Syria Update

Scale of attacks on medical neutrality unprecedented

Leaders of the Syrian-American Medical Society describe their efforts to support what remains of the Syrian healthcare system and the healthcare context in which those efforts take place in their article: “War is the Enemy of Health: Pulmonary, Critical Care and Sleep Medicine in War-torn Syria.” Middle East Heath reports.

“The Syrian conflict is unprecedented in the scale and gravity of the attacks on medical neutrality, which was something that was agreed upon 150 years ago in Geneva,” says Mohammed Z Sahloul, MD. “Nearly 700 medical workers have been killed in this war, and more than 300 hospitals attacked, according to Physicians for Human Rights.”

Dr Sahloul, a pulmonologist and critical care physician in Oak Lawn, Illinois, US, served as president of the Syrian-American Medical Society for four years. He is the lead author of the article: “War is the Enemy of Health: Pulmonary, Critical Care and Sleep Medicine in War-torn Syria” published in the Annals of the American Thoracic Society.

The Syrian-American Medical Society, formed shortly after the war began to help Syrian refugees in Turkey, has grown into a $25-million enterprise which now provides 24/7 telemedicine consulting to nine Syrian ICUs and is estimated to have helped more than two million people. It also conducts “train-the-trainer” webinars and has done so for 850 doctors, nurses, paramedics and technicians on such topics as how to resuscitate trauma patients, the fundamentals of critical care and triaging surgery patients.

And in classrooms in Turkey and Lebanon, it has trained Syrian doctors in the use of, and equipped them with, portable ultrasound to diagnose bodily injuries. Powered by rechargeable batteries, this technology has proved especially helpful in the wartorn region prone to power outages.

By all accounts, the healthcare situation in Syria is grim. The authors cite statistics that they and other organizations have compiled:

  • In the first four years of the conflict, 75,000 civilians died from war injuries; 25% of those killed were women and children.
  • More than twice that number have died from chronic and infectious disease because of inadequate medical care.
  • There is growing incidence of TB among Syrian refugees in Lebanon. A 2014 British Medical Journal article found a 27% increase in TB.
  • By 2013, 70% of the healthcare workforce had left the country. In Syria’s largest city, Aleppo, only 70 of the 6,000 physicians who once practiced there remain.
  • Syrian life expectancy has plummeted by 20 years since war broke out.

Responding to this healthcare crisis has been made much more difficult by the targeting of hospitals and healthcare workers, primarily by the Government, but also by the rebels, according to the authors.

Dr Sahloul decried the absence of a forceful response to these war crimes by physicians and international medical organizations. Medical neutrality, which is designed to protect civilians and the healthcare professionals who treat them during a war, is something “sacred among medical professionals”, he added.

“The medical community is very late in responding to the situation in Syria,” Dr Sahloul said. “As physicians, we not only have an obligation, we have a powerful voice to insist that policy makers ensure that populations under siege have access to care.”

Chemical weapons

The Syrian-American Medical Society has also documented the use of chemical weapons, another war crime, by the Syrian armed forces. Although most people have only heard of the 2013 sarin attack that killed 1,400 people and injured 10,000 others, since December 2012, the group reports that there have been 152 documented attacks using toxic gases, including 8 using sarin, which paralyzes respiratory muscles, and 92 with chlorine gas, which dissolves lung tissue.

He said the Syrian-American Medical Society has trained Syrian healthcare workers in how to treat patients exposed to chemical agents.

Despite the makeshift conditions under which medical care is provided in Syria, the authors argue that the efforts of the Syrian-American Medical Society and other groups supporting the healthcare workers remaining in the country should be subject to evaluation and measurement.

“A retrospective survey of 527 healthcare workers trained in portable ultrasound found that 87% had incorporated the technology into the daily management of violent conflict,”

Dr Sahloul said. “This technology should be studied in areas of war. It has the potential to save thousands of lives.”Dr Sahloul’s observation captures the principle of the Syrian-American Medical Society implicit in the journal article: even in humankind’s darkest moments, caring and rational people can provide light.

Tele-ICU program saves lives

Life-saving medical treatment can be readily deployed using modern cost-free social media applications in regions devastated by war, according to clinicians who launched the Syria Tele-ICU program in December 2012. In a report published online ahead of print in the American Thoracic Society journal , the researchers detail their experience in providing critical care services using telemedicine to civilians in an active war zone.

In the paper “Rapid Deployment of International Tele-ICU Services in War-torn Syria,” Craig Weinert, MD, associate professor of medicine in the Division of Pulmonary, Allergy, Critical Care and Sleep Medicine at the University of Minnesota Medical School, and Anas Moughrabieh, MD, fellow in the Pulmonary and Critical Care Fellowship Training Program at the University of Minnesota, argue that while intensive care services typically take place at the bedside, threats to the safety of health professionals as well as the lack of cooperation of government forces are significant barriers that require a less direct but effective method of healthcare delivery. Approximately a year after the conflict in Syria began in 2011, only 35 physicians were left to care for 2.5 million people in Aleppo, the largest city in Syria.

With his knowledge of tele-ICU programs in the US, Dr Moughrabieh recruited a network of Arabic-speaking clinicians in North America to develop and staff the program. Nurses working in ICUs in conflict areas in Syria were trained to use technology such as WhatsApp, Viber and Google applications to communicate and take medical orders from clinicians 6000 miles away. Their findings show that “social media applications that many people in the West regard as something frivolous that teenagers use can be easily adapted for creating a life-saving international network that can deliver care where it is too dangerous to be present on site,” said Dr Weinert.

Without the financial resources and physical security of hospitals on which US telemedicine programs can rely, the Syrian program was managed at minimal cost using volunteer clinicians, obtaining capital from humanitarian organizations such as the Syrian American Medical Society and diverting most of their budget towards satellite internet expenses.

“Effective telemedicine programs do not have to take years to develop or need massive financial support. This was the accepted paradigm for tele-ICU programs in the US – years to plan and build with million dollar budgets. This study shows it doesn’t have to be that way,” added Dr Weinert. The annual operating budget for the Syria Tele-ICU program is approximately $1000 per year.

While the researchers are hopeful that tele-ICU programs like theirs can be replicated in other war-torn regions, they acknowledge that “there is a lower limit of civil functioning below which even a telemedicine program cannot be effective. One of the reasons that the tele-ICU works in Syria is that Syria has a modern middle-class with prior experience in using computers and social media and has at least some remaining medical facilities that can provide ICU-level therapies like ventilator support.”

Nearly a year after its start, the Syria Tele-ICU Program was providing care to approximately 90 patients per month in Aleppo. It currently supports five ICUs with plans to support an additional 10 at some point this year.

doi: 10.1513/AnnalsATS.201509-589OT.


The Syrian American Medical Society (SAMS) is a nonprofit, professional and nonpolitical organization that represents over 5,000 Syrian American physicians in the United States. SAMS is working at the front lines of crisis relief in Syria and its neighbors to alleviate suffering and save lives. Please donate to:

War is the Enemy of Health: Pulmonary, Critical Care and Sleep Medicine in War-torn Syria (PDF)

Date of upload: 15th Mar 2016


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