Zaher Sahloul

In the spring of 2014, at the peak of the war in Syria, I left Chicago to volunteer as a critical care specialist at the Al-Sakhour Hospital in Aleppo. The hospital building had three stories with an emergency room in the basement. From the inside, it looked like any emergency room in Chicago. It was equipped with an otoscope, light source, suture kits, defibrillator, intravenous lines, manual resuscitation masks, and intravenous fluids. But the clerestory windows were blocked by sandbags from… Show more

In the spring of 2014, at the peak of the war in Syria, I left Chicago to volunteer as a critical care specialist at the Al-Sakhour Hospital in Aleppo. The hospital building had three stories with an emergency room in the basement. From the inside, it looked like any emergency room in Chicago. It was equipped with an otoscope, light source, suture kits, defibrillator, intravenous lines, manual resuscitation masks, and intravenous fluids. But the clerestory windows were blocked by sandbags from the outside to protect patients and doctors from shrapnel. The hospital had been bombed several times.
Aleppo was the epicenter of the Syrian crisis and the most dangerous city in the world. It was divided into a western half controlled by the regime and an eastern half controlled by rebels. The front line ran through the middle of the historic old city with the Aleppo Citadel in the center. Civilians who tried to cross were shot at by regime snipers.
I crossed the border from Turkey at Bab Al-Salamah and traveled south in an ambulance driven by a nurse from an Aleppo hospital. It was my second medical mission to the city. Rebels controlled the roads from Turkey to Aleppo, but regime militia and extremist groups made travel dangerous. There were also criminal gangs that exploited the situation and kidnapped people for ransom. We passed roadblocks controlled by masked men, each with a different flag.
The barrel bomb — barmeel in Arabic — is a clumsy weapon. It is an improvised weapon, made from barrels of various sizes, packed with 150 to 500 kilograms of TNT mixed with fertilizers, diesel fuel, and aluminum powder for incendiary effect and pieces of scrap metal, nails, and rusty pipes to serve as shrapnel. They penetrate the bodies of victims, causing visible and invisible wounds. Many die from internal bleeding. The explosive mix is ignited by a long fuse before it is pushed off helicopters. Show less

A regime that bombs hospitals and blocks convoys of baby formula does not deserve a leading role in global health.

In one day, we lost three patients in the intensive care unit due to complications related to severe COVID-19 pneumonia.
The patients who died were 45, 53 and 73 years old — two men and one woman. All three patients had been on life support for more than four weeks and had developed multiple complications, including other infections with resistant bacteria, bleeding, acute kidney failure and shock. All three patients were on maximum ventilator support, and there were no more ways to give… Show more

In one day, we lost three patients in the intensive care unit due to complications related to severe COVID-19 pneumonia.
The patients who died were 45, 53 and 73 years old — two men and one woman. All three patients had been on life support for more than four weeks and had developed multiple complications, including other infections with resistant bacteria, bleeding, acute kidney failure and shock. All three patients were on maximum ventilator support, and there were no more ways to give them more oxygen.
We tried everything to keep them alive, but the virus won. Their families have been devastated.
St. Anthony Hospital is a “safety net” facility on Chicago’s Southwest Side that serves low-income and vulnerable populations. As with many hospitals across the nation, the number of deaths related to COVID-19 at St. Anthony is accelerating, as more patients who were admitted a few weeks ago with respiratory failure and placed on mechanical ventilators are reaching the end of the road.
This virus is relentless. It attacks the body in different ways, and kills using different strategies. It is a smart and cunning virus. We have not seen anything like it in our lifetime.
One of the most demanding tasks in the ICU is to call families and share with them the progression of the disease affecting their loved ones. We answer their questions, make sure they understand the gravity of the situation and tell them that cardiopulmonary resuscitation will not help to bring life to the patient when their heart stops beating.
The situation is overwhelming. Nurses bear the brunt of caring for very sick patients and communicating with families. During this pandemic, they have to see more critical patients than usual. With the increase in patients to the ICU in the past few weeks, one nurse has been taking care of three, four or even five complicated patients instead of the usual two. Show less

