Syrian crisis: health experts say more can be done
2015; Elsevier BV; Volume: 385; Issue: 9972 Linguagem: Inglês
10.1016/s0140-6736(15)60515-3
ISSN1474-547X
Autores Tópico(s)Health and Conflict Studies
ResumoAs the Syrian conflict enters its fifth year this month, doctors and public health experts highlight the major health problems and the actions needed to address them. Sophie Cousins reports. On March 11, 2011, protestors took to the street in the southern Syrian city of Deraa after the arrest and torture of a group of teenagers who painted revolutionary slogans on a school wall. Security forces opened fire on the pro-democracy demonstrators, killing several and as a result, more protestors took to the streets. The unrest triggered nationwide protests demanding President Bashar al-Assad's resignation. But the demonstrations turned more violent and subsequently into a bloody civil war that has, 4 years on, killed more than 200 000 people. The exact death toll has been so hard to determine that the UN gave up counting the dead in early 2014. What began as another Arab Spring against a despotic ruler—as in Egypt and Libya—has burgeoned into a brutal proxy war that has drawn in regional and world powers. More recently, the rise of jihadist groups, namely the Islamic State (IS), has not only complicated the war, it has made it more brutal and bloody. Beheadings and hangings are no longer shocking; they are commonplace. Inevitably, the war has had an unprecedented and multidimensional effect on the country's health system. What was once touted as one of the best health-care systems in the Arab world is now the worst. Hundreds of doctors, nurses, dentists, pharmacists, and paramedics have been killed, or fled to neighbouring countries or further afield, leaving a huge gap in experience and expertise that cannot be filled. Zaher Sahloul, president of the Syrian American Medical Society, said more than 600 health-care professionals have been killed in the conflict. A report by Save the Children last year said remaining medical staff, some underqualified and inexperienced, were doing operations, such as amputating limbs of children with serious injuries, because they lacked the equipment to treat them. Newborn babies were dying in incubators due to power cuts and some patients opted to be “knocked out with metal bars for lack of anaesthesia”. “In some areas like Homs, Aleppo, East Ghouta, Deir ez-Zor, and Al-Raqqa, the situation is more dire: more than 75% of health-care professionals have been forced to leave”, Sahloul said. “Doctors inside Syria are ready to risk their lives but they need financial support, training, and protection.” Aleppo, formerly the country's economic hub with 2·5 million people and 6000 doctors, is now a city in ruins. Presently, in eastern Aleppo, only one neurosurgeon, one vascular surgeon, and three orthopaedic surgeons remain to serve more than 400 000 people under semi-siege conditions, according to Sahloul. The doctors who remain, work in fear of reprisal, having to assume fake names and work in a cloud of secrecy. They risk their lives everyday to provide lifesaving treatment to thousands of people who can't afford to leave or refuse to. According to a report by Physicians for Human Rights last year, there have been 150 attacks on 124 different medical facilities throughout Syria between March, 2011, and March, 2014. 90% of those attacks were by Syrian Government forces. Additionally, half the country's public hospitals have been destroyed or badly damaged and the ambulance service barely exists. David Nott is one of the few foreign doctors who have dared to venture into Syria. On his three trips to Syria since 2012, he has witnessed the destruction of the country's health-care system and the systematic targeting of innocent civilians with unimaginable injuries. During his last stint in Aleppo last year, he noticed a fundamental change from his previous trip to the city a year earlier: barrel bombs had literally razored east Aleppo to the ground. “The health situation in Syria is getting worse and worse because of the [air] strikes that are unabated”, he said. “Although clandestine shipments of vaccines and medicines are being pushed through, the amount of skilled medical workers and nurses is minimal, so lots of medicines are being stockpiled without being used.” But, as he stressed, one of the biggest problems in Syria now is financial: donors are fatigued with a war that shows no sign of waning. “Because the war has gone on now for over 4 years the amount of charitable money which is being donated is drying up”, Nott explained. “There has been a significant move to stop any finances from getting into Syria from governments and other big donors. They do not know where the money is going and need to really have one channel that they can trust…so it's getting more and more difficult to financially support the humanitarian crisis.” Public health expert Adam Coutts said the health-care system in Syria (serving 18 million people) was now divided into multiple systems: opposition and government areas and areas controlled by IS. “In opposition areas, the facilities are in terrible condition with many destroyed or partially destroyed. Many field clinics have sprung up to cater for the increasing needs but they are obviously overwhelmed”, he said. “In government areas, the situation is better but they report they are inundated with patients and cannot meet demands. As