News
Syria: the ongoing crisis
www.thelancet.com/respiratory Vol 3 February 2015
have remained are inexperienced medical students and unsupervised residents. “The situation is deteriorating— people are living in shelters without doors and windows in sub-zero temperatures”, adds Elizabeth Hoff (WHO, Damascus, Syria). WHO has access to both rebel-controlled zones and those under the aegis of the Government, but security concerns mean that they cannot enter some areas. With the collapse of surveillance systems, it is difficult to define the extent to which the population’s health is suffering. Natalie Roberts, Médecins Sans Frontières’ medical coordinator for Syria, notes that respiratory tract infections are common. No data are available for pneumonia, but it is certainly a disease that would thrive in the conditions prevalent in Syria. “One cannot underestimate the issue of shelter”, points out Paul Spiegel (United Nations High Commissioner for Refugees, Geneva, Switzerland). “People are crowded together because of the bombing—there is an increase in density, so therefore there will be an increase in infectious diseases.” Moreover, non-communicable diseases are worsening in elderly people, which renders them more susceptible to diseases such as pneumonia. “For people who have tuberculosis, it is much more difficult to continue treatment and so they remain infectious for longer—taken together with the crowding, one would expect to see an increase in incidence”, Spiegel told The Lancet Respiratory Medicine. WHO projected 3470 cases of tuberculosis in Syria in 2014, but conceded that this figure could be an underestimate. Furthermore, virtually forgotten amid the chaos of conflict is the Syrian Government’s long-running and continuing habit of jailing dissidents. “The mass incarceration of the late 1970s and 1980s meant that tuberculosis cases started multiplying in the prisons”, said Sparrow. “It is
difficult to know the numbers, but there are tens of thousands of people imprisoned across the country in conditions that are perfect for the cultivation of tuberculosis.” Were tuberculosis to take hold in Syria, it would be extremely difficult to address, in view of the drug shortage, the displaced and mobile population, the scarcity of staff and expertise, and the intransigent nature of the disease itself. “The chances of being able to treat people properly are almost negligible at this time”, said Sparrow. Some patients have received partial treatment before supplies have dried up or they have been forced to flee, increasing the risk of multidrug-resistant tuberculosis. The UN has launched a US $8·4 billion appeal to cover aid for Syrians both within the country and in neighbouring states for 2015. However, it is difficult to maintain donor interest for an emergency that stretches over years. And even in the unlikely event that the war ends soon, Syria’s public health crisis will linger. “Things are going to get worse before they get better”, asserted Roberts. “We are seeing diseases related not just to conflict but to people’s living environments”. Until the fighting began, this was a middle-income country. “Whatever happens, it is going to take a huge amount of time to get back to basic living standards in Syria”, concluded Roberts.
Published Online January 16, 2015 http://dx.doi.org/10.1016/ S2213-2600(14)70263-2 For the Physicians for Human Rights report see https://s3. amazonaws.com/PHR_other/ Syria%27s-Medical-CommunityUnder-Assault-March-2014.pdf
Talha Khan Burki
© Hosam Katan/Reuters/Corbis
After almost 4 years of civil war, the statistics tell their own story. At least 191 000 Syrians have been killed, 1 million have been injured, 9 million have been internally displaced, and 3 million have fled the country; 11 million need humanitarian aid, almost half of whom reside in regions in which it is either difficult or impossible for outside agencies to gain access. WHO estimates that 2015 will see 90% of Syrians living in poverty, with 60% unable to secure their own food supply. Vaccination rates, with the notable exception of polio, have fallen to roughly 50%, raising the spectre of future disease outbreaks. Half the country’s public hospitals have been damaged or destroyed, and the ambulance service barely exists. Supplies of clean water, electricity, and fuel have been massively disrupted, and the waste management system is falling apart. There is a critical shortage of essential medicines. Before the war, Syria produced 90% of the drugs it needed; now, the domestic pharmaceutical industry has virtually collapsed, and sharp price rises have made the drugs that are in circulation largely unaffordable. “Hospitals, field clinics, ambulances, and vehicles transporting medicine and medical supplies have been deliberately targeted for destruction. Medical personnel have also been arrested, tortured, executed, and ‘disappeared’”, noted Physicians for Human Rights (PHR) in a 2014 report. Thousands of health-care workers have fled the country. The city of Aleppo was home to 2000 doctors before the war; today, there are three dozen or so. “In the last 18 months, I’ve watched many doctors flee Syria who I thought would never leave”, said Annie Sparrow (Mount Sinai Global Health Centre, New York, NY, USA). Hospitals and health centres have been forced underground, and it is often impossible to accommodate in-patients. Many of the workers who
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Syria: the ongoing crisis
