Introduction Mobile crisis response programs (MCPs) are increasingly recognized as effective alternatives to law enforcement-led interventions for addressing behavioral health crises. However, there is limited evidence on how specific strategies and contextual factors shape the design and implementation of these programs. This study aimed to characterize key factors influencing the early development and implementation of a county-led MCP in Northern California in 2023.Methods Between 2022 and 2023, we conducted 58 interviews with stakeholders involved in program design and implementation, as well as frontline staff.Results The data revealed 4 major themes. First, sociopolitical momentum played a critical role in aligning political will and securing longitudinal funding. Second, a collaborative design process involving cross-sector stakeholders enabled broad buy-in and tailoring to community needs. Third, workforce shortages posed challenges to scaling, which this program managed through flexible hiring and staffing measures. Finally, MCP coordination with existing services, such as law enforcement and emergency medical services, benefits from strong foundational relationships and can be improved through clear role definition and protocols.Conclusion In total, this study identifies actionable policies, including protocolizing collaboration, cross-sector engagement, and implementation flexibility, which may inform the establishment of MCPs elsewhere.

OBJECTIVE:To assess the equitable implementation of a case management program integrating medical and social services for Medicaid members. STUDY SETTING AND DESIGN:This qualitative study assessed the equitable implementation of a case management program in Contra Costa County, CA. Study participants were identified using purposive sampling. Semi-structured interviews were conducted in person or by phone. DATA SOURCES AND ANALYTIC SAMPLE:Primary data were collected between Fall 2019 and Spring 2021 and included 92 semi-structured interviews with patients (n = 31), case managers (n = 47), and county administrators (n = 14). Data were coded using an inductive-deductive framework analysis approach informed by the Health Equity Implementation Framework (HEIF). PRINCIPAL FINDINGS:Characteristics of the innovation influencing equitable implementation included experienced public health nursing leadership and inclusion of social risk factors in a predictive algorithm determining patient program eligibility. Recipient factors included inequitable emotional demands of medical and social service integration work on case management teams from diverse racial/ethnic and training backgrounds, and patient experiences of mistreatment from medical and social service institutions. Clinical encounter factors highlighted the necessity for trust building between patients and case managers and the importance of multidisciplinary expertise to address patients' interconnected medical and social needs. Contextual factors described organizational readiness in the form of multidisciplinary teams with reduced hierarchical power imbalances, system-wide investments in a universal data infrastructure and data insights team, and strong intra- and inter-organizational partnerships. Societal factors included systemic discrimination and racism, insufficient affordable housing and public transit, pervasive administrative barriers in accessing health and social services, and federal funding for holistic approaches to integrated care. CONCLUSIONS:Case management programs aiming to equitably integrate social and medical services should invest in multidisciplinary case management teams, organizational readiness for equitable implementation via committed, experienced leadership, and interventions to address systemic factors hindering the engagement of historically marginalized groups.

Objective Community health centers (CHCs) are a vital safety net for under-resourced and medically underserved patients. As few studies have explored how they implemented broad-based organizational changes throughout the COVID-19 pandemic, we aimed to qualitatively examine CHCs’ longitudinal, comprehensive pandemic response through the perspectives of staff, administrators, and researchers working in CHCs. Methods 25 clinic leaders, staff, and researchers from three CHC networks and two academic medical centers in Northern California and the Central Valley of California participated in 18 focus groups and interviews between April and October 2022. We used thematic content analysis to identify key themes. Results Key themes emerged for three pandemic phases: shutdown, pivot, and recovery. During the shutdown, CHCs paused non-urgent services and in-person outreach while facing increased strain on staff capacity. Although CHCs were traditionally siloed, the pivot phase yielded efforts to build trust through information dissemination, partnerships with other health care organizations, and unprecedented innovations in care delivery. During recovery, CHCs re-prioritized preventive care but continued to face poor access to specialty care and socioeconomic resources for their patients. Conclusions The COVID-19 pandemic magnified extant barriers within CHCs, including limitations in funding, staff capacity, and infrastructure for collaboration. CHC constituents highlight lessons learned through organization-wide adaptations and opportunities for the continuation and expansion of pandemic-related changes (e.g., investments in CHCs’ workforce, care delivery infrastructure, and avenues for multidisciplinary collaboration) to better serve their communities in the post-COVID era.

