The Health of Victims of Wars and Armed Conflicts in Africa and Asia: Resilience, an Organizational Question ()
1. Introduction
WHO Sustainable Development Goal 3 is to “ensure healthy lives and promote well-being for all at all ages” and; to its target (sub-objective) 3.8, it promotes the generalization of universal health coverage, in order to curb the impact of financial risks and poverty on access to basic care for populations, while that 3.D. aims strengthening the means of identification, rapid alert and management of national and international health risks [1] .
Compared to the other SDG-3 targets, sub-goals 3.8 and 3.D seem to offer a measure of the resilience of health systems, but much more for target 3.D which includes in indicator 3.D. 1 actions (for the exhaustive list of courses of action see WHO 2014) such as:
o Support to countries to upgrade the logistics and operational chain;
o Monitoring and evaluation of national capacities of national health systems;
o Preparation in the management of mass gatherings;
o Management of health risks in the context of international traveler movements [2] .
Article 25 of the Universal Declaration of Human Rights (1948), the International Covenant on Civil and Political Rights (1966), articles 20, 21, 23 and 24 of the United Nations Refugee Convention (1951) and finally the four Geneva Conventions of 1949 and their two protocols of 1977 covering the health of refugees and displaced persons in their country, sufficiently show the extent to which the right to health of populations affected by inter-ethnic or armed conflicts remains a top priority for the United Nations since the dawn of time [3] .
Thus, health is then invited to this concern of the International Community to ensure this fundamental right of these populations finding themselves in this humanitarian emergency situation.
The health systems of many countries in the world have been affected by a certain number of catastrophic humanitarian shocks such as armed conflicts, terrorism, wars, ethnic conflicts, etc. having a direct or indirect influence on the respect of human rights. Man, migratory movements of populations, access to basic healthcare services and the functioning of the health systems of the affected nations requiring another way of adapting their organization in order to respond in a much more resilient and alleviate somewhat the problems linked to the health of these populations.
Resilience itself, being a capacity for an individual, an organization or system to maintain itself and regain acceptable functioning after the disaster, allows us to think differently and anticipate the long period following an event [4] .
Some work has been focused on this question, that of knowing how the health of victims of internal and external atrocities and refugees is organized and; how are individuals, communities or health organizations/systems in nations affected by this phenomenon in Africa and Asia going about coping with this situation?
WHO plays an important role, as a member of the International Strategy for Disaster Reduction system and as leader of the Health Sector Leaders Group in humanitarian reform, working closely with other members of the international community, such as the Secretariat of the International Strategy for Disaster Reduction, UNDP, UNICEF, the UN Office for the Coordination of Humanitarian Affairs given that the countries affected by these tragedies should protect the health, safety and well-being of these populations, guaranteeing resilience and their autonomy [5] .
Côte d’Ivoire, for example, was able to develop some health strategies alongside other partners of course to help displaced victims of the political-military conflict it experienced in 2002 [6] .
The political-military conflict of 2002 and the post-electoral humanitarian crisis of 2010 and 2011 brought not only massive population displacement, but also rape and sexual violence against women, therefore leading to a social health problem, mental; and this suffering was overcome by a group of victims of sexual violence by developing a capacity for individual resilience by adopting a positive attitude which leads them to build good relationships with others [7] .
Unaccompanied minor Afghan migrants in Hungary have also developed individual or community resilience to settle in this country and cope with the cost of living in a country where the choice of social integration has not been welcome [8] .
However, the countries of the G5 Sahel or countries of the Sahelian Band (Burkina Faso, Mali, Mauritania, Niger and Chad) and those of the Lake Chad basin (Cameroon, Niger, Nigeria, Chad and Benin) are prey to growing insecurity due to the phenomenon of the Boko terrorist sect Haram, have generated, with the support of other non-governmental partners, a pooling of efforts within the framework of global resilience in favor of all these displaced victims of this phenomenon in their sub-regions, therefore leading to a notion of overall regional resilience in favor of refugees [9] .
This question of resilience by (or in favor of) refugees and those displaced by armed conflicts has been addressed by certain other researchers before us, but under different paths. This is particularly the case of Brahima Coulibaly in 2015, who researched all the strategies used by the Ivorian health system to achieve resilience for the victims of a military-political crisis that this country experienced in 2002 [6] .
In March 2017, the WHO addressed this concept of resilience in favor of displaced victims of the atrocities of armed conflicts in North Kivu in the Democratic Republic of Congo, by expressing its desire to work alongside local authorities to strengthen the protection of health rights of victims through support for the health sector of the Province [10] .
