- Open Access
Conflict-related health research in Syria, 2011–2019: a scoping review for The Lancet - AUB Commission on Syria
Conflict and Health volume 15, Article number: 92 (2021)
The volume of health-related publications on Syria has increased considerably over the course of the conflict compared with the pre-war period. This increase is largely attributed to commentaries, news reports and editorials rather than research publications. This paper seeks to characterise the conflict-related population and humanitarian health and health systems research focused inside Syria and published over the course of the Syrian conflict.
As part of a broader scoping review covering English, Arabic and French literature on health and Syria published from 01 January 2011 to 31 December 2019 and indexed in seven citation databases (PubMed, Medline (OVID), CINAHL Complete, Global Health, EMBASE, Web of Science, Scopus), we analyzed conflict-related research papers focused on health issues inside Syria and on Syrians or residents of Syria. We classified research articles based on the major thematic areas studied. We abstracted bibliometric information, study characteristics, research focus, funding statements and key limitations and challenges of conducting research as described by the study authors. To gain additional insights, we examined, separately, non-research publications reporting field and operational activities as well as personal reflections and narrative accounts of first-hand experiences inside Syria.
Of 2073 papers identified in the scoping review, 710 (34%) exclusively focus on health issues of Syrians or residents inside Syria, of which 350 (49%) are conflict-related, including 89 (25%) research papers. Annual volume of research increased over time, from one publication in 2013 to 26 publications in 2018 and 29 in 2019. Damascus was the most frequently studied governorate (n = 33), followed by Aleppo (n = 25). Papers used a wide range of research methodologies, predominantly quantitative (n = 68). The country of institutional affiliation(s) of first and last authors are predominantly Syria (n = 30, 21 respectively), the United States (n = 25, 19 respectively) or the United Kingdom (n = 12, 10 respectively). The majority of authors had academic institutional affiliations. The most frequently examined themes were health status, the health system and humanitarian assistance, response or needs (n = 38, 34, 26 respectively). Authors described a range of contextual, methodological and administrative challenges in conducting research on health inside Syria. Thirty-one publications presented field and operational activities and eight publications were reflections or first-hand personal accounts of experiences inside Syria.
Despite a growing volume of research publications examining population and humanitarian health and health systems issues inside conflict-ravaged Syria, there are considerable geographic and thematic gaps, including limited research on several key pillars of the health system such as governance, financing and medical products; issues such as injury epidemiology and non-communicable disease burden; the situation in the north-east and south of Syria; and besieged areas and populations. Recognising the myriad of complexities of researching active conflict settings, it is essential that research in/on Syria continues, in order to build the evidence base, understand critical health issues, identify knowledge gaps and inform the research agenda to address the needs of the people of Syria following a decade of conflict.
The armed conflict in Syria is commonly described as being among the most extensively studied and documented of contemporary conflicts . There is an expanding volume of literature on a diverse range of health issues relating to the conflict, from attacks on healthcare and use of chemical weapons to refugee health status assessment. Research in and on active conflict zones is inherently difficult, and these challenges are reflected in the focus, nature and volume of research outputs produced while an armed conflict is ongoing. For example, while the challenges facing the health systems of countries hosting large numbers of Syrian refugees have been documented [2, 3], research assessments of the fragmented health system(s) inside war-torn Syria are limited. Similarly, compared with populations inside Syria, Syrian refugee populations are more accessible and therefore have received comparatively more research attention, including reviews and syntheses of this large volume of published research .
The Lancet - American University of Beirut Commission on Syria is an international research collaboration launched in December 2016 to analyse the Syrian conflict, its toll and the international response through a health and wellbeing lens, and to propose a set of recommendations to address current and future needs, inform rebuilding efforts and drive accountability . To inform its work, the Commission has conducted a number of literature reviews. A paper examining clinical, biomedical, public health and health systems articles on Syria published between 1991 and 2017 reported that compared with the pre-conflict period (i.e. pre-2011), over the course of the conflict the number of health-related publications increased while the rate, type, topic and local authorship of publications changed. News, commentaries and editorial publications and not research largely drove the increase in publication volume during the conflict period . Whilst non-research publications are crucial to raise awareness, rapidly disseminate information and inform advocacy during active conflicts, research in/on active war zones is also essential. To the best of our knowledge, a detailed thematic overview of conflict-related research on health inside Syria has not been published. Such a review is important to understand what themes, population subgroups and geographic areas have been examined, allowing identification of knowledge gaps to inform the health research agenda. In this paper, we aim to characterise conflict-related population and humanitarian health and health systems research focused inside Syria and published over the course of the conflict.
This study is a sub-analysis of a broader scoping review of literature published between 2011 and 2019 and examining human health and Syria or Syrians, including studies of refugees and multi-country publications that include but are not exclusively limited to Syria. This review is different to, and complements, the prior review by Abdul-Khalek et al.  in that it covers a larger set of issues, has a broader geographical scope (inside Syria, outside Syria, multicountry settings including Syria), covers exclusively the conflict years and over a longer time-span of the conflict, and has specifically examined publications by conflict and non-conflict-related status. The search strategy for the broader scoping review is provided in the Additional file 1. Briefly, the broader scoping review searched for literature on human health and Syria or Syrians published in English, Arabic or French from 1 January 2011 to 31 December 2019 and indexed in seven bibliographic and citation databases (PubMed, Medline (OVID), CINAHL Complete, Global Health, EMBASE, Web of Science, Scopus). After de-duplication, 13,699 records were identified. Two-stage screening against pre-specified criteria by at least two reviewers, review of reference lists and review of additional papers known to the authors resulted in a total of 2073 relevant publications.
For this current analysis, we examined only conflict-related research papers that studied health issues inside Syria and focused on Syrians or residents in Syria (e.g. Palestinian or Iraqi refugees). We defined conflict-related publications as those examining the Syrian conflict, its effects or the conflict response. We defined research papers as publications of any type (including traditional research papers, letters, commentaries and other) that report on the primary collection of data, or the secondary analysis and interpretation of existing data. We therefore excluded review publications and literature syntheses, as well as non-conflict related publications (e.g. biomedical or genomic studies conducted during the war but not related to the Syrian conflict, its effects or the conflict response), clinical case studies and case series, conflict-related studies focused only on Syrians outside Syria (e.g. studies of Syrian refugees or studies of war casualties evacuated for treatment in neighbouring countries), and studies conducted in multiple countries that include Syria as one of any number of study countries. Field and operational activities publications, defined as papers describing operational activities or organizational field experiences inside Syria but not presenting research per se (e.g. papers describing set-up of a field facility and number of patients seen, or describing humanitarian operations), which provide important insights or data about health issues inside Syria during the conflict, were considered separately to the research papers. Similarly, personal reflections and narrative accounts of first-hand experiences inside Syria were considered separately. News reports and news interviews with personnel inside Syria were not included in this analysis.
Literature dataset analysis
We classified research articles into six categories based on the major thematic areas studied: mortality; population health status; health determinants and risks (including behavioural, physiological, environmental and social determinants of health); humanitarian assistance, response or needs (including any studies conducted by humanitarian agencies or analysis of services provided by humanitarian actors); health system (including papers examining any of the six health system pillars as defined by the World Health Organization , namely service delivery (unless delivered by humanitarian actors), health workforce, health information systems, medical products, financing, governance); and war strategies & alleged international humanitarian law (IHL) violations (including studies reporting on warfare, besiegement and related human rights violations, attacks on civilian infrastructures such as health facilities, and publications on chemical attacks). A single paper could be classified into multiple thematic categories if it had a major focus on more than one theme.
For each paper, at least one reviewer abstracted bibliometric information and study characteristics (including study description, study period, methodology, governorates/ geographic location of the study, study population, country of affiliation(s) of first and last authors, type of institutional affiliation(s) of first and last authors). We also extracted qualitative data on selected key limitations and challenges of conducting research as described by the authors, and categorized these as contextual (which we defined as including issues of safety, accessibility, stakeholder engagement and cultural considerations), methodological (including issues related to design and conduct of the study) or administrative (including issues related to research permits and permissions, logistics, research capacity). Where available, funding statements were also reviewed and assigned to one of three categories (funded, not funded, not reported). Classification of each paper was discussed by three reviewers.
We used basic descriptive statistics to summarise key bibliometric characteristics of the research papers and changes in the volume and focus of research over time. Key challenges encountered were summarized narratively.
