically flawed. The past decade, however, has seen improvements in the quality of research on elder abuse that should be of interest to clinicians who care for older adults and their families. Financial exploitation of older adults, which was explored only minimally in the initial studies, has recently been identified as a virtual epidemic and as a problem that may be detected or suspected by an alert physician.

In the field of long-term care, studies have uncovered high rates of interpersonal violence and aggression toward older adults; in particular, abuse of older residents by other residents in long-term care facilities is now recognized as a problem that is more common than physical abuse by staff.2,3 The use of interdisciplinary or interprofessional teams, also referred to as multidisciplinary teams in the context of elder abuse, has emerged as one of the intervention strategies to address the complex and multidimensional needs and problems of victims of elder abuse, and such teams are an important resource for physicians.4,5 These new developments suggest an expanded role for physicians in assessing and treating victims of elder abuse and in referring them for further care.

In this review, we summarize research and clinical evidence on the extent, assessment, and management of elder abuse, derived from our analysis of high-quality studies and recent systematic studies and reviews of the literature on elder abuse.6-10…

…Conclusions
Because victims of elder abuse tend to be isolated, their interactions with physicians, which may be intermittent or rare, present critically important opportunities to recognize elder abuse and to intervene or refer the victims to appropriate providers. Advances in our understanding of the many manifestations of elder abuse and the emergence of interprofessional-team approaches also point to an important role for physicians in addressing this major public health problem. Both research and clinical experience suggest that cases of elder abuse can rarely, if ever, be successfully treated by the physician alone. Therefore, the response of the medical professional must include connecting with specialists in other disciplines, including social work, law enforcement, and protective services, ideally in the context of an interprofessional-team approach.

PharmacoEconomics
Volume 33, Issue 11, November 2015
http://link.springer.com/journal/40273/33/10/page/1

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Systematic Review
Assessing the Economics of Dengue: Results from a Systematic Review of the Literature and Expert Survey
Dagna Constenla, Cristina Garcia, Noah Lefcourt
Abstract
Background
The economics of dengue is complex and multifaceted.
Objectives
We performed a systematic review of the literature to provide a critical overview of the issues related to dengue economics research and to form a background with which to address the question of cost.
Methods
Three literature databases were searched [PubMed, Embase and Latin American and Caribbean Health Sciences Literature (LILACS)], covering a period from 1980 to 2013, to identify papers meeting preset inclusion criteria. Studies were reviewed for methodological quality on the basis of a quality checklist developed for this purpose. An expert survey was designed to identify priority areas in dengue economics research and to identify gaps between the methodology and actual practice. Survey responses were combined with the literature review findings to determine stakeholder priorities in dengue economics research.
Results
The review identified over 700 papers. Forty-two of these papers met the selection criteria. The studies that were reviewed presented results from 32 dengue-endemic countries, underscoring the importance of dengue as a global public health problem. Cost analyses were the most common, with 21 papers, followed by nine cost-effectiveness analyses and seven cost-of-illness studies, indicating a relatively strong mix of methodologies. Dengue annual overall costs (in 2010 values) ranged from US$13.5 million (in Nicaragua) to $56 million (in Malaysia), showing cost variations across countries. Little consistency exists in the way costs were estimated and dengue interventions evaluated, making generalizations around costs difficult.
Conclusions
The current evidence suggests that dengue costs are substantial because of the cost of hospital care and lost earnings. Further research in this area will broaden our understanding of the true economic impact of dengue.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 21 November 2015)

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Generating Evidence to Improve the Response to Neglected Diseases: How Operational Research in a Médecins Sans Frontières Buruli Ulcer Treatment Programme Informed International Management Guidance
Daniel P. O’Brien, Nathan Ford, Marco Vitoria, Kingsley Asiedu, Alexandra Calmy, Philipp Du Cros, Eric Comte, Vanessa Christinet
Viewpoints | published 12 Nov 2015 | PLOS Neglected Tropical Diseases
10.1371/journal.pntd.0004075

Public Health Ethics
Volume 8 Issue 3 November 2015
http://phe.oxfordjournals.org/content/current

