“What’s happening is a scandal”: Health is Still a Target in Syria

Credit: Image by dj2216 under Creative Commons license via Pixabay

Dr. Naser AlMhawish speaks with admiration for his fellow health care workers in Syria. A surgeon turned surveillance coordinator for the Assistance Coordination Unit (ACU), he describes how a colleague smuggled himself into a village stuck between conflict groups and gathered potential polio samples. Before returning the samples to Turkey, the colleague was arrested and questioned.

“They couldn’t understand that someone would risk his life [to carry samples],” said AlMhawish, noting the samples were eventually used to identify an outbreak. Other members of the team have been attacked and even killed while working to end polio. In some areas, AlMhawish said the association with an organization like ACU made otherwise routine health work “like a suicide mission”.

Prior to joining ACU, AlMhawish practiced surgery in his home town of Raqqah, Syria, where he survived bombings and faced ethical dilemmas. “You are dealing with patients regardless of their background,” he said, remembering the messages he posted at a hospital announcing “No Guns Allowed”. He had to leave Syria when it became impossible to avoid coercion to work for conflict actors.

Dr. Fadi Hakim, advocacy manager at the Syrian American Medical Society (SAMS), worked in similar circumstances. Before his displacement from Syria, Hakim practiced in Eastern Aleppo where he was the only dentist for miles. “I was myself subjected to attacks on facilities while I was inside,” he said. “It is really terrifying when you hear the jet…when you start to hear the barrel bomb falling down over your head, and you don’t know whether it’s going to fall down on you or next to you”.

He cited the experiences of friends and coworkers surviving multiple attacks and the impact to their mental health and family life. “Imagine the family’s reaction every time they hear about a hit,” he said, “the children always saying bye to dad, not sure if he is coming back or not.”

Both Hakim and AlMhawish work with Dr. Rohini Haar, an APHA International Health (IH) section member, to demonstrate the impact of attacks on population health. An emergency physician in Berkeley, California, Haar began researching attacks on health with human rights lawyer and IH section member Leonard Rubenstein in Myanmar.

Rubenstein is a past president and executive director of Physicians for Human Rights and current chair of the Safeguarding Health in Conflict Coalition (SHCC) which raises awareness about, strengthens documentation of, and empowers local groups to demand accountability regarding attacks on health.

These efforts mingle with the work of IH governing councilor Dr. Samer Jabbour, a cardiologist and professor at the American University of Beirut. Jabbour chairs the Lancet-AUB Commission on Syria which introduced the concept of weaponisation of health.

Several additional collaborations and surveillance initiatives emerged during the past decade, including the WHO’s Surveillance System of Attacks on Healthcare (SSA) and the ICRC’s Health in Danger (HCiD) project. In 2016, United Nations Security Council Resolution 2286 was adopted to extend provisions of international law for healthcare personnel and facilities in conflict situations. In 2019, an APHA policy statement outlined a research agenda and called for protection of health workers and health facilities in war.

Despite other encouraging developments, such as the launch of criminal trials and a recent conviction on crimes against humanity in Syria, attacks on health continue with impunity. “What’s happening is a scandal,” said Hakim, “This is a terror tactic. We are just being hit and nobody seems to care except for sending a statement, condemning, etc.”

While documentation and reporting remain an important part of the accountability and justice process, researchers like Jabbour and Haar express the need to demonstrate impacts on population health. Jabbour said the research should also measure “the efficacy of interventions” like the 2286 Resolution which turned five years old in March.

Various efforts are already underway. In addition to forthcoming research from the AUB-Lancet Commission, Hakim and AlMhawish are working with Haar at the University of California, Berkeley. The Researching the Impact of Healthcare (RIAH) consortium includes Rubenstein and Haar as co-investigator and researcher, respectively. SHCC also recently released a report, “Ineffective Past, Uncertain Future”, that concluded an “absence of follow-through on these commitments” and called for appointment of a special representative or monitor on the UN Resolution’s implementation.

SAMS will continue to focus on violations of international humanitarian law (IHL), said Hakim, including attacks on health care workers and facilities. “Recently we are getting more focused on accountability issues and… building of cases with the hope to be able to someday go to courts and be able to have accountability,” he said.

