Saskia van der Kam

The trauma of war in Sierra Leone

Civilians are increasingly targeted in todays wars. To reduce military casualties, civilians are used as protective shields; to facilitate guerrilla warfare, they are abducted or enslaved; torture, rape, and executions are carried out to undermine morale and to eradicate the cultural links and self-esteem of the population. Most civilians in zones of conflict witness war-related traumatic events such as shootings, killings, rape, and loss of family members. The extent of psychosocial problems that results from this mass exposure to traumatic events may ultimately threaten the prospects for long-term stability in society.

The trauma of ongoing conflict and displacement in Chechnya: quantitative assessment of living conditions, and psychosocial and general health status among war displaced in Chechnya and Ingushetia

BackgroundConflict in Chechnya has resulted in over a decade of violence, human rights abuses, criminality and poverty, and a steady flow of displaced seeking refuge throughout the region. At the beginning of 2004 MSF undertook quantitative surveys among the displaced populations in Chechnya and neighbouring Ingushetia.MethodsSurveys were carried out in Ingushetia (January 2004) and Chechnya (February 2004) through systematic sampling. Various conflict-related factors contributing to ill health were researched to obtain information on displacement history, living conditions, and psychosocial and general health status.ResultsThe average length of displacement was five years. Conditions in both locations were poor, and people in both locations indicated food shortages (Chechnya (C): 13.3%, Ingushetia (I): 11.3%), and there was a high degree of dependency on outside help (C: 95.4%, I: 94.3%). Most people (C: 94%, I: 98%) were confronted with violence in the past. Many respondents had witnessed the killing of people (C: 22.7%, I: 24.1%) and nearly half of people interviewed witnessed arrests (C: 53.1%, I: 48.4%) and maltreatment (C: 56.2%, I: 44.5%). Approximately one third of those interviewed had directly experienced war-related violence. A substantial number of people interviewed – one third in Ingushetia (37.5%) and two-thirds in Chechnya (66.8%) – rarely felt safe. The violence was ongoing, with respondents reporting violence in the month before the survey (C: 12.5%, I: 4.6%). Results of the general health questionnaire (GHQ 28) showed that nearly all internally displaced persons interviewed were suffering from health complaints such as somatic complaints, anxiety/insomnia, depressive feelings or social dysfunction (C: 201, 78.5%, CI: 73.0% – 83.4%; I: 230, 81.3%, CI: 76.2% – 85.6%). Poor health status was reflected in other survey questions, but health services were difficult to access for around half the population (C: 54.3%, I: 46.6%).DiscussionThe study demonstrates that the health needs of internally displaced in both locations are similarly high and equally unaddressed. The high levels of past confrontation with violence and ongoing exposure in both locations is likely to contribute to a further deterioration of the health status of internally displaced. As of March 2007, concerns remain about how the return process is being managed by the authorities.

Exposure to violence and PTSD symptoms among Somali women

Posttraumatic stress disorder (PTSD) symptoms, exposure to traumatic stressors, and health care utilization were examined in 84 women attending a primary health care clinic in Mogadishu, Somalia. The Somalia-Posttraumatic Diagnostic Scale was used in this active warzone to measure symptoms. Nearly all women reported high levels of confrontations with violence; half described being exposed to a potentially traumatizing event. Nearly one third had significant PTSD symptoms. Compared to those who did not, women who reported exposure to a traumatic stressor reported more confrontations with violence (7.1 vs. 3.3; p < . 001), health complaints (3.8 vs. 2.9; p = .03), and nearly 3 times as much (p = .03) health service utilization. A potentially traumatizing event was found to be a simplified proxy for assessing mental health distress in women attending a primary health care facility in highly insecure, unpredictable, resource-limited settings.

Effect of Short-Term Supplementation with Ready-to-Use Therapeutic Food or Micronutrients for Children after Illness for Prevention of Malnutrition: A Randomised Controlled Trial in Nigeria.