Among the 13,699 records initially identified through the full scoping review, 2073 papers were considered relevant to human health and Syria. For this conflict-related research subanalysis, we excluded clinical case reports and case series (n = 169), publications that examined multiple countries of which Syria was one (n = 268), publications that studied Syrians outside Syria (n = 924), publications focussed inside Syria but not related to the conflict (n = 359) and conflict-related publications focussed inside Syria that were not research publications, personal reflections or descriptions of field and operational activities (n = 225). This resulted in a total of 89 conflict-related research publications focused inside Syria, which form the dataset of this analysis. These conflict-related research papers were all published in English. We also identified 31 English-language field and operational activities papers focused on health inside Syria and eight personal narrative reflections, which we examine separately.
Table 1 presents summary characteristics of the 89 conflict-related research papers. The conflict in Syria started in 2011 but there were no conflict-related research papers published during 2011–2012. Thereafter the annual volume of research increased over time, from one publication in 2013, three in 2014, to 26 publications in 2018 and 29 in 2019. There is considerable variation in the governorates studied by thematic focus and over time (Table 1, Fig. 1). Damascus is the most frequently studied governorate (n = 33), followed by Aleppo (n = 25), Idlib (n = 20), Lattakia (n = 15) and Hama (n = 14). Deir Al Zour (n = 3), Quenietra (n = 3) and As-Sweida (n = 3) are the least frequently studied. Twelve papers have a national scope. Several papers do not identify specific governorates, instead referring to the controlling factions, describing for example opposition-controlled territories generally. There are no papers on health in areas while controlled by the so-called Islamic State (IS).
Papers have used a wide range of research methodologies, including primary quantitative methods (n = 40) such as surveys, questionnaires and clinical trials; secondary quantitative data analysis (n = 28) mainly using surveillance system, medical record or program data; and qualitative methodologies (n = 15). Six papers used mixed methods (Table 1).
For the majority of papers, the country of institutional affiliation(s) of first and last (assumed to be the senior) authors are Syria (n = 30, 21 respectively), the United States (n = 25, 19 respectively) or the United Kingdom (n = 12, 10 respectively). For 20 papers (22.4%), both first and last authors had a Syrian affiliation. The institutional affiliation of first authors was predominantly academic (including universities and university hospitals) (n = 69), followed by humanitarian organizations (n = 14), clinical facilities (n = 7), think tank or research organization (n = 2), United Nations (UN) agencies (n = 2), government (n = 1), military (n = 1) and independent (n = 1). The institutional affiliation of senior/ last authors was predominantly academic (n = 65), followed by humanitarian (n = 13) or clinical (n = 7) organisations, with a few senior authors affiliated to governmental or UN agencies (n = 2 for each), and military (n = 1). Of the 37 papers reporting a specific funding source, five listed Syrian universities as the funding source.
Table 2 presents detailed summaries of each research paper.
Health status is the most frequently researched theme, examined in 38 research papers covering nutrition [10, 94], communicable diseases and/or vaccination status [8, 18, 23, 26, 28, 30, 38, 41, 47, 54, 61, 88, 94, 95], mental health [20, 27, 39, 55, 56, 60, 79, 83, 91, 94], child [22, 41, 57, 92] and maternal  health, oral health [44, 72, 75, 83], gender-based violence , anaemia  and non-communicable diseases [39, 84, 94]. Of studies examining injuries, three are studies of hospital patients [29, 46, 89], one examines injury burden among children surveyed at home and in camps for internally displaced persons (IDPs)  and one reports injury counts among children and the general population as provided by key informants . One additional study reports reasons for patient encounters at health facilities .
Of these health status studies, a few also report on socioeconomic associations with disease burden [43, 72, 79, 91], health seeking behaviours [84, 93] and exposure to violence as a determinant of health . Several other papers focus primarily on health determinants and risks, including neighbourhood socioeconomic status [9, 68], occupational stress , food security , and smoking prevalence and smoking behaviours before and during the war .
Thirty-four research papers examine the various pillars of the health system. Research on health workforce includes studies of the prevalence of psychological symptoms and burnout among medical students and trainees [27, 71], workforce training , interventions using social media platforms as a teaching medium , consideration of the impact of conflict on workforce size, support or wellbeing [17, 25, 40, 49, 80, 85], including numbers of health workers killed or injured by attacks on health care [35, 36, 52], workforce wellbeing interventions , workforce requirements to address estimates of likely disease burden , and studies of medical student career plans  and attitudes to research .
Health information systems are studied largely in the context of communicable disease surveillance and comparison of surveillance systems covering government and non-government controlled areas [18, 23, 26, 88]. Two papers cover issues of health system governance, one through key informant interviews with health service providers, donors and end-users in opposition-controlled areas  and the other through interviews with UNRWA personnel that included consideration of adaptive mechanisms used to ensure resilience and ongoing function of the UNRWA health system . Medical products are the focus of two papers, one of which surveyed community pharmacists in Damascus and Damascus countryside (Rural Damascus) regarding prescription drug misuse and characteristics of patients seeking such medications , and the other considered impacts of conflict on the UNRWA system, including on availability of medicines and medical supplies . There are no studies on health financing.
Twenty-one papers cover issues of service provision including renal , mental health [20, 24, 56], orthopaedic , cancer , communicable disease surveillance , respiratory , antenatal , and trauma services [25, 74, 89], disruptions to service provision due to attacks on healthcare [35, 36, 49, 52, 67], challenges of service provision under siege [58, 80], factors enabling sustained UNRWA service delivery , and interplays of local service provision with cross-border humanitarian assistance .
Humanitarian assistance, response or needs (which included any studies conducted or analysis of services provided by humanitarian agencies) are the focus of 26 papers. These include estimates of IDP numbers and trends , humanitarian needs assessments among the general population, many of whom were displaced, in nine predominantly government-controlled governorates in 2014 [13, 14] and among the general population  and displaced and female-headed households in 10 largely urban government-controlled areas in 2016 ; identifying optimal locations for IDP shelters  and primary healthcare facilities  in Idlib based on beneficiary needs assessments and modelling; and a snapshot survey of community income and humanitarian assistance in Idlib . Other studies included analysis of Qatar Red Crescent surveys of the impacts of the conflict on education, family and public health status  and diagnoses, injuries and comorbidities  among children in Northern Syria in 2015; and household surveys of water, sanitation and hygiene (WASH) and health outcomes in opposition-controlled Daraa and Quneitra in 2016–17 . Review of humanitarian programmatic data and operations included middle-upper arm circumference screening, survey of living conditions and food security, and nutritional programming administered by Medecins Sans Frontiers (MSF) in Al-Raqqa in 2013 , MSF vaccine-preventable disease risk assessment, pre- and post-vaccine coverage surveys and immunization activity in Aleppo in 2015 , 2012–2014 surgical data from an MSF field hospital in Northwest Syria , blast injuries managed at an MSF-supported facility in Raqqa in 2017–18 , MSF paediatric consultations in Aleppo and Raqqa in 2013–16 , MSF assessment of health status of recently arrived IDPs in Al-Raqqa in 2017 , primary care services delivered by 10 Union of Medical Care and Relief Organisations (UOSSM) centres in opposition-controlled territories in 2014–2015 , and analysis of data from the humanitarian health response in contested and opposition-controlled areas in 2013–14 . Additional interventions and program evaluations included delivery and evaluation of an intervention through provision of information and follow-up questionnaire in bread packages being distributed by a humanitarian organization in Northern Syria , evaluation of three modes of food assistance programming in Idlib in 2014–15 , evaluation of an International Rescue Committee cash assistance program on violence against women in Raqqa , evaluation of effectiveness of multi-level WASH risk reduction interventions in southern Syria in 2018  and examination of the impact of a psychosocial support program on the wellbeing of a control and intervention group of farmers . Several papers interviewed humanitarian workers, including humanitarian health staff working on non-communicable disease (NCD) care in Syria  and those involved in the cross-border humanitarian response from Turkey [78, 81].
Fourteen papers research health issues related to war strategies and alleged IHL violations, including an expert panel review of YouTube videos following a sarin gas attack  and interviews with healthcare workers in opposition-controlled areas regarding attacks on healthcare and challenges and experiences in responding to chemical attacks . Other research in this theme examined attacks on health care [35, 36, 52, 67, 90], areas under or the effects of siege [40, 58, 80], and war-related mortality [15, 45, 51, 90] including a study of characteristics of deceased victims of a chemical weapons attack .
Mortality is the subject of ten papers, which report mortality counts provided by key informants in contested and opposition areas ; examine mortality data documented by the Violations Documentation Centre (VDC) [15, 51, 62]), examine associations between attacks on healthcare and civilian casualties  or confirm conflict events against war-related deaths from VDC in a fake-news dataset ; use capture-recapture methods on four datasets to estimate mortality in two governorates ; estimate the number of unique identifiable deaths by deduplicating four datasets ; use spatio-temporal death data to forecast conflict events  and report on a household survey of IDPs in Raqqa and retrospective one-year mortality, largely conflict-related deaths .
