The Lancet and the American University of Beirut have together established the concept for a Commission on Syria: Health in Conflict. The aim of the Commission will be to describe, analyse and interrogate the calamity before us through the lens of health and wellbeing. With this Commission, we aim to examine five priority areas: health of people inside Syria; health of refugees and host communities; health systems, which includes the pillars of health professionals, delivery, infrastructure, and transition to rebuilding; challenges of the international response to the crisis particularly health-related international law violations and humanitarian aid design and delivery; and policy options and next steps, including those that can strengthen the role of global health in conflict and health more broadly. The Commission will develop concrete recommendations to address the unmet current and future health needs.
Researchers in Lancet study say the ‘weaponisation’ of healthcare in Syria, involving killing of hundreds of medical workers, is unprecedented
The “weaponisation” of healthcare in Syria, involving the targeted destruction of medical facilities and the killing of hundreds of healthcare workers, is unprecedented and has profound and dangerous implications for medical neutrality in conflict zones, according to an authoritative study.
“Syria has become the most dangerous place on earth for healthcare providers,” say the researchers involved. Their study of the attacks on healthcare in Syria since 2011, published by the Lancet medical journal, reveals that the death toll among medical workers is at least 814. Some of those health workers were tortured and executed.
The authors define what they call the weaponisation of healthcare in Syria as a situation “in which healthcare facilities are attacked, workers are targeted, medical neutrality is obliterated and international humanitarian laws are violated to restrict or prevent access to care as a weapon of war”.
They criticise UN agencies and the international community for failing to hold the aggressors, who are breaking international conventions, to account.
“The application of this strategy in the Syria conflict, largely by pro-government forces and allies, with limited consequences for perpetrators has profound implications for health protection,” they write.
Doctors and other medical staff are having to practise “siege medicine”, improvising to help trauma victims, women in labour or patients suffering from infectious diseases with severe shortages of supplies.
Operations are carried out using the light from mobile phones while health workers have devised ways to make some of the essentials, such as saline, since intravenous fluids are routinely removed from aid convoys allowed in to blockaded cities.
“There is now an underground factory in eastern Ghouta near Damascus producing normal saline,” the authors write. “Denied blood bags for the collection and storage of blood, urine bags with anticoagulants added are used.”
Some medical facilities have been repeatedly bombed in an apparent attempt to close them down. Kafr Zita cave hospital in Hama has been bombed 33 times since 2014, including six times so far in 2017. M10, an underground hospital in eastern Aleppo, was attacked 19 times in three years and completely destroyed in October 2016.
“Over time, targeting has become more frequent, more obvious, and more geographically widespread. To the best of our knowledge, this level of targeting health facilities has not occurred in any previous war, and the data we were able to collect overwhelmingly show intent to target, which falls under the definition of a war crime,” says Dr Samer Jabbour, co-chair of the commission and associate professor of public health practice at the university’s faculty of health sciences.
In 2009, there were 29,927 doctors in Syria. Between 2011 and 2015, an estimated 15,000 doctors left the country. The effect on civilians is profound, says the paper.
“Based on data from 2,100 key informant interviews in 698 subdistricts in both government-controlled and non-government-controlled areas, only 42% of the population live in areas that are likely to have sufficient health workers, whereas 31% live in areas where health workers are insufficient and 27% live in areas where health workers are completely absent.”
The report comes on the sixth anniversary of the conflict, which grew out of the 2011 Arab Spring protests. Two separate reports also reveal the extent of the atrocities committed in Syria. The UN’s Independent International Commission of Inquiry on Syria accused government forces and their allies of showing a “complete disregard for civilian life and international law” through continued use of cluster munitions, incendiary weapons and chlorine gas as weapons of war. Separately, a Physicians for Human Rights report accused the Syrian government of wilfully denying international shipments of food and medicine to millions of Syrians in besieged areas.
Targeting of healthcare workers started well before the current conflict, says the paper. The first documented execution of a doctor by pro-government forces was in March 2011. The following month, Syrian forces started arresting doctors, patients and paramedics in Douma and other areas of eastern Ghouta, where protests took place.