The control of TB in Syria requires a multipronged, tailored, and pragmatic approach to improve timely diagnosis, increase detection, stop transmission, and mitigate the risk of drug resistance. Solutions must also consider vulnerable populations such as imprisoned and besieged communities where the risk of drug resistance is particularly high, and must recognize the limitations of national programming. Strengthening capacity to control TB in Syria with particular attention to these factors… Show more

The control of TB in Syria requires a multipronged, tailored, and pragmatic approach to improve timely diagnosis, increase detection, stop transmission, and mitigate the risk of drug resistance. Solutions must also consider vulnerable populations such as imprisoned and besieged communities where the risk of drug resistance is particularly high, and must recognize the limitations of national programming. Strengthening capacity to control TB in Syria with particular attention to these factors will positively impact other parallel conditions; this is key as attention turns to post-conflict reconstruction. yria’s borders impacts refugee destination countries.

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Innovative measures for case finding, diagnosis, and management in conflict are needed. Show less

Objectives: To explore the impact of the conflict, including the use of chemical weapons, in Syria on healthcare through the experiences of health providers using a public health and human rights lens.

Design: A qualitative study using semi-structured interviews conducted in-person or over Skype using a thematic analysis approach.

Setting: Interviews were conducted with Syrian health workers operating in opposition-held Syria in cooperation with a medical relief organisation in… Show more

Objectives: To explore the impact of the conflict, including the use of chemical weapons, in Syria on healthcare through the experiences of health providers using a public health and human rights lens.

Design: A qualitative study using semi-structured interviews conducted in-person or over Skype using a thematic analysis approach.

Setting: Interviews were conducted with Syrian health workers operating in opposition-held Syria in cooperation with a medical relief organisation in Gaziantep, Turkey.

Participants: We examined data from 29 semi-structured in-depth interviews with a sample of health professionals with current or recent work-related experience in opposition-controlled areas of Syria, including respondents to chemical attacks.

Results: Findings highlight the health worker experience of attacks on health infrastructure and services in Syria and consequences in terms of access and scarcity in availability of essential medicines and equipment. Quality of services is explored through physicians' accounts of the knock-on effect of shortages of equipment, supplies and personnel on the right to health and its ethical implications. Health workers themselves were found to be operating under extreme conditions, in particular responding to the most recent chemical attacks that occurred in 2017, with implications for their own health and mental well-being.

Conclusions: The study provides unique insight into the impact war has had on Syrian's right to health through the accounts of a sample of Syrian health professionals, with continuing relevance to the current conflict and professional issues facing health workers in conflict settings. Show less

The article describe the impact of war in Syria on the health care delivery in general and pulmonary and critical care medicine in particular.

We believe that the reasons behind the present health-care crisis in Syria are much more complex. Since the beginning of the crisis, there were systematic attacks on health-care professionals and targeting of health-care facilities by the Syrian Government and to lesser extent some armed groups, as a tactic of warfare. According to the most recent report of Physicians for Human Rights,3 633 health-care workers have been killed and 271 health-care facilities attacked since the beginning of the… Show more

We believe that the reasons behind the present health-care crisis in Syria are much more complex. Since the beginning of the crisis, there were systematic attacks on health-care professionals and targeting of health-care facilities by the Syrian Government and to lesser extent some armed groups, as a tactic of warfare. According to the most recent report of Physicians for Human Rights,3 633 health-care workers have been killed and 271 health-care facilities attacked since the beginning of the conflict. Of these, 611 and 243, respectively, were by Syrian Government forces.
Another factor is the improper distribution of available resources. For example, immunisation coverage for poliomyelitis in 2013 was 100% in Tartous Province but only 36% in Deir Azzor province, which is where the first case of the recent epidemic occurred.4 Aid agencies are essentially prohibited from sending materials to opposition-controlled areas, the assumption being that they could be used to treat rebel fighters.5
Furthermore, civilians' access to health care in certain areas that are under complete siege is almost impossible. The UN's April, 2015, report6 on the implementation of Security Council resolutions 2139, 2165, and 2191 cited that 440 000 Syrians live in areas besieged by government forces, non-state armed groups, and ISIS. The UN was able to reach a mere 0·3% with health assistance.
Improving health care for all Syrians and abiding by principles of medical neutrality should be a priority for humanitarian organisations and the UN, but lifting sanctions alone without providing measures for fair distribution of resources and protection of health-care workers and facilities would be futile and might have its own unintended consequences. Show less

