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2. Short essay (maximum 2 pages): Identify TWO approaches in which conflict and migration impact the health of Syrian children and adolescents. Propose ONE approach public health officials in Syria can utilize to mitigate the risks of conflict on the mental health of children under 10 years of age in Syria. Propose ONE approach to reduce the risk of gender-based violence amongst Syrian girl adolescent refugees in Lebanon. Read and use: Alhaffar, M. B. A., & Janos, S. (2021). Public health consequences after ten years of the Syrian crisis: a literature review. Globalization and health, 17, 1-11.2. Short essay (maximum 2 pages): Describe the main objectives of the Global Fund to end the global epidemic of HIV/AIDs. Select one Low- or Middle-Income country. Using the article below, briefly describe two ways that GFATM support to the selected country for HIV/AIDs (i.e., the conditions on their grants) is neocolonial. That is, identify and describe two examples of inequitable power relationships between GFATM and that country. Then, provide two specific, measurable, feasible, and realistic recommendations that address these power imbalances by engaging Indigenous groups as active participants in decolonizing and redesigning the support the country receives from the Global Fund. Answers should be written using double space, 12 pt. font (Arial, Cambria, or Times New Roman), and 1-inch margins in a Word document
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Alhaffar and Janos Globalization and Health
https://doi.org/10.1186/s12992-021-00762-9
(2021) 17:111
REVIEW
Open Access
Public health consequences after ten years
of the Syrian crisis: a literature review
M. H. D. Bahaa Aldin Alhaffar1*
and Sandor Janos2
Abstract
Ten years of the Syrian war had a devastating effect on Syrian lives, including millions of refugees and displaced
people, enormous destruction in the infrastructure, and the worst economic crisis Syria has ever faced. The health
sector was hit hard by this war, up to 50% of the health facilities have been destroyed and up to 70% of the
healthcare providers fled the country seeking safety, which increased the workload and mental pressure for the
remaining medical staff. Five databases were searched and 438 articles were included according to the inclusion
criteria, the articles were divided into categories according to the topic of the article.
Through this review, the current health status of the Syrian population living inside Syria, whether under
governmental or opposition control, was reviewed, and also, the health status of the Syrian refugees was examined
according to each host country. Public health indicators were used to summarize and categorize the information.
This research reviewed mental health, children and maternal health, oral health, non-communicable diseases,
infectious diseases, occupational health, and the effect of the COVID − 19 pandemic on the Syrian healthcare
system. The results of the review are irritating, as still after ten years of war and millions of refugees there is an
enormous need for healthcare services, and international organization has failed to respond to those needs. The
review ended with the current and future challenges facing the healthcare system, and suggestions about
rebuilding the healthcare system.
Through this review, the major consequences of the Syrian war on the health of the Syrian population have been
reviewed and highlighted. Considerable challenges will face the future of health in Syria which require the
collaboration of the health authorities to respond to the growing needs of the Syrian population. This article draws
an overview about how the Syrian war affected health sector for Syrian population inside and outside Syria after
ten years of war which makes it an important reference for future researchers to get the main highlight of the
health sector during the Syrian crisis.
Keywords: Syrian crisis, Syrian war, Healthcare system, Public health
Introduction
The Syrian war is without a doubt the largest humanitarian crisis of the twenty-first century. The war, which
began in 2011, entered its tenth year by March 2021,
with millions of displaced people both inside and outside
Syria, and hundreds of thousands were slain, injured,
disabled, or gone without a trace [1].
* Correspondence: [email protected]
1
Damascus University, Damascus, Syria
Full list of author information is available at the end of the article
The movement which was a part of the Arab spring in
2011, turned into the biggest refugee’s crisis of the modern world, with millions of Syrian flee their houses and
became refugees in other countries, and over six millions
internally displaced, and enormous destruction to the infrastructure, healthcare system, social status of the population, economic crisis, and an increasing need for
humanitarian support from the international community
[2]. The international community failed to prevent the
destruction of the health infrastructure, which resulted
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Alhaffar and Janos Globalization and Health
(2021) 17:111
in the collapse of Syrian’s healthcare system and left millions of internally displaced people (IDPs) in desperate
need of medical assistance [3].