with opposition areas, there is evidence from IS-controlled areas that facilities are still functioning although they lack equipment and access to training.” Polio, which is highly contagious and transmitted via contaminated food and water, can cause paralysis and even death, and re-emerged in Syria in October, 2013—14 years since the country had been declared polio-free. The resurfacing of the virus led to a huge immunisation campaign, which targeted 27 million children across the region, several times. A year ago the UN labelled the outbreak in Syria and its subsequent spread to Iraq as “the most challenging in the history of polio eradication”. A year later, in January, WHO declared there had been no cases of polio reported in the past year. Although health experts have welcomed the news, others are sceptical that the country could go from 36 new cases in 2013, to zero, given the difficulty of monitoring the disease under the circumstances. Chris Mayer, manager for polio eradication and emergency support at WHO, said it was evident efforts to contain the outbreak were working. “The likelihood is that if a sensitive surveillance system is looking for polio and can't find it for a year, there is no polio, but given the circumstances in Syria and Iraq we are cautious”, he said. However, he added that although the transmission of wild poliovirus had allegedly been halted in Syria and Iraq, “a further phase of outbreak response is recommended for both countries for the coming 6 months”. However, some health experts have highlighted the limitations of polio surveillance, including delayed and incomplete testing and verification of suspected polio cases. Public health and polio specialist Annie Sparrow says she had “low grade confidence” in WHO's report, citing serious limitations with getting stool samples to laboratories for formal diagnosis. She said the Syrian opposition's humanitarian arm, the Assistance Coordination Unit, which has been vaccinating children in northern Syria, reported 105 cases of acute flaccid paralysis in 2014 and only 63% stool adequacy. So, she explained, because of a lack of adequate facilities and the challenges of diagnosing poliovirus in Syria, many cases cannot and have not been fully confirmed. “The absence of laboratory evidence of wild poliovirus cannot be said to mean the absence of polio in this setting where accurate surveillance is impossible and where clinically compatible cases of polio are not reported”, she said. Coutts said the news from WHO was reassuring but noted the lack of information coming from IS-controlled areas. “The challenge is now to sustain these campaigns and strengthen health information systems and support local non-governmental organisations (NGOs), despite an ever-worsening security situation, increased movement of people, declining sanitation conditions, and reduced aid budgets”, he said. Martin Eichner from the Department of Medical Biometry at the University of Tubingen, Germany, and colleagues warned in The Lancet in late 2013 that the re-emergence of polio in Syria could threaten nearby regions. They wrote that because only one in 200 infected people developed paralysis, there could be a year of “silent transmission” before an outbreak is detected. More than a year later, Eichner referred to previous simulation studies he has run in which he increased vaccination coverage and then looked at the time periods between two occurrences of polio. “Periods of 1 year without disease were an extremely weak indicator for extinction”, he said. He added that it was only after 3 years had passed without occurrence that the probability was very high that it had been eradicated. “It is dangerous to trust that the infection can be kept out of the region, if vaccination does not provide immunity. It may just be ‘waiting’ to come back.” Sahloul echoed his thoughts. “There are thousands of children who are in difficult-to-reach areas such as areas under the control of IS and areas under siege, who haven't been receiving polio and other routine vaccinations consistently. It's not unlikely that we will have other cases of polio in the near future, especially with the deterioration of public health infrastructure, a lack of adequate and clean water, and poor nutritional status.” Sparrow added that a measles vaccine mix-up in which the vaccine was mixed with atracurium, a muscle relaxant used in surgery, rather than diluent, and led to the deaths of 17 children late last year, had eroded community trust in vaccination campaigns. Although a new polio vaccination campaign was scheduled for late February, it has been suspended, along with a planned measles immunisation campaign. “This tragedy underscores the lack of support to Syrian NGOs on the ground, and the irresponsibility of…international NGOs in withholding direct support, and attempting, absurdly, to run such critical public health campaigns by remote control”, Sparrow said. “Syrian children pay the price. The problem goes well beyond polio.” In 2014, at least 10 000 cases of measles were reported in Syria and Turkey, and as Sparrow points out, a disturbing increase in serious respiratory illness. There was an outbreak of deadly bronchiolitis in Idleb, Hama, and Aleppo this winter and 700 cases in Atme, in northern Syria, in 1 month alone, Sparrow said. “Without adequate surveillance—bearing in mind the lack of laboratories, the ongoing attrition of doctors, and the added burdens