Other challenges also remain. In addition to the constant threat of violence, for example, AlMhawish wonders about the next funding cycle. “In the field we have more than 200 working,” he said. “So 200 families, and with the economic situation, yes—funding is critical for us.”

With COVID-19 exacting even more stress on the tenuous health workforce, humanitarian access, and funding sources, the situation looks bleak. “We said to ourselves we will not stay silent about what is happening,” said Hakim. “Sometimes people say everybody is tired from hearing about Syria. Ok, let it be so. We want everyone to be tired about what’s happening in Syria. We don’t want to stay silent about what is happening. Because unfortunately right now, this is the only thing that we have.”

As population health impacts of attacks on conflict are more effectively measured and additional voices appeal for justice from governments and policy makers, will perpetrators finally be brought to heel?

The latest Section Connection newsletter is here!

Dear friends and colleagues,

We are proud to share with you the latest issue of our newsletter, Section Connection. In this issue, you will hear from two of our members on their global health perspectives and journeys; get up close and personal with IH section member – Mara Howard-Williams; dive into a little bit of the section’s history; and hear about the work that the program committee does.

We will also share updates from our members, hear about our section’s activities, and learn what our various committee and working groups have been up to.

Please click here to access our latest issue of Section Connection: http://bit.ly/SectionConnection15

We hope you continue to stay connected and involved with our section,
Jean Armas, Heather de Vries McClintock, and Sarah Edmonds
The IH Section Communications Team

PS Don’t forget to submit your abstract by March 21st for this year’s Annual Meeting!

Trade, Health, and Access to the COVID Vaccines

By: Mary Anne Mercer, IH Section representative in the Trade and Health Forum

The International Health Section is part of the Trade and Health Forum, an intersectional group that aims to inform and activate members on how various aspects of trade affects health, both at home and in the rest of the world. That topic is a bit of a mystery to most of us. But as globalization becomes ever more evident, the relevance of its effects on health is more obvious.

Take the COVID-19 pandemic, for example.  If there is one key lesson to be learned from this past year, it’s that we will only be able to crush the pandemic here when it can be done everywhere. And an important strategy to making that happen is to step up access to the new vaccines as quickly and as widely as possible.  “Herd immunity” can only be reached safely by massive levels of immunizations.

 Right now the 84% of the world’s population that lives in low and middle-income countries is at a huge disadvantage because of rules of the World Trade Organization (WTO) constraining the development of generic drugs and vaccines. Those of us who were involved in the early response to AIDS in Africa see eerie parallels with that time. The first drugs to treat AIDS were too costly for low-income countries to adopt. I worked with a health program in Mozambique in the late 1990’s, and it was only after an Indian pharmaceutical company, CIPLA, began producing generic versions of the triple-drug therapy in 2001 that we were able to support drug treatment for people living with HIV and AIDS.  As a result of that delay of more than a dozen years—during which HIV spread unchecked in countries unable to afford drug treatment—some 15 million Africans died of AIDS. 

Right now global access to the vaccine is an important issue that is central to concerns of the Trade and Health group. The WTO patent regulations in question are documented as Trade-Related Intellectual Property right section (TRIPS). The WTO can temporarily waive the patents on COVID vaccines to allow generics to be developed—which would allow a massive scale-up of the immunization effort. The proposal to issue an emergency TRIPS waiver for the period of the pandemic has wide support in low and middle income countries but, so far, is opposed by the currently US administration as well as several other of the rich countries. 

The essence of the patent waiver controversy is, of course, the bottom line. Pharmaceutical profits tend to be substantial; it’s estimated that the profit margin for the Pfizer vaccine, for example, will be four billion dollars by the time the pandemic ends.  The US could be a leader in supporting the proposed TRIPS waiver, but so far has not indicated it’s willing to take that stand.

For more information about this issue, please check out my recent Medium article or any number of concerned groups such as Global Trade Watch and HealthGap.  And take action!

