Syrian field hospitals: A creative solution in urban military conflict combat in Syria

Medical aid to war victims in Syria in 2019: a report of organized healthcare support from a charity organization

Background

In 2011, a civil war started in Syria, which is on-going and has reached a death toll of over 400,000 people. Humanitarian organizations, including Aid to The Church in Need (ACN), have strived to provide help and medical support to the civilian victims.

Methods

We performed a retrospective analysis of data gathered in ACN projects in Syria in 2019. The datasets included descriptions of diseases, treatments, costs, cities, and hospitals. For each patient, we assigned the following additional categories: type of help (treatment, diagnosis, or nonmedical), type of treatment (medical or surgical), medical specialty, gross anatomic region, and presence of trauma.

Results

A total of 3835 patients benefited from ACN support in Syria in 2019. The majority of financial support went towards treatment (78.4%), while other support went towards nonmedical help (15.7%) or providing a diagnosis (5.9%). Among treatments, 66.6% were medical and 33.4% surgical. The most common medical specialty was internal medicine (48.4%), followed by public health (13.7%) and surgery (7.3%). Anatomic region was undefined in 68.3% of cases and, when defined, was most commonly the abdominal cavity and pelvis (13%). The vast majority of cases 95.1%) were not associated with trauma. Procedural costs were highest in the Valley of Christians region, and lowest in Tartous. Network graphs were used to visualize the three most common diagnoses and treatments for each medical specialty.

Conclusions

The present report describes the treatment of war victims in Syria in 2019. The patients lacked the most basic medical or surgical healthcare. Charity organizations, like ACN, constitute a valuable source of information about the healthcare of war victims. Unfortunately, the methods of describing medical treatment provided to civilian victims remain underdeveloped. Future studies will require the cooperation of healthcare providers, humanists, and social workers. The present findings can help to optimize the provision of humanitarian help by charity organizations, by tailoring projects to the specific needs of Syrian war victims.

'We will never give up': a qualitative study of ethical challenges Syrian health workers face in situations of extreme violence

Active conflict settings constitute challenging operating environments for humanitarian health organisations and workers. An emerging feature of some conflicts is direct violence against health workers, facilities, and patients. Since the start of the war in 2011, Syria has endured extreme and deliberate violent attacks on health facilities and workers. This paper reports on the findings from a qualitative study that examined the lived experiences of Syrian humanitarian health workers facing extreme ethical challenges and coping with moral distress. In-depth interviews were carried out with 58 front-line health workers in north-western and southern Syria. Participants described a number of ethical and operational challenges experienced while providing services in extreme conditions, as well as strategies used to deal with them. The complex intersection of personal and organisational challenges is considered and findings are linked to key ethical and humanitarian principles. Both practical recommendations and action steps are provided to guide humanitarian health organisations.

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 systematic review and comprehensive legislative framework to address chemical assault globally

The incidence of chemical assault is increasing globally. In response, a number of countries are proposing legislation. However, current legislative initiatives are uncoordinated and do not address the spectrum of activities to prevent and care for victims of chemical assaults. To fill this gap, we aimed to review legislation, policies and regulations relevant to chemical assault to classify and catalogue current strategies into a legislative framework. Terms related to chemical assault were used to systematically search the academic, lay and legal literatures. Chemical assault was defined as the use of acid or another caustic or corrosive substance or vitriol by one person against another with the intent to injure or disfigure. Reports that described the use of chemical weapons in warfare were excluded. A second search of national legislations of countries with reports of chemical assaults was performed to identify enacted laws and gaps in legislative approaches to chemical assault control. Data regarding relevant laws, policies and regulations were extracted. The findings were used to classify and catalogue current strategies into a legislative framework using content analysis. The search returned 3769 records. Chemical assaults were reported from 104 countries. Using legislation from those countries, a framework consisting of five legislative priorities was developed: (a) apply a public health approach; (b) adopt legal definitions specific to chemical assault; (c) control chemical supply, sales and procurement; (d) facilitate justice; and (e) support survivors. Although many countries have implemented one or more of these legislative priorities, no country has a comprehensive address to chemical assault control. Comparative policy analysis and assessments of the impacts of legislative efforts may further inform strategies to prevent, prosecute and mitigate the impact of chemical assaults. In the meantime, advocacy groups and governments might consider implementation and enforcement of one or more components of this legislative framework to control the growing epidemic of chemical assault.