Syria’s healthcare facilities and workers have been directly affected by the conflict and violence. These attacks
have destroyed the public healthcare system, resulting in
serious population health consequences such as an increase in infectious and non-communicable disease risks,
serious maternal and child health challenges, conflictrelated trauma, and mental health issues, as well as the
exodus of Syrian healthcare workers who are seeking to
flee the conflict [4]. Moreover, one of the most pressing
concerns for Syrian refugees is access to health care. Primary health care and emergency lifesaving interventions
are top priorities for UNHCR and its partners. The overall access to healthcare services is more difficult than
any time before. Donors need to increase funding,
personnel, and medical supplies to support these health
needs until a diplomatic solution for Syria allows refugees to return safely [5, 6], as access to healthcare is one
of the refugees’ rights [7].
Therefore, it is of great importance to document the
health status of the Syrian population after ten years of
war, to have an overview of the current health situation,
the remaining health facilities, and the challenges facing
the healthcare system. This review will benefit the future
of the Syrian healthcare system as it highlights the significant gaps and suggests solutions to ensure equal access to healthcare for Syrian population, and to be
prepared for the return of the refugees and their health
needs in the future Syria.
Aim of the research
This research aims to provide an overview of the current
health status and health problems for the Syrian
population.
Methods
This scoping literature review covered the articles published on the subject of Syrian population health during
the years of war. The modified Arksey and O’Malley
framework for conducting the scoping review was used
as the conceptual approach for the review process [8].
A combination of basic keywords and MeSH (medical
subject headings) were used to identify relevant articles
and publications through the different databases. The
search strategy included the following: (“Syria” or “Syrian”) AND (“war” or “crisis” or “conflict”) AND
(“Health”). The databases included in the search are the
following: Medline Ovid, PubMed, Embase, Scopus,
Google Scholar.
Articles were included if they covered any field related
to the health of the Syrian population and Syrian refugees, the effect of the Syrian war on public health,
Page 2 of 11
healthcare for refugees, access to healthcare among Syrian refugees, and published after 2012. We excluded articles that are not related to the Syrian war, Syrian
refugees, articles on general medical subjects not related
to the Syrian crisis, articles on animal research, articles
published before 2012, articles not written in English,
and gray literature. Articles were included with or without the availability of full text.
We included primary research, secondary research,
and different study designs (cross-sectional, cohort, cases
control, literature review, systematic review), and excluded news, editorials, letter to the editor, reports, and
conference proceedings.
After applying the research strategy on each database,
results were imported into Endnote database, first, the
duplication was automatically removed, and then the titles and the abstracts were screened independently by
two teams (each team has two reviewers) to remove articles not related to the health of the Syrian population
during the years of war. Articles were divided into different categories (e.g. mental health, oral health, etc..) according to the World Health Organization (WHO)
categorization of health areas [9], and any disagreement
between the reviewers was solved by discussion or consulting a third reviewer. PRISMA 2020 flow diagram was
used to present the results of the literature search, and
to identify the included and the excluded articles with
the reason of exclusion [10].
Results of the search
Figure 1 represents the search strategy and the citations
included and excluded through the process. Five databases were screened following the search strategy described in the methods section, a total number of
(13669) references appeared through the search, 530 in
PubMed, 8534 in Google Scholar, 1492 in Medline Ovid,
175 in Embase, and 2938 in Scopus. References were
imported into Endnote citation manager library, an initial check was made for the search results, and 2853
were removed as a duplicated article. Total number
10816 were included in the initial screening and 8566
were excluded as they were not related to the research
topic.