Purpose: As growing numbers of people are deprived of housing and forced to live in precarious conditions, housing has become a public health priority. However, researchers and policymakers have given less attention to the experience of housing instability among people living at the intersections of multiple marginalized identities. In collaboration with the Coalition on Homelessness, this study used a critical intersectional lens and participatory action research approach to analyze interviews conducted among transgender Latinas (translatinas) experiencing housing instability in San Francisco, California.Methods: We performed secondary qualitative analysis of 34 interviews conducted among translatinas as part of a community-based needs assessment that took place beginning in the fall of 2019. Researchers conducted inductive thematic analysis and discussed preliminary codes and findings with community partners at multiple points throughout the analytic process.Results: We report findings along three thematic groups: (1) experiencing housing instability through the intersections of identity and position; (2) navigating the close relationship between housing and health, and (3) visions for housing stability and greater social support for translatinas. Translatinas experience unique patterns of discrimination related to Latinidad, transness, status as unauthorized migrants, and tensions between community visibility and invisibility. Improvement recommendations focused on translatina-specific funding and programs, increasing trans leadership in housing and social service organizations, and increasing language and legal support for trans migrants.Conclusion: Housing instability among translatinas is experienced through multiple, intersecting axes of oppression. Participants recommended an intersectional approach to housing and social services that attends to the complexity of their multiple identities.

ABSTRACT:X-linked sideroblastic anemia (XLSA) and X-linked protoporphyria (XLPP) are uncommon diseases caused by loss-of-function and gain-of-function mutations, respectively, in the erythroid form of 5-aminolevulinic acid synthetase (ALAS), ALAS2, which encodes the first enzyme in heme biosynthesis. A related congenital sideroblastic anemia (CSA) is due to mutations in SLC25A38 (solute carrier family 25 member A38), which supplies mitochondrial glycine for ALAS2 (SLC25A38-CSA). The lack of viable animal models has limited the studies on pathophysiology and development of therapies for these conditions. Here, using CRISPR-CAS9 gene editing technology, we have generated knockin mouse models that recapitulate the main features of XLSA and XLPP; and using conventional conditional gene targeting in embryonic stem cells, we also developed a faithful model of the SLC25A38-CSA. In addition to examining the phenotypes and natural history of each disease, we determine the effect of restriction or supplementation of dietary pyridoxine (vitamin B6), the essential cofactor of ALAS2, on the anemia and porphyria. In addition to the well-documented response of XLSA mutations to pyridoxine supplementation, we also demonstrate the relative insensitivity of the XLPP/EPP protoporphyrias, severe sensitivity of the XLSA models, and an extreme hypersensitivity of the SLC25A38-CSA model to pyridoxine deficiency, a phenotype that is not shared with another mouse hereditary anemia model, Hbbth3/+ β-thalassemia intermedia. Thus, in addition to generating animal models useful for examining the pathophysiology and treatment of these diseases, we have uncovered an unsuspected conditional synthetic lethality between the heme synthesis-related CSAs and pyridoxine deficiency. These findings have the potential to inform novel therapeutic paradigms for the treatment of these diseases.

Copy number variants (CNVs) are significant contributors to the pathogenicity of rare genetic diseases and, with new innovative methods, can now reliably be identified from exome sequencing. Challenges still remain in accurate classification of CNV pathogenicity. CNV calling using GATK-gCNV was performed on exomes from a cohort of 6,633 families (15,759 individuals) with heterogeneous phenotypes and variable prior genetic testing collected at the Broad Institute Center for Mendelian Genomics of the Genomics Research to Elucidate the Genetics of Rare Diseases consortium and analyzed using the seqr platform. The addition of CNV detection to exome analysis identified causal CNVs for 171 families (2.6%). The estimated sizes of CNVs ranged from 293 bp to 80 Mb. The causal CNVs consisted of 140 deletions, 15 duplications, 3 suspected complex structural variants (SVs), 3 insertions, and 10 complex SVs, the latter two groups being identified by orthogonal confirmation methods. To classify CNV variant pathogenicity, we used the 2020 American College of Medical Genetics and Genomics/ClinGen CNV interpretation standards and developed additional criteria to evaluate allelic and functional data as well as variants on the X chromosome to further advance the framework. We interpreted 151 CNVs as likely pathogenic/pathogenic and 20 CNVs as high-interest variants of uncertain significance. Calling CNVs from existing exome data increases the diagnostic yield for individuals undiagnosed after standard testing approaches, providing a higher-resolution alternative to arrays at a fraction of the cost of genome sequencing. Our improvements to the classification approach advances the systematic framework to assess the pathogenicity of CNVs.

