This case study series documents the experience of R2HC-funded research teams in engaging with people affected by crisis. The full case series can be found here.

STUDY BACKGROUND

Ethical challenges in humanitarian health in situations of extreme violence

This work was led by the Johns Hopkins Bloomburg School of Public Health in collaboration with the Syrian American Medical Society and International Rescue Committee.

The study aimed to investigate the nature of ethical challenges experienced by humanitarian health organisations in Syria, where there is significant violence directed at civilians and especially towards healthcare providers/services. The research sought to provide processes and mechanisms, as well as practical tools, to guide humanitarian health organisations through complex ethical challenges facing them in these settings

Key findings

Frequent ethical challenges arise for organisations working in conflict settings. These are particularly difficult when health workers and facilities are themselves subjected to violence that both puts them at severe risk and affects their obligations to serve communities in need.

Humanitarian organisations can better address ethical challenges faced in conflict settings by establishing internal procedures and mechanisms, and utilising existing tools to approach the challenges in a systematic way.

Organisations are encouraged to commit time and resources for addressing ethical challenges, including: the use of decision-making tools and processes, organisation-wide training, dedicated staff, and structures to support ethical decision making and engaging with communities.

APPROACHES TO ENGAGING WITH PEOPLE AFFECTED BY CRISES

DESIGN PHASE

Defining the decision-makers

The study team focused on those who had to make very difficult healthcare decisions many of them involving ethical concerns.

“One of the issues that people talked about is that when hospitals were attacked, should they be rebuilt or not? Some didn’t want them to be rebuilt because it would be attacked again, and some did”
– Len Rubenstein, PI

Problem identification

Initial conversations and design started with the leadership of partner organisations working in Syria, based in Turkey and Jordan. The leadership were interested in and recognised the ethical concerns needing to be addressed. Groups based in Turkey could gain access to Syria but Jordanian based groups could not, resulting in remote operations.

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IMPLEMENTATION PHASE

Diverse participants

The study group conducted interviews with key informants from many organizations providing health services in Syria and followed these with in-depth interviews with front-line health workers and managers, most of them hospital based

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POST-RESEARCH PHASE

Discussing conclusions within workshops

Workshops were held with healthcare organizations based in Turkey and Jordan, one to share and gain feedback on initial findings and their implications, and one to discuss conclusions with partners. The PI noted that if he were to repeat the study, he would have planned for a workshop with healthcare organizations at the beginning of the study.

ENABLING FACTORS

Good relationships at the ‘field’ level between partners and healthcare provision in Syria was noted as a factor that enabled greater participation.

Furthermore, pre-existing relationships and prior research between the lead organisation and partners was a strength.

“There was a level of trust and belief in the partners. We were not seen as an academic group looking to take advantage. They believed that we were genuinely committed to helping.”
– Len Rubenstein, PI

CHALLENGES TO PARTICIPATION

A number of factors presented challenges at various stages of the research including a) turnover in personnel in the partner organizations and the heavy healthcare workload and b) border closures or restrictions affecting access.

The research team was made up of the research group (JHU) and NGO healthcare partners SAMS and IRC, which engaged with organizations providing health services in Syria. While these partnerships and the engagement were effective in supporting the research aims, due to time and staffing constraints on the part of the NGOs there was less follow-through on project recommendations than would have been ideal.

Participation of communities or patients seeking health services was not part of the study. The study team reflected that this would have extremely difficult, especially because the interviews would have had to be conducted remotely, the ethical issues that arise in conducting such interviews among a very vulnerable population, and the time in which they needed to complete the project,

“In retrospect, I would want to talk to directors – managers of Syrian health directorates not affiliated with NGOs who were not really involved in the planning of the project. We worked with our NGO partners in the planning, proposal, methodology. We had limited input from people in the directorates”
– Len Rubenstein, PI

FIND OUT MORE

To find out more, please see the study profile.

ACKNOWLEDGEMENTS

R2HC thanks Len Rubenstein for their expertise and reflections.