Research themes by governorate
Themes studied vary by governorate (Table 1, Fig. 1). In Damascus, health status and the health system are the most frequently studied themes (n = 14 for each). The health system was also the main theme examined in studies of Aleppo (n = 12) and Idlib (n = 9). Humanitarian assistance, response or needs are most frequently studied in the north-west of Syria, including Aleppo (n = 8), Idlib (n = 7) and Lattakia (n = 7), and of the studies examining specific governorates, all 14 governorates were covered in at least one paper. Of the papers examining war strategies and alleged IHL violations, the majority include a focus on Aleppo (n = 6) or Damascus (n = 5). On the national level, the health system is the most frequently studied theme (n = 8), followed by health status (n = 6), war strategies and alleged IHL violations (n = 4) and mortality (n = 3).
Research themes by author country of affiliation
Themes examined vary by country of affiliation of authors (Table 1). Authors with Syrian affiliations commonly publish on health status (n = 21 for first authors, n = 15 for last authors), the health system (n = 12 for first authors, n = 7 for last authors), and health determinants and risks (n = 6 for first authors, n = 5 for last authors), while the most frequently researched themes among US-affiliated authors are the health system (n = 11 for first authors, n = 10 for last authors), humanitarian assistance, response or needs (n = 9 for first authors, n = 3 for last authors), health status (n = 8 for first authors, n = 3 for last authors) and war strategies and alleged IHL violations (n = 6 for first authors, n = 8 for last authors).
Field and operational activities publications
Table 3 presents a summary of the 31 papers reporting on field and operational activities, of which 12 describe humanitarian assessment, responses or needs, including development of a rapid gender analysis tool , cross-border, sectoral and cluster coordination mechanisms [104, 115,116,117], and needs assessments and/or operational programming [98, 105, 107,108,109,110, 122]. Nineteen papers discuss various aspects of the health system, most commonly reporting on experiences of establishing and / or presentations to field hospitals [99,100,101, 103], or establishing or delivering specific services including renal [102, 112], dental , mental health , obstetric , maternal and child health , tele-cardiology , tele-intensive care [114, 121], tele-radiology [118, 123] and polio outbreak response activities . Other papers described the national tuberculosis control program , activities of Syrian expatriate medical associations in supporting the health system, including through training, establishment of hospitals and provision of telemedicine services , and translation and uptake of an online medical education platform into Arabic by Syrian medical students . War strategies and alleged IHL violations are the secondary theme of two papers, one describing experiences in besieged settings  and one paper reporting birth outcomes by chemical weapons exposure status for pregnant women seen at Al Ghouta hospital in late 2014 . Only 12 (39%) of these field and operational activities publications are first-authored by an author with a Syrian affiliation. Of the 21 publications with multiple authors, only 5 (24%) had a senior (last) author with a Syrian affiliation.
Narrative personal reflections
Eight publications were reflections or first-hand personal accounts of experiences inside Syria. These included reflections of an expatriate physician on missions to field hospitals  including in Aleppo in 2013 ; experiences of a resident physician working in the neurosurgery department of a hospital under siege in Aleppo ; experiences of a medical resident working in Aleppo University Hospital following a chemical weapons attack, including reports of number of patient presentations and outcomes ; experiences of medical volunteers during a mission in Idlib ; and personal and professional experiences of a Syrian neurosurgeon working in Syria . Two papers are experiences of medical students, one reporting experiences undertaking research and accessing research training  and another reporting experiences of studying medicine in conflict .
Challenges reported in researching Syria
Researchers note a range of considerations and challenges of conducting research in/on Syria (Table 4). Contextual challenges are largely related to safety and security issues, including the impact of conflict on access, often being limited to specific governorates or relatively safer areas, and conflict events impacting the ability to conduct research as planned.
Researchers report numerous methodological challenges, including limited data availability and access, data quality and completeness concerns, lack of population denominator data, and potential for bias at all stages of the research process.
Administrative considerations are largely related to securing permissions to conduct research and ethical review board processes, most notably the absence of such formal in-country governance structures. Conflict also impacted other aspects of research administration, including the availability of research funding.
Although increasing over time, our analysis shows that a relatively limited number of research studies focused on health or populations inside Syria have been published over the course of the conflict to 2019. There are several geographic and thematic information gaps which likely reflect a myriad of factors, including issues of access and other challenges of conducting research during active conflict. There is a relative paucity of research on several key pillars of the health system such as governance, financing and medical products, and on a number of critical population health issues such as NCDs. Research coverage of governorates shows a heavy emphasis on Damascus and the north-west, with comparatively little research covering the north-east and the south of Syria. Our analysis does not identify any research on some specific vulnerable populations such as those currently or formerly imprisoned or detainees, and very few studies of besieged areas.
Some thematic areas have received limited research attention
Health status is the most frequently researched theme, with communicable diseases the most common focus. Given the disruption of health and social infrastructures during conflict, with attendant impacts on communicable disease surveillance and control, and the global health threat posed by outbreaks of communicable diseases such as polio, it is not surprising that communicable disease epidemiology and control is a major focus of research attention. Similarly, mental health is the focus of several papers which cover a number of population subgroups, including medical students , women [79, 91], children [56, 60, 83], selected patient populations , and IDPs [39, 94], in addition to modelling estimates of disease burden and associated workforce requirements for the general population . This is a crucial area of research in a conflict context and in a cultural setting where mental health issues remain stigmatized.
Other direct health effects of conflict receive comparatively little research attention. For example, injury epidemiology is covered in just five papers, three of which described a cohort of inpatients with abdominal , paediatric chest  or blast injuries . Understanding injury epidemiology is critical to informing health and social system needs, both to address immediate acute care needs but also to inform estimates of likely disability burden in future and requirements for health and social infrastructures. This limited research focus may reflect data gaps due to lack of research infrastructure and/or prioritization of lifesaving provision of care above record-keeping in acute emergencies and mass casualty events. The referral of many wounded individuals for treatment in neighboring countries may have also contributed to this gap, supported by an observation from our broader scoping review that there is more injury research from Turkey, Israel and Jordan than there is from within Syria.
NCDs are another major research gap, despite being identified as such in 2015 and a call for action issued . Prior to conflict onset, Syria was advancing in its demographic and epidemiological transition, with NCDs dominating disease burden and health expenditure . Left unaddressed and due to disruptions to the health system and altered health behaviours and preventive measures, this underlying disease burden is likely to have magnified. Studies among Syrian refugees indicate a high NCD burden ; a similar high burden likely exists among populations inside Syria. This warrants urgent research attention.
For a protracted conflict that has caused a large number of deaths, surprisingly few research studies have examined mortality. Notably, most of the mortality research considers direct war-related deaths. Few studies report on general mortality or examine indirect conflict-related deaths, such as those due to treatment forgone and service unavailability, for instance cancer deaths due to lack of access to chemotherapy or end-stage renal failure deaths due to lack of dialysis services (one paper provides an anecdotal estimate of renal deaths for one centre ). Such information is essential at the facility, governorate and national levels, both to inform immediate needs and to drive accountability – the effects of war, and the impacts of atrocities such as killing a doctor or attacking a hospital, extend far beyond the immediate acute losses.
Accurately estimating mortality in conflict presents numerous challenges  and several factors may explain the relative paucity of mortality research in Syria. Human rights organizations tracking deaths, such as VDC, are reliant on ground reporters, but relative inaccessibility of some geographic areas influences data collection and completeness. Local researchers based inside Syria may find it difficult to investigate this sensitive issue. Insecurities may render conducting household assessment on representative samples difficult, or generate security threats to families, witnesses or data collectors. In some instances, there may be no witnesses left to report the deaths . Disruption of health information infrastructure means limited availability and completeness of data from official local sources such as hospital records and vital registration data. The fact that the United Nations stopped officially reporting deaths in Syria since 2014 introduced a further barrier to rigorous mortality analyses. Mortality data are also highly politicised. Recognising the data limitations and challenges, there is a clear need to advance methods for researching mortality in conflict, including developing better estimates of mortality considering the difficulty in enumerating deaths (numerator) in a highly charged political environment and the changing population numbers (denominator) due to displacement.
War strategies and IHL violations are the focus of several papers, including those examining attacks on health care, effects of siege, and chemical weapons attacks. Attacks on health care in Syria have been well documented, both by the research community as well as by a number of human rights and humanitarian organisations. There are numerous methodological and contextual challenges to such research. Issues noted among the studies in this review included concerns about validation of reported data on either chemical weapons or attacks on healthcare infrastructure and personnel [11, 35, 52, 67]. Reporting commonly depends on ground reporting systems which are subject to their own inherent limitations [35, 67].
