Conference Material > Abstract
Hopkins S, Hazel A, Pourtois J, Chamberlin A, Gajewski Z, et al.
MSF Scientific Day International 2023. 7 June 2023; DOI:10.57740/vj1f-v594
INTRODUCTION
An undervalued role of rural healthcare provision is its impact on forests and carbon balance. In addition to the effects of healthcare provision and livelihood programmes on improved human health, these programmes can also reduce forest degradation and prevent deforestation-related carbon emissions, since unaffordable healthcare drives logging as a source of rescue income. Shocks such as the Covid-19 pandemic may exacerbate this dynamic. Health In Harmony and Planet Indonesia are two planetary health non-governmental organisations (NGO’s) that work together with communities living in and around tropical rainforests in West Kalimantan, Indonesia.
METHODS
We used a cross-sectional mixed-methods survey in November-December 2021 to evaluate healthcare access and livelihoods in 1,016 households across six NGO-affiliated villages and four unaffiliated control villages. Additionally, satellite-generated imagery retrieved between January 2018 and December 2021 was used to contrast relative deforestation rates in 28 NGO-affiliated and 1,421 unaffiliated control villages bordering protected rainforests across Kalimantan.
ETHICS
This study was approved by the Stanford University Institutional Review Board and by the Institut Pertanian Bogor Ethical Review Board.
RESULTS
After accounting for environmental variables that affect deforestation, satellite analysis suggested that prior to the Covid-19 pandemic, average weekly deforestation rates in NGO-affiliated villages (0.018%; 95% confidence interval (CI), 0.012-0.026%) were 70% lower than in unaffiliated villages (0.062%; 95%CI, 0.045-0.078%; p<0.0001). Following the WHO pandemic declaration, deforestation rates dropped and then gradually rebounded in both NGO-affiliated and unaffiliated villages, with NGO-affiliated villages maintaining significantly lower average deforestation rates (0.008%; 95%CI, 0.005-0.011%) during the pandemic than unaffiliated villages (0.026%; 95%CI, 0.019-0.032%; p<0.01). Survey results indicated that clinic visits, out-of-pocket healthcare spending, and the proportion of households unable to access healthcare increased across all villages during the pandemic. The main reasons given for access problems were around fears of contracting Covid-19, unaffordability, or clinic closure. Throughout the pandemic, households affiliated with Health In Harmony, which runs a health clinic, were less likely to report barriers to affordable clinic access than households in unaffiliated villages (14% vs. 29%; odds ratio (OR); 0.41,95%CI, 0.2-0.69). Households in NGO-affiliated villages were more likely to do jobs with low environmental impact (e.g., small-scale farming, conservation; OR 1.61,95%CI, 1.15-2.24). Half of households in both groups reported income loss from at least one source during the pandemic, but households in NGO-affiliated villages were more likely to gain alternative income from multiple job types, especially resource-neutral jobs (e.g., public servant, sales, services). Additionally, households in NGO-affiliated villages had more sources of economic support, such as government programmes, co-operatives, family and NGO’s (OR 1.36, 95%CI, 1.11-1.69).
CONCLUSION
Communities with better access to healthcare and livelihood support were associated with significantly lower deforestation rates prior to the Covid-19 pandemic, and this lower reliance on forest-degrading income was resilient to the pandemic shock.
CONFLICTS OF INTEREST
None declared.
An undervalued role of rural healthcare provision is its impact on forests and carbon balance. In addition to the effects of healthcare provision and livelihood programmes on improved human health, these programmes can also reduce forest degradation and prevent deforestation-related carbon emissions, since unaffordable healthcare drives logging as a source of rescue income. Shocks such as the Covid-19 pandemic may exacerbate this dynamic. Health In Harmony and Planet Indonesia are two planetary health non-governmental organisations (NGO’s) that work together with communities living in and around tropical rainforests in West Kalimantan, Indonesia.
METHODS
We used a cross-sectional mixed-methods survey in November-December 2021 to evaluate healthcare access and livelihoods in 1,016 households across six NGO-affiliated villages and four unaffiliated control villages. Additionally, satellite-generated imagery retrieved between January 2018 and December 2021 was used to contrast relative deforestation rates in 28 NGO-affiliated and 1,421 unaffiliated control villages bordering protected rainforests across Kalimantan.
ETHICS
This study was approved by the Stanford University Institutional Review Board and by the Institut Pertanian Bogor Ethical Review Board.