Objective Gastroschisis is the most common congenital abdominal wall defect, with an increasing incidence. It results in extrusion of abdominal contents with associated delayed intestinal motility. Abnormal heart rate characteristics (HRCs) such as decreased variability occur due to the inflammatory response to sepsis in preterm infants. This study aimed to test the hypothesis that infants with gastroschisis have decreased heart rate variability (HRV) after birth and that this physiomarker may predict outcomes. Study Design We analyzed heart rate data from and clinical variables for all infants admitted with gastroschisis from 2009 to 2020. Results Forty-seven infants were admitted during the study period and had available data. Complex gastroschisis infants had reduced HRV after birth. For those with sepsis and necrotizing enterocolitis, abnormal HRCs occurred early in the course of illness. Conclusion Decreased HRV was associated with complex gastroschisis. Infants in this group experienced complications that prolonged time to full enteral feeding and time on total parenteral nutrition. Key Points

ObjectiveTo assess multi-level factors influencing the sustainability of 26 social care pilots integrating medical and social services for Medicaid enrollees across California in newly developed Medicaid benefits.Study Setting and DesignThis qualitative study assessed the sustainability of Whole Person Care (WPC) pilots implemented between 2016 and 2021. Pilots (n = 26) represented a majority of counties in California.Data Sources and Analytic SamplePrimary qualitative data were collected between June and August 2021 and included 58 hour-long, semi-structured individual and group interviews with administrators, middle managers, and frontline case management staff representing all WPC pilots. We used hybrid inductive-deductive thematic analysis to identify and analyze patterns, and outliers, in factors influencing sustainment. Deductive codes included established implementation science factors influencing the sustainability of new programs (e.g., innovation characteristics, capacity, processes and interactions, and context).Principal FindingsOf 26 WPC pilots, 22 pilots sustained WPC by contracting with Medicaid managed care plans to provide services as part of newly developed Medicaid benefits. Three pilots chose not to sustain before the pilot period ended and one pilot decided not to sustain following completion of the full pilot. Factors influencing sustainability included: (1) program adaptability and flexibility; (2) funding structure and reimbursement requirements; (3) shared leadership with managed care plans; and (4) whether pilots chose to build out program infrastructure internally or contracted out core components to partner organizations. Many pilots, particularly those in rural areas, indicated that system and policy changes introduced as part of transitioning pilot services into Medicaid benefits reduced the sustainability of WPC for participating providers.ConclusionsMulti-level factors including program adaptability, funding, leadership, and capacity to build out infrastructure influenced the sustainability of WPC pilots. These findings have significant implications for health equity as equitable distribution of services, resources, and benefits from these programs can be supported through sustained implementation over time.

ImportanceHousing deposits and tenancy supports have become new Medicaid benefits in multiple states; however, evidence on impacts from these specific housing interventions is limited.ObjectiveTo evaluate the association of rental housing deposits and health care use among Medicaid beneficiaries receiving social needs case management as part of a Whole-Person Care (Medicaid 1115 waiver) pilot program in California.Design, Setting, and ParticipantsThis cohort study compared changes in health care use among a group of adults who received a housing deposit between October 2018 and December 2021 along with case management vs a matched comparison group who received case management only in Contra Costa County, California, a large county in the San Francisco Bay Area. All participants were enrolled in health and social needs case management based on elevated risk of acute care use. Data analysis took place from March 2023 to June 2024.ExposureRental housing deposit funds that covered 1-time moving transition costs. Funds averaged $1750 per recipient.Main Outcomes and MeasuresChanges in hospitalizations, emergency department visits, primary care visits, specialty care visits, behavioral health visits, psychiatric emergency services, or detention intakes during the 6 months before vs 6 months after deposit receipt. Changes 12 months before and after deposit receipt were examined as a sensitivity analysis.ResultsOf 1690 case management participants, 845 received a housing deposit (362 [42.8%] <40 years old; 422 [49.9%] male) and 845 received case management only (367 [43.4%] <40 years old; 426 [50.4%] male). In adjusted analyses, deposit recipients had no statistically significant differential changes in health care use for any measure compared to participants who received case management alone. Twelve-month sensitivity analyses yielded consistent results.Conclusions and RelevanceIn this cohort study, compared to case management only, housing deposits with case management were not associated with short-term changes in health care use. There may be other unmeasured health benefits or downstream benefits from greater case management engagement. States considering housing deposits as an expanded Medicaid benefit may need to temper expectations about short-term health care use impacts.

