‘While there is a role for medical missions in Syria, these must be strategic and intentionally integrative. Their overarching goal must be to strengthen, rather than replace, Syria’s existing health infrastructure,’ writes Sasha Fahme. [GETTY]
One of the many challenges over the coming months and years will be to rebuild Syria’s health system, obliterated by over a decade of targeted destruction, chronic neglect, and the killing and forced attrition of the health workforce.
The fragmentation and politicisation of Syria’s healthcare infrastructure mirrors that of the country at large, with multiple, autonomous health systems operating in parallel, each with a distinct set of stakeholders and funders within its respective geopolitical region. While the repatriation of forcibly displaced healthcare workers is critical to rebuilding Syria’s health system, there is limited guidance on how this can be feasibly accomplished.
Meanwhile, the medical needs on the ground are immense.
In just over two weeks following the overthrow of the Assad regime, Syrian physicians are raising alarm over vaccine-preventable infections and the risk of refeeding syndrome among the thousands of newly-liberated prisoners, many of whom had been starved in detention.
As Syrian refugees return and hundreds of thousands are continually displaced within Syria, we can expect similar warnings of food- and water-borne disease epidemics, excess mortality from non-communicable diseases and disability, and severe psychological distress, particularly among survivors of torture.
Already, international medical relief agencies are responding. The impulse by many will be to convene medical humanitarian missions to meet these needs. These short-term deployments of clinicians who overwhelmingly practice in the Global North typically last one to a few weeks and range in scope from general primary care to dentistry and specialised surgical practice.
‘Do no harm’
While there is a role for medical missions in Syria, these must be strategic and intentionally integrative. Their overarching goal must be to strengthen, rather than replace, Syria’s existing health infrastructure, or else run the risk of violating the most revered tenet of the Hippocratic Oath to “first, do no harm.”
Dating back to the 16th century, humanitarian medical missions are rooted in European Christian imperialism. While the practice has since evolved, it remains predicated on a fundamental power imbalance between Global North and South actors. The funding and manpower for such missions tend to be concentrated in cities like Geneva and New York, while the priorities of the communities they aim to serve remain, perhaps inadvertently, neglected.
Often, well-intentioned clinician volunteers will not speak the same language as the populations they treat, and a lack of interpreters further widens the communication gap.
The population health impact of short-term medical missions has long been debated in the medical literature. The problem, in part, lies in how these missions are evaluated. To date, there have been only a handful of studies examining their efficacy, and there are no formal guidelines outlining best practices. As a result, they’re often guided by good intentions, rather than data.
This care model, potentially effective at addressing imminent needs in acute emergencies, is not well adapted for the increasingly protracted and urbanised nature of conflicts in the 21st century. In such contexts, the temporary deployment of foreign clinicians instead serves to deepen paternalistic power differentials between the doctor and patient and manufactures dependency upon a colonialist framework of global health.
Sustainable solutions
As a physician who has participated in these missions – specifically caring for Syrian refugees forcibly displaced in Lebanon – I can personally attest to the feeling of immediate gratification when helping the patient in front of you, who seemingly has no other options for medical care. But the question we do not ask ourselves enough is: what happens to this person a month from now when I’m no longer here?
Yet despite these shortcomings, if implemented thoughtfully, medical missions can play a significant and valuable role in strengthening Syria’s health system. By leveraging the existing community health workforce within Syria, as well as utilising medical missions as a means of both reintegrating exiled Syrian healthcare workers and training early-career Syrian doctors, medical relief agencies have a unique opportunity to heal, rather than simply mend.
Globally, there is strong evidence supporting the role of community health workers in providing critical health services in protracted conflict and displacement settings. Recognising their role in reducing health disparities, the World Health Organisation (WHO) has called for sustainable investment into community health worker programs, specifically within fragile settings.
In Syria, as in countless other conflict-affected settings where medical missions are common, there is a growing cadre of community health workers who have worked to fill the gaps left by the decimated health workforce. For instance, in Northwest Syria, there are examples of successful “skill substitution”, wherein tasks previously ascribed to physicians are effectively implemented by non-physician actors, for patients requiring dialysis.
While there are sparse data on the effectiveness of community health worker-led initiatives in Syria, integration into local health systems and normalising their roles are key to their success. Herein lies the opportunity for medical missions.
Harnessing the skills of local experts
Rather than assembling teams of European and North American physicians to volunteer in Syria over the coming months, medical relief agencies should instead invest in the advancement and retention of the Syrian community health workers already on the ground, as well as support forcibly displaced healthcare workers to return and participate in these missions.
As health professionals who have experienced first-hand the weaponisation of healthcare in Syria, their participation and leadership are essential to ensure that medical needs, particularly those related to torture and gender-based violence, are addressed effectively, sustainably, and in a socio-culturally sensitive manner.
Syrian medical students and junior doctors should be included in these missions, both to support their training and contribute to reconstituting medical education infrastructure.
These missions must necessarily be conducted in coordination with existing hospitals, clinics, and other healthcare facilities, to which medications, equipment, and supplies should be directly donated. Medical organisations within the Syrian diaspora, such as the Syrian American Medical Society (SAMS) and the Syrian British Medical Society (SBMS) have worked tirelessly over the past fourteen years to train Syrian healthcare workers and provide medical relief in areas of Syria where they were permitted to work. Together with Syrian health facilities that remain operational, these organisations are well-positioned to oversee and evaluate these missions.
International health organisations, including but not limited to the WHO, Médecins Sans Frontieres, Médecins du Monde, and others, should mobilise their resources in support of this ongoing work, led by local and diasporic healthcare workers, to limit duplication of efforts and optimise impact.
The brutal destruction of Syria’s health system offers an opportunity to re-envision the outdated medical mission model into one that is focused on integration, education, and sustainability. There is no one more capable than the thousands of Syrian nurses, doctors, pharmacists, community health workers, technicians, and other allied healthcare professionals to lead these missions and spearhead the reconstruction of Syria’s health system. Let them.
Dr. Sasha Fahme is a physician and global health researcher who lives and works between Beirut, Lebanon and New York City, USA. Her research focuses on the syndemic impact of conflict and forced displacement on women’s health in humanitarian settings.
Follow her on Twitter: @SashaFahme
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Opinions expressed in this article remain those of the author and do not necessarily represent those of The New Arab, its editorial board or staff.
