Dealing with dramatic health care problems during times of natural disaster and armed conflict.

Disasters, both natural and man-made, can significantly disrupt the delivery of health services, especially those that rely on complex infrastructure such as acute kidney injury (AKI) management and dialysis.1Sekkarie M. Murad L. Al-Makki A. et al.End-stage kidney disease in areas of armed conflicts: challenges and solutions.Semin Nephrol. 2020; 40: 354-362Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 2Al-Makki A. Rifai A.O. Murad L. et al.The syrian national kidney foundation: response for the need of kidney patients during the crisis.Avicenna J Med. 2014; 4: 54-57Crossref PubMed Google Scholar, 3Alasfar S. Isreb M. Kaysi S. Hatahet K. Renal transplantation in areas of armed conflict.Semin Nephrol. 2020; 40: 386-392Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar While a single disaster can halt these services, concurrent disasters can have catastrophic effects, disrupting power, water, aid delivery, and transportation systems. These disruptions can be deadly for patients requiring maintenance or in need of acute dialysis. With the increasing number of prolonged armed conflicts around the world, such as those in Afghanistan, Ethiopia, Libya, Syria, Ukraine, and Yemen, the potential for natural disasters to worsen these already dire situations is a serious concern.4Alasfar S. Alashavi H. Hajj Nasan K. et al.Improving and maintaining quality of hemodialysis in areas affected by war: a call to action.Kidney Int. 2023; 103: 817-820Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar The impact of simultaneous disasters on the delivery of acute dialysis has not been adequately described. However, it is important to describe these experiences and outline the challenges associated with delivering such services under these infrequent circumstances so that local and international humanitarian agencies can prepare the necessary resources. The Syrian conflict, which erupted in 2011, is regarded as one of the worst humanitarian crises of the past 2 decades.5Sekkarie M.A. Zanabli A.R. Rifai A.O. et al.The Syrian conflict: assessment of the ESRD system and response to hemodialysis needs during a humanitarian and medical crisis.Kidney Int. 2015; 87: 262-265Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar As a result of the violent conflict, several areas in Syria were left without government control, including the heavily populated northwest region of 4.6 million people, of whom over 2.8 million were internally displaced.4Alasfar S. Alashavi H. Hajj Nasan K. et al.Improving and maintaining quality of hemodialysis in areas affected by war: a call to action.Kidney Int. 2023; 103: 817-820Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Before the conflict, the region had only a few hemodialysis facilities that treated around 300 patients with kidney failure. However, because of forced migration to the area—such as Idlib, a region in northwest (NW) Syria that has seen an influx of displaced individuals due to the ongoing civil war—this number increased to approximately 800 patients.4Alasfar S. Alashavi H. Hajj Nasan K. et al.Improving and maintaining quality of hemodialysis in areas affected by war: a call to action.Kidney Int. 2023; 103: 817-820Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar After the conflict began, only 1 border crossing from neighboring Turkey provided aid to the area under UN resolution 2858.4Alasfar S. Alashavi H. Hajj Nasan K. et al.Improving and maintaining quality of hemodialysis in areas affected by war: a call to action.Kidney Int. 2023; 103: 817-820Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Although nongovernmental organizations (NGOs) opened more dialysis facilities to cater to growing demand, several factors have led to significant deficiencies in dialysis operations.1Sekkarie M. Murad L. Al-Makki A. et al.End-stage kidney disease in areas of armed conflicts: challenges and solutions.Semin Nephrol. 2020; 40: 354-362Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar,2Al-Makki A. Rifai A.O. Murad L. et al.The syrian national kidney foundation: response for the need of kidney patients during the crisis.Avicenna J Med. 2014; 4: 54-57Crossref PubMed Google Scholar,5Sekkarie M.A. Zanabli A.R. Rifai A.O. et al.The Syrian conflict: assessment of the ESRD system and response to hemodialysis needs during a humanitarian and medical crisis.Kidney Int. 2015; 87: 262-265Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar These include the lack of reliable health departments in the region, migration, targeting of health care workers and facilities, NGOs’ limited experience in dialysis, and disruptions in civil infrastructure. Disruptions have also affected the delivery of acute dialysis for patients with AKI, including those with crush injuries from bombardment, testing the limitations of clinicians who used primitive tools to administer dialysis.6Rifai A.O. Murad L.B. Sekkarie M.A. et al.Continuous venovenous hemofiltration using a stand-alone blood pump for acute kidney injury in field hospitals in Syria.Kidney Int. 2015; 87: 254-261Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Moreover, there are a small number of nephrologists in the area, with an estimated 1 nephrologist per 1 million population.7Koubar S.H. Hajj Nasan K. Sekkarie M.A.K. Nephrology workforce and education in conflict zones.Kidney Int Rep. 2021; 7: 129-132Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar On February 6, 2023, the same area of NW Syria that is situated on an earthquake fault line was struck by 2 major earthquakes, resulting in the deadliest natural disaster in the area’s modern history.The earthquakes caused over 55,700 confirmed deaths, including over 48,400 in Turkey and over 7200 in Syria, with 4500 being in NW Syria.8Jabbour S. Abbara A. Ekzayez A. et al.The catastrophic response to the earthquake in Syria: the need for corrective actions and accountability.Lancet. 