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Tarnas MC, Almhawish N, Karah N, Sullivan R, Abbara A. Communicable diseases in northwest Syria in the context of protracted armed conflict and earthquakes. Lancet Infect Dis 2023; 23:e477-e481. [PMID: 37419130 DOI: 10.1016/s1473-3099(23)00201-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 07/09/2023]
Abstract
The earthquakes in Türkiye and Syria in February, 2023, have caused further devastation in northwest Syria-an area already affected by protracted armed conflict, mass forced displacement, and inadequate health and humanitarian provision. The earthquake damaged infrastructure supporting water, sanitation, and hygiene, and health-care facilities. The disruptions to epidemiological surveillance and ongoing disease control measures resulting from the earthquake will accelerate and expand ongoing and new outbreaks of many communicable diseases including measles, cholera, tuberculosis, and leishmaniasis. Investing in existing early warning and response network activities in the area is essential. Antimicrobial resistance, which had already been an increasing concern in Syria before the earthquake, will also be exacerbated given the high number of traumatic injuries and breakdown of antimicrobial stewardship, and the collapse of infection prevention and control measures. Tackling communicable diseases in this setting requires multisectoral collaboration at the human-animal-environment nexus given the effect of the earthquakes on all these sectors. Without this collaboration, communicable disease outbreaks will further strain the already overburdened health system and cause further harm to the population.
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Affiliation(s)
| | | | - Nabil Karah
- Department of Molecular Biology. Umea University, Umea, Sweden
| | - Richard Sullivan
- Institute of Cancer Policy and the Centre for Conflict & Health Research, King's College London, London, UK
| | - Aula Abbara
- Syria Public Health Network, London, UK; Department of Infectious Diseases, St Marys Hospital, Imperial College London, London, UK.
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Abbara A, Rayes D, Tappis H, Hamze M, Wais R, Alahmad H, Almhawish N, Rubenstein L, Haar R. "Actually, the psychological wounds are more difficult than physical injuries:" a qualitative analysis of the impacts of attacks on health on the personal and professional lives of health workers in the Syrian conflict. Confl Health 2023; 17:48. [PMID: 37807074 PMCID: PMC10561459 DOI: 10.1186/s13031-023-00546-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/26/2023] [Indexed: 10/10/2023] Open
Abstract
INTRODUCTION Attacks on healthcare in armed conflict have far-reaching impacts on the personal and professional lives of health workers, as well as the communities they serve. Despite this, even in protracted conflicts such as in Syria, health workers may choose to stay despite repeated attacks on health facilities, resulting in compounded traumas. This research explores the intermediate and long-term impacts of such attacks on healthcare on the local health professionals who have lived through them with the aim of strengthening the evidence base around such impacts and better supporting them. METHODS We undertook purposive sampling of health workers in northwest and northeast Syria; we actively sought to interview non-physician and female health workers as these groups are often neglected in similar research. In-depth interviews (IDIs) were conducted in Arabic and transcribed into English for framework analysis. We used an a priori codebook to explore the short- and long-term impacts of attacks on the health workers and incorporated emergent themes as analysis progressed. RESULTS A total of 40 health workers who had experienced attacks between 2013 and 2020 participated in IDIs. 13 were female (32.5%). Various health cadres including doctors, nurses, midwives, pharmacists, students in healthcare and technicians were represented. They were mainly based in Idlib (39.5%), and Aleppo (37.5%) governorates. Themes emerged related to personal and professional impacts as well as coping mechanisms. The key themes include firstly the psychological harms, second the impacts of the nature of the attacks e.g. anticipatory stress related to the 'double tap' nature of attacks as well as opportunities related to coping mechanisms among health workers. CONCLUSION Violence against healthcare in Syria has had profound and lasting impacts on the health workforce due to the relentless and intentional targeting of healthcare facilities. They not only face the challenges of providing care for a conflict-affected population but are also part of the community themselves. They also face ethical dilemmas in their work leading to moral distress and moral injury. Donors must support funding for psychosocial support for health workers in Syria and similar contexts; the focus must be on supporting and enhancing existing context-specific coping strategies.
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Affiliation(s)
- Aula Abbara
- Syrian American Medical Society, Washington, DC, USA.
- Department of Infectious Diseases, Imperial College, London, St Marys Hospital, Praed Street, London, W2 1NY, UK.