The limited research on key health system pillars, namely governance, financing and medical products, is also of concern, particularly as governance and financing are critical to any consideration and planning for health system rebuilding.
There is geographic variation in research volume and thematic issues examined
Focus of research covering areas such as Damascus, a Syrian government stronghold, is heavily on population health status and the health system, while research on northwest Syria (Aleppo and Idlib) focused more on the health system, particularly attacks on healthcare and other IHL violations, and humanitarian needs and assistance. Research on northeast Syria is extremely limited, and no research specifically on non-government controlled areas controlled by IS was identified in this review. These findings likely reflect security and access issues, in addition to conflict events and operational needs on the ground. For example, international agencies and humanitarian organizations based in Turkey have access to the opposition-controlled areas of north/northwest Syria, directly or through Syrian/diasporic health and humanitarian organizations, including through cross-border assistance operations. This may facilitate access to populations and humanitarian providers and collection of data.
It is important to note that not all geographic areas of Syria have been impacted to the same extent and in the same ways by the conflict. Further, prior to the conflict there was considerable geographic variation in Syria’s health system infrastructures, workforce distribution and resourcing , and demographic and population health profiles also varied across the country. Current population and humanitarian health issues and research needs therefore likely vary across Syria; such variation is not captured in this quantitative thematic assessment of number of research studies conducted per governorate. Future research should seek to identify the specific health research needs within and between governorates.
Vulnerable groups and hard-to-reach populations receive limited research attention
There is limited research on some specific population subgroups. The protracted conflict has resulted in chronic and large-scale displacement inside Syria, with over 6 million IDPs . New displacements are still occurring. It is estimated that 2.5 million Syrians were subjected to siege at some point during the conflict . It is reported that to March 2021, more than 149,000 Syrians had been detained or forcibly disappeared . These highly vulnerable populations are rarely studied. For example, only three papers [40, 58, 80], one field and operational activities publication  and one personal narrative  covered issues of siege. Understanding the health status and humanitarian needs of such populations is essential in order to inform programmatic action.
Novel methodologies have been applied to study health in an active conflict zone
Numerous challenges are reported in the conduct of this body of research, largely consistent with those described by researchers who have worked in and studied a range of other active conflict zones. These include issues of access, data quality, quantity and availability (including lack of denominator data due to ongoing population displacement), and security considerations, including impacts on participant willingness to engage. A number of novel tools and methodologies were developed and described in this literature in order to overcome research constraints and to study conflict-related health issues. Humanitarian interventions have been used to piggy-back health messaging and research. For instance, El-Khani et al. distributed parenting psychosocial support information and questionnaires in humanitarian bread deliveries , highlighting the scope for existing humanitarian routes to both distribute information and serve as a research platform. Social media is increasingly used as a research tool, including in conflict settings. Research included in this review has used social media in a number of ways, including as a data collection tool [8, 11] and as a platform for delivery of an educational intervention . Communication technologies have also been incorporated into research approaches, including through use of services such as WhatsApp as part of a tool to monitor attacks on healthcare in Syria , and secure messaging platforms used for remote interviews and data collection, including to overcome security considerations and access constraints [49, 77, 80].
Strengthening academic and operational research collaboration is important
For the majority of research publications, the institutional affiliations of first and/or last authors are academic (universities or university hospitals). A limited number are authored by individuals with a humanitarian organizational affiliation. Only a few papers had a mix of first/last authors from both academic and humanitarian organisations. Humanitarian organisations have a critical role to play in conducting policy- and practice-oriented research . Strengthening academic-operational research collaboration is important, including for issues of data access and data sharing. For instance, much service provision data, however (in)complete, is held by humanitarian organizations, international agencies and government bodies. Sharing of information with researchers for secondary data analysis is often a fraught process. Bridging this information divide and encouraging collaboration between researchers and operational organisations might minimize duplication of effort, increase relevance of the research to the endusers and help ensure best outcomes for the populations who must be the ultimate beneficiaries of research. Humanitarian agencies also often have readier access to study populations than do academics. Academic researchers may face additional barriers to timely information dissemination; even when data are available to researchers, lengthy institutional processes, research governance mechanisms, protracted times to data access and peer-reviewed publication times may mean that data cannot actually be used and published in a timely manner to inform operational and policy activity. Academic-humanitarian research partnerships may help address such barriers. For example, from the Syrian refugee context in Lebanon, an academic-humanitarian-public health authority research collaboration utilizing the complementary skills and expertise of each partner has ensured a successful and comprehensive project approach .
In this study we also identified a number of non-research publications reporting on operational and field activities and personal reflections. Such sharing of experiences should be encouraged, including by journals and journal editors.
Efforts to mitigate potential barriers to Syrian-led research in and on Syria warrant attention
This review shows good representation of first and last authors from Syrian institutions, with approximately a third of first authors and almost a quarter of last authors having Syrian institutional affiliations. This does not reflect the total number of first and last authors from Syria or with Syrian background, as conflict-related displacement of Syrian academics means that some are publishing but are now affiliated with institutions in countries outside Syria.
There are several potential barriers to Syrian researcher engagement which warrant attention. These include general difficulties in access and insecurities, limited supply and/or capacity of Syrian researchers based inside Syria, and disruption or collapse of research infrastructure in Syrian institutions, including through recurrent attacks on universities, and widespread oppression of academics and freedom of speech more broadly which have had a detrimental impact on higher education institutions in Syria [145, 146]. Additionally, capacity building and training opportunities are limited: one study in this review reports lack of adequate training, research facilities and mentorship as barriers to research among undergraduates  and others also describe additional resource and funding constraints .
Such potential barriers to local research production must be addressed. Utilization of various techniques, e.g. use of pseudonyms to address security concerns, and implementation of contextually appropriate capacity building initiatives and frameworks, such as that proposed by others , to support more Syrian researchers and Syrian institutions to lead research on the health issues affecting their country and its people, is warranted.
Strengths and limitations
To the best of our knowledge, this is the first review to characterize the body of published research indexed in the main citation databases and examining health inside Syria over the course of the conflict. Themes assigned reflect a paper’s major focus and do not necessarily capture all issues covered in a given publication. Assignment of key themes is necessarily subjective, and some papers may cover multiple thematic areas. Some of the themes are not mutually exclusive but were presented in distinct categories to highlight conflict-related gaps. For example, health-related IHL violations such as attacks on healthcare are determinants of health but specific to conflict settings; we therefore considered them in a separate category to the ‘health determinants and risks’ category, which captures traditional behavioural, physiological, environmental and social determinants of health that are also present in non-conflict zones. The scope of this paper is restricted to population and humanitarian health and health systems research, so studies of war strategies and IHL violations are limited to health-related violations and do not include publications examining attacks on non-health civilian infrastructures such as schools and bakeries, which are also upstream determinants of health.
Notably, this quantitative assessment of number of research studies conducted per governorate does not take into account research quality – a single high quality study may provide greater and more useful information than multiple lower quality and less rigorous publications.
Our summary of key challenges described in the papers is not an exhaustive list of all limitations noted by the authors but rather captures the main and frequently described issues. Relevant studies may have been excluded, or missed if published in journals not indexed in the seven bibliographic databases searched. For example, Arabic language papers published in local or regional journals are not captured in this review. Our search did not include the grey literature, so the findings of this review likely to do not fully capture all operational and field research undertaken and published by humanitarian organisations. Additionally, research may be undertaken to inform policymaking or programmatic action but not published. Finally, academic research is often subject to a publication lag, so it is possible that some of the information gaps identified in this review are the subject of current work and forthcoming research publications.
Whilst there is a growing body of research examining population health issues inside conflict-ravaged Syria, there are considerable geographic and thematic gaps, and issues and populations that warrant focused research attention. Recognising the myriad of complexities of researching active conflict zones, including issues of data completeness, coverage and politicisation, it is essential that research in and on Syria continues, in order to build the evidence base and inform policy and programmatic actions that are required to protect and promote health in Syria following a decade of conflict.
Availability of data and materials
Research data and material are available for peer review.
Sigal I. Syria’s war may be the most documented ever. And yet, we know so little. The World. 19 December 2016. Available from: https://www.pri.org/stories/2016-12-19/syrias-war-may-be-most-documented-ever-and-yet-we-know-so-little. Accessed 20 Aug 2020.
El-Khatib Z, et al. Syrian refugees, between rocky crisis in Syria and hard inaccessibility to healthcare services in Lebanon and Jordan. Confl Health. 2013;7(1):18. https://doi.org/10.1186/1752-1505-7-18.