Objectives:We identify the association between high- and low-intensity case management services on hospital and emergency department (ED) use among CommunityConnect patients.Background:Social needs case management services vary in intensity, including the modality, workforce specialization, and maximum caseload. CommunityConnect is a social needs case management program implemented by Contra Costa Health, a county safety-net health system in California's San Francisco Bay Area.Methods:Due to the endogeneity of high-intensity services assigned to high-risk patients, we instrument for service intensity using the number of specialist case managers hired each month of enrollment. Zero-inflated negative binomial models with 2-stage residual inclusion estimated total and avoidable hospital admissions and ED visits 12 months post-enrollment for adult Medicaid beneficiaries enrolled between August 2017 and December 2018 (n = 19,782).Results:Compared with low-intensity case management, high-intensity services were associated with a reduction in the incidence rates of inpatient admissions [incidence rate ratio (IRR) = 0.341, 95% CI: 0.106-1.102; P = 0.072], ED visits (IRR = 0.608, 95% CI: 0.188-1.965; P = 0.058), and avoidable ED visits (IRR = 0.579, 95% CI: 0.179-1.872; P = 0.091). No significant association was found between service intensity and the likelihood of an event being an excess zero.Conclusions:High-intensity social needs case management may be more effective than low-intensity service at reducing health care use for individuals with non-zero use, suggesting that intensive case management may be especially helpful in supporting discharge and transitions of care.

Folate, an essential vitamin, is a one-carbon acceptor and donor in key metabolic reactions. Erythroid cells harbor a unique sensitivity to folate deprivation, as revealed by the primary pathological manifestation of nutritional folate deprivation: megaloblastic anemia. To study this metabolic sensitivity, we applied mild folate depletion to human and mouse erythroid cell lines and primary murine erythroid progenitors. We show that folate depletion induces early blockade of purine synthesis and accumulation of the purine synthesis intermediate and signaling molecule, 5′-phosphoribosyl-5-aminoimidazole-4-carboxamide (AICAR), followed by enhanced heme metabolism, hemoglobin synthesis, and erythroid differentiation. This is phenocopied by inhibition of folate metabolism using the inhibitor SHIN1, and by AICAR supplementation. Mechanistically, the metabolically driven differentiation is independent of mechanistic target of rapamycin complex 1 (mTORC1) and adenosine 5′-monophosphate–activated protein kinase (AMPK) and is instead mediated by protein kinase C. Our findings suggest that folate deprivation–induced premature differentiation of erythroid progenitor cells is a molecular etiology to folate deficiency–induced anemia.

While work has been established as an important social determinant of health, it remains understudied in health inequities research. Although work has the potential to both promote and harm health, this analysis focuses on the health-compromising elements of work in a sample of sexuality and gender minority (SGM) young adults in the San Francisco Bay Area who participated in a study investigating nicotine and tobacco (NT) use practices. Survey and interview data were collected from 100 participants ages 18-25 who reported current or former NT use. In-depth qualitative interviews explored their experiences of daily life, social identities and beliefs about structural oppression, practices of NT use, and perceptions of health and wellbeing. A thematic analysis of the narratives highlighted the centrality of work to daily life. Participants described how work structured time and became a site of daily exploitation. They also identified the structural barriers that shape employment opportunities for SGM young adults, compromising health, and shaping NT use. Results elucidate the harmful practices embedded in daily work and the inequities within the structure of work itself, underscoring the need to shift focus away from individual behaviors like NT use and towards the structural factors that perpetuate health inequities.

