Contemporary protracted conflicts across the Middle East have presented health systems and professionals with unprecedented challenges. The objective of this manifesto is to highlight the need for a better understanding of the different pathways of injury and re-injury within the changing ecology of war.

Ongoing conflicts in Iraq, Syria, Libya and Yemen are increasingly taking place in urban settings and result in high casualties among civilians and combatants alike. In fact, the distinction between combatants and civilians is increasingly blurred, making the injuries they suffer similar. In such settings, the delivery of treatment is often partial and inadequate due to the degradation and targeting of healthcare infrastructure under war. This affects not only the nature of the wounds inflicted, but also the capacity of health professionals to provide much needed care. The massive refugee crisis and population movement catalyzed by conflict further complicates this capacity as neighboring countries’ healthcare systems absorb the brunt of the burden.[1]

Consequently, there is an urgent need to rethink military and humanitarian medicine together as conflict medicine in light of evolving trends in contemporary warfare and their public health consequences. A conflict-centered approach to health provision goes beyond addressing the lack of resources for health in wartime. It allows us to reimagine healthcare delivery strategies and protocols in context, and to improvise appropriate technologies and approaches that better suite such volatile environments.

Until recently, the provision of healthcare in war has been shaped largely by the discipline of War Surgery, delivered predominantly through army medical corps, and by humanitarian organizations such as MSF and the ICRC. However, this expertise has remained concentrated in acute crises and among a limited number of actors who are facing increasing access constraints. The primary response to the full range of health needs in conflict is not carried by a specific humanitarian or medical team working in emergency situations but by entire health systems struggling to adapt to working amidst collapsing health infrastructure.

Advances in military medicine to address changes in war wounds (e.g., as a result of new kinds of weapons) have not fully permeated into the civilian sphere, even though this is now where the majority of the victims are treated. At the same time, existing expertise in war surgery is poorly equipped to attend to the multi-faceted and complex bio-psycho-social wounding that is characteristic of these conflicts.

War alters the biosphere, including the physical infrastructure, and the biological and social environments in which people live. These destructive and degrading transformations are often irreversible and have long-term consequences for individuals and society. Conflict medicine, a systematic approach to address these clinical, social, and public health consequences of contemporary warfare, is the response to war’s changing ecologies.

Conflict-related pathologies are becoming endemic and extend beyond the immediate damage caused by weaponry. Destroyed or degraded sanitation facilitates the microbiological seeding of wounds. The body, weakened by the wound, is re-injured when it interacts with the harsh, physically degraded environment. The social, political, and financial cost of injury and treatment burdens vulnerable families whose livelihoods are under strain from war and displacement.

Medical curricula, especially for people working in settings where war injuries constitute a big burden of the disease load, should reflect these clinical and public health realities in order to better equip health professionals to respond to the challenges of medical practice within conflict.

One critical example of the concerns of conflict medicine is multidrug resistant (MDR) bacteria, which now accounts for the majority of war wound infections across the Middle East region.[2] Reports from civilian, humanitarian and military institutions have identified MDR bacteria as the predominant pathogens causing infections in war wounds in the region.[3] Yet, most facilities in the region do not even have the laboratory capacity to diagnose MDR, leading to significant delays and clinical mismanagement of festering wounds. In addition to the real public health threat that MDR poses to compromised hospital settings in the region, it imposes a gross financial burden on patients and their families. The majority of the dwindling number of antibiotics that are effective in treating MDR infections require in-patient care and close monitoring due to their toxic side effects.

The prevalence of MDR raises important questions about the nosocomial theory of transmission, given that cases of both Iraqi civilians and wounded US servicemen have presented with MDR wound infections, despite being managed through diametrically opposite triage and treatment systems. The emergence of Iraq as the epicenter of MDR in the region raises serious questions about the long –term effects of the crippling sanctions regime during the 1990s on the practice of antibiotic prescription.

A second example of the considerations of conflict medicine is in addressing how global advances in the management of non-communicable diseases such as cancer and diabetes, have been reversed in conflict settings. This is often due to the inability of healthcare systems and technology to provide the same level of care in harsh and complex war environments: kidney failure patients can no longer access dialysis units; the delivery of chemotherapy to cancer patients is severely compromised; diabetic patients struggle to both monitor and adequately manage their disease.[4][5]  This is further exacerbated by the targeting of medical facilities and the flight and migration of medical experts from conflict zones.

In addition to this, the paradigms of diagnosing and treating the mental health consequences of protracted conflicts also need to be revisited. The predominance of psychiatric models, such as PTSD, which are premised on a temporal exposure to war and trauma, do not hold sway in areas where the everyday lives of entire generations have been shaped by chronic conflicts. At the same time, current models of psychosocial interventions and support need to be rethought to better address the complexities of injury to the collective psyche and the social body writ large. Health professionals need to be trained in the diagnosis and delivery of appropriate and culturally sensitive interventions at the primary care level.

In war-torn environments, where data collection is nearly impossible, patients’ narratives and experiences should be accorded greater value in providing insights into the early detection of health needs and changing patterns of morbidity. Furthermore, these narratives will help in better understanding the ways affected families and communities strategize their survival by triaging their health needs with the resources and facilities available to them.

An interdisciplinary conflict-centered approach to health lies at the heart of conflict medicine. This will help detect emerging trends, reshape medical education and training, and reconfigure the delivery of care in societies afflicted by war. The trans-generational legacies of present conflicts will inevitably shape the health environment of the future. This requires medical needs in conflict to be understood beyond the temporality of crisis and emergency.

Authors:

Ghassan Abu-Sittah, Conflict Medicine Program, Department of Plastic Surgery, American University of Beirut Medical Centre;

Omar Dewachi, Conflict Medicine Program, Department of Epidemiology and Population Health, American University of Beirut;

Vinh-Kim Nguyen, Department of Anthropology and Sociology of Development, Graduate Institute of International and Development Studies Geneva & Department of Social and Preventive Medicine, University of Montréal School of Public Health; and

Jonathan Whittall, Humanitarian Analysis Unit, Médecins sans Frontières.

Footnotes:

[1] Dewachi O, Skelton M, Nguyen VK, et al. Changing therapeutic geographies of the Iraqi and Syrian wars. Lancet 2014; 383: 449–57.

[2] Murphy RA, Ronat JB, Fakhri RM, et al. Multidrug-resistant chronic osteomyelitis complicating war injury in Iraqi civilians. J Trauma Acute Care Surg 2011; 71: 252–4.

[3] Petersen K, Riddle MS, Danko JR, et al. Trauma-related infections in battlefield casualties from Iraq. Ann Surg 2007; 245: 803–11

[4] Kherallah M, Alahfez T, Sahloul Z, Eddin KD, Jamil G. Health care in Syria before and during the crisis. Avicenna journal of medicine. 2012 Jul 1;2(3):51.

[5] Taleb ZB, Bahelah R, Fouad FM, Coutts A, Wilcox M, Maziak W. Syria: health in a country undergoing tragic transition. International journal of public health. 2015 Jan 1;60(1):63-72.

Photo

By Pierre-Yves Bernard © MSF, 2015.