Blanchet K, Fouad FM, Pherali T. Syrian refugees in Lebanon: the search for universal health coverage. Confl Heal. 2016;10(1):12. https://doi.org/10.1186/s13031-016-0079-4.
El Arnaout N, et al. Assessment of the health needs of Syrian refugees in Lebanon and Syria’s neighboring countries. Confl Heal. 2019;13(1):31. https://doi.org/10.1186/s13031-019-0211-3.
Jabbour S, Leaning J, Nuwayhid I, Horton R, Das P. The lancet-American University of Beirut Commission on Syria: a new role for global health in conflict and a call for papers. Lancet. 2016;388(10063):2967–8. https://doi.org/10.1016/S0140-6736(16)32583-1.
Abdul-Khalek RA, Kayyal W, Akkawi AR, Almalla M, Arif K, Bou-Karroum L, et al. Health-related articles on Syria before and after the start of armed conflict: a scoping review for the lancet-American University of Beirut Commission on Syria. Confl Heal. 2020;14(1):73. https://doi.org/10.1186/s13031-020-00316-7.
World Health Organization. Everybody’s business. Strengthening health systems to improve health outcomes: WHO’s framework for action. 2007; Available from: https://www.who.int/healthsystems/strategy/everybodys_business.pdf. Accessed 13 May 2021.
Alasaad S. War diseases revealed by the social media: massive leishmaniasis outbreak in the Syrian spring. Parasites Vectors. 2013;6:3.
Ahmad B. Exploring the role of triangulation in the production of knowledge for urban health policy: an empirical study from informal settlements in Aleppo, Syria. Forum Dev Stud. 2014;41(3):433–54. https://doi.org/10.1080/08039410.2014.963143.
Hoetjes, M., et al., Emerging cases of malnutrition amongst IDPs in Tal Abyad district, Syria. Field Exchange - Emergency Nutrition Network ENN, 2014(48): 133–137.
Rosman Y, Eisenkraft A, Milk N, Shiyovich A, Ophir N, Shrot S, et al. Lessons learned from the Syrian sarin attack: evaluation of a clinical syndrome through social media. Ann Intern Med. 2014;160(9):644–8. https://doi.org/10.7326/M13-2799.
Alshiekhly U, Arrar R, Barngkgei I, Dashash M. Facebook as a learning environment for teaching medical emergencies in dental practice. Educ Health. 2015;28(3):176–80. https://doi.org/10.4103/1357-6283.178609.
Doocy S, Delbiso TD, Guha-Sapir D. The humanitarian situation in Syria: a snapshot in the third year of the crisis. PLoS Curr. 2015;7.
Doocy S, et al. Internal displacement and the Syrian crisis: an analysis of trends from 2011-2014. Confl Heal. 2015;9(1):33. https://doi.org/10.1186/s13031-015-0060-7.
Guha-Sapir D, et al. Civilian deaths from weapons used in the Syrian conflict. BMJ (Clinical research ed.). 2015;351:h4736.
Price M, Gohdes A, Ball P. Documents of war: understanding the Syrian conflict. Significance. 2015;12(2):14–9. https://doi.org/10.1111/j.1740-9713.2015.00811.x.
Sekkarie MA, Zanabli AR, Rifai AO, Murad LB, al-Makki AA. The Syrian conflict: assessment of the ESRD system and response to hemodialysis needs during a humanitarian and medical crisis. Kidney Int. 2015;87(2):262–5. https://doi.org/10.1038/ki.2014.336.
Tajaldin B, et al. Defining polio: closing the gap in global surveillance. Ann Global Health. 2015;81(3):386–95.
Trelles M, Dominguez L, Tayler-Smith K, Kisswani K, Zerboni A, Vandenborre T, et al. Providing surgery in a war-torn context: the Medecins sans Frontieres experience in Syria. Confl Heal. 2015;9(1):36. https://doi.org/10.1186/s13031-015-0064-3.
Charlson FJ, Lee YY, Diminic S, Whiteford H. Applications of the epidemiological modelling outputs for targeted mental health planning in conflict-affected populations: the Syria case-study. Global Mental Health. 2016;3:e8. https://doi.org/10.1017/gmh.2016.4.
El-Khani A, et al. Daily bread: a novel vehicle for dissemination and evaluation of psychological first aid for families exposed to armed conflict in Syria. Global Mental Health (Cambridge, England). 2016;3:e15.
Elsafti AM, van Berlaer G, al Safadi M, Debacker M, Buyl R, Redwan A, et al. Children in the Syrian civil war: the familial, educational, and public health impact of ongoing violence. Disaster Med Public Health Preparedness. 2016;10(6):874–82. https://doi.org/10.1017/dmp.2016.165.
Ismail SA, Abbara A, Collin SM, Orcutt M, Coutts AP, Maziak W, et al. Communicable disease surveillance and control in the context of conflict and mass displacement in Syria. Intern J Infect Dis. 2016;47:15–22. https://doi.org/10.1016/j.ijid.2016.05.011.
Jefee-Bahloul H, Duchen D, Barkil-Oteo A. Attitudes towards implementation of store-and-forward Telemental health in humanitarian settings: survey of Syrian healthcare providers. Telemed J e-Health. 2016;22(1):31–5. https://doi.org/10.1089/tmj.2015.0021.
Mowafi H, Hariri M, Alnahhas H, Ludwig E, Allodami T, Mahameed B, et al. Results of a Nationwide capacity survey of hospitals providing trauma Care in war-Affected Syria. JAMA Surg. 2016;151(9):815–22. https://doi.org/10.1001/jamasurg.2016.1297.
Sparrow A, Almilaji K, Tajaldin B, Teodoro N, Langton P. Cholera in the time of war: implications of weak surveillance in Syria for the WHO’s preparedness-a comparison of two monitoring systems. BMJ Glob Health. 2016;1(3):e000029. https://doi.org/10.1136/bmjgh-2016-000029.
Al-Saadi T, et al. Psychological distress among medical students in conflicts: a cross-sectional study from Syria. BMC Med Edu. 2017;17:173.
Alsaied T, Mawas A, al Sayah F, Kental A, Saqqur M. A new primary health-care system in the Syrian opposition territories: good effort but far from being perfect. Avicenna J Med. 2017;7(4):189–92. https://doi.org/10.4103/ajm.AJM_67_17.
Arafat S, Alsabek MB, Ahmad M, Hamo I, Munder E. Penetrating abdominal injuries during the Syrian war: patterns and factors affecting mortality rates. Injury. 2017;48(5):1054–7. https://doi.org/10.1016/j.injury.2017.02.005.
Baaity Z, Almahmoud I, Khamis A. Prevalence of extended spectrum β lactamases (ESBL) in E. coli at Al-assad teaching hospital. Res J Pharm Technol. 2017;10(7):2433–6. https://doi.org/10.5958/0974-360X.2017.00430.9.
Cummins, D. and S. Moharram, Aid in context: the importance of market-based approaches to aid delivery in northern Syria. IIED Briefing Paper - International Institute for Environment and Development, 2017(17424): 4.
Diggle E, Welsch W, Sullivan R, Alkema G, Warsame A, Wafai M, et al. The role of public health information in assistance to populations living in opposition and contested areas of Syria, 2012-2014. Confl Heal. 2017;11(1):33. https://doi.org/10.1186/s13031-017-0134-9.
Doocy S, Lyles E. Humanitarian needs among displaced and female-headed households in government-controlled areas of Syria. Am J Public Health. 2017;107(6):950–9.
Doocy S, et al. Emergency food assistance in northern Syria: an evaluation of transfer programs in Idleb governorate. Food Nutr Bull. 2017;38(2):240–59.
Elamein M, Bower H, Valderrama C, Zedan D, Rihawi H, Almilaji K, et al. Attacks against health care in Syria, 2015-16: results from a real-time reporting tool. Lancet. 2017;390(10109):2278–86. https://doi.org/10.1016/S0140-6736(17)31328-4.
Fouad FM, Sparrow A, Tarakji A, Alameddine M, el-Jardali F, Coutts AP, et al. Health workers and the weaponisation of health care in Syria: a preliminary inquiry for the lancet–American University of Beirut Commission on Syria. Lancet. 2017;390(10111):2516–26. https://doi.org/10.1016/S0140-6736(17)30741-9.
Fujita K, Shinomoto S, Rocha LEC. Correlations and forecast of death tolls in the Syrian conflict. Sci Rep. 2017;7(1):15737. https://doi.org/10.1038/s41598-017-15945-x.
Hawat M, Husein M, Almahmoud I. Epidemiology of leishmaniasis in Lattakia city among last ten years (2006-2016). Epidemiology. 2017;7(5):325.
