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Conducting health research in conflict-affected areas and other complex environments is difficult, yet vital. However, the capacity to undertake such research is often limited and with little translation into practice, particularly in poorer countries. There is therefore a need to strengthen health research capacity in conflict-affected countries and regions. In this narrative review, we draw together evidence from low and middle-income countries to highlight challenges to research capacity strengthening in conflict, as well as examples of good practice. We find that authorship trends in health research indicate global imbalances in research capacity, with implications for the type and priorities of research produced, equity within epistemic communities and the development of sustainable research capacity in low and middle-income countries. Yet, there is little evidence on what constitutes effective health research capacity strengthening in conflict-affected areas. There is more evidence on health research capacity strengthening in general, from which several key enablers emerge: adequate and sustained financing; effective stewardship and equitable research partnerships; mentorship of researchers of all levels; and effective linkages of research to policy and practice. Strengthening health research capacity in conflict-affected areas needs to occur at multiple levels to ensure sustainability and equity. Capacity strengthening interventions need to take into consideration the dynamics of conflict, power dynamics within research collaborations, the potential impact of technology, and the wider political environment in which they take place.

The disruption of health-care systems in conflict-affected regions creates transnational therapeutic geographies, forcing patients with cancer to navigate complex pathways for diagnosis and treatment. In the Middle East and North Africa (MENA) region, these geographies, shaped by displacement, sociopolitical barriers, and infrastructural collapse, remain underexplored in oncology research and policy. In this Review, we argue that understanding therapeutic geographies is crucial for addressing the challenges faced by conflict-affected populations. We emphasise two key themes emerging from the existing literature on cross-border cancer care in the war-affected areas of the MENA: first, the need to prioritise therapeutic geographies as a framework for analysing cancer care in conflict zones; and second, the importance of a robust toolkit of social science methods to examine these geographies. By illustrating these dynamics through the example of Iraq—a country that has had four decades of conflict and displacement—we highlight how social science methods can uncover the lived experiences of patients and families undergoing cancer treatments across borders in conflict zones. This patient-centred and transnational perspective is essential for developing regional collaborations to address the systemic challenges of cancer care across the MENA region.

The United Nations estimate a quarter of the global population currently lives in violent conflict zones. Radiology is an integral part of any healthcare system, providing vital information to aid diagnosis and treatment of a range of disease and injury. However, its delivery in conflict-affected settings remains unclear. This study aims to understand how radiology services are currently delivered in conflict settings, the challenges of doing so, and potential solutions. A hermeneutic narrative review of multiple databases, including grey literature sources, was undertaken. Key themes were identified, and articles grouped accordingly. Various conflict zones including Gaza, Ukraine, Iraq, Yemen, Afghanistan, and Somalia were identified in literature relating to radiology services. Three key themes were identified: underserving of local medical imaging services, strong presence of military hospitals, and the importance of teleradiology. A severe shortage of radiologists, technicians, and equipment in conflict affected settings are a significant cause of the underserving by local services. Teleradiology has been used to blunt the acuity of the these struggling services, alongside military hospitals which often serve local populations. Radiology faces unique challenges compared to other healthcare services owing to its expensive equipment which is difficult to fund and can be less effective due to international sanctions placed on contrast medium to enhance image quality. Further the equipment is reliant on local infrastructure, e.g., power supply, which can be affected in conflict. Key recommendations to improve radiology services include retention of radiologists within conflict zones, careful allocation of funds to supply necessary imaging machinery, international cooperation to ensure sanctions do not affect sourcing of radiology equipment, special training for military medical teams to help preparedness for the unique demands of the local population, and investment in communication devices, like smartphones, to allow international teleradiology efforts. Key message Medical imaging services are critical element of a health system that is particularly constrained in conflict-affected settings. Much of the medical imaging provided in conflict is delivered by external or remote groups including militaries and humanitarian medical communities. The radiology workforce is very limited in conflict-affected settings – the exodus of health workers and limited training opportunities hamper further workforce development. Technological requirements are limiting the full expansion of imaging services as conflict-affected health sectors experience continued degradation of key infrastructure including information technology required to sustain services. Compliance with international regulatory frameworks for radiological safety are essential, yet even more complex in conflict-affected settings.

Background It is estimated that over 40% of the half a million humanitarian workers who provide frontline care during emergencies, wars and disasters, are women. Women are at the forefront of improving health for conflict-affected populations through service delivery, education and capacity strengthening, advocacy and research. Women are also disproportionately affected by conflict and humanitarian emergencies. The growing evidence base demonstrating excess female morbidity and mortality reflects the necessity of evaluating the role of women in leadership driving health research, policy and programmatic interventions in conflict-related humanitarian contexts. Despite global commitments to improving gender equality, the issue of women leaders in conflict and humanitarian health has been given little or no attention. The aim of this paper focuses on three domains: importance, barriers and opportunities for women leaders in conflict and humanitarian health. Following thematic analysis of the material collected, we discuss the following themes: barriers of women’s leadership domain at societal level, and organisational level, which is subcategorized into culture and strategy. Building on the available opportunities and initiatives and on inspirational experiences of the limited number of women leaders in this field, recommendations for empowering and supporting women’s leadership in conflict health are presented. Methods A desk-based literature review of academic and grey sources was conducted followed by thematic analysis. Results There is very limited evidence on women leaders in conflict and humanitarian health. Some data shows that women have leadership skills that help to support more inclusive solutions which are incredibly important in this sector. However, deeply imbedded discrimination against women at the organisational, cultural, social, financial and political levels is exacerbated in conflict which makes it more challenging for women to progress in such settings. Conclusion Advocating for women leaders in conflict and health in the humanitarian sector, governmental bodies, academia and the global health community is crucial to increasing effective interventions that adequately address the complexity and diversity of humanitarian crises.