Objective: To examine how a preexisting initiative to align health care, public health, and social services influenced COVID-19 pandemic response.Data Sources and Study Setting: In-depth interviews with administrators and frontline staff in health care, public health, and social services in Contra Costa County, California from October, 2020, to May, 2021.Study Design: Qualitative, semi-structured interviews examined how COVID-19 response used resources developed for system alignment prior to the pandemic.Data Collection: We interviewed 31 informants including 14 managers in public health, health care, or social services and 17 social needs case managers who coordinated services across these sectors on behalf of patients. An inductive-deductive qualitative coding approach was used to systematically identify recurrent themes.Principal Findings: We identified four distinct components of the county's system alignment capabilities that supported COVID-19 response, including (1) an organizational culture of adaptability fostered through earlier system alignment efforts, which included the ability and willingness to rapidly implement new organizational processes, (2) trusting relationships among organizations based on prior, positive experiences of cross-sector collaboration, (3) capacity to monitor population health of historically marginalized community members, including information infrastructures, data analytics, and population monitoring and outreach, and (4) frontline staff with flexible skills to support health and social care who had built relationships with the highest risk community members.Conclusions Prior investments in aligning systems provided unanticipated benefits for organizational and community resilience during the COVID-19 pandemic. Our results illustrate a pathway for investment in system alignment efforts that build capacity within organizations and relationships between organizations to enhance resilience to crisis. Our findings suggest the usefulness of an integrated concept of organizational and community resilience that understands the resilience of systems of care as a vital resource for community resilience during crisis.

Introduction Racial disparities in health outcomes continue to exist for children requiring surgery. Previous investigations suggest that clinical protocols may reduce racial disparities. A post-operative opioid reduction protocol was implemented in children undergoing abdominal surgery who were less than 1 years old at a tertiary level hospital. The purpose of this investigation was to determine if the clinical protocol was associated with a reduction in racial disparity in post-operative opioid prescribing patterns and associated clinical outcomes. Methods A post-operative opioid reduction protocol based on standing intravenous acetaminophen, educational sessions with nursing staff, and standardized post-operative sign-out between the surgical and NICU teams was implemented in children under 1 year old in 2016. A time series and before and after analysis was conducted using a historical pre-intervention cohort (Jan 2011-Dec 2015) and prospectively collected post-intervention cohort (Jan 2016-Jan 2021). Primary outcomes included post-operative opioid use and post-operative pain scores stratified by race. Secondary outcomes included associated clinical outcomes also stratified by race. Results A total of 249 children were included in the investigation, 117 in the pre-intervention group and 132 in the post intervention group. The majority of patients in both cohorts were either White or Black. The two cohorts were equally matched in terms of pre-operative clinical variables. In the pre-intervention cohort, the median post-operative morphine equivalents in White children was 2.1 mg/kg (IQR 0.2, 11.1) while in Black children it was 13.1 mg/kg (IQR 2.4, 65.3), p-value = 0.0352. In the post-intervention cohort, the median value for White children and Black children was statistically identical (0.05 mg/kg (IQR 0, 0.5) and 0.0 mg/kg (IQR 0, 0.3), respectively, p-value = 0.237). This pattern was also demonstrated in clinical variables including length of stay, intubation length and total parenteral nutrition use. In the pre-intervention cohort, the total length of stay for white children was 16 days while for black children it was 45 days (p = 0.007). In the postintervention cohort the length of stay for both White and Black children were identical at 8 days (p = 0.748). Conclusion The use of a clinical opioid reduction protocol implemented at a tertiary medical center was associated with a reduction in racial disparity in opioid prescribing habits in children. Prior to the protocol, there was a racial disparity in clinical variables associated with prolonged opioid use including length of stay, TPN use, and intubation length. The clinical protocol reduced variability in opioid prescribing patterns in all racial groups which was associated with a reduction in variability in associated clinical variables.

Health scientists have claimed that urban transit workers suffer from higher rates of stress-related disease than workers in most other occupations. This paper examines how a network of scientists and labor organizers constructed the problem of transit worker stress as a global phenomenon. According to study participants, transit workers worldwide are subject to a similar set of stress-related risks, which can serve as a basis for worker solidarity. This paper analyzes how the concept of stress has been used to identify pathogenic environments and considers anthropological claims that the concept often abstracts and depoliticizes harmful arrangements. The findings show that scientists and labor organizers use the stress concept to construct a figure of a universally at-risk transit worker that serves the ends of transnational labor organizing. At the same time, by focusing on the case of San Francisco's transit workers, this analysis shows that a persistent association between stress and 'hard work'-in both lay and scientific discourses-may block recognition of stress-related harms for transit workers who are accused of being lazy and overpaid.