- Syria Public Health Network, London, UK.
| | - Diana Rayes
- Syria Public Health Network, London, UK
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Hannah Tappis
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Mohamed Hamze
- Syrian American Medical Society, Washington, DC, USA
| | - Reham Wais
- Syrian American Medical Society, Gaziantep, Turkey
| | | | - Naser Almhawish
- Syria Public Health Network, London, UK
- Assistance Coordination Unit, Gaziantep, Turkey
| | | | - Rohini Haar
- School of Public Health, University of California, Berkeley, Berkeley, USA
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Tarnas M, Karah N, Almhawish N, Aladhan I, Alobaid R, Abbara A. Politicization of water, humanitarian response, and health in Syria as a contributor to the ongoing cholera outbreak. Int J Infect Dis 2023; 131:115-118. [PMID: 36990201 DOI: 10.1016/j.ijid.2023.03.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
In September 2022, the Syrian Ministry of Health declared a cholera outbreak after a surge of acute watery diarrhea cases. Since then, cases have been reported across Syria, particularly in the northwest. This ongoing outbreak reflects a pattern of politicizing water, humanitarian response, and health throughout the country's protracted conflict. Interference with water, sanitation, and hygiene (WASH) infrastructure has been a key component of this politicization, impeding detection, prevention, case management, and control. Droughts and floods have exacerbated the WASH situation, as have the early-2023 Türkiye-Syria earthquakes. Humanitarian response following the earthquakes has also faced politicization, leading to increased risk of surges in cases of cholera and other waterborne diseases. This has all occurred in a conflict where healthcare has been weaponized, attacks on healthcare and related infrastructure are the norm, and syndromic surveillance and outbreak response have been influenced and restricted by politics. Cholera outbreaks are entirely preventable; what we see in Syria is cholera reflecting the myriad ways in which the right to health has been brought under fire in the Syrian conflict. The recent earthquakes are an additional assault which raise urgent concerns that a surge of cholera cases, particularly in northwest Syria, may now become uncontrolled.
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Tabor R, Almhawish N, Aladhan I, Tarnas M, Sullivan R, Karah N, Zeitoun M, Ratnayake R, Abbara A. Disruption to water supply and waterborne communicable diseases in northeast Syria: a spatiotemporal analysis. Confl Health 2023; 17:4. [PMID: 36739427 PMCID: PMC9898953 DOI: 10.1186/s13031-023-00502-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND In Syria, disruption to water and sanitation systems, together with poor access to vaccination, forced displacement and overcrowding contribute to increases in waterborne diseases (WBDs). The aim of this study is to perform a spatiotemporal analysis to investigate potential associations between interruptions to water, sanitation, and hygiene (WASH) and WBDs in northeast Syria using data collected by the Early Warning Alert and Response Network (EWARN) from Deir-ez-Zor, Raqqa, Hassakeh and parts of Aleppo governorates. METHODS We reviewed the literature databases of MEDLINE and Google Scholar and the updates of ReliefWeb to obtain information on acute disruptions and attacks against water infrastructure in northeast Syria between January 2015 and June 2021. The EWARN weekly trends of five syndromes representing waterborne diseases were plotted and analysed to identify time trends and the influence of these disruptions. To investigate a potential relationship, the Wilcoxon rank sum test was used to compare districts with and without disruptions. Time series analyses were carried out on major disruptions to analyse their effect on WBD incidence. RESULTS The literature review found several instances where water infrastructure was attacked or disrupted, suggesting that water has been deliberately targeted by both state and non-state actors in northeast Syria throughout the conflict. Over time, there was an overall upwards trend of other acute diarrhoea (OAD, p < 0.001), but downwards trends for acute jaundice syndrome, suspected typhoid fever and acute bloody diarrhoea. For the major disruption of the Alouk water plant, an interrupted time series analysis did not find a strong correlation between the disruption and changes in disease incidence in the weeks following the incident, but long-term increases in WBD were observed. CONCLUSIONS While no strong immediate correlation could be established between disruptions to WASH and WBDs in northeast Syria, further research is essential to explore the impact of conflict-associated damage to civil infrastructure including WASH. This is vital though challenging given confounding factors which affect both WASH and WBDs in contexts like northeast Syria. As such, research which includes exploration of mitigation after damage to WASH is essential to improve understanding of impacts on quantity and quality of WASH. More granular research which explores the origin of cases of WBDs and how such communities are affected by challenges to WASH is needed. One step towards research on this, is the implementation of adequate reporting mechanisms for real time tracking of the WASH attacks, damages, direct effects, and likely impact in conjunction with environmental and public health bodies and surveillance systems.