RESULTS
After accounting for environmental variables that affect deforestation, satellite analysis suggested that prior to the Covid-19 pandemic, average weekly deforestation rates in NGO-affiliated villages (0.018%; 95% confidence interval (CI), 0.012-0.026%) were 70% lower than in unaffiliated villages (0.062%; 95%CI, 0.045-0.078%; p<0.0001). Following the WHO pandemic declaration, deforestation rates dropped and then gradually rebounded in both NGO-affiliated and unaffiliated villages, with NGO-affiliated villages maintaining significantly lower average deforestation rates (0.008%; 95%CI, 0.005-0.011%) during the pandemic than unaffiliated villages (0.026%; 95%CI, 0.019-0.032%; p<0.01). Survey results indicated that clinic visits, out-of-pocket healthcare spending, and the proportion of households unable to access healthcare increased across all villages during the pandemic. The main reasons given for access problems were around fears of contracting Covid-19, unaffordability, or clinic closure. Throughout the pandemic, households affiliated with Health In Harmony, which runs a health clinic, were less likely to report barriers to affordable clinic access than households in unaffiliated villages (14% vs. 29%; odds ratio (OR); 0.41,95%CI, 0.2-0.69). Households in NGO-affiliated villages were more likely to do jobs with low environmental impact (e.g., small-scale farming, conservation; OR 1.61,95%CI, 1.15-2.24). Half of households in both groups reported income loss from at least one source during the pandemic, but households in NGO-affiliated villages were more likely to gain alternative income from multiple job types, especially resource-neutral jobs (e.g., public servant, sales, services). Additionally, households in NGO-affiliated villages had more sources of economic support, such as government programmes, co-operatives, family and NGO’s (OR 1.36, 95%CI, 1.11-1.69).
CONCLUSION
Communities with better access to healthcare and livelihood support were associated with significantly lower deforestation rates prior to the Covid-19 pandemic, and this lower reliance on forest-degrading income was resilient to the pandemic shock.
CONFLICTS OF INTEREST
None declared.
Conference Material > Slide Presentation
Hopkins S, Hazel A, Pourtois J, Chamberlin A, Gajewski Z, et al.
MSF Scientific Day International 2023. 7 June 2023; DOI:10.57740/gr3a-mk13
MSF Ethics Review Board > Publications
BMC Medical Ethics. 26 February 2015; Volume 16; 10.; DOI:10.1186/s12910-015-0002-3
Schopper D, Dawson A, Upshur R, Ahmad ASI, Jesani A, et al.
BMC Medical Ethics. 26 February 2015; Volume 16; 10.; DOI:10.1186/s12910-015-0002-3
BACKGROUND
Médecins Sans Frontières (MSF) is one of the world’s leading humanitarian medical organizations. The increased emphasis in MSF on research led to the creation of an ethics review board (ERB) in 2001. The ERB has
encouraged innovation in the review of proposals and the interaction between the ERB and the organization. This has led to some of the advances in ethics governance described in this paper.
DISCUSSION
We first update our previous work from 2009 describing ERB performance and then highlight five innovative practices:
• A new framework to guide ethics review
• The introduction of a policy exempting a posteriori analysis of routinely collected data
• The preapproval of “emergency” protocols
• General ethical approval of “routine surveys”
• Evaluating the impact of approved studies
The new framework encourages a conversation about ethical issues, rather than imposing quasi-legalistic rules, is more engaged with the specific MSF research context and gives greater prominence to certain values and
principles. Some of the innovations implemented by the ERB, such as review exemption or approval of generic protocols, may run counter to many standard operating procedures. We argue that much standard practice in research ethics review ought to be open to challenge and revision. Continued interaction between MSF researchers and independent ERB members has allowed for progressive innovations based on a trustful and respectful partnership between the ERB and the researchers. In the future, three areas merit particular attention. First, the impact of the new framework should be assessed. Second, the impact of research needs to be defined more precisely as a first step towards being meaningfully assessed, including changes of impact over time. Finally, the dialogue between the MSF ERB and the ethics committees in the study countries should be enhanced.
SUMMARY
We hope that the innovations in research ethics governance described may be relevant for other organisations carrying out research in fragile contexts and for ethics committees reviewing such research.
Médecins Sans Frontières (MSF) is one of the world’s leading humanitarian medical organizations. The increased emphasis in MSF on research led to the creation of an ethics review board (ERB) in 2001. The ERB has
encouraged innovation in the review of proposals and the interaction between the ERB and the organization. This has led to some of the advances in ethics governance described in this paper.