of cold and malnutrition—it's impossible to know whether this outbreak and high death rate was due to the virus itself, or because of the compounding of ill-health due to cold, malnutrition, absence of fuel for generators, or the noxious and irritant results of burning clothes and furniture in attempts to keep warm”, she said. There have also been outbreaks of hepatitis A, scabies, lice, and leishmaniasis, which has continued to spread beyond its original endemic areas to neighbouring countries and refugee camps. “We have also been seeing more cases of hepatitis B and probably C and D due to lack of testing for blood transfusions in field hospitals”, Sahloul explained. “Testing kits are expensive and not always available.” He added that HIV could also be a problem because of lax blood testing before blood transfusion. Meanwhile, before the war, the estimated prevalence of tuberculosis in Syria was 23 per 100 000 people, according to WHO. The agency estimated 3470 cases in Syria in 2014, but conceded the figure could be higher. If Syria were to experience a serious outbreak of tuberculosis, it would be difficult to treat given the drug shortages, the continuous movement of people, and the threat of multidrug-resistant (MDR) tuberculosis. Neighbouring Lebanon and Jordan have already experienced an increase in tuberculosis rates associated with the refugee crisis. Lebanon has seen a 27% increase in cases since 2011, while the International Organisation for Migration said 22% of the estimated tuberculosis cases in Jordan this year will be attributed to Syrians. Sparrow said a substantial burden of tuberculosis existed, which had been incubating in prisons for decades. She also raised concerns about childhood tuberculosis. “Childhood tuberculosis is notoriously difficult to diagnose even when in a first world country, let alone in a setting of conflict and insecurity without specialists or laboratories”, she said. Sahloul added there had been an increase in MDR bacterial infections of bones, especially in patients who underwent bone surgeries for fractures sustained during bombing, which required placement of fixators. He added: “Many of these patients had to be amputated later on for severe infections and resistance to antibiotics. We expect more MDR organisms to spread in light of poor infection control among refugees and in field hospitals.” Meanwhile, some health experts have also raised concerns about the burden of non-communicable diseases (NCDs) such as diabetes, cancer, and asthma. Doctors estimate that more than 300 000 people have died in Syria from NCDs since the beginning of the crisis. “NCDs have generally been neglected due to a lack of system resources and access to medications as well as people being unable to afford them”, Fouad Mohammad Fouad, from the Department of Epidemiology and Population Health at the American University of Beiurt, and Coutts said. “The numbers of amputees and disabled due to conflict-related injuries is a big problem, although there is no accurate data on this, but it will obviously be a major post-conflict issue along with NCDs.” They also cited the lack of reliable on-the-ground data as a major barrier in understanding the scope of the problem. Sahloul said he expected Syria's health-care system to continue to disintegrate, resulting in the spread of infectious diseases and more deaths and morbidity due to NCDs. “Unless there is serious effort among the regional countries and the UN to address post-crisis recovery, the health situation may further deteriorate even after the crisis ends as relief organisations will start leaving and relief money will dry up quickly”, he said. Almost 4 million Syrians have fled their homes and sought refuge in neighbouring countries, including Jordan, Lebanon, Iraq, and Turkey. These countries have absorbed 97% of Syria's refugees, according to the UN refugee agency (UNHCR). In Lebanon, a tiny Mediterranean country, Syrians make up 25% of its population. To curb the influx of refugees, the Lebanese Government introduced a new visa requirement in January stipulating that Syrians must provide documentation identifying their reason for being in Lebanon. However, none of the six visa categories are explicitly for refugees. Although it is believed the new regulations will not affect the 1·1 million registered refugees, there are at least 300 000 unregistered refugees—many of whom move back and forth between the two countries, often for medical treatment because it's too expensive in Lebanon. “This is a huge humanitarian problem. Syrian refugees in Lebanon…can't afford to pay for health care in Lebanon, especially for elective surgeries, cancer treatment, complicated procedures, and treatment of chronic diseases like thalassaemia”, Sahloul said. “They also can't travel back to Syria to seek such treatment for safety reasons and for the high possibility that they will be blocked from re-entry to Lebanon.” Evelyne Devaud, Lebanon medical coordinator at Médecins Sans Frontières, said Lebanese hospitals were overwhelmed with refugees who were struggling to pay for treatment, particularly childbirth. Although UNHCR covers 75% of childbirth costs for registered refugees, patients are responsible for the remaining 25%. “Not all Syrians can afford to pay the 25%”, Devaud said. “Some have to take out loans. There is also limited space at hospitals. Refugees are using up all hospital beds in Lebanon and some are asked to pay