Mohammad Y, Rafea S, Latifeh Y, Khaddam A, Sawaf B, Zakaria MI, et al. Uncontrolled and under-diagnosed asthma in a Damascus shelter during the Syrian crisis. J Thoracic Dis. 2017;9(9):3415–24. https://doi.org/10.21037/jtd.2017.08.86.
Sahloul E, Salem R, Alrez W, Alkarim T, Sukari A, Maziak W, et al. Cancer Care at Times of crisis and war: the Syrian example. J Global Oncol. 2017;3(4):338–45. https://doi.org/10.1200/JGO.2016.006189.
van Berlaer G, Elsafti AM, al Safadi M, Souhil Saeed S, Buyl R, Debacker M, et al. Diagnoses, infections and injuries in northern Syrian children during the civil war: a cross-sectional study. PLoS One. 2017;12(9):e0182770. https://doi.org/10.1371/journal.pone.0182770.
Abbas F, Sawaf B, Hanafi I, Hajeer MY, Zakaria MI, Abbas W, et al. Peers versus professional training of basic life support in Syria: a randomized controlled trial. BMC Med Educ. 2018;18(1):142. https://doi.org/10.1186/s12909-018-1241-z.
Albaroudi IN, Khodder M, al Saadi T, Turk T, Youssef LA. Prevalence, diagnosis, and management of iron deficiency and iron deficiency anemia among Syrian children in a major outpatient center in Damascus, Syria. Avicenna J Med. 2018;8(3):92–103. https://doi.org/10.4103/ajm.AJM_169_17.
Ballouk MA, Dashash M. The gingival health status of 8-12 year-old children in Damascus city in Syria during the Syrian crisis: a cross-sectional epidemiological oral health survey. BMC Res Notes. 2018;11(1):887. https://doi.org/10.1186/s13104-018-3998-x.
Chen B, Shrivastava A, Steorts RC. Unique entity estimation with application to the Syrian conflict. Ann Appl Stat. 2018;12(2):1039–67.
Darwish B, Mahfouz MZ, al-Nosairat S, Izzat MB. Changing pattern and outcome of pediatric chest injuries in urban Syria. Asian Cardiovasc Thoracic Ann. 2018;26(5):367–70. https://doi.org/10.1177/0218492318776565.
de Lima Pereira A, et al. Infectious disease risk and vaccination in northern Syria after 5 years of civil war: the MSF experience. PLoS Curr. 2018;10.
Doocy S, Lyles E. Humanitarian needs in government controlled areas of Syria. PLoS Curr. 2018;10.
Footer KHA, Clouse E, Rayes D, Sahloul Z, Rubenstein LS. Qualitative accounts from Syrian health professionals regarding violations of the right to health, including the use of chemical weapons, in opposition-held Syria. BMJ Open. 2018;8(8):e021096. https://doi.org/10.1136/bmjopen-2017-021096.
Garry S, Checchi F, Cislaghi B. What influenced provision of non-communicable disease healthcare in the Syrian conflict, from policy to implementation? A qualitative study. Conflict Health. 2018;12:45.
Guha-Sapir D, Schlüter B, Rodriguez-Llanes JM, Lillywhite L, Hicks MHR. Patterns of civilian and child deaths due to war-related violence in Syria: a comparative analysis from the violation documentation center dataset, 2011–16. Lancet Glob Health. 2018;6(1):e103–10. https://doi.org/10.1016/S2214-109X(17)30469-2.
Haar RJ, Risko CB, Singh S, Rayes D, Albaik A, Alnajar M, et al. Determining the scope of attacks on health in four governorates of Syria in 2016: results of a field surveillance program. PLoS Med. 2018;15(4):e1002559. https://doi.org/10.1371/journal.pmed.1002559.
Idris A, et al. Smoking behaviour and patterns among university students during the Syrian crisis. Eastern Mediterranean Health J. 2018;4(2):154–60.
Khamis J, Ghaddar A. HIV/AIDS in Syria and the response of the national AIDS program during the war. Sex Transm Infect. 2018;94(3):173. https://doi.org/10.1136/sextrans-2017-053438.
Kubitary A, Alsaleh MA. Validity of Arabic version of the two-question quick inventory of depression (QID-2-Ar): screening for multiple sclerosis in an Arab environment and during the Syrian war. Rev Neurol. 2018;174(3):137–44.
Kubitary A, Alsaleh MA. War experiences, posttraumatic stress disorder, sleep disorders: clinical effectiveness of treatment by repeating phrases of positive thoughts (TRPPT) of mental-war disorders in Syrian refugees children and adolescents war victims - a new therapeutic trial. Sleep Hypnosis. 2018;20(3):210–26.
Meiqari L, Hoetjes M, Baxter L, Lenglet A. Impact of war on child health in northern Syria: the experience of Medecins sans Frontieres. Eur J Pediatr. 2018;177(3):371–80. https://doi.org/10.1007/s00431-017-3057-y.
Morrison C. Providing basic services under siege: preliminary insights from interim councils and medical providers in besieged urban areas of Syria. Environ Urban. 2018;31(1):309–24.
Othman M, Steel Z, Lawsin C, Wells R. Addressing occupational stress among health staff in nongovernment controlled northern Syria: supporting resilience in a dangerous workplace. Torture. 2018;28(3):104–23. https://doi.org/10.7146/torture.v28i3.111200.
Perkins JD, Ajeeb M, Fadel L, Saleh G. Mental health in Syrian children with a focus on post-traumatic stress: a cross-sectional study from Syrian schools. Soc Psychiatry Psychiatr Epidemiol. 2018;53(11):1231–9. https://doi.org/10.1007/s00127-018-1573-3.
Rehman K, Walochnik J, Mischlinger J, Alassil B, Allan R, Ramharter M. Leishmaniasis in northern Syria during civil war. Emerg Infect Dis. 2018;24(11):1973–81. https://doi.org/10.3201/eid2411.172146.
Rodriguez-Llanes JM, Guha-Sapir D, Schlüter BS, Hicks MHR. Epidemiological findings of major chemical attacks in the Syrian war are consistent with civilian targeting: a short report. Confl Heal. 2018;12(1):16. https://doi.org/10.1186/s13031-018-0150-4.
Sawaf B, Abbas F, Idris A, al Saadi T, Ibrahim N. Specialty preference and intentions to study abroad of Syrian medical students during the crisis. BMC Med Educ. 2018;18(1):39. https://doi.org/10.1186/s12909-018-1146-x.
Sikder M, Daraz U, Lantagne D, Saltori R. Effectiveness of multilevel risk management emergency response activities to ensure free chlorine residual in household drinking water in southern Syria. Environ Sci Technol. 2018;52(24):14402–10. https://doi.org/10.1021/acs.est.8b03487.
Sikder M, Daraz U, Lantagne D, Saltori R. Water, sanitation, and hygiene access in southern Syria: analysis of survey data and recommendations for response. Confl Heal. 2018;12(1):17. https://doi.org/10.1186/s13031-018-0151-3.
Turk T, al Saadi T, Alkhatib M, Hanafi I, Alahdab F, Firwana B, et al. Attitudes, barriers, and practices toward research and publication among medical students at the University of Damascus, Syria. Avicenna J Med. 2018;8(1):24–33. https://doi.org/10.4103/ajm.AJM_116_17.
Wong CH, Chen CY. Ambulances under siege in Syria. BMJ Glob Health. 2018;3(6):e001003. https://doi.org/10.1136/bmjgh-2018-001003.
Ahmad B, Fouad FM, Zaman S, Phillimore P. Women’s health and well-being in low-income formal and informal neighbourhoods on the eve of the armed conflict in Aleppo. Int J Public Health. 2019;64(1):75–82. https://doi.org/10.1007/s00038-018-1150-2.
Abu Salem FK, et al. FA-KES: A fake news dataset around the Syrian War, Proceedings of the 13th International Conference on Web and Social Media, ICWSM 2019; 2019. p. 573–82.
Alaryan T, Hasan TA, Eshelli M, Alzeer S. The misuse of prescribed drugs during the Syrian crisis: a cross-sectional study. Int J Ment Heal Addict. 2019. https://doi.org/10.1007/s11469-019-00180-4.
Alhaffar BA, Abbas G, Alhaffar AA. The prevalence of burnout syndrome among resident physicians in Syria. J Occup Med Toxicol. 2019;14(1):31. https://doi.org/10.1186/s12995-019-0250-0.
Alhaffar BA, et al. Oral health and socio-economic status among children during Syrian crisis: a cross-sectional study. BMC Oral Health. 2019;19(1):165.
Alhammoud A, Maaz B, Alhaneedi GA, Alnouri M. External fixation for primary and definitive management of open long bone fractures: the Syrian war experience. Int Orthop. 2019;43(12):2661–70. https://doi.org/10.1007/s00264-019-04314-0.
