On Tuesday 25th June, the Conflict and Health Research Group at King’s College London (KCL), in collaboration with R4HC-MENA and RECAP hosted a one-day conference on Health Research in Conflict and Complex Environments. The event focused on research capacity strengthening in conflict affected areas, mental health and trauma in conflict, ethical challenges of conducting health research in complex environments, and the challenges of translating research into policy and practice. Throughout the day, speakers relayed both personal experiences from working in conflict-affected areas and findings from their research and offered substantive recommendations for improving health research in conflict with the ultimate goal of benefitting populations affected by conflict.
The event was enriched by the various backgrounds, disciplines and research interests of the panellists, and created a space in which academics, students, programme and project managers, donors, and government representatives were able to discuss and dissect the challenges and complexities of conducting research in conflict, in order to take a step towards shifting mindsets and translating research into impactful practice.
Dr Andreas Papamichail (KCL) set the agenda for the day, outlining epistemic inequalities in capacity strengthening: a recent analysis of publications in The Lancet Global Health showed that only 35% of authors researching health in the Global South are themselves from or work in the Global South. Meanwhile, bridging the gap between collaborators across sectors is often difficult in hostile environments (created both by conflict and by restrictive visa and funder policies). Dr Hazel McCullough, from RECAP and London School of Hygiene and Tropical Medicine (LSHTM), emphasised the importance of equitable partnerships and the importance of stakeholder engagement; harmonising what others are doing to avoid duplication. Hazel also discussed a key theme for the day: sustainability and long-term funding. How do we ensure the programmes we are managing and the research we are contributing to is sustainable? Through long term funding, which is in itself exceptionally challenging as it is not only a lengthy process but is in an area that is considered low priority with limited human resource capacity.
Dr Andrew Tchie (International Institute for Strategic Studies) relayed his personal experiences of conducting research in Syria and Sierra Leone and stated a number of recommendations that would strengthen research capacity in these complex environments. These included training staff to undertake good research and embedding the research in the communities they are working in to provide the necessary upskilling of researchers in the region. As with the other panel members, Dr Tchie reiterated the importance of thinking long-term and how we support those in the Global South. Rounding off the first panel, Professor Abla Mehio Sibai (American University of Beirut) discussed increasing interest in health research in conflict and complex environments given the intensification of humanitarian crisis. She highlighted challenges such as: ensuring sustainability and engaging other stakeholders such as NGOs that can be difficult to engage with; and the dispersal of partners and the difficulties of travel to conduct research and meetings.
The numerous issues and challenges mentioned in the first panel highlight that sustained research capacity strengthening outside of the Global North is crucial. With notable exceptions, the Global North continues to dictate not only the research agenda but how the experiences and worldviews of people living in conflict-affected environments are mediated, sometimes without any contextual understanding and little desire to see sustainable and long-term research conducted to make any real impact in conflict-affected regions.
The panel on mental health research built on the ideas of the first panel, highlighting the importance of research in areas where people are bearing the scars and consequences of current and past conflicts. As Dr Hanna Kienzler (KCL) put it, ‘wars don’t end when peace treaties are signed but continue in people’s minds and bodies’. Through her research, Dr Kienzler advocates for a new research and action agenda for health in all policies. She highlighted the importance (but also the complexity) of a more holistic and upstream approach to mental health and psychosocial support (MHPSS). Dr Ayesha Ahmad (St George’s University of London) presented her work on the SHAER project that explores narrative storytelling as a culturally-relevant approach to responding to trauma from gender-based violence (GBV) against women in conflict settings. Undertaking research in conflict settings, Ayesha highlighted the need to derive research not merely out of curiosity, but from what is critically required in a specific context or region and furthermore to ensure that context and cultural sensitivity and clearly embedded in the research design.