Cyber-attacks against hospitals, medical devices, and healthcare entities are becoming increasingly common; simultaneously, physical attacks against hospitals and healthcare entities are increasing. The purpose of this article is to explore the threat to healthcare from cyber-attacks. We undertake qualitative analysis of current and past cyber-attacks on healthcare system and look at these in the context of the increase in non-traditional threats. We conclude that there is a current and systemic threat to the healthcare sector from cyber-attacks by nation state and criminal groups, which is not currently being addressed in a systematic manner. Finally, we conclude that further discussion on key issues such as legislation and regulatory frameworks needs to take place at both a policy and practitioner level.

Background Students on international medical electives face complex ethical issues when undertaking clinical work. The variety of elective destinations and the culturally specific nature of clinical ethical issues suggest that pre-elective preparation could be supplemented by in-elective support. Methods An online, asynchronous, case-based discussion was piloted to support ethical learning on medical student electives. We developed six scenarios from elective diaries to stimulate peer-facilitated discussions during electives. We evaluated the transcripts to assess whether transformative, experiential learning took place, assessing specifically for indications that 1) critical reflection, 2) reflective action and 3) reflective learning were taking place. We also completed a qualitative thematic content analysis of the discussions. Results Of forty-one extended comments, nine responses showed evidence of transformative learning (Mezirow stage three). The thematic analysis identified five themes: adopting a position on ethical issues without overt analysis; presenting issues in terms of their effects on students’ ability to complete tasks; describing local contexts and colleagues as “other”; difficulty navigating between individual and structural issues, and overestimation of the impact of individual action on structures and processes. Conclusion Results suggest a need to: frame ethical learning on elective so that it builds on earlier ethical programmes in the curriculum, and encourages students to adopt structured approaches to complex ethical issues including cross-cultural negotiation and to enhance global health training within the curriculum.

The conflict environment in Libya is characterized by continued pervasive insecurity amidst the widespread availability of small arms and light weapons (SALW). After the First Civil War, armed brigades took the law into their own hands and the resulting violence terminated a short-lived post-conflict period that has relapsed into a Second Civil War. The Libyan government has struggled to assert authority over armed groups and these brigades, refusing to disarm have contributed directly the initiation of a second conflict; some are motivated by self-defense, status, criminality, vindication or political aims. Once, a bastion of public health in the Middle East and North Africa (MENA), the country now faces a substantial and unprecedented challenge: to rebuild a devastated health system amidst the burden of armed violence and the proliferation of small and light weapons (SALW) especially firearms of various kinds. The health system in Libya is compromised; healthcare professionals have little time to record or document such cases given the immediate clinical needs of the patient. This corresponding decreased capacity to deal with an increasing demand on services caused by SALW-related morbidity compounds the challenge of data collection and indicates that external support and advocacy are required. A public health strategy towards effective SALW armed violence reduction and injury prevention requires the interdisciplinary advocacy of practitioners across the fields of justice, security, development, health and education. Through surveillance of firearms and injuries in the post-conflict environment we can better evaluate and respond to the burden of armed violence in Libya. In order to reduce armed a reconceptualisation of arms reduction campaigns must occur. Notable emerging evidence recommends the inclusion of community-based interventions and development programs which address local motivations for firearms ownership alongside improved international coordination. This renewed approach holds importance for recovery, development and securing the transition to peace. The high prevalence of firearm ownership, weak institutions, nascent security forces, porous borders, inadequate weapons stockpiles, combined with high military spending, compounds public weaponisation as a health crisis for the entire MENA region.

The Immigration Act 2014 is likely to worsen health inequalities faced by migrants. The Act sees the introduction of an annual surcharge of £150-200, with further fees to access the accident and emergency department and some primary care services, excluding general practice.

ObjectivesThe clinical impact of SARS-CoV-2 has varied across countries with varying cardiovascular manifestations. We review the cardiac presentations, in-hospital outcomes and development of cardiovascular complications in the initial cohort of SARS-CoV-2 positive patients at Imperial College Healthcare National Health Service Trust, UK.MethodsWe retrospectively analysed 498 COVID-19 positive adult admissions to our institute from 7 March to 7 April 2020. Patient data were collected for baseline demographics, comorbidities and in-hospital outcomes, especially relating to cardiovascular intervention.ResultsMean age was 67.4±16.1 years and 62.2% (n=310) were male. 64.1% (n=319) of our cohort had underlying cardiovascular disease (CVD) with 53.4% (n=266) having hypertension. 43.2%(n=215) developed acute myocardial injury. Mortality was significantly increased in those patients with myocardial injury (47.4% vs 18.4%, p<0.001). Only four COVID-19 patients had invasive coronary angiography, two underwent percutaneous coronary intervention and one required a permanent pacemaker implantation. 7.0% (n=35) of patients had an inpatient echocardiogram. Acute myocardial injury (OR 2.39, 95% CI 1.31 to 4.40, p=0.005) and history of hypertension (OR 1.88, 95% CI 1.01 to 3.55, p=0.049) approximately doubled the odds of in-hospital mortality in patients admitted with COVID-19 after other variables had been controlled for.ConclusionHypertension, pre-existing CVD and acute myocardial injury were associated with increased in-hospital mortality in our cohort of COVID-19 patients. However, only a low number of patients required invasive cardiac intervention.