My global health journey: a reflection on my time in the field and advice for students and young professionals

By: Kiran Kamble, M.B.B.S., AFIH, MPH, PhD Candidate

After graduating with a medical degree, I started my professional career as a primary care physician in Mumbai, India, where I partnered with Government of India’s Revised National Tuberculosis Control Program (RNTCP) providing free diagnostic and treatment services to my patients suffering from tuberculosis (TB). In many cases, the financial savings these services created for the low-income families made them avoid bankruptcy. This challenging yet tremendously satisfying experience showed me the complementary nature of clinical medicine and public health. Later, when I took up a job at the World Health Organization supporting India’s RNTCP implementation through public private partnerships (PPP), I got to experience the tremendously influential role of the civil society in public health. Working with the not-for-profit and for-profit health and non-health organizations, I experienced first-hand the importance of socio-economic determinants in health policies and programs.

Later, as a consultant, I got the opportunity to work on diverse projects such as developing the bottom-up (from a village level) action plan for India’s national health sector reform initiative, mapping HIV/AIDS high-risk groups to develop focused behavioral interventions for these groups, operationalizing protocols for emergency first responders, evaluating India’s financial voucher scheme for reducing maternal mortality, and conducting a feasibility study to establish super specialty diagnostic centers through PPPs in underserved areas. I learned the crucial role a public health practitioner can play in shaping public health policy and implementation to improve lives.

My first foray into global public health (global health) was as a member of an international team tasked with revising health policies for the Government of Abu Dhabi. I was amazed with the complexity of developing a health policy, let alone implementing it. Stakeholder mapping, understanding, and accommodating demands of different groups, and balancing and prioritizing conflicting needs is as difficult as performing a heart transplant. I also understood how important it is for a public health practitioner to have basic knowledge of certain quantitative and qualitative skills. On learning those tools through an MPH from Harvard University, I got the opportunity to expand my experience in global health by providing consultancies to The Global Fund, various United Nations (UN) organizations, European Union (EU), United States Agency for International Development (USAID), and other global health organizations across 30 countries and counting. Working in fragile nations such as Afghanistan, Central African Republic (CAR), Haiti, Iraq, South Sudan, and Yemen as well as developed countries like Japan and South Korea, gave me insights into different health systems.

My global health experience keeps me grounded when I think of all those ordinary people doing extraordinary tasks that I had the opportunity to learn from. From the Auxiliary Nurse Midwife in a small tribal village in India, who despite being physically assaulted, continued her work of vaccinating children for decades traveling on foot across forests; the Catholic nurses and Ramakrishna Mission priests in Jharkhand, India, who tirelessly provided care to TB and leprosy patients; the community health workers in Iraq and Yemen who risked their lives to ensure availability of HIV, TB, and malaria medicines to hard-to-reach areas; the orthopedic surgeon manning a primary health care center in Afghanistan, working on a meagre salary of $120 per month yet providing free care to the poor; the medical doctor in Guyana who spent after work hours educating people about HIV prevention in his community; the warehouse stock keeper in Haiti who acquired a supply chain management diploma to contribute to strengthening medicine supply in his country; the woman NGO owner in Somali, Ethiopia, who without any technical knowledge or experience, conceptualized a revolving fund system using funds from The Global Fund grant to help people living with HIV establish their own small-scale businesses; the Director of TB Control in Solomon Islands who spent his own funds to travel across the islands to monitor the program; the District Administrator in Oyam, Uganda, who underwent training for malaria control and attended as many village-level camps as he could to motivate his staff; and the Peace Corps volunteers from the United States who get out of their comfort zone to live and work on social projects in the most remote parts in the developing world. There are so many such stories that may never be told but will always inspire me. Besides, COVID-19 has shown us how unavoidably interconnected we are and how important the global health approach is.

So, some of you who want to make a career in global health but wonder how to go about it? Here are my two cents. Most important, in my opinion, is having a passion for public health and acknowledging that it is more than a job. I chose the path of consultancies against a full-time job as I wanted to explore different program areas and it suited my personality better. It is, however, not easy to immediately take a plunge into the world of consultancy. One would need to establish some work experience and build their network. I will give network building a higher level of importance and it should start right from when you are as a student. Try and identify your interest area and reach out to the experts in your field – seeking knowledge of the field and advice on how to maneuver your career path. It is easier said than done but you would be surprised how many would respond to you, provided that you do not put them on the spot by asking for a job recommendation. Use your school faculty and alumni to make such connections and actively use professional networking platforms. Learn what specific skill sets organizations are looking for in your field of interest. Get to know the keywords they look for and try and get those skill sets into your curriculum vitae through the academic route first. At the end I have listed a few resources, apart from your very own APHA membership, that will help you explore global health organizations and jobs.

