Health Research in Humanitarian Crises: an Urgent Global Imperative

Analysis BMJ Glob Health: first published as 10.1136/bmjgh-2019-001870 on 11 November 2019. Downloaded from Health research in humanitarian crises: an urgent global imperative

1 2 2 2 Brandon A Kohrt, Amit S Mistry ‍ ‍ , Nalini Anand, Blythe Beecroft, Iman Nuwayhid3

To cite: Kohrt BA, Mistry AS, Abstract Summary box Anand N, et al. Health Globally, humanitarian crises—such as armed conflict, research in humanitarian forced displacement, natural disasters and major disease crises: an urgent global ►► Humanitarian crises have immense short and long- outbreaks—affect more people today than at any point imperative. BMJ Global Health term health impacts, yet the evidence base for best in recorded history. These crises have immense acute 2019;4:e001870. doi:10.1136/ healthcare practices in humanitarian settings is bmjgh-2019-001870 and long-term health impacts on hundreds of millions limited. of people, predominantly in low and middle-income ►► The global health research community can and Handling editor Eduardo countries (LMIC), yet the evidence base that informs should play a significant role in addressing the Gómez how humanitarian organisations respond to them is evidence gap in humanitarian health by studying weak. Humanitarian crises are often treated as an outlier important scientific questions that can only be ad- Received 25 July 2019 in global health. However, they are an increasingly dressed by conducting research in humanitarian Revised 4 September 2019 common and widespread driver of health that should be Accepted 12 September 2019 settings. integrated into comprehensive approaches and strategies, ►► There are several effective strategies that can be especially if we hope to achieve ambitious global health used to address the many unique challenges of con- targets such as the Sustainable Development Goals. The ducting research in humanitarian crises. academic research community can play an important role ►► Global health researchers, research funders, policy- in addressing the evidence gap in humanitarian health. makers and practitioners should recognise humani- There are important scientific questions of high public tarian health as integral to progress in global health. health relevance that can only be addressed by conducting ►► Research in these challenging settings requires research in humanitarian settings. While working in consideration of flexible methodologies, research these settings is uniquely challenging, there are effective ethics, multisector partnerships, engagement with strategies that can be employed, such as using flexible available public health information systems, collabo- and adaptive research methodologies, partnering with non- ration with local communities and leaders, research governmental organisations and other humanitarian actors, capacity and multidisciplinary approaches that cut and devoting greater attention to issues of research ethics, across multiple health domains. community engagement, local LMIC-based partners, http://gh.bmj.com/ building humanitarian research capacity and collaborating across disciplines. Humanitarian crises include: (1) man-made disasters, including armed conflict, forced displacement and refugee crises; (2) natural disasters, such as floods, hurricanes, earth- Introduction on October 1, 2021 by guest. Protected copyright. © Author(s) (or their quakes and droughts; and (3) major infec- employer(s)) 2019. Re-use Today, more people are impacted by human- tious disease outbreaks. Often, multiple types permitted under CC BY-NC. No itarian crises than at any point in recorded of crises occur simultaneously, such as armed commercial re-use. See rights history. One in six children lives in close prox- conflict or natural disasters combined with and permissions. Published by 1 BMJ. imity to a conflict zone while 70.8 million famine and disease outbreaks. All of these people have been forced to flee from their 1Department of Psychiatry types of crises have a severe effect on human and Behavioral Sciences and homes—the highest number since World health, with a disproportionate impact on 2 Department of Global Health, War II. Natural disasters, on average, affect disadvantaged populations and people in low 3 George Washington University, roughly 200 million people each year. The and middle-income countries (LMIC) who Washington, DC, USA 2014–2016 Ebola outbreak in West Africa 2Fogarty International Center, are impacted by humanitarian crises more NIH, Bethesda, Maryland, USA demonstrated how an infectious disease often but are generally less prepared for 3Faculty of Health Sciences, outbreak can become an international them. American University of Beirut, humanitarian crisis. In recent years, human- Immediately following the onset of a crisis, Beirut, Lebanon itarian crises have become more frequent, acute health problems of trauma, injury Correspondence to more protracted, more complex and more and the spread of infectious disease are the Dr Amit S Mistry; costly, stretching an underfunded humani- primary concern of humanitarian response 4 5 amit. mistry@nih. gov tarian response community to its limits. organisations. However, humanitarian crises