DISCUSSION
We first update our previous work from 2009 describing ERB performance and then highlight five innovative practices:
• A new framework to guide ethics review
• The introduction of a policy exempting a posteriori analysis of routinely collected data
• The preapproval of “emergency” protocols
• General ethical approval of “routine surveys”
• Evaluating the impact of approved studies
The new framework encourages a conversation about ethical issues, rather than imposing quasi-legalistic rules, is more engaged with the specific MSF research context and gives greater prominence to certain values and
principles. Some of the innovations implemented by the ERB, such as review exemption or approval of generic protocols, may run counter to many standard operating procedures. We argue that much standard practice in research ethics review ought to be open to challenge and revision. Continued interaction between MSF researchers and independent ERB members has allowed for progressive innovations based on a trustful and respectful partnership between the ERB and the researchers. In the future, three areas merit particular attention. First, the impact of the new framework should be assessed. Second, the impact of research needs to be defined more precisely as a first step towards being meaningfully assessed, including changes of impact over time. Finally, the dialogue between the MSF ERB and the ethics committees in the study countries should be enhanced.
SUMMARY
We hope that the innovations in research ethics governance described may be relevant for other organisations carrying out research in fragile contexts and for ethics committees reviewing such research.
MSF Ethics Review Board > Publications
PLOS Med. 28 July 2009; Volume 6 (Issue 7); e1000115.; DOI:10.1371/journal.pmed.1000115
Schopper D, Upshur R, Matthys F, Singh JA, Bandewar SS, et al.
PLOS Med. 28 July 2009; Volume 6 (Issue 7); e1000115.; DOI:10.1371/journal.pmed.1000115
Journal Article > CommentaryFull Text
Bull World Health Organ. 31 August 2015; Volume 93 (Issue 10); 737-738.; DOI:10.2471/BLT.14.144816
Eckenwiler L, Hunt M, Ahmad ASI, Calain P, Dawson A, et al.
Bull World Health Organ. 31 August 2015; Volume 93 (Issue 10); 737-738.; DOI:10.2471/BLT.14.144816
Conference Material > Abstract
Moser W, Hassan Fahal MA, Abualas E, Bedri S, Elsir MT, et al.
MSF Scientific Days International 2022. 9 May 2022; DOI:10.57740/m8zq-4v79
INTRODUCTION
In Sudan, since the first Covid-19 case was declared on 13 March 2020, 32,846 confirmed cases were recorded through 10 April 2021. Of these, 72% were registered in Khartoum State alone. A convenience sample of more than 1,000 individuals from 22 neighbourhoods of Khartoum City found that between March and July 2020, 35% of sampled individuals tested positive using RT-PCR for SARS-CoV-2; 18% had anti–SARS-CoV-2 antibodies. Similar discrepancies between clinically confirmed cases and infection rates assessed by serology or PCR testing independent of symptoms have been described elsewhere in Africa.
METHODS
Omdurman, the largest among the three cities composing Sudan’s capital Khartoum, was chosen as the study site. Study design comprised two surveys: i) a retrospective mortality survey using two–stage cluster sampling methodology based on random geo–points with two recall periods: pre-pandemic (1 January 2019–29 February 2020) and pandemic (1 March 2020–day of the survey); and ii) a nested SARS-CoV-2 antibody prevalence survey. An adult household representative answered a standardised questionnaire for the mortality survey; all members of a sub-set of the household, regardless of age, were invited to participate in the seroprevalence study. Capillary blood was collected on dry blood spot cards and directly tested with the STANDARD Q COVID-19 IgM/IgG Combo, SD–Biosensor rapid test. Dry blood spot cards were transferred to the National Public Health Laboratory, Khartoum, for further analysis using enzyme- linked immunosorbent assay (ELISA; EUROIMMUN Anti–SARS-CoV-2). Differences between pre–and pandemic periods were assessed using Fisher’s exact test, and test performance was adjusted with a random effect and Bayesian latent class model.
ETHICS
This study was approved by the MSF Ethics Review Board and the Ethics Review Board, Sudan.
RESULTS
From 1 March until 10 April 2021, data from 27,315 people (3,716 households) for the entire recall period showed a 67% (95% confidence interval (CI) 32–110) increase in death rate between pre–pandemic (0.12 deaths/10000 people/day; 95%CI 0.10–0.14) and pandemic periods (0.20 deaths/10000 people/ day; 95%CI 0.16–0.23). 2,374 people participated in the seroprevalence survey. Adjusted SARS-CoV-2 seroprevalence was 54.6% (95%CI 51.4–57.8). Seroprevalence was significantly associated with age, increasing up to 80.7% (95%CI 71.7–89.7) for the oldest age group (≥50 years). We estimated that the number of infections were 50 times higher than the number of cases reported.
CONCLUSION
This population-based cross-sectional survey in Omdurman, Sudan, demonstrated significantly higher mortality in the pandemic period, compared to pre-pandemic; particularly affecting individuals aged 50 years and over. We also found elevated seropositivity in Omdurman with older populations being the most affected. Our results suggest that Omdurman was severely impacted by the COVID-19 pandemic.