The final speaker on the second panel, Professor Bayard Roberts, from RECAP and LSHTM, described the lack of research on the cost-effectiveness of MHPSS interventions and also of the dearth of research on context and mechanisms of impact. He made a strong argument for the need to integrate qualitative research into randomised controlled trials from the start and throughout research. His key message was thus that we need to think much more in terms of inter-disciplinarity, and to integrate anthropologists, political scientists, geographers, linguists, and more, into individual studies.
The third panel of the day explored ethical challenges related to undertaking research in complex environments. Dr Aula Abbara (Imperial College London) picked up on a theme that had reared its head throughout the day: ethical dilemmas and exploitation. Aula discussed the importance of questioning why you are doing research, how it can become opportunistic, and issues of hidden neo-colonialism and power dynamics. As an example, she mentioned how field-work in Lebanon is increasingly being undertaken by young Lebanese female researchers who may feel exploited while not reaping the benefits of that research in terms of recognition and career progression. She also highlighted problems associated with over-researched communities, such as Palestinian refugees, before concluding with some key ethical considerations, including to: prioritise, engage in participatory design, collaborate, be non-exploitative, and to think about the ethics of not doing research.
Dr Zedoun Alzoubi (Union of Medical Care and Relief Organizations Syria) questioned whether research in conflict-affected areas can ever be ‘ethical’, in that truth and security may not always come together in research, given the complexities of the environment. He noted the biases of donors and how politics define research, the bias of researchers, and the risks incurred by – and protections afforded to – researchers and the subjects. Dr Abdulkarim Ekzayez (KCL) built on this, discussing the importance of framing research questions and that assisting local communities possibly needs to be considered in research design and that ethical issues/settings must be based on objectivity and neutrality. Katharine Wright from Nuffield Bioethics concluded this panel by encouraging attendees to think of ethics as more than simply obtaining an ethics approval, and to think about macro ethical questions that focus on power and influences, as well as the micro ethical questions, such as whose voices are being heard through your research? Furthermore, Katharine discussed the importance of finding a common language from various disciplines to establish a common ethics approach.
The panel made clear that from an ethical perspective, we need to move beyond ‘do no harm’ to thinking about whether research is relevant and necessary for the populations we are doing research on and with.
The plenary roundtable of the event was chaired by Dr Fouad Fouad (American University of Beirut) and included Dr Slim Slama (World Health Organisation), Dr Sylvia Garry (UK Department for International Development), Anne Harmer (ELRHA) and Professor Richard Sullivan (KCL), and touched on three main issues. First, that funders and researchers are not sufficiently translating research into effective policy or ensuring that research has impact. Slim Slama highlighted the need to harness the various perspectives involved in events like this and taking a holistic approach: while one researcher or funder may face organisational constraints, they may be able to leverage their network more widely. Second, a theme which had been at the forefront of many of the presentations earlier in the day was how researchers and research institutions deal with the current trend in which donors focus on funding short-term projects in which cost-effectiveness is at the forefront of the agenda, rather than long-term, impactful programmes. Panellists noted that we are constantly dealing with the shifting sands of government/national interests which determine funding patterns. However, researchers and funders connected to researchers and NGOs and grassroots organisations need to start driving the need for change; the mindsets of funders needs to be drastically changed in order to fund long term research and activities that will have long-term, sustainable impact and translate into effective policy. Third, Richard Sullivan warned of the dangers of influencing policy or practice in detrimental directions and argued that to avoid doing this it is important to back translate what you are proposing to do. Researchers assume that they are doing good through research that alters policy, but research can shift policy in negative directions too, for example by interfering with policies and hierarchies that are there for a reason (i.e. they have developed due to vested interests and power struggles) and changing those can meet with resistance.
While individual researchers may not be able reshape the research agenda alone, collaborating can ensure that constraints and barriers are openly challenged and that funders are aware of the urgent necessity to shift toward long-term and sustainable funding which enables long-term research to deliver the meaningful impact required to translate research into policy in conflict affected settings.
Dr Andreas Papamichail and Kristen Meagher