Alothman MH, et al. Challenges and opportunities in reporting trauma-related research: a case study from Syria. Indian J Neurotrauma. 2019;16(2–3):91–3.
Ballouk MA, Dashash M. Caries prevalence and dental health of 8-12 year-old children in Damascus city in Syria during the Syrian crisis; a cross-sectional epidemiological oral health survey. BMC Oral Health. 2019;19(1):16. https://doi.org/10.1186/s12903-019-0713-9.
Blackwell A, Casey J, Habeeb R, Annan J, Falb K. Women’s status and qualitative perceptions of a cash assistance programme in Raqqa governorate, Syria. Gender Dev. 2019;27(2):253–71. https://doi.org/10.1080/13552074.2019.1624047.
Douedari Y, Howard N. Perspectives on rebuilding health system governance in opposition-controlled Syria: a qualitative study. Int J Health Policy Manag. 2019;8(4):233–44. https://doi.org/10.15171/ijhpm.2018.132.
Duclos D, Ekzayez A, Ghaddar F, Checchi F, Blanchet K. Localisation and cross-border assistance to deliver humanitarian health services in north-West Syria: a qualitative inquiry for the Lancet-AUB Commission on Syria. Confl Health. 2019;13(1):20. https://doi.org/10.1186/s13031-019-0207-z.
Falb KL, Blackwell A, Stennes J, Hussein M, Annan J. Depressive symptoms among women in Raqqa governorate, Syria: associations with intimate partner violence, food insecurity, and perceived needs. Glob Ment Health (Camb). 2019;6:e22. https://doi.org/10.1017/gmh.2019.20.
Fardousi N, Douedari Y, Howard N. Healthcare under siege: a qualitative study of health-worker responses to targeting and besiegement in Syria. BMJ Open. 2019;9(9):e029651. https://doi.org/10.1136/bmjopen-2019-029651.
Fradejas-Garcia I. Humanitarian remoteness: aid work practices from ‘little Aleppo’. Soc Anthropol. 2019;27(2):286–303. https://doi.org/10.1111/1469-8676.12651.
Hallak J, Koyuncu M, Mic P. Determining shelter locations in conflict areas by multiobjective modeling: a case study in northern Syria. Int J Disaster Risk Reduction. 2019;38:15.
Hamid SH, Dashash MAD. The impact of post-traumatic stress disorder on dental and gingival status of children during Syrian crisis: a preliminary study. J Investig Clin Dent. 2019;10(1):e12372. https://doi.org/10.1111/jicd.12372.
Hamzeh A, Almhanni G, Aljaber Y, Alhasan R, Alhasan R, Alsamman MHDI, et al. Awareness of diabetes and diabetic retinopathy among a group of diabetic patients in main public hospitals in Damascus, Syria during the Syrian crisis. BMC Health Serv Res. 2019;19(1):549. https://doi.org/10.1186/s12913-019-4375-8.
Jamal Z, Alameddine M, Diaconu K, Lough G, Witter S, Ager A, et al. Health system resilience in the face of crisis: analysing the challenges, strategies and capacities for UNRWA in Syria. Health Policy Plan. 2019. https://doi.org/10.1093/heapol/czz129.
Mic P, Koyuncu M, Hallak J. Primary Health Care Center (PHCC) Location-Allocation with Multi-Objective Modelling: A Case Study in Idleb, Syria. Int J Environ Res Public Health. 2019;16(5):811.
Mohammad Y, Shaaban R, Salman HA, Shabraq BN, Dubaybo B. Improving the quality of hospital care provided for asthma out-patients in a country in turmoil: a report from Syria. J Thorac Dis. 2019;11(3):1047–55. https://doi.org/10.21037/jtd.2019.02.76.
Muhjazi G, Gabrielli AF, Ruiz-Postigo JA, Atta H, Osman M, Bashour H, et al. Cutaneous leishmaniasis in Syria: a review of available data during the war years: 2011-2018. PLoS Negl Trop Dis. 2019;13(12):e0007827. https://doi.org/10.1371/journal.pntd.0007827.
Okeeffe J, et al. The blast wounded of Raqqa, Syria: observational results from an MSF-supported district hospital. Conflict Health. 2019;13:9.
Ri S, Blair AH, Kim CJ, Haar RJ. Attacks on healthcare facilities as an indicator of violence against civilians in Syria: an exploratory analysis of open-source data. PLoS One. 2019;14(6):e0217905. https://doi.org/10.1371/journal.pone.0217905.
Roumieh M, Bashour H, Kharouf M, Chaikha S. Prevalence and risk factors for postpartum depression among women seen at primary health care Centres in Damascus. BMC Pregnancy Childbirth. 2019;19(1):519. https://doi.org/10.1186/s12884-019-2685-9.
Terkawi AS, Bakri B, Alsadek AS, al-Hasan AH, Alrahhal MS, Alsaleh FM, et al. Child and adolescent health in northwestern Syria: findings from healthy-Syria 2017 study. Avicenna J Med. 2019;9(2):61–74. https://doi.org/10.4103/AJM.AJM_184_18.
Terkawi AS, Bakri B, Alsadek AS, Alsibaee RH, Alasfar EM, Albakour AH, et al. Women’s health in northwestern Syria: findings from healthy-Syria 2017 study. Avicenna J Med. 2019;9(3):94–106. https://doi.org/10.4103/ajm.AJM_190_18.
Vernier L, Cramond V, Hoetjes M, Lenglet A, Hoare T, Malaeb R, et al. High levels of mortality, exposure to violence and psychological distress experienced by the internally displaced population of Ein Issa camp prior to and during their displacement in Northeast Syria, November 2017. Confl Health. 2019;13(1):33. https://doi.org/10.1186/s13031-019-0216-y.
Youssef A, Harfouch R, el Zein S, Alshehabi Z, Shaaban R, Kanj SS. Visceral and cutaneous Leishmaniases in a City in Syria and the effects of the Syrian conflict. Am J Trop Med Hyg. 2019;101(1):108–12. https://doi.org/10.4269/ajtmh.18-0778.
Ziveri, D., S. Kiani, and M. Broquet, The impact of psychosocial support on well-being and agency within an inclusive livelihood programme. Intervention (15718883), 2019. 17(1): 86–95.
Hallam R. Response to Syria’s health crisis. Lancet. 2013;382(9893):679–80. https://doi.org/10.1016/S0140-6736(13)61769-9.
Harrison S, Dahman R, Ismail M, Saada E, Hassan M, Hassan R, et al. Against all odds’: UNHCR’s mental health and psychosocial support programme for Iraqi refugees and internally displaced Syrians. Intervention. 2013;11(2):190–4. https://doi.org/10.1097/01.WTF.0000431851.46268.f8.
Hasanin A, et al. Syrian revolution: a field hospital under attack. Am J Disaster Med. 2013;8(4):259–65. https://doi.org/10.5055/ajdm.2013.0132.
Sankari A, Atassi B, Sahloul MZ. Syrian field hospitals: a creative solution in urban military conflict combat in Syria. Avicenna J Med. 2013;3(3):84–6. https://doi.org/10.4103/2231-0770.118467.
Alahdab F, Omar MH, Alsakka S, Atassi B, al-Moujahed A. Syrians’ alternative to a health care system: “field hospitals”. Avicenna J Med. 2014;4(3):51–3. https://doi.org/10.4103/2231-0770.133329.
Al-Makki A, et al. The Syrian National Kidney Foundation: response for the need of kidney patients during the crisis. Avicenna J Med. 2014;4(3):54–7. https://doi.org/10.4103/2231-0770.133331.
Attar S. Field hospitals in Syria. Lancet (London, England). 2014;383(9914):303.
Dolan, C., Coordinating the response to the Syria crisis: the southern Turkey cross border experience. Field Exchange - Emergency Nutrition Network ENN, 2014(48): 138–139.
Egendal, R. and A. Badejo, WFP’s emergency programme in Syria. Field Exchange - Emergency Nutrition Network ENN, 2014(48): 113–117.
Joury E. Constructing hope and peace in Syrian dental education during the country’s time of difficulty: success in Syrian smiles. Educ Health. 2014;27(1):71–2. https://doi.org/10.4103/1357-6283.134326.
Khudari, H., M. Bozo, and E. Hoff, WHO response to malnutrition in Syria: a focus on surveillance, case detection and clinical management. Field Exchange - Emergency Nutrition Network ENN, 2014(48): 118–121.
Kingori, J., et al., Nutrition response to the Syria crisis: UNICEF’s perspective. Field Exchange - Emergency Nutrition Network ENN, 2014(48): 160–163.