In July 2012, the Syrian government passed a law that in effect criminalised the provision of medical care to anyone injured by pro-government forces in protest marches against the government. It was “an effort to justify the arrests, detention, torture, and execution of health workers” and similar to one passed by Serbia in the 1998-99 war in Kosovo.
The targeting of healthcare workers continues, most often by government forces although abuses by opposition forces have also been reported, they say.
Jabbour said the attacks on health facilities and workers, violating international law, are designed to deprive the population of care as a means of control. “The international community has left these violations of international humanitarian and human rights law largely unanswered, despite their enormous consequences.
“There have been repudiated denunciations, but little action on bringing the perpetrators to justice. This inadequate response challenges the foundation of medical neutrality needed to sustain the operations of global health and protect health workers in situations of armed conflict.”
Two infectious disease experts warn that a new polio outbreak in Syria caused by wild-type polio virus 1 (WPV1) and asymptomatic cases in Israel might endanger Europe and other neighboring regions, according to correspondence published online November 8 in theLancet.
“[The World Health Organization] has confirmed an outbreak of at least ten cases of polio in Syria, where vaccination coverage has dramatically decreased during the civil war,” write Professor Martin Eichner, from the Institute of Clinical Epidemiology and Applied Biometry, University of Tübingen, and Stefan Brockmann, from the Department for Infection Control, Reutlingen Regional Public Health Office, Germany. “Furthermore, [WPV1] has been isolated from sewage and faeces from asymptomatic carriers in Israel since February, 2013.
“Moreover, hundreds of thousands of people are fleeing Syria and seek refuge in neighbouring countries and Europe,” they continue. During the Hajj in Saudi Arabia last month, visitors from countries with known polio transmission were vaccinated, but Syria was not included with those countries.
“The potential risk of transmission to [the European Union (EU)] and elsewhere documents the need for strong ongoing global efforts to eradicate this disease,” CDC Director Tom Frieden, MD, MPH, toldMedscape Medical News. “Polio anywhere is a threat of polio everywhere.”
The situation in the Middle East, combined with the vaccination approach used in Europe, is concerning, according to the authors. Most EU countries currently use inactivated polio vaccine (IPV) rather than oral polio vaccination (OPV). Similar to many other regions, most EU states discontinued use of OPV because of rare reports that it caused acute flaccid paralysis (AFP), even though OPV offers high protection against acquiring and transmitting the infection. Only some EU member states still permit OPV use, and none has a stockpile of it.
In contrast, the more widely used IPV is highly effective in preventing AFP and active polio disease, but is only partially effective in preventing infection with polio virus. For decades, Europe has been free of circulating polio viruses and, therefore, IPV has been sufficient.
However, IPV will only continue to be effective in preventing transmission if vaccination coverage continues to be very high, if hygienic standards are good throughout the population, and if there is low crowding. These conditions could easily be disrupted by the present situation of large numbers of refugees fleeing from Syria to Europe and other neighboring countries.
If the polio virus is reintroduced into the community, herd immunity may be insufficient to prevent sustained transmission in European regions where vaccination coverage is low, such as Bosnia and Herzegovina (87%), Ukraine (74%), and Austria (IPV coverage rate 83%).
For every 200 WPV1 infections, only 1 results in symptomatic polio. Therefore, hundreds of individuals could be infected and the virus could circulate for nearly a year before an outbreak could be identified from a single case of AFP.
“Vaccinating only Syrian refugees — as has been recommended by the European Centre for Disease Prevention and Control — must be judged as insufficient; more comprehensive measures should be taken into consideration;” the authors conclude. “Routine screening of sewage for poliovirus has not been done in most European countries, but this intensified surveillance measure should be considered for settlements with large numbers of Syrian refugees.”
Implications for the United States
In the United States, routine vaccination against polio currently uses IPV, which may create concerns similar to those now affecting Europe.