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Special Symposium: Antimicrobial Resistance
The Ethical Significance of Antimicrobial Resistance
Jasper Littmann, Institute of Experimental Medicine, Christian-Albrechts University Kiel
A. M. Viens, Author Affiliations
Southampton Law School, University of Southampton
Abstract
In this paper, we provide a state-of-the-art overview of the ethical challenges that arise in the context of antimicrobial resistance (AMR), which includes an introduction to the contributions to the symposium in this issue. We begin by discussing why AMR is a distinct ethical issue, and should not be viewed purely as a technical or medical problem. In the second section, we expand on some of these arguments and argue that AMR presents us with a broad range of ethical problems that must be addressed as part of a successful policy response to emerging drug resistance. In the third section, we discuss how some of these ethical challenges should be addressed, and we argue that this requires contributions from citizens, ethicists, policy makers, practitioners and industry. We conclude with an overview of steps that should be taken in moving forward and addressing the ethical problems of AMR.

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Ebola and Learning Lessons from Moral Failures: Who Cares about Ethics?
Maxwell J. Smith, University of Toronto; Ross E. G. Upshur, University of Toronto
Abstract
The exercise of identifying lessons in the aftermath of a major public health emergency is of immense importance for the improvement of global public health emergency preparedness and response. Despite the persistence of the Ebola Virus Disease (EVD) outbreak in West Africa, it seems that the Ebola ‘lessons learned’ exercise is now in full swing. On our assessment, a significant shortcoming plagues recent articulations of lessons learned, particularly among those emerging from organizational reflections. In this article we argue that, despite not being recognized as such, the vast majority of lessons proffered in this literature should be understood as ethical lessons stemming from moral failures, and that any improvements in future global public health emergency preparedness and response are in large part dependent on acknowledging this fact and adjusting priorities, policies and practices accordingly such that they align with values that better ensure these moral failures are not repeated and that new moral failures do not arise. We cannot continue to fiddle at the margins without critically reflecting on our repeated moral failings and committing ourselves to a set of values that engenders an approach to global public health emergencies that embodies a sense of solidarity and global justice.

Science
13 November 2015 vol 350, issue 6262, pages 713-884
http://www.sciencemag.org/current.dtl

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Introduction to Special Issue
Oceans of change
Julia Fahrenkamp-Uppenbrink, David Malakoff, Jesse Smith, Caroline Ash, Sacha Vignieri
Science 13 November 2015: 760-763.
The phrase “climate change” typically evokes thoughts of rising air temperatures or other atmospheric phenomena such as droughts and extreme storms. Much less often do we consider the parallel changes that are occurring in the oceans, despite their extent and importance.

Climate change in the oceans has many facets. One is a rise in sea levels. Scientists are learning about how previous warm periods altered sea levels, and what that past may tell us about the future. To help us cope, so-called green infrastructure, such as planted marshes or oyster reefs, may help protect low-lying shorelines. Climate change is also creating problems for fisheries; for example, commercially valuable stocks move in response to warming seas.

Climate change has caused ocean temperatures to rise, a trend that will continue in the coming centuries even if fossil fuel emissions are curtailed. The uptake of carbon dioxide also makes the oceans more acidic, affecting the ability of organisms to create and maintain calcium-based shells and skeletons. Warm-water corals are particularly susceptible to these effects and may not survive the century unless carbon emissions are greatly reduced. Climate change impacts in the deep ocean are less visible, but the longevity and slow pace of life in the deep makes that ecosystem uniquely sensitive to environmental variability. Marine vertebrates at every depth are being affected, as are humans. Even if international negotiations like those kicking off soon in Paris succeed, we will be coping with the impacts of ocean climate change for centuries.

The Sentinel

Human Rights Action :: Humanitarian Response :: Health ::
Holistic Development :: Sustainable Resilience
__________________________________________________
Week ending 7 November 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 7 November 2015

blog edition: comprised of the 35+ entries  posted below on 8 November 2015

Where Is the Humanity?
Ban Ki-moon, Secretary-General, United Nations
Huffington Post, Posted: 10/31/2015 11:59 am EDT Updated: 11/02/2015 9:59 pm EST

Families at a wedding party killed mid-celebration by airstrikes. Patients at a hospital burned alive in beds set aflame by bombs. Women and girls in war zones abused and sold as sexual slaves. Monuments that stood for millennia as proud emblems of culture and civilization, reduced to rubble. The denial of humanitarian access; the deliberate starvation of besieged populations; attacks on peacekeepers and relief workers; so-called surgical strikes targeting surgical wards.