Kohrt BA, et al. BMJ Global Health 2019;4:e001870. doi:10.1136/bmjgh-2019-001870 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-001870 on 11 November 2019. Downloaded from also have many long-term impacts on health and the Humanitarian health is integral to global health environment. As health systems are disrupted, damaged Developing global health strategies without significant and/or overwhelmed, healthcare is challenging to attention to the humanitarian context is like building deliver. For many, crises also mean the loss of liveli- a hospital without an emergency room. Far too often, hoods, displacement from their homes and commu- humanitarian crises are treated as outliers or exceptions, nities, emotional distress and social suffering. Health and subsequently are neglected in the formulation of problems are exacerbated for people with pre-existing health programmes and strategies. The unfortunate reality health conditions and new health issues arise. Human- is that humanitarian crises are common and widespread itarian crises impact almost every aspect of health, experiences driving human health worldwide. If health including but not limited to: maternal and child health; in fragile contexts is not prioritised by the global health infectious disease; injury and other physical trauma; research community, it will be very difficult to achieve sexual and reproductive health; nutrition; and non- communicable diseases such as diabetes, heart disease ambitious health goals on a global level. and mental health. Much of the world made remarkable progress on the What is the role of the research community in Millennium Development Goals (MDG), which United addressing the health impacts of humanitarian crises? Nations (UN) member states committed to achieving by How can research help improve the quality of health 2015. However, countries affected by conflict and fragility 6 services during and after crises? Are there important consistently lagged behind other LMICs on these goals scientific questions that can only be addressed by research and none of these countries achieved a single MDG.7 in these contexts? How do researchers work in these chal- The UN’s updated 2030 Sustainable Development Goals lenging settings without impeding humanitarian assis- (SDG) set even more ambitious targets for many health- tance and ensure that research findings benefit affected related areas. Populations affected by conflict, such as populations? How are successful, equitable and sustain- refugees and internally displaced persons fleeing war, able research collaborations built with local researchers cannot be overlooked if we hope to achieve the SDGs.8 in humanitarian settings? Is there an advocacy role for Likewise, reducing the impacts of natural disasters and health researchers? hazards on health is critical to achieving the SDGs, as To explore these questions, the Fogarty International recognised by the UN Sendai Framework for Disaster Risk Center at the US National Institutes of Health convened 9 Reduction. a committee of experts from research and humanitarian For instance, SDG 3—Ensure healthy lives and promote communities, chaired by the authors of this paper. The well-being for all at all ages—includes targets for reducing resulting project, Advancing Health Research in Human- itarian Crises, brought together a broad range of stake- maternal and child mortality. While maternal and child holders and experts with diverse experiences in different mortality rates are declining globally, they are significantly health areas and from many geographic regions, espe- higher in fragile and conflict-affected countries than in 7 cially LMICs, to share lessons learnt and explore how stable countries. In fact, children in fragile or conflict- to catalyse timely, high-quality , ethical and actionable affected countries are twice as likely to die before the age http://gh.bmj.com/ 7 research in humanitarian crises and encourage uptake of of 5 compared with children in other, more stable LMICs. evidence into humanitarian policy and practice. SDG 3 also includes targets for infectious diseases, which are To date, this project has consulted 179 individuals incredibly difficult to manage in conflict-affected settings from more than 80 organisations representing human- as seen in the current Ebola outbreak in the Democratic itarian, research, policy and research funding commu- Republic of Congo, the recent cholera outbreak in Yemen on October 1, 2021 by guest. Protected copyright. nities. Building on these consultations, the challenges and stalled efforts to eradicate polio in parts of Afghani- and opportunities for health research in humanitarian stan, Pakistan and Nigeria.10 Similarly, the economic, polit- crises were discussed further at a workshop hosted by the ical and healthcare crisis in Venezuela is marked by the Fogarty International Center in April 2018. This paper spread and re-emergence of vectorborne diseases, such as highlights several of the findings and learnings from the malaria, Chagas disease and dengue, undermining efforts workshop and subsequent analysis, focusing on a few key to eradicate these diseases from Venezuela and neigh- messages: bouring countries.11 1. Humanitarian health is integral to global health. Other health-related SDG targets, as well as targets 2. The global health research community plays a critical related to clean water and hunger, are also much more role in addressing the significant evidence gap in humanitarian health. difficult to achieve in humanitarian settings. Given the 3. There are important scientific questions of high pub- increasing frequency and impact of humanitarian crises lic health relevance that can only be answered by re- worldwide, along with their protracted nature, these search in humanitarian settings. settings cannot be ignored. Rather, efforts that integrate 4. While humanitarian health research is uniquely chal- humanitarian settings into comprehensive approaches lenging, many effective strategies and approaches can are likely to make more significant contributions to be used. global health goals.