In 2019, Fofane M. and his colleagues instead approached it by explaining to us how the populations of the Korhogo District in Ivory Coast had developed a kind of community health resilience to replace the virtual non-existence of government resilient management in favor of their health well-being in times of armed conflict [11] .
Joseph Richard Moukarzel in 2016, exploits this notion of resilience in the sense of Lebanese solidarity granted to nearly two million refugees from Syria, Iraq, Palestine and other surrounding nations who had experienced Daesh terrorist attacks, Sunnis, Shiites and others. This solidarity consisted of Educational and Health assistance while relying on the maintenance of a resilient economy [12] .
Belko O. Dialo for his part in May 2022, focused his attention on the capacities that certain internally displaced women from the commune of Kaya in Burkina Faso had to develop during the atrocities of the deadly terrorist attacks in the Sahel region, facing to certain economic opportunities offered to them by the Government and International Humanitarian Aid Organizations in their host environments [13] .
In view of everything, we wanted to carry out this series which aims to identify the literature which has dealt with the question of the organization of individual, community, organizational and/or systemic resilience on a health or other level, among refugees and displaced victims of armed conflicts in Africa and Asia.
2. Methodology
From December 10, 2022 to January 7, 2023, we conducted a secondary scientific study, carrying out a narrative review of the literature that has addressed in one
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Figure 1. PRISMA. Flow of information through the different phases of our systematic review [14] .
way or another the theme of individual, community, organizational or systemic resilience among refugees and displaced victims of war in the WHO regions of Africa and Asia affected by this humanitarian calamity.
This method consisted of using several studies which led us to retain only 13 documents (articles and theses) of which 7 are white literature and 6 are gray literature (Figure 1).
3. Results
After exploiting this literature, we retained this:
• Individual resilience
The researcher Opadou Koudou [7] pointed out that there were determinants which mark the problem of the care of victims. But this support when offered to survivors covers the medical, psychosocial and economic aspects despite the psycho-physical trauma they have faced. Two of them reported having cysts in their genital tract after their rapes.
However, some women among them had developed resilient behavior, maintaining high self-esteem despite everything, despite having suffered the same sexual assaults or even worse than certain victims. They adopted a positive attitude which led them to build good relationships with others. This behavior had the advantage of promoting their psychological balance, envisioning their future in a positive way and maintaining good relationships with those around them. This resilient attitude was seen in their language determining a positive trajectory for their lives. Certain factors had allowed them to develop this resilience such as the personal decision of the victim, holistic care and family and social support.
With Laura Tarafas [8] , individual resilience depended on:
1) From the adaptation of the young refugee to religion, which can have aspects contributing positively but also negative effects on the life of the individual: Certain aspects of religious coping and the image of God could also testify to the destructive effect of trauma of atrocities or not.
2) Individual characteristics that imply the importance of the internal locus of control in young refugees, referring to their optimism as an important tool even if for some of these young people, humor has not always been identified as an important tool of this resilience for young people, but is hidden in the speech of many of them.
3) By having a certain level of education and a certain ability to work.
4) Their ability to master the “Hungarian” language, to trivialize their cultures of origin and finally to develop a romantic relationship to have strong bonds, even as refugees. So for him, the refugee himself is the developer of his own resilience.
For Belko O. Diallo [13] , This security crisis in the province of Kaya resulted in an upheaval of social gender roles in families due to the absence of men killed, disappeared or in exile. At best, men are present but with the capacity to assume their former roles as providers of life for the family which has become smaller. Faced with the inability of institutional funding to cover the needs of all displaced people, the survival of households requires additional efforts and women have positioned themselves as leaders in the survival and resilience of families. Each woman displaced by war should develop resilience by exploiting the economic opportunities of the host environment in order to meet primary needs such as health needs (small business and the rehabilitation of agro-pastoral activities in the urban context).
• Community resilience
Laura Tarafas [8] also found that the fact that some young refugees first think that the great suffering in a host country is the refugee status which leads to a feeling of avoidance leads them to seek to live together, developing the interpersonal relationships to meet basic needs.
Fofane M. [11] shows the military-political conflicts, the populations of the district of Korhogo in Ivory Coast had many humanitarian challenges during these conflicts, following the deterioration of living conditions and the right to their health, the population has developed community strategies to maintain and resist this situation:
o Use of village knowledge, that is to say that in the absence of a good organization of the health system, we used traditional medicine from the village which used the bark of trees, their roots and leaves having the potential to cure certain diseases,
o Use of medicine from all sources: any medicine in this time of crisis whatever its origin, its origin could be used provided that it treats (absence of the State regulating care services to offer to the population during these conflicts).
o Resort to street medicine: political-military conflicts pushed the besieged to accept the trafficking of products not recognized by the health sector authorities with the consequence of selling illicit medicines because its illicit products had been legalized by the rebels without no respect for the health rights of these war victims.