These are only the latest examples of a brazen and brutal erosion of respect for human rights and international humanitarian law in the world’s conflict areas. In the first seven months of this year, 95 per cent of the people killed or injured by explosive weapons in Yemeni towns and cities were civilians.

More than 90 per cent of civilians killed in today’s conflicts are dying in densely populated urban areas.

We often hear that sophisticated weapons systems make targeting more precise, but new technology has often ended up intensifying the violence.
In all wars, fighters and those who control them are responsible for protecting civilians, sparing them the effects of conflict and making sure they have access to food, water and medical services.

The presumption of respect for ordinary women, men and children caught up in conflict is the cornerstone of international humanitarian law, formalized after the world wars of the last century and underpinned by our shared humanity.

More than 190 governments have signed up to the laws, conventions and principles that protect civilian lives, from the Geneva Conventions to the Responsibility to Protect.
When Governments do not act to enforce these rules – or are themselves the perpetrators of violations – the resulting impunity breeds even more violence, generates vast disillusion and eats away at the foundations of international order.

The time has come for more determined efforts to save civilian lives and ensure adherence to international humanitarian law. Today in Geneva, I will join with Peter Maurer, the President of the International Committee of the Red Cross, to take a stand against the crimes and cruelty that define the current moment.

The international system has tools and mechanisms to push for greater compliance and accountability when national governments cannot or will not take action. It is time to use them.

All governments must publicly condemn violations, and work together to exert maximum pressure on those involved in the fighting.

Parties to conflict should stop using heavy explosive weapons in urban and residential areas, where most civilians are killed and injured.

Domestic and international investigations have an important role to play, and we make greater use of the International Criminal Court and special tribunals such as those that were established to pursue justice for abuses in Rwanda, the former Yugoslavia, Cambodia and Sierra Leone

And we must publicly identify and hold accountable all those who give support to governments, armed groups and terrorist organizations that commit crimes. In Iraq, Syria, Ukraine, Yemen, South Sudan and elsewhere, states outside the conflict zone are providing political, material and financial support to military forces and armed groups that are inflicting harm on civilians, who are paying the price for regional rivalries and proxy battles.

Protecting civilians in wartime is a cornerstone of the international system and the United Nations. Indifference will only make our world far less secure. Our continued failure to act is a disgrace and a stain on the conscience of the world. Even war has rules; it is time to enforce them.

António Guterres (UNHCR) on Refugees, Returnees and Displaced Persons, Third Committee, 40th Plenary – 70th General Assembly
Video: 31:47
3 Nov 2015 Statement by Mr. António Guterres United Nations High Commissioner for Refugees on questions relating to refugees, returnees and displaced persons and humanitarian questions.

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Amid Record Numbers of People Displaced by War, Humanitarian Actors No Longer Able to Provide Core Assistance, Protection, Top Official Tells Third Committee
3 November 2015
GA/SHC/4149
Until donors ramped up contributions, humanitarian actors were no longer able to provide core assistance to the record number of displaced people worldwide, the head of the United Nations refugee agency told the Third Committee (Social, Humanitarian and Cultural) today as it concluded discussions on racism and began consideration of humanitarian questions.

“The international multilateral humanitarian community, even when combining all its resources, is no longer able to provide the core protection and basic life-saving assistance,” António Guterres, United Nations High Commissioner for Refugees (UNHCR), told the Committee during an interactive dialogue. Between 2010 and 2014, the number of people that had been forced from their homes every day had nearly quadrupled and now more than 60 million people worldwide had been forcibly displaced as a result of war and persecution.

The corresponding increase in humanitarian needs, therefore, had overwhelmed the global capacity to respond, he said. In 2014, UNHCR’s focus on emergency response had strained capacities and resources across the Agency. As the explosion in humanitarian needs had inevitably outpaced the support of the donor community, there was a growing gap between requirements and resources. Most urgently, he said, the Agency had a $205 million deficit in Africa.

“Money moves freely, but people still face enormous obstacles,” he continued. As a cruel paradox, few movements were as tightly restricted as those of human beings, leading to hundreds of thousands of people having no other option but to put their lives into the hands of unscrupulous smugglers.

That desperation could be seen in the growing number of displaced persons. Since January, 750,000 people had arrived on Europe’s shores and the number of daily arrivals, on Greek islands alone, stood between 6,000 and 8,000. The European Union, he noted, had the capacity to manage the crisis, but a united and comprehensive regional approach was essential. Furthermore, Europe and Africa needed a common strategy to allow people to have a future in their own countries.