Background: Social needs casemanagement is an increasingly common strategy used by health care organizations to address integrated health and social needs (1). These programs connect patients to resources such as food assistance, housing, transportation, or income benefits, in addition to facilitating access to health care and behavioral health services (2). One theory suggests these programs may benefit patients by increasing use of primary and preventive care and decreasing need for acute care (3). In 2017, Contra Costa Health Services in California implemented a large-scale, randomized study to evaluate the effect of social needs case management on acute care use. The trial showed an 11% reduction in hospitalizations amongpatients offered casemanagement (4). Objective: To evaluate impacts of social needs casemanagement intervention on use of outpatient health care, behavioral health services, and jail intakes. Methods and Findings:We conducted a secondary analysis of a randomized encouragement study that assigned Medicaid beneficiaries with high risk for acute care use to social needs case management or to be administratively observed in the control group from August 2017 through December 2018. (ClinicalTrials.gov: NCT04000074). Eligibility criteria included being 18 years or older, a resident of Contra Costa County, and enrolled in full-scope Medicaid. Patients could not be in a vegetative state, currently in detention for more than 30 days, or enrolled in duplicative case management services. Risk for avoidable health care use was designated by a predictive risk score based on demographic information, past health care utilization, and social risk factors (91 variables in total). Patients enrolled in casemanagement were assigned to a case manager who assessed their needs, created a patient-centered care plan, and provided ongoing support including community resource referrals, coordination with primary care providers, and collaboration on applications for public benefits. Case managers had diverse professional backgrounds and included public health nurses, social workers, substance misuse counselors, mental health clinicians, homeless service specialists, and community health workers. Case management was offered as in-person or remote telephonic services for 1 year. Patients who chose to opt out or could not be contacted were still included in the intentionto-treat intervention group. About 40% (n1⁄48577) of enrolled patients engaged in services. Details of the statistical methods are available elsewhere (4). There were 21422 intervention group enrollments and 22389 weighted control group enrollments. Enrollee characteristics were balanced across intervention and control groups (Table 1). The intervention group had significantly higher rates of primary care visits compared with the control group (incidence rate ratio [IRR], 1.03 [95% CI, 1.00 to 1.07]) (Table 2). No differences were found between the treatment groups for specialty care visits (IRR, 0.98 [CI, 0.91 to 1.05]), behavioral health visits (IRR, 1.04 [CI, 0.93 to 1.15]), psychiatric emergency visits (IRR, 0.84 [CI, 0.65 to 1.03]), or jail intakes (IRR, 0.97 [CI, 0.86 to 1.07]). Discussion:Our results suggest that social needs casemanagement reduced hospitalizations in part by increasing access LETTERS

To the Editor: Erythropoietic protoporphyria (EPP) impairs quality of life because patients must limit light exposure to avoid painful cutaneous phototoxic reactions.1,2 Clinical trials in EPP have been limited by imprecise endpoints relying on patient self-reporting of time outdoors, and no methods exist for predicting and preventing symptoms.2 The current pilot study advances prior EPP light dosimetry studies, providing the initial description of the relationship between daily light dose and symptoms, and exploring novel strategies for measuring light tolerance.

ABSTRACTThis article explores the meaning, manifestations, and ramifications of medical neutrality in conflict zones. We analyse how Israeli healthcare institutions and leaders responded to the escalation of the Israeli-Palestinian conflict in May 2021 and how they represented the role of the healthcare system in society and during conflict. Based on content analysis of documents, we found that healthcare institutions and leaders called for cessation of violence between Jewish and Palestinian citizens of Israel, describing the Israeli healthcare system as a neutral space of coexistence. However, they largely overlooked the military campaign that was simultaneously taking place between Israel and Gaza, which was considered a controversial and 'political' issue. This depoliticised standpoint and boundary work enabled a limited acknowledgement of violence, while disregarding the larger causes of conflict. We suggest that a structurally competent medicine must explicitly recognise political conflict as a determinant of health. Healthcare professionals should be trained in structural competency to challenge the depoliticising effects of medical neutrality, with the aim of enhancing peace, health equity, and social justice. Concomitantly, the conceptual framework of structural competency should be broadened to include conflict-related issues and address the needs of the victims of severe structural violence in conflict areas.