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Primary care and nursing in Syria

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The Syrian conflict has dominated media coverage over the past two years: use of chemical weapons, political unrest and international involvement have become commonplace in daily news bulletins.

The death rate in Syria stands at approximately 5000 a month, which is thought to be the highest of any conflict, including the Iraq war, since the genocide in Rwanda in 1994, according to figures from the United Nations.1 Officially Syria's death toll has reached around 110,000 but the true figure is probably much higher.1

The treatment of conflict-related casualties and trauma has been extensively covered by the media. However, the day-to-day medical needs of civilians in a country in conflict are often overlooked. Until an open letter to The Lancet signed by 55 leading international healthcare professionals published last month2 was covered by mainstream media, little has been reported in the news about the declining healthcare system. The letter highlighted the medical issues affecting civilians within Syria and urged those with arms to stop targeting hospitals and health centres so that medical colleagues in Syria could treat people without fear of reprisal.

Primary care in Syria has deteriorated since the conflict began in 2011. Prior to this, Syria was a middle-income country3 with an advanced healthcare system that functioned to a high standard. The system focused on providing primary care at three levels: village, district and provincial.4

Almost all births (95 per cent) were overseen by skilled midwives and vaccination programmes were successfully administered to newborns and children by trained nurses.

Long-term conditions such as diabetes and hypertension were well monitored in local health clinics.

Nurse shortage

After two years of civil unrest, a massive decline in the numbers of nurses, doctors and medicines has meant that even basic care cannot always be delivered. The entire health system has been reduced, limited by a severe shortage of staff, unreliable medication delivery and a lack of stable locations for local health clinics.

Médicins Sans Frontières (Doctors Without Borders) has been active in Syria since the beginning of the crisis. Primary care as a structure is struggling, says communications director Polly Markandya, because of the grave security concerns and targeting of healthcare facilities.

An estimated 70 per cent of healthcare facilities and local clinics have been destroyed.

Many healthcare workers have fled to safer parts of Syria or across the borders into nearby countries.

According to the Violations Documentation Centre, an estimated 469 health workers have been imprisoned. 15,000 doctors have been forced to flee, according to the Council on Foreign Relations.2 Of the 5000 physicians in Aleppo before the conflict, only 36 remained, as of February 2013.2 This figure is likely to be even lower now.

The Lancet letter made no mention of nurses but the lack of them is also a major problem - there are simply not enough practising nurses left in Syria.

This has resulted in women giving birth without assistance and postnatal and antenatal care is not available. Life-saving surgery is being performed without anaesthetic and victims of sexual violence have nowhere to go.2

There have been outbreaks of hepatitis, typhoid, cholera and dysentery. A severe outbreak of cutaneous leishmaniasis, a severe infectious skin disease, that can cause severe disability, an increase of acute diarrhoea and a measles epidemic have broken out in districts of northern Syria. Children born since the conflict began remain unvaccinated.2

The few nurses that remain are trying to fill the gap by performing duties that would ordinarily be the responsibility of doctors, such as prescribing medicines, monitoring long-term conditions and treating severe wounds.

'Qualified nurses are like gold dust, but they're wonderful when you get them. The level of nursing here is very good. Clinics can run without doctors but it is difficult to function without nurses,' says Dr Declan Barry, a paediatric doctor from the UK just back from working in Syria with Médecins Sans Frontières.

'You can get great task-shifting done with an experienced nurse' he added.

General statistics before the conflict

  • Full name: The Syrian Arab Republic
  • Population: 21.1 million (2012)
  • Capital: Damascus
  • Population density per square kilometre: 112.1
  • Area: 185,180 sq km (71,498 sq miles)
  • Major language: Arabic
  • Major religions: Islam, Christianity
  • Life expectancy: 74 years (men), 78 years (women)
  • Monetary unit: 1 Syrian pound = 100 piastres
  • Main exports: Oil, gas
  • Infant mortality rate (per 1000 live births): 13.8
  • Fertility rate, total (live births per woman): 2.8
  • Urban population growth rate (average annual %): 2.4
  • Rural population growth rate (average annual %): 0.8

Source: http://www.bbc.co.uk/news/world-middle-east-14703910 and http://data.un.orgCountryProfiles

Lack of resources

The management of long-term conditions is difficult because the location of healthcare services is unreliable; many locations in Syria are highly unstable.

