Fifty-two maternal deaths occurred between September 2017 and August 2018 in the Rohingya refugee camps in Ukhia and Teknaf Upazilas, Cox's Bazar District, Bangladesh. Behind every one of these lives lost is a complex narrative of historical, social, and political forces, which provide an important context for reproductive health programming in Rohingya camps. Rohingya women and girls have experienced human rights violations in Myanmar for decades, including government-sponsored sexual violence and population control efforts. An extension of nationalist, anti-Rohingya policies, the attacks of 2017 resulted in the rape and murder of an unknown number of women. The socio-cultural context among Rohingya and Bangladeshi host communities limits provision of reproductive health services in the refugee camps, as does a lack of legal status and continued restrictions on movement. In this review, the historical, political, and social contexts have been overlaid below on the Three Delays Model, a conceptual framework used to understand the determinants of maternal mortality. Attempts to improve maternal mortality among Rohingya women and girls in the refugee camps in Bangladesh should take into account these complex historical, social and political factors in order to reduce maternal mortality.

Background Decades of persecution culminated in a statewide campaign of organized, systematic, and violent eviction of the Rohingya people by the Myanmar government beginning in August 2017. These attacks included the burning of homes and farms, beatings, shootings, sexual violence, summary executions, burying the dead in mass graves, and other atrocities. The Myanmar government has denied any responsibility. To document evidence of reported atrocities and identify patterns, we interviewed survivors, documented physical injuries, and assessed for consistency in their reports. Methods We use purposive and snowball sampling to identify survivors residing in refugee camps in Bangladesh. Interviews and examinations were conducted by trained investigators with the assistance of interpreters based on the Istanbul Protocol – the international standard to investigate and document instances of torture and other cruel, inhuman, and degrading treatment. The goal was to assess whether the clinical findings corroborate survivors’ narratives and to identify emblematic patterns. Results During four separate field visits between December 2017 and July 2018, we interviewed and where relevant, conducted physical examinations on a total of 114 refugees. The participants came from 36 villages in Northern Rakhine state; 36 (32%) were female, 26 (23%) were children. Testimonies described several patterns in the violence prior to their flight, including the organization of the attacks, the involvement of non-Rohingya civilians, the targeted and purposeful destruction of homes and eviction of Rohingya residents, and the denial of medical care. Physical findings included injuries from gunshots, blunt trauma, penetrating trauma such as slashings and mutilations, burns, and explosives and from sexual and gender-based violence. Conclusions While each survivor’s experience was unique, similarities in the types and organization of attacks support allegations of a systematic, widespread, and premeditated campaign of forced displacement and violence. Physical findings were consistent with survivors’ narratives of violence and brutality. These findings warrant accountability for the Myanmar military per the Rome Statute of the International Criminal Court (ICC), which has jurisdiction to try individuals for serious international crimes, including crimes against humanity and genocide. Legal accountability for these crimes should be pursued along with medical and psychological care and rehabilitation to address the ongoing effects of violence, discrimination, and displacement.