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Affiliation(s)
- Ruby Tabor
- London School of Tropical Medicine and Hygiene, London, UK ,Syria Public Health Network, London, UK
| | - Naser Almhawish
- Assistance Coordination Unit, Gaziantep, Turkey ,Syria Public Health Network, London, UK
| | - Ibrahim Aladhan
- Syrian Environmental Protection Agency, Gaziantep, Turkey ,Syria Public Health Network, London, UK
| | - Maia Tarnas
- grid.266093.80000 0001 0668 7243University of California Irvine, Irvine, USA ,Syria Public Health Network, London, UK
| | - Richard Sullivan
- grid.13097.3c0000 0001 2322 6764King’s College, London, UK ,Syria Public Health Network, London, UK
| | - Nabil Karah
- grid.12650.300000 0001 1034 3451Umea University, Umeå, Sweden ,Syria Public Health Network, London, UK
| | - Mark Zeitoun
- grid.8273.e0000 0001 1092 7967University of East Anglia, Norwich, UK ,Geneva Water Hub, Geneva, Switzerland ,Syria Public Health Network, London, UK
| | - Ruwan Ratnayake
- London School of Tropical Medicine and Hygiene, London, UK ,Syria Public Health Network, London, UK
| | - Aula Abbara
- Geneva Water Hub, Geneva, Switzerland ,grid.7445.20000 0001 2113 8111Department of Infectious Diseases, Imperial College, London, W2 1NY UK ,Syria Public Health Network, London, UK
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Affiliation(s)
- Aula Abbara
- Department of Infection, Imperial College, St Marys Hospital, London W2 1NY, UK; Syria Public Health Network, London, UK.
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Tarnas MC, Desai AN, Parker DM, Almhawish N, Zakieh O, Rayes D, Whalen-Browne M, Abbara A. Syndromic surveillance of respiratory infections during protracted conflict: experiences from northern Syria 2016-2021. Int J Infect Dis 2022; 122:337-344. [PMID: 35688310 DOI: 10.1016/j.ijid.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/30/2022] [Accepted: 06/03/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Northern Syria faces a large burden of influenza-like illness (ILI) and severe acute respiratory illness (SARI). This study aimed to investigate the trends of Early Warning and Response Network (EWARN) reported ILI and SARI in northern Syria between 2016 and 2021 and the potential impact of SARS-CoV-2. METHODS We extracted weekly EWARN data on ILI/ SARI and aggregated cases and consultations into 4-week intervals to calculate case positivity. We conducted a seasonal-trend decomposition to assess case trends in the presence of seasonal fluctuations. RESULTS It was observed that 4-week aggregates of ILI cases (n = 5,942,012), SARI cases (n = 114,939), ILI case positivity, and SARI case positivity exhibited seasonal fluctuations with peaks in the winter months. ILI and SARI cases in individuals aged ≥5 years surpassed those in individuals aged <5 years in late 2019. ILI cases clustered primarily in Aleppo and Idlib, whereas SARI cases clustered in Aleppo, Idlib, Deir Ezzor, and Hassakeh. SARI cases increased sharply in 2021, corresponding with a severe SARS-CoV-2 wave, compared with the steady increase in ILI cases over time. CONCLUSION Respiratory infections cause widespread morbidity and mortality throughout northern Syria, particularly with the emergence of SARS-CoV-2. Strengthened surveillance and access to testing and treatment are critical to manage outbreaks among conflict-affected populations.
