Hello listeners and welcome to Connecting Citizens to Science. I'm Dr. Kim Ozano, and this is a podcast where we discuss the ways that researchers connect with communities across the world to solve challenges together. Today's episode is the third of a six part mini series brought to you by ReBUILD for Resilience. ReBUILD is a research consortium that examines health systems resilience in fragile settings that experience violence, conflict, pandemics, and other shocks. And the focus of today's episode is the health workforce in fragile settings, including those that have been affected by conflict, disease, outbreaks, political and economic crisis. Today we hear from Dr. Nasher Al-Aghbari, who is a pediatrician providing healthcare and war-torn Yemen at the Al-Thawra General Modern Teaching Hospital in Sana'a. Dr. Nasher shares firsthand experiences of the challenges faced by the health workforce. As they struggled to deliver health care with limited resources, minimal to no salary, inadequate equipment and medicines necessary to save lives, and all while attacks are occurring on the doorsteps of health facilities and hospitals. The prolonged conflict has taken a devastating toll on the physical, psychological, and professional wellbeing of the health workforce. We are also joined by Dr. Jim Campbell, the Director of the Health Workforce Department at the World Health Organization. Dr. Jim Campbell reflects on the similar experiences being shared from across 40 countries who are also facing emergencies. Jim states that public health is under threat worldwide and speaks about the role of international organisations in building resilient health systems to adequately support the health workforce who are working in these very difficult contexts. To help us understand more about the workforce in fragile settings. We have our co-host Dr. Wesam Mansour from the Liverpool School of Tropical Medicine. Through Wesam's work with ReBUILD. She is being focusing on understanding the contribution of the health workforce to health systems resilience. Their role during the crisis time, including their capacities and coping strategies, they use to be able to respond to the population's needs. And the support needed both during and post crisis, which is currently lacking. There are parts of this episode that are graphic and some listeners may find distressing. Hello everyone. And a warm welcome to the podcast. We're very pleased to have you all here for this important conversation. Dr. Nasher Al-Aghbari and Dr. Jim Campbell, we're very much looking forward to your insights, but before we begin, let's hear from our co-host, Dr. Wesam Mansour. Wesam, welcome to the podcast. Perhaps you could set us up a little bit by highlighting some of the key things we need to be thinking about when considering the health workforce in fragile contexts.

Thank you for the introduction, Kim, and welcome to our broadcast today, Nasher and Jim. Let me start by clarifying that I'm a medical doctor by background, and I can understand well how it could be for health workers to work on the frontline in fragile context or in low resource settings. I know about the challenges that health workers can face, the stressors they are prone to. But when we speak about the armed conflict situation, this is, of course, another level of stress. Unfortunately, for a few months now, I'm hearing from my colleagues in Gaza about what they face. I hear about the daily struggles of providing care under fire, where health facilities are under attack. And they see their friends, family members, children, dying every day in front of them. I hear from them about how they feel. They feel low sense of self efficacy, vulnerability, helplessness, and inadequacy because they cannot help their patient. And of course, they cannot provide the health services that their populations need. But at the end of the day, I can see how they can still show incredible resilience and dedication. Nasher, I know you can relate to this situation as a medical doctor in Yemen. And today I want you to share with us your own experience and the experiences of your colleagues during the protracted conflict situation in Yemen.

Thank you Wesam. As you know, Yemen is a very poor, uh, country the health system in Yemen before war the health system is very fragile. Now during this war, the health worker is facing many problems, like financial problem, economic problem, also psychiatric problem. They are suffering for everything. They cannot come to our hospital working because they have no transport. The road is broken, bombing all time morning, afternoon, evening, so they are not coming all day to the hospital. Our health worker, they didn't give them salary since nine year or 10 years, they didn't give them any money. They are working no salary. So, some relative not allow the health worker to go to the hospitals because they are no secure, because they are bombing in front of the hospital. Also, there is some physical trauma for him. From the glasses broken in the hospital, they are wounded. Also, they are crying all the time. They are afraid from bombing because the bombing is very loud. You cannot imagine what is this. This is very difficult working in the hospital because they are bombing the street, just the street near the hospital. I see many patient. I remember one woman to come to the hospital. She can't pay for the drugs, and this child two months old only. She came to me to told me 'I will go home'. I thought why you are going to home because your child is very sick? He had renal failure. He cannot pass urine at all. I told 'Why you are going to home because this child will die?' She told me 'Let him die'. Very easy. I told 'No, but this is very difficult. He will die in the street'. She told me, 'No problem. Let him die. Let him die.' Uh, one woman, she came to our hospital with her child with convulsions. You know, we have no drugs. We have no canula for this child to stop the convulsions. We send the mother outside to buy canula and buy drugs to stop the convulsions. When she come back, the child already expired and she just collapsed. She is crying all the day. She is shouting for the doctors, for the nurse, for the health worker, shouting, but this is not our mistake. This is mistake due to the war. We haven't nothing at all. And also the health sister, uh, she starts working with me and she start crying. She is crying, crying all day. And then she didn't come to the hospital. I asked her, 'Why you not come?'. She told me 'I can't because I am crying all the day'. She's crying all the day. She cannot facing this problem. She told me I cannot see the patient die in front of me. This is just some situation in Yemen.

