Aula Abbara

Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet–American University of Beirut Commission on Syria

The conflict in Syria presents new and unprecedented challenges that undermine the principles and practice of medical neutrality in armed conflict. With direct and repeated targeting of health workers, health facilities, and ambulances, Syria has become the most dangerous place on earth for health-care providers. The weaponisation of health care-a strategy of using peoples need for health care as a weapon against them by violently depriving them of it-has translated into hundreds of health workers killed, hundreds more incarcerated or tortured, and hundreds of health facilities deliberately and systematically attacked. Evidence shows use of this strategy on an unprecedented scale by the Syrian Government and allied forces, in what human rights organisations described as a war-crime strategy, although all parties seem to have committed violations. Attacks on health care have sparked a large-scale exodus of experienced health workers. Formidable challenges face health workers who have stayed behind, and with no health care a major factor in the flight of refugees, the effect extends well beyond Syria. The international community has left these violations of international humanitarian and human rights law largely unanswered, despite their enormous consequences. There have been repudiated denunciations, but little action on bringing the perpetrators to justice. This inadequate response challenges the foundation of medical neutrality needed to sustain the operations of global health and humanitarian agencies in situations of armed conflict. In this Health Policy, we analyse the situation of health workers facing such systematic and serious violations of international humanitarian law. We describe the tremendous pressures that health workers have been under and continue to endure, and the remarkable resilience and resourcefulness they have displayed in response to this crisis. We propose policy imperatives to protect and support health workers working in armed conflict zones.

Intravenous artesunate versus intravenous quinine in the treatment of severe falciparum malaria: a retrospective evaluation from a UK centre

Abstract Introduction: Despite evidence from developing world trials that intravenous (IV) artesunate (AS) is superior to IV quinine (Q) in severe falciparum malaria (FM), IV AS remains unlicensed in the UK with national guidelines listing it as an acceptable alternative to IV Q as the drug of choice. We retrospectively evaluate the safety and effectiveness of IV AS in returning travellers with severe FM. Methods: We identified adults admitted to the Infectious Diseases unit with severe FM and treated with IV Q (1991–2009) or IV AS (2009–2011). Outcomes included adverse events, mortality, length of stay, admission to intensive care and, where data were available, parasite/fever clearance time and hypoglycaemic events. Results: Of 167 patients, 24 received IV AS and 143 IV Q. There was one potential AS-associated adverse event, a case of late onset haemolysis. Median length of stay (LOS) was significantly shorter for AS (3·5 versus 5 days, P = 0·017), even after adjusting for African ethnicity (for LOS ⩾3 days, mhor = 0·33, P = 0·027; crude OR = 0·29, P = 0·013). In the AS group, there were no fatalities (versus five in Q group, NS) and fewer intensive care unit (ICU) admissions (NS). Median parasite clearance was significantly faster in AS (65 versus 85 hours in Q, P = 0·0045) with no hypoglycaemic episodes (versus five in Q). Discussion: We found IV AS to be safe and effective, with shorter LOS, faster parasite and fever clearance, no fatalities or hypoglycaemic events, and fewer ICU admissions versus IV Q. This corroborates both developing world trials and smaller European case series (although these lacked comparison groups). As well as obvious benefits for patients, there are potential resource savings. A case of late-onset haemolysis may represent an adverse event, particularly as it has been documented elsewhere, warranting further investigation. Nonetheless, our experience suggests IV AS should be first-line for treating severe FM in the UK.

Communicable disease surveillance and control in the context of conflict and mass displacement in Syria

OBJECTIVES To describe trends in major communicable diseases in Syria during the ongoing conflict, and the challenges to communicable disease surveillance and control in the context of dynamic, large-scale population displacement, unplanned mass gatherings, and disruption to critical infrastructure. METHODS A rapid review of the peer-reviewed and non-peer-reviewed literature from 2005 to 2015 was performed, augmented by secondary analysis of monitoring data from two disease early warning systems currently operational in Syria, focusing mainly on three diseases: tuberculosis (TB), measles, and polio. RESULTS Trend data show discrepancies in case report numbers between government and non-government controlled areas, especially for TB, but interpretation is hampered by uncertainties over sentinel surveillance coverage and base population numbers. Communicable disease control has been undermined by a combination of governance fragmentation, direct and indirect damage to facilities and systems, and health worker flight. CONCLUSIONS Five years into the crisis, some progress has been made in disease surveillance, but governance and coordination problems, variable immunization coverage, and the dynamic and indiscriminate nature of the conflict continue to pose a serious threat to population health in Syria and surrounding countries. The risk of major cross-border communicable disease outbreaks is high, and challenges for health in a post-conflict Syria are formidable.

