Field hospitals in Syria

Impact of armed conflict on health professionals' education and training in Syria: a systematic review

OBJECTIVES

To provide an overview of the holistic impact of the armed conflict on medical education and health professionals' training (MEHPT) in Syria.

SETTING

Syria is a country which underwent an armed conflict for 10 years and suffered from the weaponisation of health.

METHODS

A mixed-methods systematic review including quantitative, qualitative, mixed-methods and textual literature between 2011 and 2021 including papers on the Syrian MEHPT undergraduate and postgraduate education and training personnel (including medicine, dentistry, pharmacy, nursing, midwifery and allied health professionals). The electronic search was conducted in October 2018 in Embase, Global Health, Medline, PsycINFO, Web of Science, PubMed, Scopus, CINAHL and grey literature. And an update to the search was conducted in August 2021 in PubMed, Google Scholar and Trip database.

OUTCOMES

The impact of conflict on the MEHPT system, personnel, experiences, challenges and channels of support.

RESULTS

Of the 5710 citations screened, 70 met the inclusion criteria (34 quantitative, 3 qualitative, 1 mixed-method, and 32 reports and opinion papers). The two major cross-cutting themes were attacks on MEHPT and innovations (present in 41% and 44% of the papers, respectively), followed by challenges facing the MEHPT sector and attitudes and knowledge of trainees and students, and lastly health system and policy issues, and narrating experiences.

CONCLUSION

Conflict in Syria has politicised all aspects of MEHPT. Influenced by political control, the MEHPT system has been divided into two distinguished geopolitical contexts; government-controlled areas (GCAs) and non-GCAs (NGCAs), each having its characteristics and level of war impact. International and regional academic institutes collaboration and coordination efforts are needed to formulate educational platforms using innovative approaches (such as online/blended/store-and-forward/peer-training/online tutoring) to strengthen and build the capacity of the health workforce in conflict-affected areas.

Conflict-related health research in Syria, 2011-2019: a scoping review for The Lancet - AUB Commission on Syria

BACKGROUND

The volume of health-related publications on Syria has increased considerably over the course of the conflict compared with the pre-war period. This increase is largely attributed to commentaries, news reports and editorials rather than research publications. This paper seeks to characterise the conflict-related population and humanitarian health and health systems research focused inside Syria and published over the course of the Syrian conflict.

METHODS

As part of a broader scoping review covering English, Arabic and French literature on health and Syria published from 01 January 2011 to 31 December 2019 and indexed in seven citation databases (PubMed, Medline (OVID), CINAHL Complete, Global Health, EMBASE, Web of Science, Scopus), we analyzed conflict-related research papers focused on health issues inside Syria and on Syrians or residents of Syria. We classified research articles based on the major thematic areas studied. We abstracted bibliometric information, study characteristics, research focus, funding statements and key limitations and challenges of conducting research as described by the study authors. To gain additional insights, we examined, separately, non-research publications reporting field and operational activities as well as personal reflections and narrative accounts of first-hand experiences inside Syria.

RESULTS

Of 2073 papers identified in the scoping review, 710 (34%) exclusively focus on health issues of Syrians or residents inside Syria, of which 350 (49%) are conflict-related, including 89 (25%) research papers. Annual volume of research increased over time, from one publication in 2013 to 26 publications in 2018 and 29 in 2019. Damascus was the most frequently studied governorate (n = 33), followed by Aleppo (n = 25). Papers used a wide range of research methodologies, predominantly quantitative (n = 68). The country of institutional affiliation(s) of first and last authors are predominantly Syria (n = 30, 21 respectively), the United States (n = 25, 19 respectively) or the United Kingdom (n = 12, 10 respectively). The majority of authors had academic institutional affiliations. The most frequently examined themes were health status, the health system and humanitarian assistance, response or needs (n = 38, 34, 26 respectively). Authors described a range of contextual, methodological and administrative challenges in conducting research on health inside Syria. Thirty-one publications presented field and operational activities and eight publications were reflections or first-hand personal accounts of experiences inside Syria.

CONCLUSIONS

Despite a growing volume of research publications examining population and humanitarian health and health systems issues inside conflict-ravaged Syria, there are considerable geographic and thematic gaps, including limited research on several key pillars of the health system such as governance, financing and medical products; issues such as injury epidemiology and non-communicable disease burden; the situation in the north-east and south of Syria; and besieged areas and populations. Recognising the myriad of complexities of researching active conflict settings, it is essential that research in/on Syria continues, in order to build the evidence base, understand critical health issues, identify knowledge gaps and inform the research agenda to address the needs of the people of Syria following a decade of conflict.

A new primary health-care system in the Syrian opposition territories: Good effort but far from being perfect

Objectives

The primary health-care system in Syria has suffered a great deal of damage over the past 6 years. A large number of physicians and health-care providers have left the country. The objectives of this study are to describe our experience in establishing a primary health-care system in the opposition territories (OTs) in Syria and report the most common treated diseases.