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Affiliation(s)
- Maia C Tarnas
- University of California, Population Health and Disease Prevention, Irvine, CA, USA.
| | - Angel N Desai
- University of California, Davis Medical Center, Sacramento, CA, USA
| | - Daniel M Parker
- University of California, Population Health and Disease Prevention, Irvine, CA, USA
| | | | - Omar Zakieh
- Imperial College, Department of Infection, London, UK
| | - Diana Rayes
- Syria Public Health Network, London, UK; Johns Hopkins University, Department of International Health, Baltimore, MD, USA
| | | | - Aula Abbara
- Imperial College, Department of Infection, London, UK; Syria Public Health Network, London, UK
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Marzouk M, Alhiraki OA, Aguas R, Gao B, Clapham H, Obaid W, Altaleb H, Almhawish N, Rihawi H, Abbara A, Douedari Y, Hariri M, Howard N. SARS-CoV-2 transmission in opposition-controlled Northwest Syria: modeling pandemic responses during political conflict. Int J Infect Dis 2022; 117:103-115. [PMID: 35123027 PMCID: PMC8808433 DOI: 10.1016/j.ijid.2022.01.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/02/2022] [Accepted: 01/27/2022] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Ten years of conflict has displaced more than half of Northwest Syria's (NWS) population and decimated the health system, water and sanitation, and public health infrastructure vital for infectious disease control. The first NWS COVID-19 case was declared on July 9, 2020, but impact estimations in this region are minimal. With the rollout of vaccination and emergence of the B.1.617.2 (Delta) variant, we aimed to estimate the COVID-19 trajectory in NWS and the potential effects of vaccine coverage and hospital occupancy. METHODS We conducted a mixed-method study, primarily including modeling projections of COVID-19 transmission scenarios with vaccination strategies using an age-structured, compartmental susceptible-exposed-infectious-recovered (SEIR) model, supported by data from 20 semi-structured interviews with frontline health workers to help contextualize interpretation of modeling results. RESULTS Modeling suggested that existing low stringency non-pharmaceutical interventions (NPIs) minimally affected COVID-19 transmission. Maintaining existing NPIs after the Delta variant introduction is predicted to result in a second COVID-19 wave, overwhelming hospital capacity and resulting in a fourfold increased death toll. Simulations with up to 60% vaccination coverage by June 2022 predict that a second wave is not preventable with current NPIs. However, 60% vaccination coverage by June 2022 combined with 50% coverage of mask-wearing and handwashing should reduce the number of hospital beds and ventilators needed below current capacity levels. In the worst-case scenario of a more transmissible and lethal variant emerging by January 2022, the third wave is predicted. CONCLUSION Total COVID-19 attributable deaths are expected to remain relatively low owing largely to a young population. Given the negative socioeconomic consequences of restrictive NPIs, such as border or school closures for an already deeply challenged population and their relative ineffectiveness in this context, policymakers and international partners should instead focus on increasing COVID-19 vaccination coverage as rapidly as possible and encouraging mask-wearing.
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Affiliation(s)
- Manar Marzouk
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, 117549, Singapore; Syria Research Group (SyRG), co-hosted by the Saw Swee Hock School of Public Health and London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom.
| | | | - Ricardo Aguas
- Nuffield Department of Medicine, University of Oxford, Old Road Campus, Headington, Oxford OX3 7BN.
| | - Bo Gao
- Nuffield Department of Medicine, University of Oxford, Old Road Campus, Headington, Oxford OX3 7BN.
| | - Hannah Clapham
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, 117549, Singapore.
| | - Wael Obaid
- Health Information System Unit in Northwest Syria, Gaziantep, Turkey.
| | - Hani Altaleb
- Relief Experts Association and Northwest Syria COVID-19 Taskforce, Gaziantep, Turkey.
| | - Naser Almhawish
- EWARN / Assistance Coordination Unit, Şehitkamil, Gaziantep, Turkey.
| | - Hazem Rihawi
- American Relief Coalition for Syria (ARCS), 1100 15th Street NW, Washington, DC 20005.
| | - Aula Abbara
- Syria Public Health Network and Imperial College, London, United Kingdom.
| | - Yazan Douedari
- Syria Research Group (SyRG), co-hosted by the Saw Swee Hock School of Public Health and London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom.
| | - Mahmoud Hariri
- Health Information System Unit in Northwest Syria, Gaziantep, Turkey; Health Information System Unit in Northwest Syria and Northwest Syria COVID-19 Taskforce, Gaziantep, Turkey.
| | - Natasha Howard
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, 117549, Singapore; Syria Research Group (SyRG), co-hosted by the Saw Swee Hock School of Public Health and London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom.