2250 were screened through abstract and full text (if
available), and references were excluded for the following reasons:
Not about the Syrian population or refugees (n = 854).
Not concerning public health or related topics (n =
245).
General medical research, not concerning Syrian crisis
(n = 275).
The study design is not suitable or gray literature (n =
195).
Could not translate (n = 243).
Alhaffar and Janos Globalization and Health
(2021) 17:111
Page 3 of 11
Fig. 1 Identification of studies via databases
The final number of references included in this literature review was 438, references were categorized into
the following categories: mental health, children and maternal health, non-communicable diseases, infectious
diseases, oral health, access to health care for the population inside Syria, access to healthcare for Syrian refugees, occupational health, health systems, health during
COVID-19 pandemic.
Current health status for the population inside Syria
Syria’s healthcare system has been severely damaged,
and a large number of physicians and healthcare providers have fled the country during the conflict, which
increased the pressure and the workload on the
remaining healthcare facilities and healthcare providers.
Health facilities in the areas under government control
slowly lost the ability to function and provide healthcare
services for the Syrian population. The destruction of
major health facilities and drug factories, the increased
number of doctors leaving the country, and the movement of millions of internally displaced people toward
safe cities were the main reasons for the low function of
the remaining health facilities [11]. On the other hand,
many attempts have been established to create a primary
healthcare system in the most vulnerable sides of Syria,
which is mainly the opposition territories. Those attempts have made an enormous effort to provide access
to a variety of basic healthcare services, including primary care. Despite these efforts, the current system remains fragile and unsustainable [12]. However, relatively
few papers on the current state of Syria’s healthcare system have been published. Most articles do not discuss
the Syrian healthcare system’s capabilities; however, the
information available points to massive humanitarian
and health needs for the Syrian people, which necessitates international engagement to offer the necessary
assistance.
Health status for the Syrian refugees
Starting from 2012, the number of Syrian refugees has
increased dramatically, people fled across land and sea
to reach safety in the neighboring countries [13], by the
end of 2020, statistics showed that the number of Syrian
refugees outside Syria exceeded 6 million, the majority
of them lives in Turkey which is the host of 3.6 million
Syrians, Lebanon which host almost a million, and
Alhaffar and Janos Globalization and Health
(2021) 17:111
Jordan which hosts over 600 thousand, and more hundreds of thousands in Iraq and Egypt [14]. According to
the European migration counsel, 1.3 million Syrians requested asylum in Europe, and the peak of the migration
was in 2015–2016, and it had declined significantly since
then. Most of the refugees have limited access to basic
services [15, 16].
Turkey has had an open-door policy for refugees since
the beginning of the Syrian refugee crisis, with over 3
million refugees entering the country and about 220,000
people living in camps [17]. This explosive and unexpected increase in the Syrian population in Turkey has
had several negative impacts on health and social determinants. Turkey has 20 large refugee camps spread
across ten cities. The Ministry of Health runs 21 field
hospitals within the camps, with 120 doctors and 400 allied health personnel working there. Also, 25 Syrian doctors work in clinics run by nongovernmental
organizations (NGOs) and in refugees camps, providing
medical care to fellow refugees [18]. The rate of incidence of preventable diseases has increased in Turkish
residents as a result of lower vaccination rates for polio
and measles. Furthermore, because the rate of tuberculosis has increased in Turkey in 2014, refugees, particularly those living outside of camps, pose a significant
health risk. In large cities like Istanbul, Ankara, and
Izmir, many refugees live in deplorable conditions and
are homeless [18, 19]. Furthermore, communicable diseases pose a serious public health threat to both refugees
and residents of the host country. Several factors increase the risk of refugees contracting communicable
diseases. The high prevalence of infectious diseases in
the country of origin, as well as exposure to new communicable diseases in transit and host countries, are
among these factors. Inadequate food, water, and sewage, as well as incomplete immunization, ecological
change, contact with novel antigens, crowded and unsanitary living conditions, and lack of access to adequate
food, water, and sewage, all increase the risk of infectious diseases. Reproductive health services necessitate
special consideration [20].