From my understanding, one of the core requirements in global health, in addition to domain knowledge, is the readiness to travel internationally and relocate, at least initially. The rewards are tremendous personally, academically, professionally, and financially too. Global health will make your friend circle and professional network grow exponentially. And please do not forget the pleasure and honor of interacting with different cultures and learning from them! After having explored a few different career paths myself, medical practice, pharmaceutical manufacturing and retail, and occupational health consulting, I can unequivocally state that there are few other fields like global health that give such breadth and depth of knowledge, exhilaration, soul-satisfaction, and adrenaline rush. Of course, as any other profession, there are risks and stressors, but the benefits certainly outweigh the risks.

A few photos from my global health journey:

Photo Captions
Top Left: Director of National Malaria Program directing his driver through a flooded street in Dushanbe, Tajikistan.
Bottom Left: Hotel constructed from shipping containers in Juba, South Sudan.
Middle: This may just be the world’s smallest pharmacy – in Port-au-Prince, Haiti.
Right: The smallest plane (6-seater) I have ever traveled in. The pilot asked me to plug a piece of paper in this aperture to keep it open so that air pressure inside the cabin was maintained– Solomon Islands.

Global Health Resources

https://www.fic.nih.gov/Global/Pages/NGOs.aspx, https://www.albany.edu/globalhealth/organizations-working-global-health, https://sph.umich.edu/global/non-governmental-orgs.html; https://ocs.fas.harvard.edu/explore-careers/global-health; https://www.who.int/emergencies/partners/non-governmental-organizations; https://www.tephinet.org/global-health-and-international-nonprofit-organization-websites; http://www.imva.org/Pages/orgfrm.htm;

Who, What, Where: Female Genital Mutilation

This is the first in a series of Who, What, Where: A Series on Global Health Issues. We hope to introduce public health issues across the world and educate readers about their history. 

Let’s talk about Female Genital Mutilation. 

What exactly is FGM? According to the World Health Organization, it is the practice of removing the external female genitalia for non-medical purposes, often resulting in injury due to improper surgical techniques, non-sterilized equipment/environments, and inexperienced practitioners. A large percentage of these procedures causes life-long health complications such as cysts, recurrent bladder infections, and even infertility. 

Who is affected by FGM? As the name suggests, this issue is one that plagues individuals assigned female at birth —primarily African and Middle Eastern women. Some cultures view FGM as a rite of passage girls undergo before transitioning into womanhood while others believe it suppresses a woman’s sexual desire, allowing her virginity to stay intact when the time for marriage comes. The latter has fostered an environment where FGM became the norm as mothers are expected to ensure the next generation kept the traditions alive. Certain communities also believe it enhances the sexual pleasure for their husbands. 

Where is FGM most likely practiced? There are about 200 million women and girls who are currently living with the consequences. Somalia is believed to have the highest prevalence with a whopping 98%, followed by Guinea at 97%, Djibouti with 93%, etc. Although the practice is a concern in European, Asian, and South American countries alike, cases in African countries continue to soar. Preventative measures are being taken to combat FGM through educating women on the complications, advocating for fathers and men to speak against the practice, and compelling religious leaders to denounce it. The key factor is educating mothers, as the cultural expectations are deeply ingrained into their upbringing. Young girls are more likely to follow along if their mothers are uneducated about the health issues brought on by the practice.  

While International Day of Zero Tolerance for Female Genital Mutilation falls annually on February 6th as a joint effort to combat FGM on a global level, the COVID-19 pandemic has set back the goal of stamping out the practice completely by the end of 2030. The global lockdown has brought forth high rates of domestic violence incidents, has made many educational programs wholly unable to function, and families have had easier access participating in the procedure without being cornered. Despite the unforeseeable circumstances brought by the pandemic, the fight to dismantle FGM practices continues to rage on.