2 Kohrt BA, et al. BMJ Global Health 2019;4:e001870. doi:10.1136/bmjgh-2019-001870 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-001870 on 11 November 2019. Downloaded from The need for research in humanitarian settings on public health interventions in humanitarian crisis Research is important and often necessary to under- settings found that very little evidence exists, and what standing how to best improve health and health services does exist is often low quality, with weaknesses in study in humanitarian crises. There are unique scientific ques- designs and methods.16 The review highlighted notable tions of high public health relevance that can only be deficiencies for research related to non-communicable answered through research in humanitarian settings. diseases, sexual and reproductive health, and water, sani- For example, research can help determine which health tation and hygiene.16 interventions are most effective in humanitarian settings, The lack of research and evidence-based practices in when new or adapted interventions are needed and how humanitarian crises leads to a reliance on research find- to best deliver care in crisis settings. However, not all ings from ‘stable’—typically high-income—settings to research questions should be answered in this context— inform decisions about health interventions. However, ‘If the research question could be answered in a non- health interventions proven to be effective in a stable emergency setting, then it should not be answered in an country cannot simply be ‘imported’ to a crisis setting emergency setting,’ as recommended by the Inter-Agency where health systems may be damaged, infrastructure Standing Committee (IASC).12 is weakened and populations have experienced excep- Unfortunately, the quantity and quality of evidence used tional trauma. It already takes several years for research to inform the humanitarian response is severely limited. evidence to reach clinical practice in stable settings; There are many reasons for this weak evidence base. adapting this evidence for more challenging settings can Organisations and institutions responding to humanitarian crises—including local and regional governments, take much longer. national and international non-governmental organ- Developing and evaluating interventions in stable settings isations (NGO), and UN agencies—are already over- and then waiting to test them in humanitarian settings is not stretched and underfunded. Research is not typically an effective or efficient research strategy. Instead, research perceived as a priority when immediate survival needs needs to be done with and for populations affected by of populations need to be funded and administered. humanitarian crises to determine interventions and models Furthermore, public health information systems, when of care that are feasible, effective and appropriate for the available, may be disrupted or politically biased during context. In some cases, testing health interventions in crisis such crises.13 14 Consequently, there are limited and lost environments is the only way to determine their effective- opportunities for systematic data collection, analysis, crit- ness. For example, we cannot fully know if vaccines and ther- ical reflection and dissemination to the broader human- apeutics for Ebola virus are effective without studying them itarian community. Humanitarian practice and policy, in the context of an actual Ebola outbreak and under strict therefore, are too often based on anecdotal experience, ethical guidelines.17 18 rather than rigorous, scientific research.15 When most research is designed for and conducted Researchers face a number of challenges when with populations in stable and high-income settings, we conducting health research in humanitarian crises. Most are neglecting more than 132 million people in need http://gh.bmj.com/ humanitarian crises affect already low-resourced settings. of humanitarian assistance,19 who disproportionately Academic researchers generally do not have the skills or face early mortality and excess morbidity. Furthermore, expertise to work in unstable settings, where they must research in humanitarian contexts may ultimately yield deal with safety and security concerns, political sensitiv- models and tools that can then be expanded to non- ities, damaged and overwhelmed health systems, and humanitarian settings. Just as military medicine has logistical challenges. From a methodological perspective, often led to innovations for civilian health ranging from on October 1, 2021 by guest. Protected copyright. traditional research designs may not be appropriate for surgery to mental healthcare, humanitarian settings humanitarian crises. For instance, identifying a control often necessitate innovations that can improve non- group may be impractical or unethical, baseline data emergency care. For example, innovations in mHealth may not be available and dynamic settings may require and digital health for emergency settings can also be changes to study designs with little notice. Researchers used to improve care in other settings with access and may face ethical dilemmas in balancing urgent health 20 needs with research goals that may have long-term bene- resource constraints. fits or in obtaining informed consent from extremely Health research in humanitarian crises is needed to distressed and vulnerable populations. On top of these ensure that humanitarian action is evidence-based, effec- obstacles, humanitarian settings require coordination tive and sets the stage for postcrisis health planning and with myriad local and international actors and stake- rehabilitation. Some argue that it is unethical to not holders who are rapidly changing with many only having conduct research in conflict and crisis settings as the 21 short-term and limited mandates or missions for humani- current evidence base is so deficient. Continuing to use tarian response. Funding opportunities for humanitarian practices that are not contextual and evidence-based may research are also few and far between. harm affected populations. Additionally, humanitarian Therefore, it is not surprising that a recent comprehen- responses cannot be expected to achieve optimal health sive and systematic review of currently available evidence outcomes without a rigorous and scientific evidence base.