US$500 before even entering for treatment.” Devaud said the situation had become so dire that some women were giving up their babies because they couldn't afford to take care of them. She said there had been high rates of abortions and increasing numbers of child malformations because of intra-family marriages. “The situation is getting worse. People are fed up with Syria. We need to have a solution tomorrow but it won't happen. The long-term current health situation is not sustainable.” UNHCR also covers 85% of diagnostic tests and laboratory procedures for children younger than 5 years, pregnant women, people older than 60 years, and people who are disabled, but limited funds has meant it has been unable to provide cover for complex, urgent cases such as cancer and organ transplant. “Unfortunately difficult decisions have to be made”, a spokesperson for UNHCR said, adding that “many public health-care clinics lack the trained expertise and do not have the capacity to deal with the increasing demand on the already weak infrastructure”. Sahloul said the Lebanese health-care system could accommodate more patients if there was political will and adequate international assistance. “The Lebanese Government should grant special license to Syrian health-care professionals residing in Lebanon as refugees to provide health care to Syrian and Palestinian refugees. Such a simple procedure can ease the burden on the Lebanese system, grant some level of economic security to the Syrian doctors and nurses in Lebanon, and allow these health-care professionals to treat Syrian refugees without fear of deportation and harassment. The same applies to the situation in Jordan”, he suggested. Health experts praised the Turkish Government's handling of health care for Syrian refugees, saying it was “providing a model system for refugees”. Turkey is home to 1·6 million refugees and at the end of last year the country issued new regulations that granted refugees secure legal status, which enabled them to access health care that is covered under the general health insurance system paid for by the government. But as the war in Syria continues to rage, doctors and health experts are focusing on the future of the health response, and planning for post-crisis recovery. Coutts said adequate health information systems were an essential cost-effective investment that would be invaluable in Syria and neighbouring countries. “The major need now and for the future is for adequate health information systems to be set up in opposition areas and to strengthen the government-run ones”, he explained. “This will also help prepare for addressing post-conflict health needs, which are likely to be massive. Investment into NCD surveillance, management, and care is badly needed in Syria and neighbouring countries.” Sahloul said the health situation had to be looked at in a holistic way that addresses the health impact for the whole region. “The UN and WHO should play a leading role, but right now, WHO is the least responsive body within the UN in terms of addressing the crisis from all perspectives”, he said. He added that the plight of Syrian medical and nursing students, doctors in training, and refugee physicians had to be addressed. “All effort should be exerted to stop the brain drain of Syrian doctors. Such drain is one of the worst untold stories of the crisis. They can be part of the solution instead of being an additional burden on the system.” But, as Devaud pointed out, Syrians need a solution to the crisis tomorrow. With no signs of the conflict abating and international attention waning, solutions, however, seem to be a long way off. David Nott: providing surgical care at the frontline of conflictsIn 1993, surgeon David Nott took leave from his consultancy position in Charing Cross Hospital, London, UK, to travel to Sarajevo, in the former Yugoslavia, to volunteer for Médecins Sans Frontières (MSF) in a hospital so pockmarked with bullet holes it was known as the Swiss cheese hospital. “The place would get thudded from time to time”, he remembers, “and there were lots of people with arms and legs blown off, but—and this sounds strange to say—I had never felt so alive in my life. I really enjoyed the thrill of being in a situation where I could've died.” Full-Text PDF Syrian refugee crisis: when aid is not enoughThe Syrian crisis poses an unprecedented challenge for neighbouring countries. The refugee influx has resulted in a 10% population increase in Jordan and a 25% increase in Lebanon (according to UNHCR data). Turkey, Iraq, and Egypt also face increasing strain on their infrastructures. With no political solution in sight, host countries are implementing new measures to alleviate the burden on their economies. Full-Text PDF 4 years of the humanitarian tragedy in Syria: who cares?While the humanitarian crisis continues to worsen in Syria, the international community's support continues to weaken. Since December, 2013, at least 16 Syrian children and newborns have been reported to have frozen to death within the refugee camps bordering Syria and inside the country, including seven Syrian children and newborns who have frozen to death in the 2nd week of January, 2015 alone.1,2 The fact that in the 21st century, cold weather can still claim the lives of children and destroy many other lives is outrageous, yet in Syria this occurrence is commonplace, while the rest of the world watches on. Full-Text PDF
Referência(s)