The Trifecta of Tele-Critical Care: Intrahospital, Operational, and Mass Casualty Applications

INTRODUCTION

Tele-critical care (TCC) has improved outcomes in civilian hospitals and military treatment facilities (MTFs). Tele-critical care has the potential to concurrently support MTFs and operational environments and could increase capacity and capability during mass casualty events. TCC services distributed across multiple hub sites may flexibly adapt to rapid changes in patient volume and complexity to fully optimize resources. Given the highly variable census in MTF intensive care units (ICU), the proposed TCC solution offers system resiliency and redundancy for garrison, operational, and mass casualty needs, while also maximizing return on investment for the Defense Health Agency.

MATERIALS AND METHODS

The investigators piloted simultaneous TCC support to the MTF during three field exercises: (1) TCC concurrently monitored the ICU during a remote mass casualty exercise: the TCC physician monitored a high-risk ICU patient while the nurse monitored 24 simulated field casualties; (2) TCC concurrently monitored the garrison ICU and a remote military medical field exercise: the physician provided tele-mentoring during prolonged field care for a simulated casualty, and the nurse provided hospital ICU TCC; (3) the TCC nurse simultaneously monitored the ICU while providing reach-back support to field hospital nurses training in a simulation scenario.

RESULTS

TCC proved feasible during multiple exercises with concurrent tele-mentoring to different care environments including physician and nurse alternating operational and hospital support roles, and an ICU nurse managing both simultaneously. ICU staff noted enhanced quality and safety of bedside care. Field exercise participants indicated TCC expanded multipatient monitoring during mass casualties and enhanced novice caregiver procedural capability and scope of patient complexity.

CONCLUSIONS

Tele-critical care can extend critical care services to anywhere at any time in support of garrison medicine, operational medicine, and mass casualty settings. An interoperable, flexibly staffed, and rapidly expandable TCC network must be further developed given the potential for large casualty volumes to overwhelm a single TCC provider with multiple duties. Lessons learned from development of this capability should have applicability for managing military and civilian mass casualty events.

Health care workers in conflict and post-conflict settings: Systematic mapping of the evidence

BACKGROUND

Health care workers (HCWs) are essential for the delivery of health care services in conflict areas and in rebuilding health systems post-conflict.

OBJECTIVE

The aim of this study was to systematically identify and map the published evidence on HCWs in conflict and post-conflict settings. Our ultimate aim is to inform researchers and funders on research gap on this subject and support relevant stakeholders by providing them with a comprehensive resource of evidence about HCWs in conflict and post-conflict settings on a global scale.

METHODS

We conducted a systematic mapping of the literature. We included a wide range of study designs, addressing any type of personnel providing health services in either conflict or post-conflict settings. We conducted a descriptive analysis of the general characteristics of the included papers and built two interactive systematic maps organized by country, study design and theme.

RESULTS

Out of 13,863 identified citations, we included a total of 474 studies: 304 on conflict settings, 149 on post-conflict settings, and 21 on both conflict and post-conflict settings. For conflict settings, the most studied counties were Iraq (15%), Syria (15%), Israel (10%), and the State of Palestine (9%). The most common types of publication were opinion pieces in conflict settings (39%), and primary studies (33%) in post-conflict settings. In addition, most of the first and corresponding authors were affiliated with countries different from the country focus of the paper. Violence against health workers was the most tackled theme of papers reporting on conflict settings, while workforce performance was the most addressed theme by papers reporting on post-conflict settings. The majority of papers in both conflict and post-conflict settings did not report funding sources (81% and 53%) or conflicts of interest of authors (73% and 62%), and around half of primary studies did not report on ethical approvals (45% and 41%).

CONCLUSIONS

This systematic mapping provides a comprehensive database of evidence about HCWs in conflict and post-conflict settings on a global scale that is often needed to inform policies and strategies on effective workforce planning and management and in reducing emigration. It can also be used to identify evidence for policy-relevant questions, knowledge gaps to direct future primary research, and knowledge clusters.

Tele-Critical Care: An Update From the Society of Critical Care Medicine Tele-ICU Committee

OBJECTIVES

In 2014, the Tele-ICU Committee of the Society of Critical Care Medicine published an article regarding the state of ICU telemedicine, one better defined today as tele-critical care. Given the rapid evolution in the field, the authors now provide an updated review.