“The IPV vaccine is effective at preventing disease, but [OPV] is more effective at preventing even asymptomatic infection,” Jennifer L. Lyons, MD, from the Division of Neurological Infections, Department of Neurology, Brigham and Women’s Hospital in Boston, Massachusetts, toldMedscape Medical News. “However, the OPV has been associated with a low but known risk of vaccine-related infection and, as such, is no longer routinely used.”
“It is difficult to project the effect that this scenario will have on the US, but vigilance is always good practice,” Dr. Lyons said. “Adherence to vaccination guidelines and maintenance of proper hygiene are likely the best preventive measures to take.”
Dr. Frieden toldMedscape Medical Newsthat IPV is used in Israel, as well as in the EU and the United States. “There have been no cases of indigenous polio in these regions, an especially significant fact considering that poliovirus has been found in environmental sewage samples in Israel,” Dr. Frieden said. “IPV is effective in protecting individuals against polio. The US has been free of indigenous polio since 1979.”
He also noted that the risk of importations of any infectious disease, including polio, into the United States is always a concern and highlights the importance of being vaccinated and of working to control infectious diseases wherever they are spreading.
“CDC works to minimize the risk for polio in the US through its traveler’s health and global migration program and global health program,” Dr. Frieden concluded. “We collaborate closely with international organizations and other countries to implement international and US guidance on vaccination for immigrants. In response to the polio cases in the Middle East and Horn of Africa, CDC has issued new recommendations for polio vaccine use among high-risk refugee populations and is working with international partners to implement them. Through the Global Polio Eradication Initiative, CDC works intensively with international health partners and Rotary International to eradicate polio at its source.”
More than four million Syrians who have relocated to less volatile areas of the country are mostly living in overcrowded, unsanitary conditions.
The WHO says it is already seeing increased cases of measles, typhoid and hepatitis A in Syria.
Dr Jaouad Mahjour, director of the department for communicable diseases at WHO’s regional office for the Eastern Mediterranean, said: “Given the scale of population movement both inside Syria and across borders, together with deteriorating environmental health conditions, outbreaks are inevitable.”
The cluster of suspected polio cases was detected in early October 2013 in Deir al-Zour province.
Initial results from a laboratory in Damascus indicate that at least two of the cases could indeed be polio.
A surveillance alert has been issued for the region to actively search for additional potential cases. Supplementary immunisation activities in neighbouring countries are currently being planned.
WHO’s International Travel and Health recommends that all travellers to and from polio-infected areas be fully vaccinated against polio.
Most people infected with the poliovirus have no signs of illness and are never aware they have been infected. These symptomless people carry the virus in their intestines and can “silently” spread the infection to thousands of others before the first case of polio paralysis emerges.
Polio is spread by eating food or drink contaminated with faeces or, more rarely, directly from person-to-person via saliva.
The OPCW is charged with overseeing the destruction of Syria’s arsenal of chemical weapons, following the atrocity – widely blamed on the regime of Bashar al-Assad – committed in Damascus on 21 August this year.
Experts from the Hague-based global watchdog are leading the programme which will see Syria’s chemical weapons production facilities demolished by 1 November, with a view to safely destroying Assad’s complete stockpile by the middle of 2014.
The Norwegian Nobel committee hailed the global chemical watchdog for creating “the chance to eliminate a whole category of deadly weapons”.
The statement announcing the winner read: “The conventions and the work of the OPCW have defined the use of chemical weapons as a taboo under international law.
“Recent events in Syria, where chemical weapons have again been put to use, have underlined the need to enhance the efforts to do away with such weapons. Some states are still not members of the OPCW. Certain states have not observed the deadline, which was April 2012, for destroying their chemical weapons. This applies especially to the USA and Russia.
“Disarmament figures prominently in Alfred Nobel’s will. The Norwegian Nobel Committee has through numerous prizes underlined the need to do away with nuclear weapons. By means of the present award to the OPCW, the Committee is seeking to contribute to the elimination of chemical weapons.”
The identity of the this year’s winner was leaked an hour ahead of the official announcement by Norweigan public broadcaster NRK – which confirmed the winner would not to be hotly-tipped favourite 16-year-old girls’ education activist Malala Yousafzai.