One key element in effectively responding to humanitarian crises was development actors working side by side with humanitarian actors to help prevent further conflict, support host communities, and pave the way for durable solutions. But, “more than anything else, we must be able to understand and address the root causes of displacement” from conflict over resources, poor governance, human rights violations, unequal access to development benefits, or climate change, he said.

“Migration should be an option, not a necessity; an expression of hope, not of despair,” he noted.

Indeed, all countries must meet their obligations under international refugee law, and political solutions must be found to conflicts that had prompted refugee flows, Mogens Lykketoft, President of the General Assembly, told the Committee. With a humanitarian and refugee crisis of a magnitude not seen since the Second World War, no region or country could address that crisis on its own.

To address those grave challenges, he said the Assembly would hold a plenary meeting 20 November to discuss global awareness of the tragedies of irregular migrants in the Mediterranean basin, with specific emphasis on Syrian asylum seekers. It would be preceded by an informal meeting on 19 November on ways towards a comprehensive approach to the humanitarian response to the global refugee crisis. Additionally, a high-level thematic debate would be held on 12 and 13 July 2016 on the United Nations and human rights, with particular attention being given to the needs of the millions of people who had been affected by conflict and disaster…

Joint open letter to the European Council – Time to act to ensure children’s rights in the EU’s migration policy: 10 action points
59 leading organisations in the fields of human rights, child rights, health and social inclusion, including UNICEF, OHCHR and the European Network of Ombudspersons for Children, expressed their concern on the lack of attention afforded to children’s rights in these policy discussions and developments.

The joint letter urges the Heads of Government and Ministers to develop and implement concrete measures towards a comprehensive and rights-based strategy ensuring effective protection for all children affected by migration, including in the upcoming meetings at European level.
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[Text bolding from original text]
Brussels, 30 October 2015

Significant numbers of children from third countries migrate to Europe, for a variety of reasons, travelling with their families, alone or separated from their family. Between January and August 2015 alone, 174,235 children sought asylum in the European Union, representing one in four asylum seekers.i From January to September, tens of thousands of unaccompanied children arrived by sea.ii Comprehensive data on children that have not claimed asylum or are residing undocumented in the EU is lacking. As children and as migrants they face a number of risks,
particularly when they are undocumented.

Over the past few months, several European Council as well as Justice and Home Affairs and Foreign Affairs Council meetings have been convened to discuss and develop immediate responses and policies to address the recent increase in migrants and refugees arriving to Europe.

As 59 leading organisations in the fields of human rights, child rights, health and social inclusion, including UNICEF, OHCHR and the European Network of Ombudspersons for Children, we are concerned by the lack of attention afforded to children’s rights in these policy discussions and developments. iv

All the policy decisions and practical developments are having – and will continue to have – a profound impact on the lives of children. The EU and its Member States need to ensure that their responses to the current situation properly address the specific needs, rights and risks that children face.

The current situation also demonstrates the necessity of implementing a rights-based approach to protect all migrant children, regardless of whether they are seeking asylum, are documented, undocumented, trafficked, accompanied or unaccompanied.

Children often move from category to category, and fall through the gaps in the protection framework. Many of the children who have experienced situations of violence, insecurity, child-specific forms of persecution, and other human rights violations are not recognised as in need of international protection, or are only provided a status for a short period of time. Many of the children claiming asylum today, are likely to be undocumented in a few months or years. Many were first documented, but lost their status at a later stage, for example, if their parent lost their job or experienced domestic violence.v While many unaccompanied children migrate entirely independently, many do so to join family members already in Europe, and later reside regularly or irregularly with their family.

Furthermore, as the Council has noted, ‘the EU Charter for Fundamental Rights and the United Nations Convention on the Rights of the Child, establish that children should be treated as such regardless of their migratory status, nationality or background’.vi Some children may have additional protection needs that should be met, but all children have equal rights, and must have their rights protected, as children first and foremost. No form of discrimination is acceptable or justifiable, whether taken by public authorities or private actors.