Methods

The administrative databases of ten primary care centers in the OT from January 2014 to December 2015 were reviewed. All patients' encounters, including children and adults, in these centers were included in the study.

Results

Within the study period, the ten centers served 46,039 patients encounter per month (and average of 4600 patients encounters per center per month). A high number of communicable diseases were noted. Cutaneous leishmaniasis was the most common communicable disease (1170 cases a month). Tuberculosis was treated in 14 patients a month. Other infectious diseases that were almost eradicated before the crises were seen increasingly (29 mumps cases/month, 6 measles cases/month, and 34 cases of typhoid fever/month).

Conclusion

The primary health-care system in Syria has been greatly damaged, and tremendous efforts are ongoing to provide access to various basic health-care services including primary care services. Despite these efforts, the current system is very vulnerable and not sustainable. This study summarizes basic health services provided by primary health-care centers in Syrian OTs.

Fangcang shelter hospitals: a novel concept for responding to public health emergencies

Fangcang shelter hospitals are a novel public health concept. They were implemented for the first time in China in February, 2020, to tackle the coronavirus disease 2019 (COVID-19) outbreak. The Fangcang shelter hospitals in China were large-scale, temporary hospitals, rapidly built by converting existing public venues, such as stadiums and exhibition centres, into health-care facilities. They served to isolate patients with mild to moderate COVID-19 from their families and communities, while providing medical care, disease monitoring, food, shelter, and social activities. We document the development of Fangcang shelter hospitals during the COVID-19 outbreak in China and explain their three key characteristics (rapid construction, massive scale, and low cost) and five essential functions (isolation, triage, basic medical care, frequent monitoring and rapid referral, and essential living and social engagement). Fangcang shelter hospitals could be powerful components of national responses to the COVID-19 pandemic, as well as future epidemics and public health emergencies.

Health Care Workers in the setting of the "Arab Spring": a scoping review for the Lancet-AUB Commission on Syria

Background

"Health Care Workers in Conflict Areas" emerged as one of the priority themes for a Lancet Commission addressing health in conflict. The objective of our study was to conduct a scoping review on health workers in the setting of the Syrian conflict, addressing four topics of interest: violence against health care workers, education, practicing in conflict setting, and migration.

Methods

Considering the likelihood of scarcity of data, we broadened the scope of the scoping review to include indirect evidence on health care workers from other countries affected by the "Arab Spring". We electronically searched six electronic databases. We conducted descriptive analysis of the general characteristics of the included papers. We also used the results of this scoping review to build an evidence gap map.

Results

Out of the 11 165 identified citations, 136 met our eligibility criteria. The majority of the articles tackled the issue of violence against health care workers (63%) followed by practicing in conflict setting (19%), migration (17%) and education (10%). Countries in focus of most articles were: Syria (35%), Iraq (33%), and Bahrain (29%). News, editorials, commentaries and opinion pieces made up 81% of all included papers, while primary studies made up only 9%. All the primary studies identified in this review were conducted on Iraq. Most of the articles about violence against health care workers were on Bahrain, followed by Syria and Iraq. The first and corresponding authors were most frequently affiliated with institutions from non-Arab countries (79% and 79% respectively).

Conclusions

Research evidence on health care workers in the setting of the "Arab Spring" is scarce. This review and the gap map can inform the research agendas of funders and researchers working in the field of health care workers in conflict setting. More well-designed primary studies are needed to inform the decisions of policymakers and other interested parties.

Evidence-based medicine: a persisting desire under fire

Healthcare infrastructure and medical schools in Syria have been greatly compromised by military conflict and humanitarian disaster. Medical students and healthcare professionals reached out for remote learning opportunities. Surprisingly, they desired a curriculum in evidence-based medicine. We report on a curriculum that was delivered to 126 learners using an online remote delivery platform. This experience demonstrates the feasibility of this approach in disaster-stricken areas and underscores the importance of evidence-based medicine even under such conditions.

[Medical caravan in Morocco: Mobile dermatology]

This publication is based on personal experiences gathered during participation in several "medical caravans". These caravans where under the leadership of either a Moroccan nongovernmental organization (NGO) or a Belgian NGO. Medical caravans are multidisciplinary mobile groups that offer basic medical care in rural areas. The location usually changes every 1-2 days. The physician team comprises more than 10 different specialties including midwives, psychologists, nurses, hearing instrument specialists and podologists. The work was supported by Moroccan caregivers (fluent in French, Arabic and Berber). They were able to reduce the linguistic and cultural barriers as well as fear and insecurity thus creating an environment of trust for the consultations. The spectrum of diagnosed and treated dermatoses included benign and malignant cutaneous tumors like basal cell carcinoma, squamous cell carcinoma, melanoma, infectious skin diseases, inflammatory dermatoses like atopic dermatitis and psoriasis as well as genodermatosis. The personal satisfaction and the feeling of being able to contribute to medical support for an underprivileged population in a remote rural area outweighed critical aspects, e.g. regarding the sustainable effects of a temporary medical caravan.