Background Globally, Médecins Sans Frontières (MSF) treats more than 300,000 severely malnourished children annually. Malnutrition is not only caused by lack of food and poor infant and child feeding practices but also by illnesses. Breaking the vicious cycle of illness and malnutrition by providing ill children with nutritional supplementation is a potentially powerful strategy for preventing malnutrition that has not been adequately investigated. Therefore, MSF investigated whether incidence of malnutrition among ill children <5 y old could be reduced by providing a fortified food product or micronutrients during their 2-wk convalescence period. Two trials, one in Nigeria and one in Uganda, were conducted; here we report on the trial that took place in Goronyo, a rural region of northwest Nigeria with high morbidity and malnutrition rates. Methods and Findings We investigated the effect of supplementation with ready-to-use therapeutic food (RUTF) and a micronutrient powder (MNP) on the incidence of malnutrition in ill children presenting at an outpatient clinic in Goronyo during February to September 2012. A three-armed, partially-blinded, randomised controlled trial was conducted in children diagnosed as having malaria, diarrhoea, or lower respiratory tract infection. Children aged 6 to 59 mo were randomised to one of three arms: one sachet/d of RUTF; two sachets/d of micronutrients or no supplement (control) for 14 d for each illness over 6 mo. The primary outcome was the incidence of first negative nutritional outcome (NNO) during the 6 mo follow-up. NNO was a study-specific measure used to indicate occurrence of malnutrition; it was defined as low weight-for-height z-score (<−2 for non-malnourished and <−3 for moderately malnourished children), mid-upper arm circumference <115 mm, or oedema, whichever came first. Of the 2,213 randomised participants, 50.0% were female and the mean age was 20.2 (standard deviation 11.2) months; 160 (7.2%) were lost to follow-up, 54 (2.4%) were admitted to hospital, and 29 (1.3%) died. The incidence rates of NNO for the RUTF, MNP, and control groups were 0.522 (95% confidence interval (95% CI), 0.442–0.617), 0.495 (0.415–0.589), and 0.566 (0.479–0.668) first events/y, respectively. The incidence rate ratio was 0.92 (95% CI, 0.74–1.15; p = 0.471) for RUTF versus control; 0.87 (0.70–1.10; p = 0.242) for MNP versus control and 1.06 (0.84–1.33, p = 0.642) for RUTF versus MNP. A subgroup analysis showed no interaction nor confounding, nor a different effectiveness of supplementation, among children who were moderately malnourished compared with non-malnourished at enrollment. The average number of study illnesses for the RUTF, MNP, and control groups were 4.2 (95% CI, 4.0–4.3), 3.4 (3.2–3.6), and 3.6 (3.4–3.7). The proportion of children who died in the RUTF, MNP, and control groups were 0.8% (95% CI, 0.3–1.8), 1.8% (1.0–3.3), and 1.4% (0.7–2.8). Conclusions A 2-wk supplementation with RUTF or MNP to ill children as part of routine primary medical care did not reduce the incidence of malnutrition. The lack of effect in Goronyo may be due to a high frequency of morbidity, which probably further affects a child’s nutritional status and children’s ability to escape from the illness–malnutrition cycle. The duration of the supplementation may have been too short or the doses of the supplements may have been too low to mitigate the effects of high morbidity and pre-existing malnutrition. An integrated approach combining prevention and treatment of diseases and treatment of moderate malnutrition, rather than prevention of malnutrition by nutritional supplementation alone, might be more effective in reducing the incidence of acute malnutrition in ill children. Trial Registration clinicaltrials.gov NCT01154803

Monitoring and Evaluating Psychosocial Intervention Outcomes in Humanitarian Aid

Existing tools for evaluating psychosocial interventions (un-validated self-reporting questionnaires) are not ideal for use in non-Western conflict settings. We implement a generic method of treatment evaluation, using client and counsellor feedback, in 18 projects in non-Western humanitarian settings. We discuss our findings from the perspective of validity and suggestions for future research. A retrospective analysis is executed using data gathered from psychosocial projects. Clients (n = 7,058) complete two (complaints and functioning) rating scales each session and counsellors rate the client’s status at exit. The client-completed pre- and post-intervention rating scales show substantial changes. Counsellor evaluation of the clients’ status shows a similar trend in improvement. All three multivariable models for each separate scale have similar associations between the scales and the investigated variables despite different cultural settings. The validity is good. Limitations are: ratings give only a general impression and clinical risk factors are not measured. Potential ceiling effects may influence change of scales. The intra and inter-rater reliability of the counsellors’ rating is not assessed. The focus on client and counsellor perspectives to evaluate treatment outcome seems a strong alternative for evaluation instruments frequently used in psychosocial programming. The session client rated scales helps client and counsellor to set mutual treatment objectives and reduce drop-out risk. Further research should test the scales against a cross-cultural valid gold standard to obtain insight into their clinical relevance.