• National resilience
Here, we have listed literatures that have reported any resilient measures at the government level of either the host country or countries that have experienced atrocities in favor of IDPs or refugees.
According to Coulibaly (2015) [6] , it appears from the investigations that even if during the armed conflicts of 2002, the Ivorian health system was failing, it rather favored the emergence of new actors which are international NGOs. While offering care services, they have also strengthened the capacities of local structures (state and national NGOs) in material resources, equipment, financial resources, medicines, training, etc. By relaying state structures, these new actors placed emphasis on collaboration, solidarity, staff recruitment, training, selection of activities, extrinsic motivation, the establishment of a mobile clinic, orientation of patients to the government zone and the use of airways to meet the health needs of the populations, we have witnessed the emergence of new actors who are international NGOs. While offering care services, they have also strengthened the capacities of local structures (state and national NGOs) in material resources, equipment, financial resources, medicines, training, etc. By relaying state structures, these new actors placed emphasis on collaboration, solidarity, staff recruitment, training, selection of activities, extrinsic motivation, the establishment of a mobile clinic, orientation patients to the government area and the use of airways to meet the health needs of affected populations.
The government of the DRC in 2017 initiated the facilitation of technical collaboration requiring joint actions between human health and animal health actors for better management and reinforced control of certain emerging and zoonotic infectious diseases in the event of their occurrence. It strengthened a partnership with the WHO, based on a complementarity of mutual and enriching expertise within the framework of intersectoral technical cooperation in favor of victims of the armed conflict in North Kivu [10] .
It was also the same for the Middle Eastern refugees in Lebanon, Joseph Moukarzel [12] tells us that this small country has, through its efforts, set the machine in motion to assist these victimized populations in two ways, namely, by readjusting its teaching pace, doubling the rotation in the regions where there were refugees. In order to help refugee children have access to education (students, regular Lebanese pupils are received in the morning and Syrians or others in the afternoon); and on the health front, Lebanese women have engaged in an exhausting fight to prevent the spread of epidemics and the resurgence of diseases such as cholera and scabies. This is without taking into account water pollution, electricity squatting and other ecological and socio-economic problems.
• Regional resilience
A kind of resilience in the Sahel and Lake Chad basin regions has been developed following the migratory movement of populations victims of security instability having visible impacts in many areas of their lives.
It was noted by Ali Mahamane and Belko O. Dialo [9] [13] that the governments of these regions have pooled their efforts in the fight against insurgencies and attacks by Boko terrorists Haram which lead to the displacement of their inhabitants of respective countries and have invited their partners to carry out recovery actions through improving the resilience of populations, promoting income-generating activities, family farming, fattening, the development of women’s groups victims of persecution.
4. Discussion
In view of our results, armed conflicts in the WHO Africa region and that of Asia have led to migratory movements of populations and communities victims of these atrocities. But, these refugees as well as the systems of directly or indirectly affected countries have developed four kinds of resilience, namely individual [7] [8] [13] , community [8] [11] [13] , national [6] resilience [10] [12] and finally a kind of sub-regional or regional resilience [9] .
All this falls within the framework of the protection of refugee rights as required by Articles 20, 21, 23 and 24 of the United Nations Refugee Convention (1951), the four Geneva Conventions of 1949 and their two protocols of 1977 covering the health of refugees and internally displaced persons [3] .
5. Conclusion
It emerges from our research that, all the articles consulted revealed that in all the countries affected by armed conflicts, the living conditions of these victim populations have been the subject of debates and mobilizations of nations, communities or victims themselves. In order to guarantee as little as possible the right to health, humanitarian, economic, security and other protection according to international standards, despite the fact that this resilience desired in equity has not for the most part been effective revelations. Efforts need to be doubled in this area of resilient management of humanitarian disaster situations among victims of armed conflicts and refugees in Africa and Asia.
Acknowledgements
We thank all the colleagues who agreed to sacrifice their time in order to carry out with us this study which is ready to be submitted today.
Author Contributions
Bukasa designed the study, conducted the data collection and analysis and drafted the manuscript; Mutombo, Musoya, Bakona and Kasongo contributed to the development of the manuscript, the data collection; Tshiama and Chuy contributed to data collection and analysis. All have read and approved the latest version of the manuscript.