Pathogens, prejudice, and politics: the role of the global health community in the European refugee crisis

Summary Involuntary migration is a crucially important global challenge from an economic, social, and public health perspective. The number of displaced people reached an unprecedented level in 2015, at a total of 60 million worldwide, with more than 1 million crossing into Europe in the past year alone. Migrants and refugees are often perceived to carry a higher load of infectious diseases, despite no systematic association. We propose three important contributions that the global health community can make to help address infectious disease risks and global health inequalities worldwide, with a particular focus on the refugee crisis in Europe. First, policy decisions should be based on a sound evidence base regarding health risks and burdens to health systems, rather than prejudice or unfounded fears. Second, for incoming refugees, we must focus on building inclusive, cost-effective health services to promote collective health security. Finally, alongside protracted conflicts, widening of health and socioeconomic inequalities between high-income and lower-income countries should be acknowledged as major drivers for the global refugee crisis, and fully considered in planning long-term solutions.

Mental Health among displaced Syrians: findings from the Syria Public Health Network

Aula Abbara, Adam Coutts, Fouad M Fouad, Sharif A Ismail, Miriam Orcutt; the Syria Public Health Network National Heart and Lung Institute, Imperial College London, London, UK Department of Politics and International Studies, University of Cambridge, Cambridge, UK Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon Department of Primary Care and Public Health, Imperial College London, London, UK Conflict and Health Research Group, King’s College London, London, UK Corresponding author: Sharif A Ismail. Email: sharif.ismail15@imperial.ac.uk

Equipping doctors for global health challenges

Marisa Casanova Dias, Aula Abbara, Rosie Gilbert, May CI van Schalkwyk, Claire P Rees, Howard Ryland, Andrew JM Leather, Bhanu Williams and Nigel Crisp MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff CF24 4HQ, UK International Advisory Committee, Royal College of Psychiatrists, London E1 8BB, UK National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK Moorfields Eye Hospital, UCL Institute of Ophthalmology, London EC1V 2PD, UK School of Public Health, Imperial College London, London W6 6RP, UK Junior International Committee, Royal College of General Practitioners, London NW1 2FB, UK Halswell Ward, Shaftesbury Clinic Forensic Unit, South West London and St. George’s Mental Health NHS Trust, London SW17 7DJ, UK King’s Centre for Global Health and Health Partnerships, King’s College London, London NW1 2FB, UK Department of Paediatrics, London North West Healthcare NHS Trust, London HA1 3UJ, UK Royal College of Paediatrics and Child Health, London WC1X 8SH, UK All Party Parliamentary Group on Global Health, House of Lords, London SW1A 0PW, UK Corresponding author: Marisa Casanova Dias. Email: CasanovaDiasM@cardiff.ac.uk

Syria’s lost generation of doctors

Aula Abbara, Miriam Orcutt, and Omar Gabbar report on the difficulties facing doctors who flee Syria

An unusual cause of obstructive jaundice.

An 80-year-old Caucasian woman presented with a 3-week history of painless jaundice, pruritis, dark urine and weight loss. Blood analysis demonstrated an obstructive jaundice pattern. A CT scan demonstrated a gas-filled duodenal diverticulum arising from the second part of the duodenum. Once food material was cleared from the diverticulum endoscopically, there was clinical and biochemical improvement. This case demonstrates an unusual cause of obstructive jaundice that has seldom been reported in the literature; once impacted food material was removed from the diverticulum, there was radiological improvement of the patient’s condition.

Pneumomediastinum complicating adult-onset measles

Adult-onset measles is rare in the UK, particularly in patients with a complete vaccination history.We present a case of a UK-born patient who received all childhood vaccinations, had no history of recent travel or unwell contacts who was diagnosed with measles complicated by pneumomediastinum. This case highlights the need to consider measles in any patient presenting with a constellation of a macular rash, fever and conjunctivitis, regardless of vaccination status. The nature of the rash can provide an important clue to the diagnosis. Liaison with infection specialists facilitates early diagnosis, allowing for appropriate initial investigations, improving clinical management and early infection control precautions being instituted.

Systematic destruction of healthcare in Eastern Ghouta, Syria

The international community needs to act urgently to protect civilians