DATA SOURCES AND STUDY SELECTION

We searched PubMed and OVID for peer-reviewed literature published between 2010 and 2018 related to significant developments in tele-critical care, including its prevalence, function, activity, and technologies. Search terms included electronic ICU, tele-ICU, critical care telemedicine, and ICU telemedicine with appropriate descriptors relevant to each sub-section. Additionally, information from surveys done by the Society of Critical Care Medicine was included given the relevance to the discussion and was referenced accordingly.

DATA EXTRACTION AND DATA SYNTHESIS

Tele-critical care continues to evolve in multiple domains, including organizational structure, technologies, expanded-use case scenarios, and novel applications. Insights have been gained in economic impact and human and organizational factors affecting tele-critical care delivery. Legislation and credentialing continue to significantly influence the pace of tele-critical care growth and adoption.

CONCLUSIONS

Tele-critical care is an established mechanism to leverage critical care expertise to ICUs and beyond, but systematic research comparing different models, approaches, and technologies is still needed.

A scoping review of the wider and long-term impacts of attacks on healthcare in conflict zones

Attacks on health care in conflict zones are widespread and show no signs of relenting. Since 2011 several organizations have systemically collected data of these attacks and revealed their scale. However, little is known of the consequences of these attacks. The purpose of this scoping review was to explore the literature on attacks on health care in conflict zones to understand what is known of the wider and long-term impacts. Using the Arksey and O'Malley framework we identified 233 articles for inclusion. Extracting descriptions of impacts, we were able to categorize this information into 15 broad themes. However, there are limitations in the data collection on impacts. Firstly it is not systemically collected after every attack or in all regions where attacks take place. Secondly, this data stops short of working down the chain of impacts to describe the full range of consequences. Lastly, the literature does not often distinguish between the impacts of attacks on health care and the impact of conflict on health. Discussion is needed as to how we define and understand attacks on health care and therefore the impacts of these attacks. Systematic methods for data collection on the impacts of attacks on healthcare are also needed to produce comprehensive data sets.

The Syrian public health and humanitarian crisis: A 'displacement' in global governance?

Ongoing failure by the international community to resolve the Syrian conflict has led to destruction of critical infrastructure. This includes the collapse of the Syrian health system, leaving millions of internally displaced persons (IDPs) in urgent need of healthcare services. As the conflict intensifies, IDP populations are suffering from infectious and non-communicable disease risks, poor maternal and child health outcomes, trauma, and mental health issues, while healthcare workers continually exit the country. Healthcare workers who remain face significant challenges, including systematic attacks on healthcare facilities and conditions that severely inhibit healthcare delivery and assistance. Within this conflict-driven public health crisis, the most susceptible population is arguably the IDP. Though the fundamental 'right to health' is a recognised international legal principle, its application is inadequate due to limited recognition by the UN Security Council and stymied global governance by the broader international community. These factors have also negatively impacted other vulnerable groups other than IDPs, such as refugees and ethnic minorities, who may or may not be displaced. Hence, this article reviews the current Syrian conflict, assesses challenges with local and global governance for IDPs, and explores potential governance solutions needed to address this health and humanitarian crisis.

The Syrian civil war: The experience of the Surgical Intensive Care Units

Objective:

Since the civilian war in Syria began, thousands of seriously injured trauma patients from Syria were brought to Turkey for emergency operations and/or postoperative intensive care. The aim of this study was to present the demographics and clinical features of the wounded patients in Syrian civil war admitted to the surgical intensive care units in a tertiary care centre.

Methods:

The records of 80 trauma patients admitted to the Anaesthesia, General Surgery and Neurosurgery ICUs between June 1, 2012 and July 15, 2014 were included in the study. The data were reviewed regarding the demographics, time of presentation, place of reference, Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Injury Severity Score (ISS), surgical procedures, complications, length of stay and mortality.

Results:

A total of 80 wounded patients (70 males and 10 females) with a mean age of 28.7 years were admitted to surgical ICUs. The most frequent cause of injury was gunshot injury. The mean time interval between the occurrence of injury and time of admission was 2.87 days. Mean ISS score on admission was 21, and mean APACHE II score was 15.7. APACHE II scores of non-survivors were significantly increased compared with those of survivors (P=0.001). No significant differences was found in the age, ISS, time interval before admission, length of stay in ICU, rate of surgery before or after admission.

Conclusion:

The most important factor affecting mortality in this particular trauma-ICU patient population from Syrian civil war was the physiological condition of patients on admission. Rapid transport and effective initial and on-road resuscitation are critical in decreasing the mortality rate in civil wars and military conflicts.