Yet, the current package of policies reinforces a very differentiated treatment of children. While essential avenues for protection are foreseen for some children, the increasing focus on detention and deportation, further investment in border control, and significantly reducing the number of people that can arrive to the EU’s borders through cooperation with third countries raises serious child rights concerns. All measures must be developed, implemented, evaluated and adapted to ensure compliance with child rights. It is the responsibility and duty of governments to respect, protect and fulfil the rights of every child.

We call on the EU and its member states to implement the following ten actions:
1. Consider children’s rights and views, and guarantee their best interests when making decisions, including on immigration and asylum applications and in any decision to move a child or family to another country. The best interests of the child must never be outweighed by migration and border control concerns.

2. Meet immediate humanitarian and reception needs, while also investing in systemic reform to ensure access to services in a sustainable way, and to facilitate integration.

3. Ensure that all children have non-discriminatory access to services, such as health care, including mental health, and education, and have adequate accommodation together with their family.

4. Ensure effective protection of all children from all forms of violence, abuse and exploitation and discrimination, including gender-based, and access to justice for acts of violence or other rights violations.vii

5. Ensure that no child is detained or subject to other punitive measures because of their or their parent’s residence or migration status.

6. Protect family unity when in the child’s best interests, including by ensuring that no child is separated from a parent by immigration-related detention.

7. Provide adequate search and rescue and humanitarian assistance to prevent all avoidable deaths, whether at sea or on land.

8. Provide regular and safe ways for children and their families to come to Europe to seek protection and join family members and open more rights-respecting avenues for work and study.

9. Ensure that all agreements with countries of origin and transit include child rights safeguards and pay particular attention to the needs and rights of children. Children and their families should not be returned to a country where there is a risk of human rights violation (non-refoulement).

10. Empower children to access justice, and have their views heard, including through providing information and access to legal representation in all proceedings that can affect their status, rights and freedoms.

Child rights and protection safeguards and impact assessments must be integrated in all migration-related policy and practice. The best interests of the child should always be a primary consideration in all policies, practices, decisions and procedures. While extending essential protection to some children, governments cannot detain, forcibly deport and deny essential services to others.

We urge Heads of Government and Ministers to develop and implement concrete measures towards a comprehensive and rights-based strategy ensuring effective protection for all children affected by migration viii, including in the upcoming meetings at European level, in particular when discussing drivers for migration at the Valletta Summit on 11-12 November and the Justice and Home Affairs Council on 3-4 December and through its Council Conclusions.

[Signatory list and pdf of letter at http://childfundalliance.org/documents/Letter-to-council.pdf]

References
i Latest available Eurostat figures available on http://ec.europa.eu/eurostat/web/asylum-and-managed-migration/data/main-tables (select ‘Asylum and new asylum applicants – monthly data’), dated 27 October 2015.
ii UNHCR Italy reports 10,000 unaccompanied children arriving to Italy (UNHCR, ‘Italy – Sea arrivals. UNHCR Update no.1’, September 2015).
iii This letter is being sent by PICUM – the Platform for International for International Cooperation on Undocumented Migrants on behalf of the undersigned organisations. For follow up, please contact PICUM, Rue du Congrès 37-41/ 5, Brussels 1000, Belgium (www.picum.org).
iv European Commission Communication, ‘A European Agenda on Migration’, COM(2015) 240 final, Brussels, 13.5.2015; European Council Conclusions 25 and 26 June 2015 (EUCO 22/15); Presidency Conclusions 14 September 2015 (12002/15); Council Conclusions on the future of the return policy, 8 October 2015 (12856/15); European Council Conclusions 15 October 2015 (EUCO 26/15); Leaders’ Statement, Leaders’ Meeting on refugee flows along the Western Balkans Route, 25 October 2015.
v If someone has a spouse-dependent visa, they are liable to lose their status and become undocumented when that relationship breaks down, even if the reason is domestic violence.
vi Council conclusions on unaccompanied minors, 3018th Justice and Home Affairs Council meeting, Luxembourg, 3 June 2010, para c. See also the 36 concrete recommendations for States Parties to implement a systemic, comprehensive child-rights approach to migration that were issued by the Committee on the Rights of the Child in its Report of the 2012 Day of General Discussion.
vii See also the European Commission principles on integrated child protection systems, as published in the Reflection paper for the EU Child Rights Forum, 2-3 June 2015, Brussels, pending final publication.
viii See also Joint open letter to the European Council calling for European commitments on children’s rights to be prioritised in future common migration and asylum policies, dated 22 May 2014, sent by 38 leading organisations in the fields of human rights, health, education and social inclusion, including the UN Committee on the Rights of the Child, UNICEF, OHCHR and the European Network for Ombudspersons.