Kohrt BA, et al. BMJ Global Health 2019;4:e001870. doi:10.1136/bmjgh-2019-001870 3 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-001870 on 11 November 2019. Downloaded from Research priorities in humanitarian crises detailed humanitarian health research gaps, priority Research should only be conducted in the context of a questions and agendas have been articulated in areas humanitarian crisis for research questions that cannot be such as: neonatal health,23 child protection,24 mental addressed in non-emergency settings. The IASC further health and psychosocial support,25 non-communicable recommends that research questions: respond to a recog- diseases,26 27 sexual and reproductive health,28 ethics29 nised gap or need; ensure fair and direct benefits to partic- and health systems research.30 Table 1 presents several ipants with minimised risks; and include planned dissemi- illustrative research questions, some of which are based nation to participants, collaborators and funders.12 on the aforementioned research agendas, that can only With these principles in mind, there are many be addressed in the context of humanitarian crises. important scientific questions that require research in While these questions are focused on humanitarian the context of a humanitarian crisis and several groups contexts, studying them may also provide insights that are have developed research agendas accordingly. Evidence relevant to public health more generally. For example, Aid, an international initiative supporting the use of mental health outcomes from collective trauma compared evidence in humanitarian action, consulted a broad with individual trauma can be more effectively studied in range of humanitarian practitioners, policymakers and a humanitarian crisis. The impact of social networks on researchers to identify priority areas of research in need risk of depression and post-traumatic stress disorder after of updated evidence and 4 of the top 10 are related to bushfires in Australia31 can be used to better understand health: water and sanitation, nutrition and food security, the social patterning of mental illness in non-crisis settings. maternal and child health, and mental health.22 More Similarly, biological pathways associated with resilience

Table 1 Illustrative humanitarian health research questions Type of research Illustrative research questions

Methodological ►► How do we protect and promote the rights of research participants in humanitarian crises? ►► What ethical guidelines and IRB procedures should be adopted? Should they differ from ethical guidelines in stable settings?38 ►► How should research methodologies be adapted for humanitarian crises? What new methodological approaches are needed for humanitarian research? ►► What are the most effective methodological approaches for evaluating a new health intervention (eg, a new vaccine) in a humanitarian crisis? 22 ►► What is the most effective way to identify the needs of the population affected by a disaster? Descriptive ►► What are the causes, spreading patterns and risk factors for (a specific disease or health condition) in epidemiology humanitarian crises? 25 ►► What are the stressors faced by populations in humanitarian settings? ►► What is the additional burden of neonatal mortality in different emergency situations (eg, conflict, acute vs protracted, natural disaster)?23 http://gh.bmj.com/ ►► How can public health information systems be better leveraged in humanitarian settings for determination of mortality and morbidity?13 14 Discovery ►► What new health interventions (eg, treatments, vaccines, technologies, etc.) are needed for humanitarian crises? ►► Develop and validate strategies to identify preterm babies at the community level by CHWs and family members.23 39 Intervention ►► What are the most effective mental health and psychosocial interventions for conflict-af fected children? on October 1, 2021 by guest. Protected copyright. research ►► How effective is (a specific evidence-based health intervention) in a humanitarian setting? ►► What are the most effective interventions to reduce childhood morbidity and mortality, and improve well-being after a disaster or in other humanitarian emergencies?22 ►► What are the effects of breast feeding promotion interventions, including integrated breast feeding, on breast feeding rates and duration after a disaster or in other humanitarian emergencies?22 Implementation ►► How can evidence-based health interventions developed in stable settings best be delivered or implemented in research humanitarian crises? ►► What are the most effective ways to culturally adapt existing mental health and psychosocial support interventions for use after a disaster or in other humanitarian emergencies?22 Health system ►► How can the quality of health services in humanitarian settings be improved and sustained? research ►► What attributes favour an adaptive, responsive and resilient healthcare system? ►► What approaches do people affected by humanitarian crises adopt to successfully gain access to health services? 30 ►► How to get the right balance between emergency service delivery and long-term systems strengthening? ►► What healthcare delivery models work best in humanitarian contexts? And what kind of actors can best implement such models and deliver the best results?30