Trauma of Chechnya's ongoing war on internally displaced people

Despite repeated claims from Russian and pro-Russian Chechen officials that the situation in Chechnya is normalising, the conflict and related human rights abuses continue. 1 The decade of conflict has resulted in an estimated 260 000 internally displaced people. By mid 2004, around 52 000 remained in the neighbouring Republic of Ingushetia. Most live in places unfit for human habitation—tent camps or spontaneous settlements such as train wagons, abandoned farms, factories, and warehouses. Since September, 2003, the Russian and Ingush authorities have been putting considerable pressure on internally displaced people in Ingushetia to return to within Chechnyas border. Health systems and other public services in Chechnya are in a dire state, and a lack of security in the region means that aid agencies are severely restricted in their ability to move around the region to provide additional support. Earlier this year, Médecins Sans Frontières (MSF) undertook quantitative health surveys 2 in the displaced populations both in the spontaneous settlements in Ingushetia and temporary accommodation centres on the Chechen side to obtain information on displacement history, living conditions, and psychosocial and general health status. Results show that insecurity and substandard living conditions prevail in both camps. Most people in the settlements and temporary accommodation centres have been displaced in two waves, either in 1994 or 1999, during periods of severe conflict in Chechnya, and have since been forced to relocate several times. Interviewees said they were prevented from returning home because of security fears or because their property had been destroyed. Almost all people interviewed had been exposed to crossfire, aerial bombardments, and mortar fire. More than one in five had seen killings, and nearly half had seen maltreatment of family. About 90% of people in the Chechen camps and 80% in Ingushetia had had someone close to them die as a result of the war-related violence. Ongoing conflict in Chechnya continues to disrupt peoples lives. Over a third of people in Ingushetia felt unsafe, while in Chechnya two-thirds expressed concern about their security. 7% of people in Chechnya and 9% in Ingushetia reported that a family member had died in the 2 months before survey, many as a result of violence. The arrest or disappearance of friends or neighbours was common on both sides of the border. The health effects of these experiences continue to take their toll. However, access to medicines and health services is problematic in both locations. …

Risk factors for diagnosed noma in northwest Nigeria: A case-control study, 2017

Background Noma (cancrum oris), a neglected tropical disease, rapidly disintegrates the hard and soft tissue of the face and leads to severe disfiguration and high mortality. The disease is poorly understood. We aimed to estimate risk factors for diagnosed noma to better guide existing prevention and treatment strategies using a case-control study design. Methods Cases were patients admitted between May 2015 and June 2016, who were under 15 years of age at reported onset of the disease. Controls were individuals matched to cases by village, age and sex. Caretakers answered the questionnaires. Risk factors for diagnosed noma were estimated by calculating unadjusted and adjusted odds ratios (ORs) and respective 95% confidence intervals (CI) using conditional logistic regression. Findings We included 74 cases and 222 controls (both median age 5 (IQR 3, 15)). Five cases (6.5%) and 36 (16.2%) controls had a vaccination card (p = 0.03). Vaccination coverage for polio and measles was below 7% in both groups. The two main reported water sources were a bore hole in the village (cases n = 27, 35.1%; controls n = 63, 28.4%; p = 0.08), and a well in the compound (cases n = 24, 31.2%; controls n = 102, 45.9%; p = 0.08). The adjusted analysis identified potential risk and protective factors for diagnosed noma which need further exploration. These include the potential risk factor of the child being fed pap every day (OR 9.8; CI 1.5, 62.7); and potential protective factors including the mother being the primary caretaker (OR 0.08; CI 0.01, 0.5); the caretaker being married (OR 0.006; CI 0.0006, 0.5) and colostrum being given to the baby (OR 0.4; CI 0.09, 2.09). Interpretation This study suggests that social conditions and infant feeding practices are potentially associated with being a diagnosed noma case in northwest Nigeria; these findings warrant further investigation into these factors.