Lebanon, which is the closest country to Syria (about
one hour drive from Damascus) hosts a very high percentage of Syrian refugees taking into account the Lebanese population which is around 4 million [21].
Estimation reports that the number of Syrian refugees in
Lebanon is around 1.3 million [22]. Tuberculosis, leishmaniasis, hepatitis A, and measles have become more
common among refugees. Lebanese doctors are unfamiliar with Leishmaniasis treatment and been struggling to
keep up with the rising number of cases. Furthermore,
chronic diseases such as type 2 diabetes, cardiovascular
disease, hypertension, chronic obstructive pulmonary
disease, musculoskeletal pain, and surprisingly epilepsy,
Page 4 of 11
are prevalent among refugees [23]. However, due to the
current funding situation, few resources are available to
adequately treat chronic conditions or provide antenatal
and postnatal care. There are no services or treatments
available for cancer patients. Moreover, Lebanese doctors reported outbreaks of cholera, typhoid, and hepatitis
A, among those refugees living in informal urban and
rural settings [24]. The current political and economic
crisis in Lebanon has further worsened the health situation for the refugees, the major factors are the lack of
international support and the hard access to health care
facilities which also triggered outbreaks of treatable diseases among the refugees [21, 22, 24]. The healthcare
system in Lebanon is faced by the rapid increase of its
population by 30% as a result of the massive influx of
refugees, who can’t gain access to health care for refugees [23]. Therefore, the majority of the refugees are left
for their fate, and the small acts of non-governmental
organizations, and informal healthcare workers [25, 26].
Now communicable diseases, women’s health, and mental health are the main health problems of Syrian refugees in Lebanon [27].
In Jordan, the health situation of the Syrian refugees is
different, as over 70% of the refugees are residing among
host Jordanian communities, and only 30% are living in
camps. The largest camp in Jordan is called Zaatari with
an estimated population of 120,000, and for those, not
all needs are addressed as they are not allowed to exit
the camp and access the health facilities [21, 28]. Acute
and communicable diseases, chronic diseases, and dental
problems were all prevalent. Advanced services were
more difficult to obtain than preventive and primary
health care. Access was hampered by structural and financial barriers. Primary health care for adults and children with acute illnesses was the most common service,
with more than half of the refugees requiring it, followed
by vaccination and dental services. Over a third of the
refugees said they needed primary health care for
chronic illnesses [29]. Syrian refugees in Jordan’s noncamp settings have difficulty accessing health services,
primarily due to financial situations. The transition from
free to subsidized health services, as well as the gradual
deterioration of economic status that occurs in many
refugee households as a result of prolonged displacement, are likely to exacerbate this barrier. The Jordanian
healthcare system has been overburdened as a result of
refugees’ reliance on the public sector for primary and
specialist care. Increased co-pays for public services, as
well as a shift toward private-sector services, are likely to
reduce refugee access to services [30].
In Europe, the economic and social costs of absorbing
large numbers of refugees have alarmed European countries. They are doubting their ability to provide more humanitarian aid. Serbia and Germany account for the
Alhaffar and Janos Globalization and Health
(2021) 17:111
majority of Syrian refugees in Europe (57%) compared to
(31%) in Sweden, Hungary, Austria, the Netherlands,
and Bulgaria, and (12%) in the remaining 37 European
countries. Health officials fear that the influx of refugees
into Europe will introduce infectious diseases that have
historically had low rates of morbidity and mortality in
the host countries. Among these diseases are measles,
polio, hepatitis A, hepatitis B, tuberculosis, human immunodeficiency virus (HIV), hepatitis C virus (HCV),
cutaneous leishmaniasis, schistosomiasis, and MERSCoV. This is largely due to the collapse of Syria’s healthcare infrastructure, which resulted in the suspension of
the country’s vaccination programs [16]. Psychiatric disorders and unspecified somatic symptoms were surprising of high number among the young age group of
refugees [31]. Barriers to quality health care for both
physical and mental health problems are frequently cited
as language and translation issues. For those with limited
language skills, interactions with health care professionals can be intimidating, from discussing medical history to describing the characteristics and duration of
symptoms. Syrian refugees in Germany face all of these
challenges. They were made worse by the large number
of people who arrived in a short period, making it difficult to practice the new language [32]. The European response to the refugee crisis was an emergency response
that needed more structural changes in the EU healthcare system [33, 34].