Prior to the conflict, Syria’s health system was comparable with that of other middle-income countries; however, the prolonged conflict has led to significant destruction of the health infrastructure. The lack of security and the direct targeting of health workers and health facilities have led to an exodus of trained staff leaving junior health workers to work beyond their capabilities in increasingly difficult circumstances. This exodus together with the destruction of the health… Show more

Prior to the conflict, Syria’s health system was comparable with that of other middle-income countries; however, the prolonged conflict has led to significant destruction of the health infrastructure. The lack of security and the direct targeting of health workers and health facilities have led to an exodus of trained staff leaving junior health workers to work beyond their capabilities in increasingly difficult circumstances. This exodus together with the destruction of the health infrastructure has contributed to the increase in communicable and non-communicable diseases and the rising morbidity and mortality of the Syrian population. Strengthening the health system in the current and post-conflict phase requires the retention of the remaining health workers, incentives for health workers who have left to return as well as engagement with the expatriate Syrian and international medical communities.

Rebuilding Syria’s shattered health system requires a holistic approach that addresses a number of issues several . Among the most important are focus on the retention of health workers, provide support and training, and establish incentives for those who have left to return. Encouraging innovative approaches including the harnessing of technology will aid the remaining health workers, and task shifting will allow for the training of enough health workers to support the health needs of the population. Policies that uphold medical neutrality and the safety of medical workers and prohibit attacks on medical facilities are key to protecting the remaining health workers. Given the protracted nature of the conflict and the funding shortage, engagement with the expatriate Syrian and international medical communities is key in supporting the health needs of the Syrians both inside and outside of Syria. Show less

As described in the News report about the ongoing crisis in Syria1 in The Lancet Respiratory Medicine, the health situation of internally displaced people and refugees in Syria is severe and continues to deteriorate. The author called attention to many of the challenges faced by international organisations in addressing the health situation of internally displaced people and refugees in the country.
However, we believe that urgent policy and research attention needs to be given to the… Show more

As described in the News report about the ongoing crisis in Syria1 in The Lancet Respiratory Medicine, the health situation of internally displaced people and refugees in Syria is severe and continues to deteriorate. The author called attention to many of the challenges faced by international organisations in addressing the health situation of internally displaced people and refugees in the country.
However, we believe that urgent policy and research attention needs to be given to the generation of timely and high-quality evidence on the effectiveness of the humanitarian health response, the capacity of health systems within Syria, and the issue of non-communicable diseases among internally displaced people and refugees. Media outlets and decision makers have tended to focus on disorders such as leishmaniasis and poliomyelitis, rather than on non-communicable diseases. We agree with WHO and other humanitarian agencies when they act to stem the incidence of poliomyelitis in Syria. However, many less visible and untreated non-communicable disorders, such as cardiovascular disease, cancer, diabetes, and mental health issues are also highly prevalent in Syria and have caused the deaths and disability of thousands of internally displaced people and refugees from Syria. Show less

“Working in a field hospital is like death,” a surgeon told us two weeks ago in Turkey, where more than two dozen Syrian doctors and other health workers had come for training. As if treating victims of the Syrian Army’s weapon of choice, the barrel bomb, wasn’t enough, they themselves were often victims of those same terrible devices.

International law is supposed to protect health workers treating anyone who is sick or wounded. Not in Syria: There, along with bakeries and schools, one… Show more

“Working in a field hospital is like death,” a surgeon told us two weeks ago in Turkey, where more than two dozen Syrian doctors and other health workers had come for training. As if treating victims of the Syrian Army’s weapon of choice, the barrel bomb, wasn’t enough, they themselves were often victims of those same terrible devices.

International law is supposed to protect health workers treating anyone who is sick or wounded. Not in Syria: There, along with bakeries and schools, one of the most dangerous places to be is in a hospital or an ambulance. According to Physicians for Human Rights, more than 560 medical personnel have been killed and 155 medical facilities have been attacked since the conflict began, though based on our interviews these numbers are understated.