Background In August, 2017, Myanmar security forces initiated a widespread response against the Rohingya ethnic minority in Northern Rakhine State, displacing thousands of people to Bangladesh. This attack was purportedly in response to attacks committed by the Arakan Rohingya Salvation Army, a non-state insurgent group, on Myanmar police, Border Guard Police, and military posts, killing 12 security personnel on Aug 25, 2017. This study aimed to capture the experiences of the population from all Rohingya hamlets in the Northern Rakhine State who have been displaced to Bangladesh. Methods A quantitative survey was done among Rohingya leaders displaced to refugee camps in Bangladesh. Community leaders from 590 Rohingya hamlets and eight urban wards provided hamlet-level data on the extent, nature, and perpetrators of the violence in Northern Rakhine State in August, 2017, and the resulting morbidity and mortality.Results From May 28 to July 25, 2018, 462 (77%) of 604 hamlet leaders reported that the primary reason they and their community members fled was because of violence in their hamlet or in a neighbouring hamlet. 568 (94%) respondents reported that they had experienced destruction in their hamlets, including burning or destruction of fields or farms, homes, and mosques; 531 (89%) of 599 respondents reported violence in their hamlets before flight and 373 (64%) of 586 reported violence against civilians in flight. The main perpetrators of violence included but were not limited to Border Guard Police, Myanmar military, and Rakhine extremists. Of the 531 respondents who reported violence in their hamlets, 408 (77%) reported that military forces used helicopters, 372 (70%) reported military vehicles, and 113 (21%) reported tanks in these assaults on civilian communities. We estimate that 7803 Rohingya died from violent and non-violent causes associated with the August, 2017, attacks and subsequent displacement.Interpretation In 2017, the Rohingya ethnic minority population of Northern Rakhine State were the targets of a campaign of widespread and systematic violence, including violence by state forces.Funding An anonymous grant to Physicians for Human Rights.

IMPORTANCE The management of noncommunicable diseases in humanitarian crises has been slow to progress from episodic care. Understanding disease burden and access to care among crisisaffected populations can inform more comprehensive management. OBJECTIVE To estimate the prevalence of hypertension and diabetes with biological measures and to evaluate access to care among Syrian refugees in northern Jordan. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study was undertaken from March 25 to April 26, 2019, in the districts of Ramtha and Mafraq, Jordan. Seventy clusters of 15 households were randomly sampled, and chain referral was used to sample Syrian households, representative of 59 617 Syrian refugees. Adults were screened and interviewed about their access to care. Data analysis was performed from May to September 2019. EXPOSURES Primary care delivered through a humanitarian organization since 2012. MAIN OUTCOMES AND MEASURES The main outcomes were self-reported prevalence of hypertension and diabetes among adults aged 18 years or older and biologically based prevalence among adults aged 30 years or older. The secondary outcome was access to care during the past month among adults aged 18 years or older with a diagnosis of hypertension or diabetes. RESULTS In 1022 randomly sampled households, 2798 adults aged 18 years or older, including 275 with self-reported diagnoses (mean [SD] age, 56.5 [13.2] years; 174 women [63.3%]), and 915 adults aged 30 years or older (608 women [66.5%]; mean [SD] age, 46.0 [12.8] years) were screened for diabetes and hypertension. Among adults aged 18 years or older, the self-reported prevalence was 17.2% (95% CI, 15.9%-18.6%) for hypertension, 9.8% (95% CI, 8.6%-11.1%) for diabetes, and 7.3% (95% CI, 6.3%-8.5%) for both conditions. Among adults aged 30 years or older, the biologically based prevalence was 39.5% (95% CI, 36.4%-42.6%) for hypertension, 19.3% (95% CI, 16.7%-22.1%) for diabetes, and 13.5% (95% CI, 11.4%-15.9%) for both conditions. Adjusted for age and sex, prevalence for all conditions increased with age, and women had a higher prevalence of diabetes than men (adjusted prevalence ratio, 1.3%; 95% CI, 1.0%-1.7%), although the difference was not significant. Complications (57.4%; 95% CI, 51.5%-63.1%) and obese or overweight status (82.8%; 95% CI, 79.7%-85.5%) were highly prevalent. Among adults aged 30 years or older with known diagnoses, 94.1% (95% CI, 90.9%-96.2%) currently took medication. Among adults aged 18 years or older with known diagnoses, 26.8% (95% CI, 21.3%-33.1%) missed a medication dose in the past week, and 49.1% (95% CI, 43.3%-54.9%) sought care in the last month. CONCLUSIONS AND RELEVANCE During this protracted crisis, obtaining care for noncommunicable diseases was feasible, as demonstrated by biologically based prevalence that was (continued)