The major number of Syrian refugees are settled in
Turkey, Lebanon, Jordan, and Germany. More countries
have hosted the Syrian refugees such as Iraq which hosts
about 250 thousand, Egypt 150 thousand approximately,
and Canada which hosts over 50 thousand, and many
other European countries have hosted thousands of Syrian refugees for years. Each of the previous countries has
its unique healthcare system and allowed different levels
of access to health care services for the refugees.
Public health indicators of the Syrian population
Maternal and children health
Children and maternal health are considered one of the
most important public health aspects of any population,
especially after war or disaster, as they are the worst affected by the war and the most vulnerable. The number
of children affected by the Syrian war is shocking, reports until the end of 2014 state that over 12,000 children had been killed during the war, with no accurate
reports after 2014 on the true number of the loss in children’s lives. Moreover, by 2015, 5.6 million children
needed assistance, 3.8 million children were internally
displaced and a further 2.1 million children were refugees in nearby countries [35]. Younger children were
more likely to have an incomplete vaccination status
[36]. In 2017, data collected from Northwestern Syria
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reported that respiratory diseases were the most commonly encountered illnesses across all age groups (27%),
except for late teen females, who had the most
gynecological/obstetric complaints. Across all age
groups, infectious diseases caused the most disease burden, with upper respiratory tract infections (URTIs), infectious diarrhea, and otitis media accounting for nearly
half (47%) of all cases. Nutritional deficiencies were discovered in 8% of the patients, the majority of whom
were infants and toddlers (92%). Acute diarrhea was
identified in 17% of all age groups, making it the second
most common condition after URTIs [37].
Women’s health suffers disproportionately during
times of conflict. Sexual and gender-based violence, a reduction in the use of modern contraceptives, menstrual
irregularity, unintended pregnancies, preterm birth, and
infant morbidity are issues that persist in all settings.
Taking a multilevel approach to eliminate social and service delivery barriers that prevent access to care, conducting thorough needs assessments, and developing
policy and programmatic solutions that establish longterm care for Syrian refugee women are among the recommendations for improved practice [38]. In refugees’
camps in Lebanon and Jordan, almost all births took
place in a health facility (98% in Jordan and 94% in
Lebanon). Cesarean delivery rates were similar in both
countries, accounting for roughly one-third of all births.
Exposure to war-related events was linked to maternal
post-traumatic stress (PTS) and general psychological
distress both directly and indirectly through daily
stressors. Negative parenting and child psychosocial difficulties were directly linked to mothers’ general psychological distress, but not PTS, which can cause an
increase in the risk of negative parenting behavior [39].
For the population inside Syria, 24% of pregnant women
are adolescents due to the increase in early marriage,
and the main problem is the lack of access to antenatal
(ANC) and postnatal (PNC) healthcare. Statistics found
that 85, 82, 44% of the pregnant women did not have a
single ANC visit in the first, second, and third trimmest
retrospectively. The current situation can be briefly described as a significant lack of ANC and PNC visits, a
high adolescent birth rate, and a higher cesarean-tovaginal delivery ratio than what the WHO recommends
[40, 41].