It's really a devastating situation and I cannot imagine how health workers face that constant danger, all different forms of violence and how that affects their mental health, making it of course more difficult for them to continue providing the health care and the requirements they need to fulfill for their population. But Jim, in such situation, what are the role of international organisations like the W.H.O. In supporting the resilience of these health workforce in Yemen and in other fragile and conflict affected settings?

So, thank you, Dr. Wesam and Dr. Nasher. As-salamu alaykum to you both. Just to, to express solidarity with the work of Dr. Nasher and all his colleagues in Yemen and the lived realities, the lived experience that we just heard. The challenges of that day to day work environment, conflict, uh, resource constraints. Um, populations with their anxieties, with their illnesses, the mental health stress, the impact that is coming into this, and whilst Yemen is the topic here now, it's one of just many, many examples around the world that W.H.O. Is contending with. So, Dr. Wesam, you mentioned in your introduction, across the Middle East, in Gaza, some of the stories that we're, we're seeing through our networks, through our engagement, but also in the media. Heartbreaking to see these live realities. So, if we look around the world today, over 40 emergencies, the W.H.O. Is responding to in terms of the conflict related events; in Gaza, in Ukraine, in Sudan, in the Sahel, in Afghanistan, Iraq and many others. But also then the infectious disease outbreaks, the cholera, um, multi-country outbreaks of cholera that we're seeing with all the climate related disasters and the impact of that. Impacting our lived environments, the environments where our populations are engaged. So, this is a true reality for W.H.O. on a multiple, multiple scale and what Dr. Nasher was sharing with us there, we're hearing similar testimony from each and every one of these environments. Public health is under threat worldwide. When it comes then to, Wesam, the whole issue of resilience, which I know is part of the ReBUILD work, then we've got to start to look at what are we actually interested in here? Are we interested in the resilience of the health system to respond to the emergency, to the conflict, to the humanitarian disaster? Or are we looking at the resilience of the individual to operate in a substandard system to respond to the needs of the population? And those two questions are very different. It's not necessarily the system is unable to respond. Every worker in that system has got this pressure upon them. I think, Nasher, you gave the story of the mother and the young infant, and just the lack of equipment, lack of supplies. It wasn't the worker's fault. So is it the system that should be resilient, or is it the worker that should be resilient in a dysfunctioning system? And we need to tease out these differences. The W.H.O. perspective is we fix the broken system. We don't fix resilience of an individual worker.

Do you think we can separate the resilience of the health system from the resilience of the workforce?

I think we can, Wesam, yes. And I think we must, I think, I think there's a moral obligation upon stakeholders not to burden workers with the expectation that their resilience or lack of resilience is the factor. I'll give you a concrete example that helps think this through. During the COVID pandemic, we standardised, uh, W.H.O's approach to assess the impact on health and care workers worldwide. We looked across the different domains of their physical health, their mental health, the infections, the morbidity, the mortality, but we looked also at the role of employers, and the role of government employers, the role of private employers, to create environments which are productive, which remove stress from the worker, which remove anxiety from the worker. Is the employer ensuring that these workers are in situations where they are resourced, where they are enabled, the equipment, the supply chain, uh, the remuneration is coming through, etc, etc. And we've got to look at those obligations, that moral duty that exists. It is a duty of care to the worker as well as to the population that the worker serves. And we need to disentangle these two. And Nasher's, Nasher's example that he gave of those lived experiences in the hospital, in this conflict scenario, where transferring the responsibility in the entire system collapsed to an individual worker is, is not appropriate and it's not right.

