The current study aimed to describe and analyze health-related publication on people living in fragile states listed in the alert zone based on the FSI scores. The vulnerable and fragile setting is considered by the WHO as one of the top ten global health threats . Therefore, shedding light on health research on people living in fragile states is justifiable and in support of the WHO vision to tighten global health security by minimizing or eradicating sources of health threat.
The current study showed a relatively limited volume of health-related publications on people living in the selected fragile states when compared to other countries. This might reflect a lack of adequate international interest on the health situation in these countries. It is also possible that security problems hinder researchers from developed countries to participate in health studies on fragile states. The research capacities in fragile states 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 [48, 49]. Health research is needed to uncover all health aspects in fragile states and guide the international community in their future intervention.
The current study showed a limited number of publications on psychosocial and mental health field on people living in the fragile states. Poverty, substance abuse, and violence against women are associated with fragile states and vulnerable settings . A recent systematic review suggested that both depression and post-traumatic stress disorder were highly prevalent in war survivors who stayed in areas of conflict [51-53]. 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 [56-58]. The limited number of publications on psychosocial and mental health reflects weak mental health services and limited mental health experts in the selected fragile states. This seems to be common not only in fragile states but also in low- and middle-income countries. For example, the African region has 1·4 mental health workers per 100000 people, compared with a global average of 9·0 per 100000. The same weakness applies to other mental health services .
The current study also showed that research on the health policy/system constituted less than 12% of the retrieved literature despite that the health system in fragile states is poorly functioning. A developed and resilient health system in any country is the guarantee for minimizing health-related aspects of outbreaks or natural disasters [28, 60]. In conflict and post-conflict areas, health facilities and health workers might come under attack which further weakens the health systems. An example of the attack on health facilities and health workers has been reported in Syria [61, 62]. The attack on health facilities is an important cause of limited health human resources and weak health systems in these fragile states . The Ebola crisis in certain areas in Africa is also a strong example of how weak health systems in fragile countries could not face and contain a serious disaster or infectious outbreak [64, 65]. Research on 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 [66, 67]. The Health Systems Global Conference series had emphasized the importance of research on resilience and fragility as a lesson learned from the Ebola crisis. Achieving a strong and resilient health system in fragile states is an important step in building a strong state and major contributor to state legitimacy. Furthermore, building strong health systems and services in fragile states will minimize maternal death and will improve health services to mothers and patients with chronic diseases. Unfortunately, most of the international aids to fragile states is limited to humanitarian relief which does not advance either health systems development or state legitimacy. This might explain the persistent nature of conflicts in Syria, Libya, Somalia, Yemen, Congo, and many other countries in Africa [68, 69]. Strengthening health systems in fragile states should be a priority in the global health agenda and for international health organizations. Humanitarian relief to fragile states and economic investments in fragile states are mostly driven by political agendas rather than a global health security agenda. The current study also showed that the majority of fragile states lack adequate international research collaboration with high-income countries. A recent study on health system research in fragile and conflict-affected states indicated that collaboration is a key challenge to conducting health research in fragile states. Reasons cited for this were the presence of many different actors in health systems strengthening efforts and the language barriers .
The current study showed that the volume of research 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 the involvement of the private sector as well as international organizations to address maternal and neonatal health services in fragile states. A study on maternal and neonatal health in fragile and conflict-affected areas in Asia and the Middle-East indicated that poor maternal and neonatal health services is a leading contributor to the burden of maternal and neonatal ill health in Asia and Middle-East and additional resources and policy attention are needed to address key barriers to effective maternal and neonatal care . A study published recently in The Lancet about women and children in conflict areas in Africa concluded that deaths of young women in sub-Saharan Africa are exceptionally high relative to developed countries and effective approaches to prevent and mitigate the deleterious effects of armed conflicts on women and children should be a global priority . Another study indicated that young people, including adolescents, continue to be a neglected group in humanitarian settings and more attention is needed to the sexual and adolescents health in humanitarian settings .
The lack of stable health systems, as well as lack of access to medications, is an important risk factor for various NCD such as hypertension, diabetes mellitus, and cardiovascular diseases in many fragile states. Unfortunately, the prevalence of hypertension is reportedly increasing in low- and middle-income countries. A study showed that approximately three-quarters of individuals with hypertension lived in low- and middle-income countries and that the prevalence of hypertension decreased by 2.6% in high-income countries but increased by 7.7% in low- and middle-income countries from 2000 to 2010 . Most of the countries in the alert zone are classified within low- and middle-income countries and therefore, non-communicable diseases such as hypertension is expected to be a true health burden in these countries. A report by the WHO stated that over 30% of males and females have raised blood pressure in five fragile countries: Afghanistan, Central African Republic, Chad, Mali, and Somalia – all of which are of low-income status .
Research on infectious diseases had the largest number of publications. The current study showed most research interests were directed toward malaria and infections that had an immediate potential for a global outbreak such as Ebola or Lassa 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 the elimination of certain pockets in fragile states such as Pakistan, Afghanistan, and Nigeria [78, 79]. 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 scores 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 [81-83]. 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 [84-87].
Three research themes within the retrieved literature focused on the infectious diseases: one on HIV/AIDS, a second one on water-borne diseases such as cholera, and the third one was on different types of infections including tuberculosis. One of the major issues in infectious diseases that threaten the spread of infectious diseases is the drop in immunization rates in children which might lead to outbreaks of measles, polio, and other diseases. For example, coverage for each vaccination was above 80% in Syria before the civil war in 2011 and dropped to 53% for measles and 41% for hepatitis B and DPT among 1-year-old . The second important issue regarding infectious diseases in fragile states is that in conflict settings, especially in Africa, seven out of ten women are exposed to sexual violence and more than 50% of those women are most likely to develop HIV and transfer it to their babies . The third issue regarding infectious diseases in fragile states is the poor water supply, poor sanitation system, and poor hygiene leading to cholera, trachoma, diarrhea, and other water-borne infectious diseases .
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 of academic institution with medical facilities and health-related journals indexed in Scopus. Authors in these countries had a better chance than authors in other fragile states to disseminate their research observations in local journals. The international community needs to support these academic journals to make local research in fragile states more visible to international health and political communities.
The current study indicated that the African region had the highest contribution to the retrieved articles. This was not surprising given that the bulk of investigated fragile states were in the African region. Furthermore, the presence of a few medical journals indexed in Scopus and based in the African region helped increased the contribution of the African region relative to other world regions. Thirdly, the nature of problems facing the fragile states in the African region is also facing other stable countries in the African region such as South Africa. For example, HIV/AIDS, tuberculosis, malaria, trachoma, female genital mutilation, teen pregnancies, water security, climate change, and many other health-related problems are present in almost all African countries but with varying degrees .
This was a bibliometric analysis that used the FSI score for the 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 a large number of publications that are irrelevant to people living in fragile states. Furthermore, using the title/abstract search strategy will also retrieve many false-positive results. Therefore, the approach adopted in the current study is the one with least false-positive results. Regardless of the pros and cons of the search methodology adopted, the current study was meant to draw attention to health status in fragile states through shedding light on research volume and research pattern on the selected fragile states. The goal was not to negatively criticize or expose weak research activity in this field. The goal was to promote research on this field as an important contributor to global health security.