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Abbara A, Zakieh O, Rayes D, Collin SM, Almhawish N, Sullivan R, Aladhan I, Tarnas M, Whalen-Browne M, Omar M, Tarakji A, Karah N. Weaponizing water as an instrument of war in Syria: Impact on diarrhoeal disease in Idlib and Aleppo governorates, 2011-2019. Int J Infect Dis 2021; 108:202-208. [PMID: 34010668 PMCID: PMC9972299 DOI: 10.1016/j.ijid.2021.05.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/12/2021] [Accepted: 05/14/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Investigate the weaponization of water during the Syrian conflict and the correlation of attacks on water, sanitation, and hygiene (WASH) infrastructure in Idlib and Aleppo governorates with trends in waterborne diseases reported by Early Warning and Response surveillance systems. METHODS We reviewed literature and databases to obtain information on attacks on WASH in Aleppo and Idlib governorates between 2011 and 2019. We plotted weekly trends in waterborne diseases from two surveillance systems operational in Aleppo and Idlib governorates between 2015 and early 2020. RESULTS The literature review noted several attacks on water and related infrastructure in both governorates, suggesting that WASH infrastructure was weaponized by state and non-state actors. Most interference with WASH in the Aleppo governorate occurred before 2019 and in the Idlib governorate in the summer of 2020. Other acute diarrhea represented >90% of cases of diarrhea; children under 5 years contributed 50% of cases. There was substantial evidence (p < 0.001) of an overall upward trend in cases of diarrheal disease. CONCLUSIONS Though no direct correlation can be drawn between the weaponization of WASH and the burden of waterborne infections due to multiple confounders, this research introduces important concepts on attacks on WASH and their potential impacts on waterborne diseases.
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Affiliation(s)
- Aula Abbara
- Imperial College, London, UK; Syria Public Health Network, UK.
| | | | - Diana Rayes
- Syria Public Health Network, UK,Johns Hopkins, USA
| | | | | | | | | | - Maia Tarnas
- Community Research Initiative, Charlestown, MA, USA
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Knipper M, Sedas AC, Keshavjee S, Abbara A, Almhawish N, Alashawi H, Lecca L, Wilson M, Zumla A, Abubakar I, Orcutt M. The need for protecting and enhancing TB health policies and services for forcibly displaced and migrant populations during the ongoing COVID-19 pandemic. Int J Infect Dis 2021; 113 Suppl 1:S22-S27. [PMID: 33775886 PMCID: PMC8752449 DOI: 10.1016/j.ijid.2021.03.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 11/29/2022] Open
Abstract
Disruption of health services due to the COVID-19 pandemic threatens to derail progress being made in tuberculosis control efforts. Forcibly displaced people and migrant populations face particular vulnerabilities as a result of the COVID-19 pandemic, which leaves them at further risk of developing TB. They inhabit environments where measures such as “physical distancing” are impossible to realize and where facilities like camps and informal temporary settlements can easily become sites of rapid disease transmission. In this viewpoint we utilize three case studies—from Peru, South Africa, and Syria—to illustrate the lived experience of forced migration and mobile populations, and the impact of COVID-19 on TB among these populations. We discuss the dual pandemics of TB and COVID-19 in the context of migration through a syndemic lens, to systematically address the upstream social, economic, structural and political factors that - in often deleterious dynamics - foster increased vulnerabilities and risk. Addressing TB, COVID-19 and migration from a syndemic perspective, not only draws systematic attention to comorbidity and the relevance of social and structural context, but also helps to find solutions: the true reality of syndemic interactions can only be fully understood by considering a particular population and bio- social context, and ensuring that they receive the comprehensive care that they need. It also provides avenues for strengthening and expanding the existing infrastructure for TB care to tackle both COVID-19 and TB in migrants and refugees in an integrated and synergistic manner.
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Affiliation(s)
- Michael Knipper
- Institute for the History of Medicine, University Justus Liebig Giessen, 35392 Giessen, Germany.
| | - Ana Cristina Sedas
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
| | - Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
| | - Aula Abbara
- Imperial College London, Department of Infectious Disease, St Mary's Hospital, London, UK; Syria Public Health Network, Syria.
| | - Naser Almhawish
- Assistance Coordination Unit (ACU), Early Warning Alert and Response Network (EWARN), Gaziantep, Turkey.
| | | | - Leonid Lecca
- Partners in Health, Lima, Peru, and Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
| | | | - Almuddin Zumla
- Department of Infection, Division of Infection and Immunity, University College London NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, UK.