Dr. Nasher, I understand you received some support internationally how has that support, strengthened the resilience of both the workforce and the system?

Yeah, the support from Liverpool School of Tropical Medicine and from Habibti Liverpool, they start to give us a small amount of the money. Maybe £200 per month, and we did small group to encourage the health worker to come. We give some money, we can buy some medication for people. This amount is increased about £2, 000. Before that we have three or four health worker. Now we have 40 health worker. They are working with us. This is because LSTM and have a Habibti Liverpool, they help us. Also we buy some medication for poor people. We can do some investigation for them because everything in our hospital or other hospital, uh, government hospital, they can buy for admission, for investigation, for treatment, for everything. Uh, so sometimes we help patients sometimes, we help health worker.

Is it acceptable that Dr. Nasher and his colleagues in Yemen, that workers in Afghanistan, workers in Sudan should not receive remuneration for years and years and years on end. Is that an acceptable proposition in the 21st century that, uh, the conflict allows us to continue to have that expectation? I would say no. Um, these are workers who are owed an obligation, a duty of care that we should be insisting upon. And wonderful as it is that the Friends of Liverpool are stepping in, and other friends of organisations step in with charity, but we shouldn't expect health systems to be run on charity. And so there's a moral obligation. There's a solidarity obligation. There's a public health obligation, to actually ensure resources are made available in these conflict scenarios to ensure that we can get beyond that. Yes. As we saw during COVID, the capability of humankind, the capability of health and care workers to step forward, to volunteer, to be there, that's, that's the role that they take, that is wonderful and should be continuously recognised, but we can't go beyond that short term emergency phase and make it become the norm.

Great. Thanks, Jim. And that brings me to a question; what do you think about the tensions between the emergency responses and the long term efforts to foster health workforce resilience?

So I think in every environment there's always the balance of what are the key policy priorities in front of us for the next 24 hours, the next seven days, the next 30 days? What is it we must deliver? And obviously we want to ensure improvements in population health outcomes. We wanna be able to treat trauma, we want to be able to treat mental health. The second element of it then in parallel is to say, well, actually, what is the rebuild? What is the forward vision? What is the developmental phase of this? And when is that going to kick in? And when can we start to transition to some of that thinking? Health workers around the world today are exhausted, whether they're in conflict situations or in their in normal environments. They're exhausted from the pressures of COVID. They're exhausted from the pressures of the working conditions. There are shortages in every single country around the world, in some form or another. So how do we ensure the long term resources are coming through accordingly? I would put the emphasis on the system resilience, because we know if the system is stronger, the worker is more efficient, more productive, more engaged, more motivated, which gives us improvement in quality and improvement in patient outcomes.

Thanks, Jim. Unfortunately, in such situation, we find that most of these health workers leave the country and I know this is like as a chronic problem in Yemen, right? For the protracted conflict situation in Yemen for 10 years now, many of the health workers have left the country looking for better opportunities, safer countries and places to stay and work. There should be a call for urgent actions and intersectoral collaboration to find a way to support health workers, to strengthen health systems resilience, and especially in this context, we need strong actions.

Wesam, I think that's really important important. Dr. Nasher, anything you would like to share in response?

I wish the war is stopped, I wish this.

Of course.

Nasher, absolutely, that’s that’s the fundamental and unless we tackle the root case issue of these conflicts through national, regional, and global mechanisms... unless we look at the vested interest for conflict, the interferences in conflict, and tackle those and call them out. We're never going to be able to compensate for some of those issues. So, uh, W.H.O. Is preparing a new paper for publication in November on attacks on healthcare. It's looking at the rise over the last 20 years and more in the last five years. increasing number incidents and the prevalence of conflict on the attacks, the deliberate attacks, the clear, motivation for warring parties, political leadership, different stakeholders to deliberately attack health institutions, health facilities, ambulances, medical and healthcare personnel to prevent them from serving the populations. This is becoming an epidemic of its own right. And so we've got to come back. Nasher, your wish is shared by all of us. We must tackle the root causes of conflict and make clear that attacks on health care is unacceptable.

Could you elaborate more on what is this paper is looking at and how it can help us move things forward?