2023; 401: 802-805Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar The structural collapse resulting from the earthquakes led to a sudden influx of crush injuries complicated by life-threatening rhabdomyolysis and AKI. With the poor government presence and building standards, it was even more critical to have the necessary expertise, aid, and tools to manage such injuries. The incidence of crush injury patients requiring kidney replacement therapy in earthquakes can vary depending on several factors. A study comparing the Kashmir earthquake of 2005 and the Marmara earthquake of 1999 in Turkey found that the ratio of dialyzed AKI victims to deaths was significantly lower in Kashmir (0.8 per 1000) than in Marmara (27.1 per 1000).9van der Tol A. Hussain A. Sever M.S. et al.Impact of local circumstances on outcome of renal casualties in major disasters.Nephrol Dial Transplant. 2009; 24: 907-912Crossref PubMed Scopus (22) Google Scholar Data on this ratio are not currently available for the 2023 earthquake in Turkey, but data collected from NW Syria (Table 1) showed a ratio of 8 patients per 1000 deaths (37 of 4500), which is lower than that of Marmara despite similar earthquake intensity. The difference could be due to inferior rescue efforts resulting from limited resources and delayed aid in NW Syria. Table 1 shows data on earthquake victims in NW Syria who developed AKI while being treated for their injuries in the hospital. The Syrian Board of Medical Specialties (SBOMS) approved the survey conducted to collect these data from all treating physicians in the region. Of the 57 AKI cases reported, all patients who required hemodialysis were able to receive it. Dialysis for AKI cases was often initiated by non-nephrologist physicians in consultation with nephrologists in the United States and France via social media platforms such as WhatsApp and Zoom. Rhabdomyolysis was often diagnosed clinically due to the unavailability of the creatine kinase test in most treating hospitals, using the presence of crush injuries, compartment syndrome, and dark urine. Four cases of AKI requiring dialysis occurred after patients were discharged from the hospital, highlighting the importance of follow-up care after initial hospital discharge.Table 1Characteristics and outcome of hospitalized earthquake victims with acute kidney injury in Northwest Syria (N = 57)CharacteristicValueAge, yr, median (range)26 (2–68)Female sex, n (%)26 (45)Estimated hours under rubble, median (range)8 (2–96)Estimated hours until evaluated in the hospital, median (range)24 (9–120)Serum creatinine, mg/dl, at KRT initiation, mean (range)6.1 (1.5–14.1)Peak potassium, mEq/l, mean (range)6.0 (2.8–11.3)Victims who required dialysis, n (%)37 (65)Victims who developed pulmonary edema during hospitalization, n (%)10 (18)Number of dialysis sessions per patient, median (range)3 (1–12)Outcome, n (%) Did not need dialysis20 (35) Dialyzed but longer on dialysis31 (54) Dialyzed and remain on dialysis1 (2) Death5 (9)KRT, kidney replacement therapy. Open table in a new tab KRT, kidney replacement therapy. Although many cases of rhabdomyolysis after earthquakes may have gone unrecognized, data from NW Syria suggest favorable outcomes for those who made to medical facilities. This relative but highly commendable success is likely due to several factors. Although the overall international response to the earthquake in Syria has been labeled as “catastrophic” by some experts, the nephrology community’s response was an exception.8Jabbour S. Abbara A. Ekzayez A. et al.The catastrophic response to the earthquake in Syria: the need for corrective actions and accountability.Lancet. 2023; 401: 802-805Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar The Renal Disaster Preparedness Working Group of the International Society of Nephrology (ISN) played an important role in supporting earthquake victims and the nephrology workforce. Their support activities included identifying donors of supplies and equipment and informing them about the needs on the ground, arranging educational activities for providers by world renowned experts, and providing advice on cost-effective supplies and safe modalities of treatment. The experiences of physicians on the ground dealing with crush injuries from war-related trauma likely contributed to the rapid recognition and treatment of this complication during the earthquake. Since 2011, the commitment of Syrian physicians to medical education has been continued through networks such as the Syrian American Medical Society (SAMS), the SBOMS—which accredits training programs in NW Syria—and the Syria