Without healthcare workers (HCWs), health and humanitarian provision in Syria cannot be sustained either now or in the post-conflict phase. The protracted conflict has led to the exodus of more than 70% of the healthcare workforce. Those remaining work in dangerous conditions with insufficient resources and a healthcare system that has been decimated by protracted conflict. For many HCWs, particularly those in non-government-controlled areas (NGCAs) of Syria, undergraduate education and postgraduate training has been interrupted with few opportunities to continue. In this manuscript, we explore initiatives present in north west Syria at both undergraduate and postgraduate level for physician and non-physician HCWs. Conclusion: Challenges to HCW education in north west Syria can be broadly divided into 1. Organisational (local healthcare leadership and governance, coordination and collaboration between stakeholders, competition between stakeholders and insufficient funding.) 2. Programmatic (lack of accreditation or recognition of qualifications, insufficient physical space for teaching, exodus of faculty affecting teaching and training, prioritisation of physicians over non-physicians, informally trained healthcare workers.) 3. Healthcare system related (politicisation of healthcare system, changing healthcare needs of the population, ongoing attacks on healthcare.) Locally implementable strategies including dedicated funding are key to supporting retention of HCWs and return during post-conflict reconstruction.

Syrian trauma hospitals operate in the Syrian civil war under severe material and human resource constraints. Attention must be paid to providing biomedical engineering support and to directing resources to currently unsupported and geographically isolated critical access surgical hospitals.

for their valuable and constructive suggestions during the planning and development of this research work. Their willingness to give their time so generously have been very much appreciated.Introduction: There is limited research on how the COVD-19 pandemic will affect countries with weakened health systems and particularly those in conflict. Syria's protracted conflict has strained its health systems and caused fragmentation. In this study, we focus on northwest (NW) Syria, where recent violence has driven almost one million civilians (of the 4.17 million in the area) from their homes between December 2019 and March 2020. The area is challenged by overcrowding, inadequate WASH, shelter and insufficient healthcare services. Internationally promoted measures (social distancing, self-isolation, quarantine, lockdown) are not impossible. We model outcomes, according to three scenarios, should there be a COVD-19 outbreak. We aim to: 1. Predict the numbers of cases, including severe and critical ones, and deaths. 2. Identify critical time points when the health system capacity is overwhelmed due to COVID-19.Methodology: using the WHO COVD-19 Essential Supplies Forecasting Tool (COVID-ESFT) and data from the Health Information System Unit on population and health facility capacity and utilization in northwest Syria, we generate predicted numbers of cases, deaths and health care needs according to three scenarios. Scenario One assumes a medium doubling rate (every 4 days) and a medium clinical attack rate (20% of the population). Scenario Two assumes a fast doubling rate (every 3.2 days) and a medium clinical attack rate (20% of the population). Camppopulation Scenario assumes a very fast doubling rate (every 2.3 days) and a medium clinical attack rate (20% of the population). Scenarios One and Two apply to the total population of 4.17 million and for 8 weeks from the first case while Camp-population Scenario applies only to the 1.2 million internally displaced persons (IDPs) in camps and tented settlements and for 6 weeks from the first case. For each scenario, we identify critical time-points when the health system capacity is overwhelmed assuming a highly conservative estimate that 50% of regular hospital (ward) and ICU beds can be occupied by COVID-19 patients.Results: Scenario One predicts 16,384 cases (0.4% of the total population), of which 2,458 are severe and 819 are critical, and 978 deaths in the first 8 weeks. Scenario Two predicts 185,364 cases (4.4% of the population), of which 27805 are severe and 9268 are critical, and 11,066 deaths in the first 8 weeks. Camp-population Scenario predicts 240,000 cases (20% of the IDP population) of which 36,000 are severe and 12,000 are critical and 14,328 deaths in the first 6 weeks. With only 2,429 inpatient beds and 240 ICU beds (98 with adult ventilators, 62 with paediatric ventilators) in northwest Syria, ward and ICU bed capacities will be overwhelmed within 4-7 weeks. The Camp-population Scenario will see the earliest critical time-points. Conclusion and recommenda...

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 9 July 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 COVID-19 trajectory in NWS and potential effects of vaccine coverage and hospital occupancy. Methods We conducted a mixed-method study, primarily including modelling 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 contextualise interpretation of modelling results. Results Modelling suggested that existing low stringency non-pharmaceutical interventions (NPIs) minimally affected COVID-19 transmission. Maintaining existing NPIs after Delta variant introduction is predicted to result in a second COVID-19 wave overwhelming hospital capacity and resulting in a 4-fold increased death toll. Simulations with up to 60% vaccination coverage by June 2022 predict 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, a third wave is predicted. Conclusion Total COVID-19 attributable deaths are expected to remain relatively low, due 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.

Introduction: Despite nearly a decade of con ict, little is known about trauma and injuries resulting from the Syrian war.Methods: Secondary analysis was conducted of an administrative dataset of patient presentations to a network of 95 war-affected hospitals in Syria from July 2013 -July 2015. Logistic regression was performed to identify factors associated with mortality of neurotrauma patients.Results: Of 193,618 overall trauma presentations, 41,143 were for neurotrauma (37,410 head trauma, 1,407 spinal trauma and 3,133 peripheral nervous system). There were 31,359 males (76.2%) and 9,784 females (23.8%). Males aged 19-30 years (10,113; 24.6%) were the largest single demographic group. Presumed non-combatants including females, elders and children under 13 years (16,214; 39.4%) were the largest group of patients overall. There were 16,881 (41.0%) presentations with blunt injuries (blunt/crush injuries) and 21,307 (51.8%) patients with penetrating injuries (shrapnel, cut, gunshot). A total of 36,589 patients (89.6%) were treated and discharged from the hospital, 2,100 (5.1%) were transferred to another facility, 2,050 patients (5.0%) died in-hospital, 26 remained in the hospital (0.1%), 108 (0.3%) had unknown disposition. The median length of hospital stay was 1 day. There were 4,034 (9.7%) neurosurgical procedures documented. Patients with combined neurotrauma and general trauma suffered 30 times higher mortality than neurotrauma alone (aOR: 30.4; 95%CI: 20.8-44.2, p<0.0001). Conclusion:The Syrian War resulted in large volumes of neurotrauma patients. Presumed noncombatants comprised 39.4% of patients who survived to treatment at a facility. Further study is needed on long-term needs of neurotrauma victims of the Syrian war.