Yes, you mentioned in the Middle East in particular, has got the challenges that we're seeing at record levels. So what is the reality? What is the incidence of conflict that we're seeing? What's the incidence on the numbers on attacks on health care? Are we reaching proportions? The questions become, why are we starting to see this increase? Why are the international humanitarian law, UN resolutions, why are they no longer having the impact that was intended? Where is there a clear breach of those provisions? And therefore, what are some of the opportunities that we need to be, what, not the opportunity, but what are the key points in the contemporary discussion, given that the sort of empirical base of conflict. Where do we need to be looking? Do the instruments need to be strengthened? Does accountability need to be strengthened? Do we need to prosecute noncompliance? Do we need to hold people to greater to account? Meanwhile, what can we do through stakeholder engagement? What can we do through partnership? What's the role of the Gulf states. What's the role of the Middle East groups? The Arab League of Nations? What's the role of the African Union in these debates? What's the political leadership role to have peer mechanisms which hold people to account because it can't be sustainable. Uh, we can't accept this as the new normal.

Yeah, I agree. And I'm looking forward to reading it because I personally, with the situation in the Middle East, I think that will be a great piece of work and it will guide us as a researcher and academics on how can we support health systems resilience and health workforce resilience in such a fragile context.

Absolutely. And Wesam, it is very much in the sharing, please help us to bring the evidence together on this where, um, it's a partnership with the World Innovation Summit for Health. The paper and the debate will continue at the forum in November. But more importantly, how do we then get this evidence into practitioners hands into academics and into researchers hands to really call for accountability.

I think that brings us very succinctly to the end of the podcast, where we ask for the one piece of advice that you would give to researchers and others trying to strengthen the resilience of both the health workforce and the health system. Wesam, maybe you could start with that piece of advice.

I believe good governance is critical, and this should include strong coordination mechanisms between international organisations and NGOs, especially with the role they are playing in supporting the humanitarian response during and post conflicts. And by Having strong coordination mechanisms between these organisations and the national governments in conflict affected settings. I think these can support health systems resilience and health workforce resilience in these contexts.

Thanks, Wesam. I'm a real call for collaboration and working together there. So thank you very much. Dr. Nasher, firstly, I want to say thank you so much for joining the podcast and for giving your lived experiences, that are clearly very traumatic. I also know how difficult it was to come to Liverpool and be able to speak to us. So thank you for making that very difficult journey. What's the piece of advice you would like others to hear when supporting the health workforce?

Yes. Uh, I wish the work of W.H.O. and other organisation not to be lead by politics. This will facilitate the aid to us, and I wish that there is transparency in the distribution of aid.

Thank you very much, Dr. Nasher. I think that's a very important piece of advice that you have shared there. Jim, would you like to give a piece of advice to others who are very passionate to support Dr. Nasher and his colleagues and people around the world who are trying to deliver healthcare in very, very difficult situations?

Yeah, Kim. I mean, I think advice is one thing, but I would I would suggest that we also need to come back to evidence. What does the evidence tell us that is critical here. And for the workers huge appreciation for those workers in these these complex scenarios who continue to provide services, but appreciation and applause is not the action that we need. The evidence tells us that we must come back to looking at the duty of care to the health and care workforce, largely women all around the world. Make sure that the environment in which they serve is protected from attacks, it's protected from any harassment, it's protected with decent occupational health and safety. To Nasher and his colleagues working at the hospital there in the pediatric unit, they should be able to go to work every single day knowing that they are empowered, enabled, and supported in that work. And every one of us has an obligation towards that duty of care. That's the evidence. That's the moral obligation. It's the empirical basis, and it's the right thing to do, irrespective of the country, the health system, the conflict that exists.

I think that's a great place to end the podcast and a wonderful reflection to think about moving forward. So at this point, I would like to say, thank you very much to our guests, Dr. Nasher Al-Aghbari and Dr. Jim Campbell for sharing your experiences and extremely insightful reflections. Also, thank you to Dr. Wesam Mansour for co-hosting and adding important considerations to this conversation. Listeners just as a reminder, this episode is part of six part mini series, entitled Stories of Resilience: Local Lives and Health Systems. So do have a listen to all of the episodes as they provide a really excellent opportunity to learn more about health systems in fragile contexts until next time, thank you for listening.