NRK also correctly anticipated the winner of last year’s award an hour early – taken by the EU.
The 16-year-old came to global attention, campaigning for female education in the country, in the face of violent fundamentalism. Her efforts led to her being shot in the head on a school bus a year ago.
Psychologist Audrey Magis recently returned home after spending two months working with Doctors Without Borders/Médecins Sans Frontières (MSF) inSyria, where she set up and ran a mental health program in one of MSF’s projects in the north of the country. Magis, who had previously worked for MSF in Gaza, Libya, and in a camp for Syrian refugees, explains how the war has affected people and what MSF is doing to help.
In most places I have worked, people are rather hesitant when I tell them that I am a psychologist. But in Syria, it was quite the opposite. People actually came and told me they needed my services. The war has been raging for two years and people have completely lost their bearings. At first, they would come and tell me about their social problems at home. Children are not going to school and so become disruptive. Adults are not working. People are living in tents or ten-up crowded into one room. But when you dig a little, you quickly find that most have experienced deeply traumatic events. Some have lost friends or family. Some have seen their home destroyed. Some have lived through bombing raids . . .
Loss of Identity
People have lost their identity. Older men cannot find their place in society and in the family. They have lost their job or stopped being a fighter. Maybe they have responsibility for a family but they have had to move house several times in quick succession.
“I don’t have to find them; they come and ask for help . . .”
I don’t have to find them; they come and ask for help, saying things like, “I’m starting to be violent towards my wife and children. Please help me, I cannot be like that.”
I have seen many women who are finding it increasingly hard to form a bond with their children. There are few contraceptives available, and a lot of women are becoming pregnant without really wanting to. They struggle to imagine their future with their child. I met several women in the final term of pregnancy who had prepared nothing—no cot, no baby clothes, no ideas for a name. People have lost their ability to project their lives into the future.
All the children are playing at war. You don’t see them playing with cars or other normal games; they pretend to shoot each other. I’ve seen kids throwing stones at donkeys, hurting animals. This is their way of expressing the pent up anger. I have also seen young men in their 20s, ex-fighters who have come to me with complaints about depression, traumatic stress, flashbacks, nightmares . . .
Loss of Meaning
A number of people have quietly told me that they no longer know what the war is about. They are terrified at the idea that they are fighting their neighbors, their friends . . . and they don’t know why anymore. At first there seemed to be some purpose, but two years on, that’s all gone. They just want it all to end so they can go home.
“People have lost their ability to project their lives into the future.”
Things have gone way beyond the breaking point. People are on automatic pilot. But somehow they manage to hold it all together. They cannot allow themselves to fall apart. They have developed an amazing ability to cope and keep going. To survive two years living through this, it’s impressive. The family and community support is enormous.
Sometimes just one session is enough. Some people just need to hear that what’s happening to them is normal, that they are not going mad. But there are other patients who I had to work with for longer. The idea is to set a clear objective with them, and to get there step by step with behavioral therapy. There is no time for long analysis sessions, but you can do very sound psychological work with these short-form therapy techniques.
I remember one patient, a woman who was six months pregnant. She came to the hospital asking for a premature delivery. There was no medical reason; she just wanted us to do a C-section and deliver her baby as soon as possible. She was very jumpy, very agitated.
“A number of people have quietly told me that they no longer know what the war is about. They are terrified at the idea that they are fighting their neighbors, their friends… and they don’t know why anymore.”
I sat with her and we worked out that this was one baby too many, a child born of the war, and she felt that the baby was sapping all her energy. All she wanted to do was take anti-depressants, but she couldn’t because she was pregnant.
We worked out a plan of relaxation exercises. And we made a diary where she would write down when she felt tense and what had happened to cause the tension. And a few sessions later we moved on to preparing for the arrival of her baby.
At our last session she showed me the baby clothes for her soon-to-be-born baby. She hadn’t yet chosen a name, but she had made great strides and was ready. She was my last patient, my last session on my last day. I left the project with the sense that my time had been well spent.