CONFLICTS OF INTEREST
None declared.
In Sudan, since the first Covid-19 case was declared on 13 March 2020, 32,846 confirmed cases were recorded through 10 April 2021. Of these, 72% were registered in Khartoum State alone. A convenience sample of more than 1,000 individuals from 22 neighbourhoods of Khartoum City found that between March and July 2020, 35% of sampled individuals tested positive using RT-PCR for SARS-CoV-2; 18% had anti–SARS-CoV-2 antibodies. Similar discrepancies between clinically confirmed cases and infection rates assessed by serology or PCR testing independent of symptoms have been described elsewhere in Africa.
METHODS
Omdurman, the largest among the three cities composing Sudan’s capital Khartoum, was chosen as the study site. Study design comprised two surveys: i) a retrospective mortality survey using two–stage cluster sampling methodology based on random geo–points with two recall periods: pre-pandemic (1 January 2019–29 February 2020) and pandemic (1 March 2020–day of the survey); and ii) a nested SARS-CoV-2 antibody prevalence survey. An adult household representative answered a standardised questionnaire for the mortality survey; all members of a sub-set of the household, regardless of age, were invited to participate in the seroprevalence study. Capillary blood was collected on dry blood spot cards and directly tested with the STANDARD Q COVID-19 IgM/IgG Combo, SD–Biosensor rapid test. Dry blood spot cards were transferred to the National Public Health Laboratory, Khartoum, for further analysis using enzyme- linked immunosorbent assay (ELISA; EUROIMMUN Anti–SARS-CoV-2). Differences between pre–and pandemic periods were assessed using Fisher’s exact test, and test performance was adjusted with a random effect and Bayesian latent class model.
ETHICS
This study was approved by the MSF Ethics Review Board and the Ethics Review Board, Sudan.
RESULTS
From 1 March until 10 April 2021, data from 27,315 people (3,716 households) for the entire recall period showed a 67% (95% confidence interval (CI) 32–110) increase in death rate between pre–pandemic (0.12 deaths/10000 people/day; 95%CI 0.10–0.14) and pandemic periods (0.20 deaths/10000 people/ day; 95%CI 0.16–0.23). 2,374 people participated in the seroprevalence survey. Adjusted SARS-CoV-2 seroprevalence was 54.6% (95%CI 51.4–57.8). Seroprevalence was significantly associated with age, increasing up to 80.7% (95%CI 71.7–89.7) for the oldest age group (≥50 years). We estimated that the number of infections were 50 times higher than the number of cases reported.
CONCLUSION
This population-based cross-sectional survey in Omdurman, Sudan, demonstrated significantly higher mortality in the pandemic period, compared to pre-pandemic; particularly affecting individuals aged 50 years and over. We also found elevated seropositivity in Omdurman with older populations being the most affected. Our results suggest that Omdurman was severely impacted by the COVID-19 pandemic.
CONFLICTS OF INTEREST
None declared.
MSF Ethics Review Board > Publications
Public Health Ethics. 1 November 2016; Volume 10 (Issue 1); 49-61.; DOI:10.1093/phe/phw039
Schopper D, Ravinetto R, Schwartz L, Kamaara E, Sheel S, et al.
Public Health Ethics. 1 November 2016; Volume 10 (Issue 1); 49-61.; DOI:10.1093/phe/phw039
The Médecins Sans Frontières (MSF) ethics review board (ERB) has been solicited in an unprecedented way to provide advice and review research protocols in an 'emergency' mode during the recent Ebola epidemic. Twenty-seven Ebola-related study protocols were reviewed between March 2014 and August 2015, ranging from epidemiological research, to behavioural research, infectivity studies and clinical trials with investigational products at (very) early development stages. This article examines the MSF ERB's experience addressing issues related to both the process of review and substantive ethical issues in this context. These topics include lack of policies regarding blood sample collection and use, and engaging communities regarding their storage and future use; exclusion of pregnant women from clinical and vaccine trials; and the difficulty of implementing timely and high-quality qualitative/anthropological research to consider potential upfront harms. Having noticed different standards across ethics committees (ECs), we propose that when multiple ethics reviews of clinical and vaccine trials are carried out during a public health emergency they should be accompanied by transparent communication between the ECs involved. The MSF ERB experience should trigger a broader discussion on the 'optimal' ethics review in an emergency outbreak and what enduring structural changes are needed to improve the ethics review process.
Conference Material > Slide Presentation
Moser W, Hassan Fahal MA, Abualas E, Bedri S, Elsir MT, et al.
MSF Scientific Days International 2022. 10 May 2022; DOI:10.57740/674p-r370