From the start of the war, the regime of Bashar al-Assad has attacked civilians and obstructed humanitarian relief, including vaccinations for children. It has cut off electricity and clean water to areas controlled by the opposition, punished health workers treating protesters and opposition fighters, and deployed chemical weapons against defenseless fellow Syrians.

But things have gotten worse over the past year. The Assad regime has descended to an unprecedented level of barbarism, escalating its use of air power against enormous numbers of civilians. The number of injured, according to the World Health Organization, has risen to 25,000 people per month. Show less

WHO data on routine immunisations for polio2 show that a large proportion of the Syrian population has not been vaccinated over the past 2 years. Coverage in what are now mainly opposition areas was already far below accepted standards. Across Syria, coverage went down to 60% in 2012, and was as low as 50% in Deir al-Zour. The 2013 data show2 immunisation coverage is now 36% in Deir al-Zour, but is 100% in government-controlled areas such as Tartous. To date, all reported cases of the polio… Show more

WHO data on routine immunisations for polio2 show that a large proportion of the Syrian population has not been vaccinated over the past 2 years. Coverage in what are now mainly opposition areas was already far below accepted standards. Across Syria, coverage went down to 60% in 2012, and was as low as 50% in Deir al-Zour. The 2013 data show2 immunisation coverage is now 36% in Deir al-Zour, but is 100% in government-controlled areas such as Tartous. To date, all reported cases of the polio outbreak occurred in opposition areas.3 Since the early warning and response system was established in September 2012, why did WHO Syria and the Ministry of Health not identify sites at increased risk and better prepare for an outbreak?
WHO Syria and the Syrian Government excluded the largely rebel-held Deir al-Zour where polio was discovered, from their vaccination drive in December 2012. WHO Syria explained4 that this governorate was not included in the campaign because most of its residents have relocated to other areas in the country. However, the UN World Food Programme was able to deliver assistance to 69 000 people in the province in December 2012. Why the province was omitted in the December 2012 vaccination campaign is unclear. Show less

Since the war started in Syria nearly two years ago several independent organizations reported the use of medicine as a weapon by the Syrian authorities, killing of doctors and arresting patients who were admitted to the hospitals for treatment. In year 2012 the World Health Organization (WHO) found nearly 50% of hospitals are not functioning due to lack of staff, equipment and medicine. This report highlights how the doctors in Syria are creative and courageous to risk their own lives to save… Show more

Since the war started in Syria nearly two years ago several independent organizations reported the use of medicine as a weapon by the Syrian authorities, killing of doctors and arresting patients who were admitted to the hospitals for treatment. In year 2012 the World Health Organization (WHO) found nearly 50% of hospitals are not functioning due to lack of staff, equipment and medicine. This report highlights how the doctors in Syria are creative and courageous to risk their own lives to save thousands of innocent lives Show less

Health indicators improved considerably in the Syrian Arab Republic over the past three decades according to data from the Syrian Ministry of Health with life expectancy at birth increasing from 56 years in 1970 to 73.1 years in 2009; infant mortality dropped from 132 per 1000 live births in 1970 to 17.9 per 1000 in 2009; under-five mortality dropped significantly from 164 to 21.4 per 1000 live births; and maternal mortality fell from 482 per 100 000 live births in 1970 to 52 in 2009.[1] The… Show more

Health indicators improved considerably in the Syrian Arab Republic over the past three decades according to data from the Syrian Ministry of Health with life expectancy at birth increasing from 56 years in 1970 to 73.1 years in 2009; infant mortality dropped from 132 per 1000 live births in 1970 to 17.9 per 1000 in 2009; under-five mortality dropped significantly from 164 to 21.4 per 1000 live births; and maternal mortality fell from 482 per 100 000 live births in 1970 to 52 in 2009.[1] The Syrian Arab Republic was in epidemiological transition from communicable to non- communicable diseases with the latest data showing that 77% of mortalities were caused by non-communicable diseases.[2] Total government expenditure on health as a percentage of Gross Domestic Product was 2.9 in 2009.[3] Despite such low public investment access to health services increased dramatically since the 1980s, with rural populations achieving better equity than before.[1] Show less