Mental health
There has been a considerable number of publications
related to the mental and psychological health and status
of the Syrian population and Syrian refugees, both inside
(IDPs) and outside Syria. Those articles discussed almost
every factor affecting mental health, and most of the articles used the most recent diagnosis methods available.
The high prevalence of post-traumatic stress disorder
Alhaffar and Janos Globalization and Health
(2021) 17:111
(PTSD) was between 36 and 61% in 2013 of the population in Syria, exposure to fighting and hostility, and a
history of trauma during the current conflict were the
main predictors of current symptoms of PTSD [42, 43].
Moreover, some studies focused on specific groups like
the survivors of torture, because very limited data is
available on the mental health of this specific group.
Survivors of torture are more likely to develop psychological issues, such as depression, posttraumatic stress
disorder, panic attacks, chronic pain, medically unexplained somatic symptoms, and suicidal behavior [43]. In
a nationwide study conducted in 2020 and included
about 2000 participants from different Syrian governates,
44% of Syrian participants living inside Syria are more
likely to have a severe mental disorder, 27% had both
likely severe mental disorder and full PTSD symptoms,
36.9% had full PTSD symptoms, and only 10.8% had neither positive PTSD symptoms nor mental disorder on
the K10- scale. Even years after the traumatic event,
86.6% of respondents believed that the war was the main
cause of their mental distress [44, 45]. The conflict in
Syria has put the inside population at a higher risk of
mental illness than Syrian refugees elsewhere. Many
measures, with a focus on mental health, are required to
aid people in avoiding long-term suffering [46–48].
Oral health
Few articles have addressed the state of oral health during the Syrian crisis, as well as its impact on Syrian refugees. A high prevalence of caries, periodontal diseases,
and periodontitis were noticed among the refugees because oral health and dental treatments are not considered a priority for the refugee’s overall health. Dental
caries and odontogenic infections have increased, including acute periapical abscesses and even orofacial infections [49]. The average number of DMFT (Decayed,
Missed, or Filled tooth which is an oral health index
based on the total number of decayed, missed, or filled
teeth) among all children was 3.36, which is higher than
the WHO-recommended number. Only 14% of the sample in the study had good oral health, while 86% had at
least one decayed, missing, or filled tooth. There was
also a strong link between a child’s socioeconomic status
and his or her oral health [50, 51].
Non-communicable diseases
Despite the high importance of providing health services
for NCDs, very limited research articles and resources
have been found covering this issue [52]. The World
health organization (WHO) published a report in 2016
regarding the prevalence of NCDs for the population living inside Syria. Cardiovascular diseases had the highest
percentage of NCDs with almost 25% of all the cases, 9%
were cancer, 2% chronic respiratory diseases, 1%
Page 6 of 11
diabetes, 5% had communicable maternal or perinatal
and nutritional conditions, and 8% for other NCDs,
while war-related injures had a significantly high percentage for about 50% [53]. In 2016, cross-sectional research studied the prevalence of non-communicable
diseases in Lebanon among Syrian refugees and compared the results to the host community. Over half of
the Syrian refugees reported at least one of the five main
NCDs which are (hypertension, cardiovascular disease,
diabetes, chronic respiratory diseases, and arthritis) [54].
Among the refugees, arthritis had the highest prevalence
(60%), followed by hypertension (47%), chronic respiratory diseases (38%), cardiovascular disease (3.3%), and
diabetes (3.3%) [55].
Infectious and communicable diseases
The Syrian war has created the ideal conditions for the
spread and outbreak of infectious and treatable diseases,
the interruption in the vaccination program, the destruction of the health infrastructure, the migration of healthcare workers, along with the mass movement of the
refugees to other countries and living without the proper
health conditions in refugees camps where significant
reasons for the epidemics of infections such as tuberculosis, leishmaniasis, polio, measles, hepatitis, and other
infectious diseases, among both the refugees and within
the hosting communities [56]. Since poliomyelitis thrives
in unsanitary, crowded conditions and among malnourished children, it has been declared a public health
emergency in Syria, requiring international efforts and
solidarity to prevent a global epidemic. The WHO estimates that over 7600 Syrians are currently infected [57–
59]. High Tuberculosis (TB) rates were found among
Syrian refugees in Jordan through active screening and
will probably persist as the Syrian crisis continues [60].
