The Syrian Civil War—now entering its sixth year—has displaced the greatest number of civilians of any conflict since World War II. Over a million people have sought refuge from the war in neighbouring Lebanon; a country with a population of only four and a half million. Spinal News International speaks to Ghassan Abu-Sittah, co-director of the American University of Beirut’s Conflict Medicine Program, about his involvement in the department’s spinal injury registry, cataloguing the direct and indirect consequences of war on Syrian refugees suffering from spinal problems in Lebanon.
Described by Médicins sans Frontières (MSF/Doctors Without Borders) as a conflict characterised by “extreme violence” towards civilians, the war in Syria has led to the widespread destruction of healthcare facilities across the country, in what Amnesty International has called “a strategy of war” by Russian and Syrian pro-government forces.
This “double tap” approach—where mass casualties are inflicted in the bombing of civilian hubs like schools and markets, before secondary attacks wipe out hospitals and trauma centres—has led to widespread injury and scant opportunity for treatment.
Ghassan Abu-Sittah (Beirut, Lebanon) explains, “War surgery came out of the start of the Napoleonic Wars, where two armies met at the front line. The injured were mainly combatants who were treated in military hospitals. From the Yugoslav Wars onwards, there has been a complete change in the nature of war. Now there is no front line; both combatants and civilians are injured in the same manner, and the overwhelming majority of injuries are being treated in civilian hospitals.”
Compounded by the emigration of up to 60% of domestic healthcare professionals, the availability of treatment for the huge numbers of injured people across the country is sparse. Life-threatening injuries are given priority at initial contact, with follow-up in Syria largely non-existent.
Abu-Sittah is involved in a registry of Syrian refugees in Lebanon who have suffered spinal injuries. “Together with Mousawat—a Palestinian non-governmental organisation (NGO) set up during the Lebanese Civil War to look after Palestinians with spinal injuries—and URDA—(Union of Relief and Development Associations, comprising a number of Syrian organisations and NORWAC, the Norwegian Aid Committee)—we wanted to set up a database of what we believe is about 200 Syrian spinal injury patients, 80% of whom were injured during conflict,” he says. “The aim of our project is to identify those at risk of developing two killer complications—pressure ulcers and urological infections—and to intervene in an effort to decrease the risk.”
By cataloguing injuries and investigating the patients’ living situations, the team have been able to respond with targeted interventions.
“The long nature of these conflicts creates what we call an ecology of war; a whole set of physical and biological circumstances which open up injury and re-injury pathways. Traditionally, war injuries are considered to be the bomb, blast and bullet injury,” Abu-Sittah says. “We believe now that there are secondary injuries which have to do with the interaction between the wounded body and the harsh environment.”We did a primary pilot survey of around 17 patients with spinal injuries and urological complications, and intervened with regards to providing mattresses, wheelchairs and seating,” Abu-Sittah tells Spinal News International. “We discovered that one of the reasons behind the prevalence of urological complications is that these patients do not have the money to change their catheters every week, as is recommended. The catheters are being left in for three weeks, for four weeks, because the patients do not have the money to change them.” The difficulties of life as a refugee, Abu-Sittah explains, can allow preventable complications to kill.
While undertaking the pilot study, the team realised that much wider recording of spinal injury patients was necessary. “We really needed to look at the whole of the population. We need to try and intervene now by identifying those that require surgical intervention and medical treatment to prevent such complications.”
Describing typical patients included in the registry, Abu-Sittah says, “We have a 22 year-old injured by shrapnel. When we went to his house, we found that he had been lying on only a thin sponge mattress, leading him to develop a pressure ulcer. We needed to get him an air mattress and a proper mattress for his wheelchair.
“We have an 11 year-old injured by shrapnel. Because of urological complications, the volume of his bladder had been reduced to 15cc, which means that he gets kidney stones. When we came across him he was basically going down the road of sepsis. He needs surgical intervention to reconstruct a new bladder to prevent kidney stones from developing.
“We also have a 30 year-old man who is the main breadwinner for his extended family—10 people—so he cannot afford to be off work to treat his pressure ulcer. We were trying to intervene to get him decent seating so that he can carry on working.
“For us at the Conflict Medicine Program, it is this interaction between the harsh environment and the body weakened by injury that we need to also start thinking about in terms of conflict-related injuries.”
Recovery from traumatic injury, he explains, is compounded by the dangers of life in a refugee camp. “Beyond direct war injuries, you have those related to the cruel realities of refugee life. We have a high percentage of paediatric burns because of poor housing and overcrowding, and the fact that cooking takes place in the same area in which children play. We find work-related injuries in children as a result of child labour; the fact that these kids, unprotected by the law, have to go out and become the bread-winners. You add this to the fact that because of the impoverishment of the refugee population, you encounter malnourishment and poverty-related illness,” Abu-Sittah explains. “What we are trying to say in our programme is that these are war injuries.”