BackgroundMyanmar/Burma has received increased development and humanitarian assistance since the election in November 2010. Monitoring the impact of foreign assistance and economic development on health and human rights requires knowledge of pre-election conditions.MethodsFrom October 2008-January 2009, community-based organizations conducted household surveys using three-stage cluster sampling in Shan, Kayin, Bago, Kayah, Mon and Tanintharyi areas of Myanmar. Data was collected from 5,592 heads of household on household demographics, reproductive health, diarrhea, births, deaths, malaria, and acute malnutrition of children 6–59 months and women aged 15–49 years. A human rights focused survey module evaluated human rights violations (HRVs) experienced by household members during the previous year.ResultsEstimated infant and under-five rates were 77 (95% CI 56 to 98) and 139 (95% CI 107 to 171) deaths per 1,000 live births; and the crude mortality rate was 13 (95% CI 11 to 15) deaths per thousand persons. The leading respondent-reported cause of death was malaria, followed by acute respiratory infection and diarrhea, causing 21.2% (95% CI 16.5 to 25.8), 16.6% (95% CI 11.8 to 21.4), and 12.3% (95% CI 8.7 to 15.8), respectively. Over a third of households suffered at least one human rights violation in the preceding year (36.2%; 30.7 to 41.7). Household exposure to forced labor increased risk of death among infants (rate ratio (RR) = 2.2; 95% CI 1.1 to 4.4) and children under five (RR = 2.1; 95% CI 1.3 to 3.6). The proportion of children suffering from moderate to severe acute malnutrition was higher among households that were displaced (prevalence ratio (PR) = 3.3; 95% CI 1.9 to 5.6).ConclusionsPrior to the 2010 election, populations of eastern Myanmar experienced high rates of disease and death and high rates of HRVs. These population-based data provide a baseline that can be used to monitor national and international efforts to improve the health and human rights situation in the region.

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The World Health Organization estimates that the burden of surgical disease due to war, self-inflicted injuries, and road traffic incidents will rise dramatically by 2020. During the 2009 Harvard Humanitarian Initiative's Humanitarian Action Summit (HHI/HAS), members of the Burden of Surgical Disease Working Group met to review the state of surgical epidemiology, the unmet global surgical need, and the role international organizations play in filling the surgical gap during humanitarian crises, conflict, and war. An outline of the group's findings and recommendations is provided.

BackgroundMyanmar transitioned to a nominally civilian parliamentary government in March 2011. Qualitative reports suggest that exposure to violence and displacement has declined while international assistance for health services has increased. An assessment of the impact of these changes on the health and human rights situation has not been published.Methods and FindingsFive community-based organizations conducted household surveys using two-stage cluster sampling in five states in eastern Myanmar from July 2013-September 2013. Data was collected from 6, 178 households on demographics, mortality, health outcomes, water and sanitation, food security and nutrition, malaria, and human rights violations (HRV). Among children aged 6-59 months screened, the prevalence of global acute malnutrition (representing moderate or severe malnutrition) was 11.3% (8.0 – 14.7). A total of 250 deaths occurred during the year prior to the survey. Infant deaths accounted for 64 of these (IMR 94.2; 95% CI 66.5-133.5) and there were 94 child deaths (U5MR 141.9; 95% CI 94.8-189.0). 10.7% of households (95% CI 7.0-14.5) experienced at least one HRV in the past year, while four percent reported 2 or more HRVs. Household exposure to one or more HRVs was associated with moderate-severe malnutrition among children (14.9 vs. 6.8%; prevalence ratio 2.2, 95% CI 1.2-4.2). Household exposure to HRVs was associated with self-reported fair or poor health status among respondents (PR 1.3; 95% CI 1.1 – 1.5).ConclusionThis large survey of health and human rights demonstrates that two years after political transition, vulnerable populations of eastern Myanmar are less likely to experience human rights violations compared to previous surveys. However, access to health services remains constrained, and risk of disease and death remains higher than the country as a whole. Efforts to address these poor health indicators should prioritize support for populations that remain outside the scope of most formal government and donor programs.