Questions from previously published research agendas or literature reviews include references to the source publication. CHW, community health worker; IRB, Institutional Review Board.

4 Kohrt BA, et al. BMJ Global Health 2019;4:e001870. doi:10.1136/bmjgh-2019-001870 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-001870 on 11 November 2019. Downloaded from after humanitarian crises32 can inform physical and mental humanitarian training, education and research activities health promotion for general populations. Research in with a range of humanitarian actors. humanitarian settings can also uniquely examine the interaction of social, ecological, environmental and/or Strategies for conducting research in LMICs that are economic factors with multiple domains of health prob- especially important in humanitarian crises lems through syndemic theory and systems science.33 Engage with affected populations and communities. Popula- tions affected by crises are especially vulnerable and often severely distressed. They should not be treated solely as Strategies for humanitarian health research research participants, but rather as partners throughout For many in the global health research community, the the research process to help ensure that the research challenges and risks associated with humanitarian health is addressing the highest community priorities and is research dampen or outweigh their interest in this field conducted in a culturally sensitive manner. Engaging local of study. This may also explain the reluctance of funding communities and affected populations enables community agencies to invest in such research. Yet, there are a variety trust, improves research designs and provides a pathway for of strategies that can be used to address these challenges research dissemination, resulting in higher quality research and mitigate risks. Based on the learning from the and more actionable findings. Advancing Health Research in Humanitarian Crises project Local leadership. Whenever possible, local actors—in- to date, several principles for conducting research in cluding researchers, national and local NGOs, govern- humanitarian crises are highlighted in this section, ments and communities—should lead research efforts, grouped into principles specific to humanitarian crises in partnership with the international research and and more general principles for LMIC-based research humanitarian communities. If they do not have the that are especially important in humanitarian settings. capacity to lead these efforts, they should be actively engaged as much as possible. Local partners under- Research strategies specific to humanitarian crises stand cultural and historical context and are better Use flexible and adaptive methodologies. Humanitarian crises linked with local communities, and their engagement are unstable, unpredictable environments and as such, improves the quality and relevance of research. Polit- researchers should be prepared to adjust study parame- ical, institutional and societal dynamics are especially ters and methodologies as needed. However, researchers important in humanitarian research and local actors should not compromise the rigour or quality of their are key partners in navigating these factors.35 Support work as they must ensure that findings are valid and can to local organisations, such as NGOs, should also inform humanitarian practice and policy. This includes consider the sustainability of those organisations and conducting randomised controlled trials and other strictly retention of local experts in their home countries. quantitative analysis when feasible. Mixed and qualitative Leadership by local actors increases the sustainability methods should also be considered as they can be equally of research efforts beyond crisis events, contributing robust and may be more appropriate for humanitarian to preparedness and resiliency against future crises settings. For example, qualitative methods can make an and disasters. For partnerships between international http://gh.bmj.com/ important contribution to interpreting mortality estimates, and local researchers to be sustainable and equitable, which often have wide confidence interval in humanitarian guiding principles of collaboration need to be estab- crises.13 14 Other research actors, such as funders, ethical lished regarding data sharing and ownership, publica- review boards and journal publishers, should similarly be tion and dissemination of findings, compensation for aware of the importance of flexible and adaptive method- research efforts, opportunities for further training and ologies in these settings. recognition in social and traditional media.36 37 on October 1, 2021 by guest. Protected copyright. Partner across the humanitarian-academic divide. While Build local and global humanitarian research capacity. humanitarian organisations and academic organisa- Conducting health research in humanitarian crises is tions have extremely different cultures, time frames and uniquely challenging and as such, requires specialised missions, partnerships between these two sectors can research skills. Building the capacity of academic and be especially fruitful in humanitarian health research. NGO-based researchers in and from regions affected by Academic institutions are experienced in designing humanitarian crises leads to better preparedness and resil- and conducting high-quality studies while humanitarian ience to future disasters. It is important for training efforts organisations have the logistical capabilities and rela- to focus on the bidirectionality of learning to ensure that tionships with local communities necessary to operate researchers from high-income countries gain methodolog- in humanitarian settings.34 Collaboration between the ical skills as well as the interpersonal skills and cultural two is critical, and often necessary, to produce research competencies needed to work in challenging humanitarian that is rigorous and actionable. Notably, several humani- environments. Ultimately, achieving the goals of local tarian NGOs are deepening partnerships with academic leadership and funding to local organisations will require research institutions and others already have or are devel- strengthened local capacity and retention of researchers. oping their own in-house research capabilities. At the Beyond research training, strengthening public health same time, several academic institutions are engaging in information systems enables valid, reliable and timely data