In Lebanon, an increasing number of TB cases have
been reported among refugees. Since 2011, the number
of TB cases in Lebanon has increased by 27%, and Syrians were responsible for 22% of the estimated TB cases
in Jordan in 2013 [61, 62]. Other infections have been
reported, including acute diarrhea and hepatitis A., Malaria outbreaks appear to be unlikely, as Syria had eradicated the disease before the conflict. A Plasmodium
vivax outbreak imported from Iraq in 2012 resulted in
291 cases. In Syria, as well as among Syrian refugees in
Lebanon, there has been an increase in the number of
typhoid fever cases. In Iraq, there has been a cholera
outbreak among Syrian refugees [61]. Another hidden
consequence of the Syrian crisis is the rise of antibioticresistant bacteria. As a result of mis-prescribing and
overprescribing antibiotics, the antibiotic resistance
phenomenon is widespread in Syria, with a high rate of
multidrug resistance cases in both Gram-negative and
Alhaffar and Janos Globalization and Health
(2021) 17:111
Gram-positive organisms during and after the Syrian crisis [63, 64].
Occupational health and healthcare providers situation
Estimation found that up to 70% of healthcare workers
have fled the country, seeking a better situation or surviving the attacks on healthcare facilities during the
years of war [65]. Moreover, less than 64% of hospitals
and 52% of primary healthcare facilities in Syria are operational. According to the United Nations, this fact put
greater pressure on the remain active healthcare workers
inside Syria [66–68]. The international organization has
tried to protect the healthcare workers on both sides of
the Syrian conflict; however, those attempts have failed
to achieve any significant protection for health workers
and facilities. In late 2013, Al-Kindy Hospital, which is
the largest hospital in the Middle East, and specialized in
treating cancer patients, has been destroyed, this case is
among many more revealing the true losses of the health
sector in Syria [69–71]. Psychological distress among
healthcare providers in Syria has been documented in
several studies. In 2017, high levels of depression, anxiety, and stress were noticed and the percentage were
60.6, 35.1, and 52.6%, respectively [72]. In 2019, the consequences of the war on healthcare providers got even
worse. The research studied the prevalence of burnout
syndrome among the healthcare providers in Syria found
that 93.75% of the residents had a high level of burnout
in at least one of the three domains of the burnout index
(emotional exhaustion, depersonalization, personal accomplishment), and 19.3% had a high level of burnout in
all three domains. This high prevalence of burnout syndrome highlights the role of the current situation in raising the workload on the Syrian residents and healthcare
providers [73]. Furthermore, despite all the challenges
facing healthcare providers which are the high load of
work, the increased psychological distress, and working
in low-resources settings with very limited equipment,
healthcare providers in Syria are facing an increased rate
of workplace violence which further impacts the psychological status of healthcare workers. 84% said they had
been exposed to workplace violence in the 12 months
leading up to the survey. 74% were exposed to verbal
violence, while 19% were exposed to physical violence.
There was a significant positive correlation between verbal and physical violence and each item of depression
and stress, as well as a significant negative correlation
between subjective sleep quality and subjective health
[74].
Healthcare system in Syria during COVID-19 pandemic
The Syrian government’s response to the pandemic
started with the complete closure of the country by the
end of March. The health quarantine lasted for 2 months
Page 7 of 11
but had a deep impact on the economic situation in the
country. Therefore, the restrictions were canceled by
June, which led to an increased number of cases and a
significant rise in the death rate among the population
[75, 76]. A recent study reported the perspective of the
internally displaced population towards the COVI