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London WC1N 1EH, UK.
| | - Miriam Orcutt
- Institute for Global Health, University College London, London WC1N 1EH, UK.
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Almhawish N, Karah N, Elferruh Y, Aksh A, Abbara A. Protecting healthcare workers in conflict zones during the COVID-19 pandemic: Northwest Syria. J Infect 2021; 82:186-230. [PMID: 33545168 PMCID: PMC7857032 DOI: 10.1016/j.jinf.2021.01.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 01/30/2021] [Indexed: 10/25/2022]
Affiliation(s)
| | | | | | - Aya Aksh
- Assistance Coordination Unit, Gaziantep, Turkey
| | - Aula Abbara
- Department of Infection, Imperial College, St Mary's Hospital, Praed Street, London W2 1NY, United Kingdom; Syria Public Health Network, London, United Kingdom.
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Elamein M, Bower H, Valderrama C, Zedan D, Rihawi H, Almilaji K, Abdelhafeez M, Tabbal N, Almhawish N, Maes S, AbouZeid A. Attacks against health care in Syria, 2015-16: results from a real-time reporting tool. Lancet 2017; 390:2278-2286. [PMID: 28602556 DOI: 10.1016/s0140-6736(17)31328-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 04/30/2017] [Accepted: 05/12/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Collecting credible data on violence against health services, health workers, and patients in war zones is a massive challenge, but crucial to understanding the extent to which international humanitarian law is being breached. We describe a new system used mainly in areas of Syria with a substantial presence of armed opposition groups since November, 2015, to detect and verify attacks on health-care services and describe their effect. METHODS All Turkey health cluster organisations with a physical presence in Syria, either through deployed and locally employed staff, were asked to participate in the Monitoring Violence against Health Care (MVH) alert network. The Turkey hub of the health cluster, a UN-activated humanitarian health coordination body, received alerts from health cluster partners via WhatsApp and an anonymised online data-entry tool. Field staff were asked to seek further information by interviewing victims and other witnesses when possible. The MVH data team triangulated alerts to identify individual events and distributed a preliminary flash update of key information (location, type of service, modality of attack, deaths, and casualties) to partners, WHO, United Nations Office for the Coordination of Humanitarian Affairs, and donors. The team also received and entered alerts from several large non-health cluster organisations (known as external partners, who do their own information-gathering and verification processes before sharing their information). Each incident was then assessed in a stringent process of information-matching. Attacks were deemed to be verified if they were reported by a minimum of one health cluster partner and one external partner, and the majority of the key datapoints matched. Alerts that did not meet this standard were deemed to be unverified. Results were tabulated to describe attack occurrence and impact, disaggregated where possible by age, sex, and location. FINDINGS Between early November, 2015, and Dec 31 2016, 938 people were directly harmed in 402 incidents of violence against health care: 677 (72%) were wounded and 261 (28%) were killed. Most of the dead were adult males (68%), but the highest case fatality (39%) was seen in children aged younger than 5 years. 24% of attack victims were health workers. Around 44% of hospitals and 5% of all primary care clinics in mainly areas with a substantial presence of armed opposition groups experienced attacks. Aerial bombardment was the main form of attack. A third of health-care services were hit more than once. Services providing trauma care were attacked more than other services. INTERPRETATION The data system used in this study addressed double-counting, reduced the effect of potentially biased self-reports, and produced credible data from anonymous information. The MVH tool could be feasibly deployed in many conflict areas. Reliable data are essential to show how far warring parties have strayed from international law protecting health care in conflict and to effectively harness legal mechanisms to discourage future perpetrators. FUNDING None.
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Affiliation(s)
| | - Hilary Bower
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Daher Zedan
- Union of Medical Care and Relief Organizations, Gaziantep, Turkey
| | - Hazem Rihawi
- Syrian American Medical Society, Gaziantep, Turkey
| | - Khaled Almilaji
- Canadian International Medical Relief Organization, Gaziantep, Turkey
| | | | | | - Naser Almhawish
- Early Warning and Response Network, Assistance Coordination Unit, Gaziantep, Turkey
| | - Sophie Maes
- WHO Gaziantep Field Office, Gaziantep, Turkey
| | - Alaa AbouZeid
- WHO Gaziantep Field Office, Gaziantep, Turkey; Public Health Department, Faculty of Medicine, Cairo University, Giza, Egypt.
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