Kohrt BA, et al. BMJ Global Health 2019;4:e001870. doi:10.1136/bmjgh-2019-001870 5 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-001870 on 11 November 2019. Downloaded from

Table 2 Selected resources, tools and networks available to humanitarian health researchers Organisation Resource description Website Evidence Aid A collection of systematic reviews that provide http://www.evidenceaid.org/ reliable, up-to-date evidence on interventions that might be considered in the context of natural disasters and other major healthcare emergencies. United Nations (UN) Global Migration, Health and Development Research https://mhadri.org/ International Organization Initiative (MHADRI)—a global alliance of migration for Migration (IOM) health researchers and scholars and a platform to share, collaborate, develop, advocate and disseminate research at the nexus of health and migration. Medecins Sans Frontieres Field research—a free repository of articles based on https://fieldresearch.msf.org/ (MSF) the field research of MSF. National Institutes of Disaster Lit Database for Disaster Medicine and Public https://disasterinfo.nlm.nih.gov/disaster-lit Health (NIH) National Health—a free collection of disaster medicine and Library of Medicine public health documents. NIH National Institute of Disaster Research Response (DR2)—a collection of https://dr2.nlm.nih.gov/ Environmental Health data collection tools, research protocols, disaster Sciences and National research news and events, and more. Library of Medicine UN Office for the The Humanitarian Data Exchange—an open platform https://data.humdata.org/ Coordination of for sharing data across crises and organisations. Humanitarian Affairs (OCHA) Post-Research Ethics A research project investigating ethical issues in http://www.preaportal.org/ Analysis (PREA) health research in humanitarian crises. It aims to identify good ethical practice from lessons learned in the field and develop a tool that assists reflection on ethical issues in humanitarian research. Nuffield Council on Research in global health emergencies—a project http://nuffieldbioethics.org/project/global- Bioethics exploring how research may be conducted ethically in health-emergencies global health emergencies. Elrha Research for Health in Humanitarian Crises (R2HC) https://www.elrha.org/programme/ – A research funding programme specific to health research-for-health-in-humanitarian-crises/ research in humanitarian crises, funded by the UK Department for International Development, http://gh.bmj.com/ UK National Institute for Health Research, and the Wellcome Trust.