National Kidney Foundation (SNKF), which is made up of volunteer Syrian nephrologists abroad. Their dedication has promoted quality health care, ongoing education, and mentorship for physicians in the region. The earthquake underscored the importance of teamwork and organization in delivering medical care, as demonstrated by the immediate consultation support provided by nephrologists from the United States and Europe. The local SBOMS organization, with its network of senior and junior medical and surgical residents, also played a pivotal role in accommodating and treating patients. Communication channels and medical hierarchy were already established, and social media tools such as WhatsApp were used for communication and promoting uniform treatment protocols in Arabic and English. Daily medical rounds, with participation from both local and foreign physicians, were conducted for 2 weeks after the earthquake. In-kind donations of dialysis equipment and potassium binders were facilitated by these organizations and delivered along with medical missions as soon as the only border crossing point opened to this region. Verbal reports from dialysis facilities recorded at least 117 new dialysis cases, but this number may include displaced patients with kidney failure. One of the 19 dialysis facilities became out of service, and 1 dialysis technician lost his life due to the earthquake. Although most AKI earthquake victims in NW Syria received successful treatment, various challenges that could have prevented the likely missed cases of crush rhabdomyolysis were brough to light. While fully addressing the underlying geopolitical challenges is beyond the scope of this review, the most significant include the destruction of health care facilities, targeting of medical facilities during the conflict, the flight of medical personnel leading to a shortage of nephrologists, interrupted provision of primary and secondary health care, and interruptions in water, food, electricity, and transportation. Formal registration of morbidity and mortality data is currently unavailable due to the destruction of information systems, leading to inaccurate and inconsistent data. Also, significant psychological distress exists among both the general population and health care personnel, which has not been addressed over the last 12 years. The 6-day delay in delivering aid due to the closure of borders likely added an unmeasured detrimental effect on health care delivery and the mental health of health care staff in the area. The provision of nephrology care in NW Syria after the earthquake faced specific challenges in gathering information on patients’ needs, care processes, aid distribution, and measuring outcomes. To overcome these difficulties, existing communication channels between health care providers, expatriate physicians, NGOs, donors, and the ISN were used. The most challenging aspect of the nephrology response was aid coordination, as multiple donors with diverse resources and many providers, including hospitals, dialysis centers, and charitable clinics, made it challenging to determine who needed what and who had received aid. Overall, this experience highlights important lessons that can be applied to other areas affected by conflict and natural disasters. First, physicians may need to adjust their standard approaches to diagnosis and management by learning basic skills from other specialties and seeking support from outside experts. Secondly, disaster preparedness needs to be promoted through advertisement programs, with both international and local NGOs and medical societies establishing operational budgets, securing sources of income, ensuring accountability, data collection, and enhancing donations and volunteerism to respond to such situations. Collaborative efforts among medical societies and regional and international organizations are also crucial. Thirdly, UN agencies should ensure immediate aid delivery after disasters, regardless of the political environment, and quickly activate proper channels to overcome any political barrier. Lastly, given the limited long-term outcomes data on survivors of crush injuries, implementing basic research infrastructure for prospective data collection is crucial to fully understand the long-term morbidity among those who require dialysis after disasters.10Harris P.A. Taylor R. Minor B.L. et al.The REDCap consortium: building an international community of software platform partners.J Biomed Inform. 2019; 95103208Crossref PubMed Scopus (7635) Google Scholar SA has received research/grant support from the World Health Organization, Shire, and CareDx. WZ is a member of the Syrian Board of Medical Specialties (SBOMS). ARZ, FA-S, AOR, AA-M, and MS are the members of the Syrian National Kidney Foundation (SNKF). VL is a member of the Renal Disaster Preparedness Working Group of the International Society of Nephrology (ISN). LM is a member of the SNKF and SBOMS. All other authors declared no competing interests. We acknowledge the World Health Organization and the Health Cluster in Gaziantep Hub for supporting dialysis needs, the 339 medical trainess of the SBOMS for providing heroic efforts in managing crush victims in NW Syria, and the Médecins Sans Frontières organization for providing aid to dialysis centers in NW Syria.