'Local health clinics have to constantly move location to avoid being targeted and attacked. In many areas health services are no longer running, in others they've been forced underground or to operate in an ad hoc manner,'says Ms Markandya.

Around 25 per cent of patients have chronic, long-term illnesses such as cancer, diabetes, hypertension and heart disease, says Dr Barry.

'Services have to be incredibly mobile due to the lack of stability and targeted attacks on clinics and hospitals. This means that people in some areas of Syria are unable to access healthcare facilities for medication and diagnosis,' Dr Barry agrees.

'We had mobile clinics and we would try and return to an area two weeks later but would be unable to due to security reasons,' he recalls. 'We can't monitor conditions, for only a few weeks at a time. You need a reliable structure to do that which we just don't have.'

He also highlighted the difficulties of diagnosis and identification of severe health problems without stable healthcare facilities. 'We saw a lot of people with severe stomach tumours, which could have been dealt with had we the right services to do so. That is not to say it would have always ended favourably, but quicker diagnosis could mean that we could catch and treat serious conditions earlier. Accessing medicine has also become a huge issue,' he added.

Before the conflict, Syria had a functioning pharmaceutical industry, which is no longer operating.

Healthcare professionals rely on medicines to be sent from other countries but Dr Barry believes this is not happening as quickly as it could be.

Prescribing has been outsourced to dispensers who do not necessarily have the required medical knowledge.

'In general, a lot of work has been shifted to those that do not have specific medical training to deal with more severe health issues,' he adds.

Impact of crisis

  • 6.8 million people are in need of aid within Syria
  • 4.25 million people are internally displaced within Syria
  • 2 million people have fled the country, seeking refuge in Jordan, Lebanon, Turkey, Egypt, Iraq and North Africa.
  • At least 8000 people per day are leaving Syria
  • 4 million people are in need of food
  • Over 100,000 civilians killed
  • Over 500,000 civilians injured
  • 70 per cent of the medical community have fled
  • The number of Syrians in public hospitals has increased by 250 percent.
  • Syrians requiring surgical operations outside refugee camps increased by 600 per cent.

Source: http://www.dec.org.uk/syria-crisis-appeal-facts-and-figures and The Lancet.

Action

Organisations and charities are sending nurses and doctors to Syria to alleviate everyday health problems.

Charities like Médecins Sans Frontières are providing training packs, with a standard, recognisable protocol for training, which are being delivered by trained expats. These are matched with pharmacy packages providing much needed medicines.

In order to try and alleviate the demand on nurses, Syrian civilians are being trained up as healthcare assistants to provide a basic level of care. Dr Barry, found civilians were motivated, educated and keen to help their own people. While these up-skilled civilians are unable to perform more in-depth clinical procedures, they are able to assist in basic checks and services that local people need, he explains.

'We've set up hospitals in caves and tents, and regularly donate essential medicines and give technical support to Syrian-run health facilities,' says Ms Markandya.

Other organisations helping to provide medical care include Hand in Hand for Syria and the International Committee of the Red Cross, along with financial aid from national governments.

Dibeh Fakhr, a spokesperson from the International Committee of the Red Cross, cites poor infrastructure as a barrier. 'We are trying to deliver medical assistance and equipment to health facilities. However, this has been one of our major challenges in the country.

'Our major concern when it comes to healthcare is the fact that medical personnel and facilities are being targeted and that wounded and sick, especially the fighters, are not being allowed access to medical care. We know that, in certain areas, people are dying because there are no medical materials to treat them with or not enough doctors to attend for them.'

Dr Barry believes that the health system will not get better without support and this has to come in the form of a reliable medical system. Echoing the sentiments of the letter to The Lancet, he added, 'People need to have healthcare as a safe place to go to. If this is not implemented there will be huge casualties.

'Staff have to feel safe and need good supporters and clinical experts and a reliable chain of drugs.'

Dr Barry concluded, 'There needs to be a decision to actively make it get better, it won't get better by itself'.

References

1. Syria: genocide by international consensus. 2013.

2. Open letter: let us treat patients in Syria. The Lancet. 2013.

3. Syria Crisis Appeal Facts and Figures. 2013.

4. Library of Congress: Country Profile. 2005.

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