collection during emergencies, improves the quality of settings, there are many organisations actively working to research and promotes transparency and accountability in address the gap. These efforts, some of which are described on October 1, 2021 by guest. Protected copyright. the humanitarian response. in table 2, build relevant capacity and develop resources Collaborate across disciplines. Humanitarian crises such as: systematic reviews of humanitarian research; repos- impact almost all facets of human health. Affected itories of scientific literature; platforms for sharing human- individuals and communities may suffer from multiple itarian data and study protocols; ethics guidelines; and new conditions simultaneously and as a result, humanitarian funding opportunities. responders may be expected to deal with a broad range of health problems. Furthermore, political, social, environmental and economic factors and their effects on Conclusion health must be considered in humanitarian settings. Humanitarian crises are having a bigger impact on Researchers should take a multidisciplinary approach human health now than at any time in recent history, yet across health disciplines and an integrated approach the evidence base that informs humanitarian practice beyond health disciplines, while also being aware of the and policy is lacking. While research in these settings is broader contextual factors affecting study populations. especially challenging, there are reasons to be optimistic. Leverage existing tools and networks. While very little human- Awareness of the need for evidence in humanitarian itarian health research is currently being funded and is health is growing among academics, humanitarians mostly supporting researchers from outside the affected and research funders. In some protracted crises, such

6 Kohrt BA, et al. BMJ Global Health 2019;4:e001870. doi:10.1136/bmjgh-2019-001870 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-001870 on 11 November 2019. Downloaded from as for Syrian and Palestinian refugees, significant References research efforts are building a formidable evidence 1 Bahgat K, Dupuy K, Østby G, et al. Children and armed conflict: what existing data can tell us. Oslo: Peace Research Institute Oslo base. And while there are limited research funding (PRIO), 2018. opportunities specific to humanitarian crises, several 2. United Nations High Commissioner for Refugees (UNHCR). Global trends: forced displacement in 2018. Geneva United Nations; 2019. research funding agencies are supporting humani- 3. Centre for Research on the Epidemiology of Disasters (CRED). tarian research through other non-specific funding Natural disasters 2017. Brussels CRED; 2018. calls. Furthermore, humanitarian NGOs, such as 4. 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United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA). Global humanitarian overview 2019. Geneva United Contributors All authors contributed to the conceptualisation of the manuscript Nations; 2019. with leadership from BAK and IN. ASM drafted the main text and all other authors 20 Perakslis ED. Using digital health to enable ethical health research in reviewed and contributed additional content to further develop the text. All authors conflict and other humanitarian settings. Confl Health 2018;12:23. have read and agreed to the contents of the final draft of the manuscript. 21 Allden K, Jones L, Weissbecker I, et al. Mental health and psychosocial support in crisis and conflict: report of the mental

Funding The authors have not declared a specific grant for this research from any health Working group. Prehosp Disaster Med 2009;24:s217–27. on October 1, 2021 by guest. Protected copyright. funding agency in the public, commercial or not-for-profit sectors. 22 Evidence Aid Priority Setting Group. Prioritization of themes and Competing interests None declared. research questions for health outcomes in natural disasters, humanitarian crises or other major healthcare emergencies. PLoS Patient consent for publication Not required. Curr 2013;5. 23 Morof DF, Kerber K, Tomczyk B, et al. Neonatal survival in complex Provenance and peer review Not commissioned; externally peer reviewed. humanitarian emergencies: setting an evidence-based research Data availability statement There are no data in this work. agenda. Confl Health 2014;8:8. 24. Alliance for Child Protection in Humanitarian Action. Setting the Open access This is an open access article distributed in accordance with the global research agenda for child protection in humanitarian contexts: Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which briefing note; 2017. https://alliancecpha.org/en/child-protection- permits others to distribute, remix, adapt, build upon this work non-commercially , online-library/briefing-note-setting-global-research-agenda-child- and license their derivative works on different terms, provided the original work is protection properly cited, appropriate credit is given, any changes made indicated, and the 25 Tol WA, Patel V, Tomlinson M, et al. Research priorities for mental use is non-commercial. See: http://creativecommons. org/licenses/ by-nc/ 4.0/. health and psychosocial support in humanitarian settings. PLoS Med 2011;8:e1001096. ORCID iD 26 Aebischer Perone S, Martinez E, du Mortier S, et al. Non- Amit S Mistry http://orcid. org/0000- 0001-6206- 3793 Communicable diseases in humanitarian settings: ten essential questions. Confl Health 2017;11:17. 27 Akik C, Ghattas H, Mesmar S, et al. Host country responses to non- communicable diseases amongst Syrian refugees: a review. Confl Health 2019;13:8. 28. Inter-Agency Working Group on Reproductive Health in Crisis. Workshop on sexual and reproductive health research priorities

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