www.thelancet.com/respiratory Vol 3 February 2015
have remained are inexperienced medical students and unsupervised residents. “The situation is deteriorating— people are living in shelters without doors and windows in sub-zero temperatures”, adds Elizabeth Hoff (WHO, Damascus, Syria). WHO has access to both rebel-controlled zones and those under the aegis of the Government, but security concerns mean that they cannot enter some areas. With the collapse of surveillance systems, it is difficult to define the extent to which the population’s health is suffering. Natalie Roberts, Médecins Sans Frontières’ medical coordinator for Syria, notes that respiratory tract infections are common. No data are available for pneumonia, but it is certainly a disease that would thrive in the conditions prevalent in Syria. “One cannot underestimate the issue of shelter”, points out Paul Spiegel (United Nations High Commissioner for Refugees, Geneva, Switzerland). “People are crowded together because of the bombing—there is an increase in density, so therefore there will be an increase in infectious diseases.” Moreover, non-communicable diseases are worsening in elderly people, which renders them more susceptible to diseases such as pneumonia. “For people who have tuberculosis, it is much more difficult to continue treatment and so they remain infectious for longer—taken together with the crowding, one would expect to see an increase in incidence”, Spiegel told The Lancet Respiratory Medicine. WHO projected 3470 cases of tuberculosis in Syria in 2014, but conceded that this figure could be an underestimate. Furthermore, virtually forgotten amid the chaos of conflict is the Syrian Government’s long-running and continuing habit of jailing dissidents. “The mass incarceration of the late 1970s and 1980s meant that tuberculosis cases started multiplying in the prisons”, said Sparrow. “It is
difficult to know the numbers, but there are tens of thousands of people imprisoned across the country in conditions that are perfect for the cultivation of tuberculosis.” Were tuberculosis to take hold in Syria, it would be extremely difficult to address, in view of the drug shortage, the displaced and mobile population, the scarcity of staff and expertise, and the intransigent nature of the disease itself. “The chances of being able to treat people properly are almost negligible at this time”, said Sparrow. Some patients have received partial treatment before supplies have dried up or they have been forced to flee, increasing the risk of multidrug-resistant tuberculosis. The UN has launched a US $8·4 billion appeal to cover aid for Syrians both within the country and in neighbouring states for 2015. However, it is difficult to maintain donor interest for an emergency that stretches over years. And even in the unlikely event that the war ends soon, Syria’s public health crisis will linger. “Things are going to get worse before they get better”, asserted Roberts. “We are seeing diseases related not just to conflict but to people’s living environments”. Until the fighting began, this was a middle-income country. “Whatever happens, it is going to take a huge amount of time to get back to basic living standards in Syria”, concluded Roberts.
Published Online January 16, 2015 http://dx.doi.org/10.1016/ S2213-2600(14)70263-2 For the Physicians for Human Rights report see https://s3. amazonaws.com/PHR_other/ Syria%27s-Medical-CommunityUnder-Assault-March-2014.pdf
Talha Khan Burki
© Hosam Katan/Reuters/Corbis
After almost 4 years of civil war, the statistics tell their own story. At least 191 000 Syrians have been killed, 1 million have been injured, 9 million have been internally displaced, and 3 million have fled the country; 11 million need humanitarian aid, almost half of whom reside in regions in which it is either difficult or impossible for outside agencies to gain access. WHO estimates that 2015 will see 90% of Syrians living in poverty, with 60% unable to secure their own food supply. Vaccination rates, with the notable exception of polio, have fallen to roughly 50%, raising the spectre of future disease outbreaks. Half the country’s public hospitals have been damaged or destroyed, and the ambulance service barely exists. Supplies of clean water, electricity, and fuel have been massively disrupted, and the waste management system is falling apart. There is a critical shortage of essential medicines. Before the war, Syria produced 90% of the drugs it needed; now, the domestic pharmaceutical industry has virtually collapsed, and sharp price rises have made the drugs that are in circulation largely unaffordable. “Hospitals, field clinics, ambulances, and vehicles transporting medicine and medical supplies have been deliberately targeted for destruction. Medical personnel have also been arrested, tortured, executed, and ‘disappeared’”, noted Physicians for Human Rights (PHR) in a 2014 report. Thousands of health-care workers have fled the country. The city of Aleppo was home to 2000 doctors before the war; today, there are three dozen or so. “In the last 18 months, I’ve watched many doctors flee Syria who I thought would never leave”, said Annie Sparrow (Mount Sinai Global Health Centre, New York, NY, USA). Hospitals and health centres have been forced underground, and it is often impossible to accommodate in-patients. Many of the workers who
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