Littledike, E. and C. Beck, Experiences and challenges of programming in Northern Syria. Field Exchange - Emergency Nutrition Network ENN, 2014(48): 122–125.
Reed, H., GOAL’s food and voucher assistance programme in Northern Syria. Field Exchange - Emergency Nutrition Network ENN, 2014(48): 128–132.
Hakeem O, Jabri S. Adverse birth outcomes in women exposed to Syrian chemical attack. Lancet. 2015;3(4):e196.
Saeed B. The effect of the Syrian crisis on organ transplantation in Syria. Experimental Clin Transpl. 2015;13(2):206–8.
Jefee-Bahloul H, Barkil-Oteo A, Shukair N, Alraas W, Mahasneh W. Using a store-and-forward system to provide global Telemental health supervision and training: a case from Syria. Academic Psychiatry. 2016;40(4):707–9. https://doi.org/10.1007/s40596-015-0423-9.
Moughrabieh A, Weinert C. Rapid deployment of international tele-intensive care unit Services in war-Torn Syria. Ann Ame Thoracic Soc. 2016;13(2):165–72. https://doi.org/10.1513/AnnalsATS.201509-589OT.
Abdulahi, M., Experiences of Nutrition Sector coordination in Syria. Field Exchange - Emergency Nutrition Network ENN, 2017(56): 25–28.
Abdullah, S.F. and L.S. Baker, Experiences of the ‘Whole of Syria’ coordination for nutrition. Field Exchange - Emergency Nutrition Network ENN, 2017(56):79–83.
Madani, W.B.M., Development and added value of the Nutrition Cluster in Turkey. Field Exchange - Emergency Nutrition Network ENN, 2017(56): 11–15.
Mohammad A, et al. Practice of teleradiology in crisis zones: the unique case of Syria. Lancet Global Health. 2017;5(4):e399–400.
Aburas R, Najeeb A, Baageel L, Mackey TK. The Syrian conflict: a case study of the challenges and acute need for medical humanitarian operations for women and children internally displaced persons. BMC Med. 2018;16(1):65. https://doi.org/10.1186/s12916-018-1041-7.
Alrifai A, Alyousef T, Fanari Z. Tele-cardiology in the Syrian war. J Am Coll Cardiol. 2018;71(6):698–9. https://doi.org/10.1016/j.jacc.2018.01.001.
Ghbeis MB, Steffen KM, Braunlin EA, Beilman GJ, Dahman J, Ostwani W, et al. Tele-pediatric intensive Care for Critically ill Children in Syria. Telemed J e-Health. 2018;24(8):621–3. https://doi.org/10.1089/tmj.2017.0216.
Lester N. Introducing a trauma-informed practice framework to provide support in conflict-affected countries: the case of the Syrian white helmets. RUSI J. 2018;163(6):28–41. https://doi.org/10.1080/03071847.2018.1562016.
Masrani A, Mamoun I, Tarabishy B, Tarabishy A, Arabi M. Delivering humanitarian Teleradiology services to besieged areas in Syria. J Am College Radiol. 2018;15(8):1175–7. https://doi.org/10.1016/j.jacr.2018.03.052.
Mbaeyi C, et al. Strategic response to an outbreak of circulating vaccine-derived poliovirus type 2, Syrian Arab Republic, 2017-2018. Wkly Epidemiol Rec. 2018;93(25):362–8.
Muhjazi G, Baghdadi S, Dye C, Qusaibaty M. Sustaining a national tuberculosis control programme during civil crisis: 6 years of experience in Syria. Lancet Respir Med. 2018;6(4):255–6.
Kouba L, Amin B, Azzam A. Online education opportunity for Syria’s future doctors. Lancet. 2019;394(10211):1805–6. https://doi.org/10.1016/S0140-6736(19)31899-9.
Quay I. Rapid gender analysis and its use in crises: from zero to fifty in five years. Gend Dev. 2019;27(2):221–36. https://doi.org/10.1080/13552074.2019.1615282.
Attar S. The hell of Syria’s field hospitals. N Engl J Med. 2016;374(23):2205–7. https://doi.org/10.1056/NEJMp1603673.
Attar S. Syria’s humanitarian crisis. J Bone Joint Surg (Am Vol). 2014;96(9):e74.1–3.
Fakhouri F. Neurosurgery under siege - stories from Aleppo and the Syrian war: a narrative article. Asian J Neurosurg. 2017;12(2):342–3.
Kaadan MI, Cranmer H. The Management of the Khan Al-Assal Chemical Attack in Aleppo University hospital (AUH). Disaster Med Public Health Prepared. 2018;12(5):663–5. https://doi.org/10.1017/dmp.2017.132.
Mahomed Z, Motara F, Bham A. Humanitarian medical response to the Syrian Arab Republic (April 7, 2013 to April 23, 2013). Prehospital Disaster Med. 2016;31(1):114–6.
Kassem M. A Syrian neurosurgeon’s journey. Surg Neurol Int. 2016;7(1):6. https://doi.org/10.4103/2152-7806.173405.
Saadi TA, Abbas F, Turk T, Alkhatib M, Hanafi I, Alahdab F. Medical research in war-torn Syria: medical students’ perspective. Lancet. 2018;391(10139):2497–8. https://doi.org/10.1016/S0140-6736(18)31207-8.
Turk T, Aboshady OA, Albittar A. Studying medicine in crisis: Students’ perspectives from Syria. Med Teach. 2016;38(8):861–2. https://doi.org/10.1080/0142159X.2016.1204432.
Coutts A, Fouad FM, Abbara A, Sibai AM, Sahloul Z, Blanchet K. Responding to the Syrian health crisis: the need for data and research. The lancet. Respir Med. 2015;3(3):e8–9. https://doi.org/10.1016/S2213-2600(15)00041-7.
Taleb ZB, et al. Syria: health in a country undergoing tragic transition. Intern j Public Health. 2015;60:S63–72.
Rehr M, et al. Prevalence of non-communicable diseases and access to care among non-camp Syrian refugees in northern Jordan. Confl Heal. 2018;12:33.
Abbara A, et al. The effect of the conflict on Syria’s health system and human resources for health. World Health Popul. 2015;16(1):87–95.
Internal Displacement Monitoring Centre. The global report on internal displacement 2019. [cited 2019 Oct]; Available from: http://www.internal-displacement.org/global-report/grid2019/
Siege Watch. Siege Watch: final report – out of sight, Out of Mind: The Aftermath of Syria’s Sieges. 2019 [cited 2019 Oct]; Available from: https://siegewatch.org/wp-content/uploads/2015/10/pax-siege-watch-final-report-spread.pdf.
Syrian Network for Human Rights. Record of Arbitrary Arrests. 2019. http://sn4hr.org/blog/2018/09/24/record-of-arbitrary-arrests1/. Accessed 21 May 2021.
Zachariah R, Ford N, Draguez B, Yun O, Reid T. Conducting operational research within a non governmental organization: the example of Médecins Sans Frontières. Int Health. 2010;2(1):1–8. https://doi.org/10.1016/j.inhe.2009.12.008.
Leresche E, Truppa C, Martin C, Marnicio A, Rossi R, Zmeter C, et al. Conducting operational research in humanitarian settings: is there a shared path for humanitarians, national public health authorities and academics? Confl Heal. 2020;14(1):25. https://doi.org/10.1186/s13031-020-00280-2.
Bariscil A. An emergency academic support - Syrian refugee students in the Turkish higher education. Romanian J Multidimensional Educ / Revista Romaneasca pentru Educatie Multidimensionala. 2017;9(1):39–49. https://doi.org/10.18662/rrem/2017.0901.03.
Watenpaugh K, et al. We will stop here and go no further: Syrian university students and scholars in Turkey. New York: Institute of International Education; 2014. p. 55.
El Achi N, et al. A conceptual framework for capacity strengthening of health research in conflict: the case of the Middle East and North Africa region. Glob Health. 2019;15:81.
We thank Dr. Omar Asfour for his useful comments on the development of this draft.
MA was funded by the IKEA Foundation through their support to the Centre for Humanitarian Leadership, and the Swiss Government Peace and Human Rights Division through their support to the Lancet-American University of Beirut Commission on Syria; MKE was funded by the Department for International Development (DFID) through their support to the Lancet-American University of Beirut Commission on Syria.
Ethics approval and consent to participate
Not applicable as this is a literature review.
Consent for publication
Not applicable as this is a literature review.
No competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Abouzeid, M., Elzalabany, M.K., Nuwayhid, I. et al. Conflict-related health research in Syria, 2011–2019: a scoping review for The Lancet - AUB Commission on Syria. Confl Health 15, 92 (2021). https://doi.org/10.1186/s13031-021-00384-3