War is the Enemy of Health. Pulmonary, Critical Care, and Sleep Medicine in War-Torn Syria

Abstract

The Syrian crisis, now in its fifth year, has created an unprecedented strain on health services and systems due to the protracted nature of the warfare, the targeting of medics and health care infrastructure, the exodus of physicians and nurses, the shortage of medical supplies and medications, and the disruption of medical education and training. Within a few short years, the life expectancy of resident Syrians has declined by 20 years. Over the first 4 years of the conflict, more than 75,000 civilians died from injuries incurred in the violence. More than twice as many civilians, including many women and children, have died prematurely of infectious and noninfectious chronic diseases for want of adequate health care. Doctors, local administrators, and nongovernmental organizations are struggling to manage the consequences of the conflict under substandard conditions, often using unorthodox methods of health care delivery in field hospitals and remotely by telehealth communication. Much-needed medical supplies are channeled through dangerous routes across the borders from Lebanon, Jordan, and Turkey. Physicians in the United States and other western nations have helped Syrian physicians make the most of the situation by providing training on introducing innovations in technology and treatment. Portable ultrasound machines have been introduced and are being used extensively in the management of trauma and shock. This report, prepared by members of the Syrian American Medical Society, documents current needs for health care relief within Syria, focusing on pulmonary, critical care, and sleep medicine, and some of the efforts currently underway to meet those needs.

The challenges of tuberculosis control in protracted conflict: The case of Syria

“…The widespread destruction of healthcare facilities has limited the number of functioning TB treatment centers and mycobacteriology laboratories. Attrition of medical staff through death, migration, or flight has similarly limited skilled technicians, microbiologists, and TB physicians and nurses (Health Cluster Turkey Hub, 2018;Sahloul et al, 2016). The exodus of an estimated 15 000 doctors including TB clinicians, specialists, and microbiologists has left gaps in the diagnosis, investigation, and management of TB patients (Fouad et al, 2017;Abbara et al, 2018b).…”

Maintaining Preparedness to Severe Though Infrequent Threats—Can It Be Done?

“…Emergencies caused by hazardous toxicological/chemical materials may result from "inadvertent residential, industrial, occupational or transportation mishaps; natural disasters; and hazardous-substance releases that are intended to cause harm" [5]. Beyond such risks, the use of hazardous materials may be intentionally directed by humans to cause mass devastation, as part of political or military conflicts or wars, as was displayed in the Syrian civilian war [5,11,12]. Mass casualty incidents that involve hazardous materials may be detrimental to the functional continuity of emergency departments (EDs), leading to chaos, confusion, miscommunication, lack of coordination, and misinformation [13,14].…”

Hazardous Chemical Emergencies and Poisonings

“…41,42 Chlorine was deployed as a weapon in World War I and has been used against civilians, with devastating consequences, in the current Syrian civil war. 13 Standard treatment of exposures to such water-soluble agents is supportive, including removal from exposure, decontamination, and provision of humidified oxygen and nebulized bronchodilators as indicated 37,38 (Table 2). Potentially salutary, but less established, interventions include inhaled or systemic glucocorticoids and nebulized sodium bicarbonate for chlorine inhalation.…”

“…Casualties have been reported from the use of sulfur mustard in the 1980s Iran-Iraq conflict and attacks against civilians in the current Syrian conflict and have also been reported among fishermen exposed to munitions that were disposed of at sea and resurfaced in fishing dredges. 13,49,50 Liquid mustard persists in the environment at room temperature and is primarily a dermal hazard. 48 Vapors, formed at higher ambient temperatures, or aerosolized liquids, are an inhalation hazard.…”

“…86 Sarin was deployed as a terrorist weapon in the 1995 Tokyo subway attack 15 and has been used in military conflicts against civilian populations in Iraq and Syria. 13,14 Nerve agents were also used in the widely publicized assassination attempts in Malaysia in 2017 and the United Kingdom in 2018. 11,12 The incident in the United Kingdom highlighted fourth-generation agents, also known as Novichok agents.…”