Refugee camps within Syria itself have experienced the resurgence of illnesses such as cholera in 2015, as harsh living conditions weaken the bodies of scores of internally displaced persons. The World Health Organisation even began a poliomyelitis immunisation campaign in 2013 after the first cases of the disease since 1999 arose in Syria—an outbreak which has now been contained.
As well as those wounds inflicted by exposure to conflict itself, and the complications which may arise from them, refugees are also impacted by those illnesses which would have previously been treated by the Syrian health system. The absence of healthcare affects not only those acutely injured by the war, but those who develop unrelated illnesses for which they can no longer find treatment.
Before the civil war, Syria had a universal, state-funded healthcare system, which has now disintegrated. At the time of December 2016’s ceasefire, for example, not a single functioning hospital remained in eastern Aleppo, Syria’s second-largest city and financial hub. That month, the Syrian American Medical Society (SAMS) announced that it could no longer function in the city, following months of government besiegement and intensive, daily attacks on its facilities. Calling the consequences for civilians “unimaginable”, the NGO states that aerial bombing and use of “indiscriminate and unconventional weapons” has left “more than 250,000 people, including 100,000 children, with no access to medical care.”
“What is happening in Aleppo is catastrophic, but it constitutes a very small geographic percentage of the country, and a small percentage of the total injured. The tragedy in Syria is that you had a robust healthcare system—you had free, universal coverage,” explains Abu-Sittah. “The whole infrastructure of that health system has now collapsed. You have a whole battery of suffering from direct blast injuries, to the fact that cancer patients in Syria now have limited resources, and children born with congenital anomalies struggle to find the specialist centres and to treat them. You have a cumulative effect of both the disappearance of the health system, and the direct consequences of the war.”
International humanitarian efforts have been criticised for a slow and patchy response to the conflict, both within Syria, and in neighbouring countries like Lebanon. Not only are efforts suffocated by political disruption—MSF, for example, is not permitted to work with government-controlled hospitals—but many agencies have been slow to respond, and offered fragmented relief.
A problem faced by efforts in refugee camps is donor fatigue. The chronicity of the war itself, as well as that of spinal injury, does not match up with the concept of a “crisis” invoked by many NGOs to drive fundraising.
Abu-Sittah argues that instead of providing long-term funding, international humanitarian relief efforts arrived too late, and remain piecemeal and unreliable. “There has been a very slow and inadequate response from the international community, basically based on the idea that this is a ‘crisis’ that will end. ‘Crisis’ implies a transience which we do not see. There is no transience in the situation in Iraq. There is no transience in the situation of Palestinian refugees in Lebanon. There is no transience in the situation in Syria,” he explains. “You go through a cycle of response delayed by donor fatigue. Humanitarian agencies function on the principle of ‘crisis’, but crises must end. What happens is they ‘end’ arbitrarily when the money ends.”
This sporadic response is echoed in the coverage decisions of international humanitarian organisations, “When you look at the conditions that a health agency like the United Nations High Commissioner for Refugees (UNHCR) would cover, the list of exclusions is bigger than the list of inclusions.
Things like spinal injuries and rehabilitation are not covered,” Abu-Sittah says. “So, this large population has really been left to fend for and try to negotiate itself through a myriad of small- to medium-sized NGOs trying to plug the gaps. What you really need is universal coverage, which can offer a systematic approach to treating a million people and meeting all their health needs.”
The massive influx of over a million registered refugees—and around 500,000 unregistered—has been difficult to absorb into the Lebanese health system.
“Before the Syrian Civil War, the health system in Lebanon was fragmented. It was primarily private, and was not in the best shape,” explains Abu-Sittah. “Imagine an equivalent proportion of refugees showing up in the UK within three to four years, but in a country whose health system is not functioning well to begin with.”
Moving forward, Abu-Sittah believes an integrated approach by international relief organisations could provide a better response in future. Lebanon stopped accepting Syrian refugees in May 2015, but perhaps lessons can be learnt for future humanitarian administrators, as well as those involved in continuing efforts to support victims of the Syrian Civil War. “A proactive approach by the international community would have helped the Lebanese health system with these challenges,” asserts Abu-Sittah. “Integrating patients into the health sector would have been much better than providing piecemeal services here and there—one NGO that provides help for spinal injuries, another that provides help for children with cleft palates, and another which helps with burns.”
As for those within Abu-Sittah’s registry, the team plan to continue following them and intervening wherever possible to ensure fewer patients develop painful and life-threatening complications. “By proactively working with these refugees, we can prevent these complications from happening,” he says. “In this way at least, we can improve patient health.”
As well as leading the Conflict Medicine Program at the American University of Beirut (Beirut, Lebanon)—a programme launched in May 2016 which aims to provide an interdisciplinary approach to the study and treatment of war injuries—Ghassan Abu-Sittah is the head of the American University of Beirut Medical Center’s Division of Plastic and Reconstructive Surgery, and honorary senior clinical lecturer at Queen Mary University of London, London, UK