Report: I am Here, I Belong: the Urgent Need to End Childhood Statelessness
UNHCR
November 2015 [Release] :: 28 pages
http://www.unhcr.org/ibelong/wp-content/uploads/2015-10-StatelessReport_ENG15-web.pdf

Overview from Report Preface
Stateless children are born into a world in which they will face a lifetime of discrimination; their status profoundly affects their ability to learn and grow, and to fulfil their ambitions and dreams for the future.

With a stateless child being born somewhere in the world at least every 10 minutes, this is a problem that is growing. In countries hosting the 20 largest stateless populations, at least 70,000 stateless children are born each year.

The effects of being born stateless are severe. In more than 30 countries, children need nationality documentation to receive medical care. In at least 20 countries, stateless children cannot be legally vaccinated.

This report aims to go beyond these statistics, providing direct testimony of children and young people and how being stateless affects them.

In July and August 2015, UNHCR spoke with more than 250 children and youth,1 and their parents and guardians, in seven countries around the world about their experiences of childhood statelessness.

This is the first geographically diverse survey of the views of stateless children and youth. Many of the children and young people had never spoken to anyone about what it was like to be stateless.

The report highlights how not being recognized as a national of any country can create insurmountable barriers to education and adequate health care and stifle job prospects. It reveals the devastating psychological toll of statelessness and its serious ramifications not only for young people, whose whole futures are before them, but also for their families, communities and countries. It powerfully demonstrates the urgency of ending and preventing childhood
statelessness.

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Press Release
UNHCR report reveals debilitating impact of statelessness on children
Press Releases, 3 November 2015
Stateless children across the world share similar feelings of discrimination, frustration and despair, says a new UNHCR report, creating problems that can endure into adulthood.
The first geographically diverse survey of the views of stateless children says the common problems they face in the countries under review profoundly affect their ability to enjoy childhood, lead a healthy life, study and fulfil their ambitions.

Many of the dozens of young people in seven countries interviewed for the I am Here, I Belong: the Urgent Need to End Childhood Statelessness report said that being stateless had taken a serious psychological toll, describing themselves as “invisible,” “alien,” “living in a shadow,” “like a street dog” and “worthless.”

UN High Commissioner for Refugees António Guterres stressed that the report, released one year after the launch of UNHCR’s #IBelong Campaign to End Statelessness by 2024, highlights the need to end the suffering of stateless children in a world where a child is born stateless at least every 10 minutes.

“In the short time that children get to be children, statelessness can set in stone grave problems that will haunt them throughout their childhoods and sentence them to a life of discrimination, frustration and despair,” said Guterres. “None of our children should be stateless. All children should belong.”

The High Commissioner will, at the UN Headquarters in New York today, present the report at a high-level panel discussion on the importance of the right to nationality. More than 250 people, including children, youth and their parents or guardians were interviewed in Côte d’Ivoire, Dominican Republic, Georgia, Italy, Jordan, Malaysia and Thailand last July and August for the report.

In the report, the children tell of the tough challenges they face growing up, often on the margins of society, denied the rights most citizens enjoy. Stateless children say they are often treated like foreigners in the country they have lived in all their lives.

Stateless young people are often denied the opportunity to receive school qualifications, go to university and find a decent job. They face discrimination and harassment by authorities and are more vulnerable to exploitation. Their lack of nationality often sentences them and their families and communities to remain impoverished and marginalized for generations.

Statelessness also affects the future of young people. One young woman in Asia, told UNHCR researchers that she has been unable to take up job offers as a teacher because she is stateless and can only find work in a local shop. “I want to tell the country, that there are many people like me.”

UNHCR is calling on more countries to support the campaign launched on November 4, 2014 to end statelessness. In the year since, regional initiatives and action by states have seen the global community rally behind the campaign.

In order to end statelessness, UNHCR is urging all states to take the following steps:
:: Allow children to gain the nationality of the country in which they are born if they would otherwise be stateless.
:: Reform laws that prevent mothers from passing their nationality to their children on an equal basis as fathers.
:: Eliminate laws and practices that deny children nationality because of their ethnicity, race or religion.
:: Ensure universal birth registration to prevent statelessness.