Impact of the Syrian conflict and forced displacement on respiratory health: an analysis of primary data from a humanitarian organisation.

BACKGROUND: Despite a decade of conflict, there has been little exploration of respiratory health in Syria, notwithstanding the known impacts of conflict on lung health. Our aim is to explore the burden and trends of respiratory consultations in Syrian American Medical Society (SAMS) facilities in northwest Syria through an ecological analysis. METHODS: We performed a retrospective review of routinely collected data relating to respiratory presentations in SAMS' facilities between March 2017 and June 2020; we compared data by facility type, infectious versus non-infectious aetiologies and age. RESULTS: Data were available for 5 058 864 consultations, of which 1 228 722 (24%) were respiratory presentations, across 22 hospitals, 22 primary healthcare centres, 3 mobile clinics and 1 polyclinic. The median number of respiratory consultations per month was 30 279 (IQR: 25 792-33 732). Key findings include: 73% of respiratory consultations were for children; respiratory presentations accounted for up to 38% of consultations each month, seasonal variation was evident; respiratory tract infections accounted for 91% of all respiratory presentations. A steep decrease in consultations occurred between the end of 2019 (160 000) and the first quarter of 2020 (90 000), correlating with an escalation of violence in Idlib governorate. CONCLUSION: This study presents the largest quantitative analysis of respiratory data collected during the Syrian conflict. It supports the need for improved measures to aid the prevention, diagnosis and management of respiratory conditions during conflict as well as further research to explore the impact of conflict on respiratory health.

Protracted armed conflict and maternal health: a scoping review of literature and a retrospective analysis of primary data from northwest Syria.

INTRODUCTION: Syria's protracted conflict has devastated the health system reversing progress made on maternal health preconflict. Our aim is to understand the state of maternal health in Syria focused on underage pregnancy and caesarean sections using a scoping review and quantitative analysis; the latter draws on data from the Syrian American Medical Society's (SAMS) maternal health facilities in northwest Syria. METHODS: We performed a scoping review of academic and grey literature on the state of maternal health across Syria since the onset of conflict (taken as March 2011). Identified articles were screened using pre-established criteria and themes identified. We also performed a retrospective quantitative analysis of maternal health data from SAMS' facilities in a microcontext in north-west Syria between March 2017 and July 2020, analysing the trends in the proportion of births by caesarean section and age at pregnancy. RESULTS: Scoping review: of 2824 articles, 21 remained after screening. Main themes related to maternal mortality rates, caesarean sections, maternal age and perinatal care. 12 studies reported caesarean section rates; these varied from 16% to 64% of all births: northern Syria (19%-45%,) Damascus (16%-54%,) Lattakia (64%) and Tartous (59%.) Quantitative analysis: Of 77 746 births across 17 facilities, trend data for caesarean sections showed a decrease from 35% in March 2017 to 23% in July 2020 across SAMS facilities. Girls under 18 years accounted for 10% of births and had a lower proportion of caesarean section births. There was notable geographical and interfacility variation in the findings. CONCLUSION: The quality of available literature was poor with country-level generalisations. Research which explores microcontexts in Syria is important given the different effects of conflict across the country and the fragmented health system. Our quantitative analysis provides some evidence around the changes to caesarean section rates in northwest Syria. Despite limitations, this study adds to sparse literature on this important topic.

Determining the scope of attacks on health in four governorates of Syria in 2016: Results of a field surveillance program.

BACKGROUND: Violent attacks on and interferences with hospitals, ambulances, health workers, and patients during conflict destroy vital health services during a time when they are most needed and undermine the long-term capacity of the health system. In Syria, such attacks have been frequent and intense and represent grave violations of the Geneva Conventions, but the number reported has varied considerably. A systematic mechanism to document these attacks could assist in designing more protection strategies and play a critical role in influencing policy, promoting justice, and addressing the health needs of the population. METHODS AND FINDINGS: We developed a mobile data collection questionnaire to collect data on incidents of attacks on healthcare directly from the field. Data collectors from the Syrian American Medical Society (SAMS), using the tool or a text messaging system, recorded information on incidents across four of Syria's northern governorates (Aleppo, Idleb, Hama, and Homs) from January 1, 2016, to December 31, 2016. SAMS recorded a total of 200 attacks on healthcare in 2016, 102 of them using the mobile data collection tool. Direct attacks on health facilities comprised the majority of attacks recorded (88.0%; n = 176). One hundred and twelve healthcare staff and 185 patients were killed in these incidents. Thirty-five percent of the facilities were attacked more than once over the data collection period; hospitals were significantly more likely to be attacked more than once compared to clinics and other types of healthcare facilities. Aerial bombs were used in the overwhelming majority of cases (91.5%). We also compared the SAMS data to a separate database developed by Physicians for Human Rights (PHR) based on media reports and matched the incidents to compare the results from the two methods (this analysis was limited to incidents at health facilities). Among 90 relevant incidents verified by PHR and 177 by SAMS, there were 60 that could be matched to each other, highlighting the differences in results from the two methods. This study is limited by the complexities of data collection in a conflict setting, only partial use of the standardized reporting tool, and the fact that limited accessibility of some health facilities and workers and may be biased towards the reporting of attacks on larger or more visible health facilities. CONCLUSIONS: The use of field data collectors and use of consistent definitions can play an important role in the tracking incidents of attacks on health services. A mobile systematic data collection tool can complement other methods for tracking incidents of attacks on healthcare and ensure the collection of detailed information about each attack that may assist in better advocacy, programs, and accountability but can be practically challenging. Comparing attacks between SAMS and PHR suggests that there may have been significantly more attacks than previously captured by any one methodology. This scale of attacks suggests that targeting of healthcare in Syria is systematic and highlights the failure of condemnation by the international community and medical groups working in Syria of such attacks to stop them.