The current study aimed to describe and analyze health-related publication on countries listed in the alert zone based on the FSI scores. Vulnerable and fragile setting is considered by the WHO as one of the top ten global health threats in 2019 . Therefore, shedding light on health research on fragile states is justifiable and in support of the WHO vision to tighten global security by minimizing or eradicating sources of health threat.
The current study showed relatively limited volume of health-related publications on people living in the selected fragile states. This might reflect a lack of adequate international research interest on health situation in these countries. It is possible that security problems hinder researchers from developed countries to participate in health studies about fragile states. The research capacity in fragile might also be limited by the lack of adequate infrastructure or human resources which further limit potential research collaboration with researchers from developed countries. Fragile states might lack the infrastructure needed to educate and train health professionals to develop medical skills and research capacities [31, 32]. Large number of people in these countries is needed to expose all health aspects and guide the international community in their future intervention.
The current study showed limited number of publications in psychosocial and mental health field on people living in fragile states. Poverty, substance abuse, and violence against women are associated with fragile and vulnerable settings . A recent systematic review suggested that both depression and post-traumatic stress disorder were highly prevalent in war survivors who stayed areas of conflict [34–36]. Even refugees who live abroad continue to suffer mental health problems due to the horrific sciences and scary journey to safe places . The state of war and conflict reflects negatively on the mental health of children and women . Therefore, upgrading mental health services and directing research toward mental health problems in children, women, and elderly are highly needed . Furthermore, interventions by the national health authorities or international health organizations should focus on these vulnerable groups using cost-effective and sharing techniques [39–41].
The current study also showed that research on health policy/system constituted less than 12% of the retrieved literature despite that health system in fragile states is poorly functioning. Developed and resilient health systems in any country is the guarantee for minimizing health-related aspects of outbreaks or natural disasters [14, 42]. The Ebola crisis in certain areas in Africa is a strong example of how weak health systems in fragile countries could not face and contain a serious disaster or infectious outbreak [43, 44]. Research that points out aspects of weakness of health system/services/policies in fragile countries might help international and national funding authorities to fill the gaps and build sustainable health systems in fragile states [45, 46]. The Health Systems Global Conference series had emphasized the importance of research on resilience and fragility as a lesson learned from Ebola crisis. Achieving a strong and resilient health system in fragile states is an important step in building a strong state. Furthermore, building strong health systems and services in fragile states will minimize maternal death and will improve health services to mothers and to patients with chronic diseases. The current study showed that the volume of research on NCD as well as on maternal/women's health was next to that of infectious diseases. According to the United Nation Population Fund, in 2015 the maternal mortality in countries affected by humanitarian crisis due to conflict was 417 per 100,000 live births, which is 1.9 times higher than the global estimate of 216 . Closing the gap requires involvement of private sector as well as international organizations to address maternal and neonatal health services in fragile states.
Research on infectious diseases had the largest number of publications. The current study showed most research interest was directed toward malaria and infections that had an immediate potential for a global outbreak such as Ebloa or Lass fever. Early detection of infectious disease outbreaks is important for global health security. A review article on fragile states recommended implementing infectious disease surveillance to enhance detection of outbreaks . Research on other serious and common infection must be encouraged. Tuberculosis is a well-known infection in poor countries killing approximately 1.5 million people in 2018 . The eradication of TB by 2030 requires elimination of certain pockets in fragile states such as Pakistan, Afghanistan, and Nigeria [49, 50]. Helminthiasis, scabies, schistosomiasis, enteric bacterial and parasitic infections, as well as many other types of infections are common in poor communities and research on these infections are also needed . Therefore, more research efforts, funding, collaboration should be directed toward infectious diseases that do not pose an immediate threat to developed countries. Furthermore, research on fragile states with FSI score above 100 (very high and high alert zone) such as Yemen need to be strengthened. Conflict in Yemen has generated several infectious disease outbreaks such as cholera and diphtheria which can cause mass fatalities [52–54]. The same applies to the situation in Syria where health teams and health facilities have been attacked in addition to the threat of chemical weapons [55–58].
Certain fragile states had received a good number of publications. Most of these countries, e.g. Uganda, Nigeria, Pakistan, Congo, and Cameron had an FSI score below 100. Despite that, gaps in certain research domains have been found. For example, more research on psychosocial and mental health research domain is needed since the volume of research on this domain was the minimum. Another potential reason for the reasonable contribution of these fragile states is the presence pf academic institution with medical facilities and health – related journals indexed in Scopus. Authors in these countries had better chance than authors in other fragile states to disseminate their research observations in local journals. It is important for the international community to support these academic journals to make local research in fragile states more visible to international health and political communities.
This was a bibliometric analysis that used the FSI score for inclusion of countries. However, the FSI score might not be the perfect indicator of fragility and therefore the results obtained in this study should be interpreted based on the methodology adopted to calculate the FSI score . In the current study, we used the title search for all selected countries to find the volume and pattern of publications on people living in the selected fragile states. This methodology might not be a perfect one but it is the most feasible and the most accurate. Using affiliation strategy will retrieve large number of publications that are irrelevant to people living in fragile states.