Correspondence
whereby benefits and burdens are fairly distributed. Hölldobler and Wilson’s illustration of the ant colony is fitting: just as ants cooperate within their own colony but compete with new colonies when they are introduced, so must individual health-care providers learn to cooperate within a wider setting of competition, without an inherent need for a hierarchy or a market.5 We declare that we have no conflicts of interest.
*Barnabas J Gilbert, Mahiben Maruthappu, Laurence Leaver, Muir Gray [email protected]; University of Oxford, Oxford OX2 6HG, UK (BJG, LL, MG); and Harvard University, Cambridge, MA, USA (MM) 1
2 3 4
5
Davis J. What were you doing while the NHS was being destroyed? Nov 13, 2013. http:// www.theguardian.com/commentisfree/2013/ nov/13/nhs-being-destroyed-labour (accessed Nov 15, 2013). The Lancet. The NHS: free and caring or a market commodity? Lancet 2013; 382: 571. Sullivan R. The Cost Disease. Lancet Oncol 2013; 14: 295. Hellowell M. The role of public-private partnerships in health systems is getting stronger. Commonwealth Health Partnerships, 2012. Hölldobler B, Wilson EO. The ants. Cambridge, MA: Springer-Verlag, 1990.
See Online for appendix
An early warning and response system for Syria The conflict in Syria has continued for more than 2 years: many Syrians have fled to escape the fighting (more than 5 million people have been internally displaced and about 2 million refugees are in neighbouring countries),1 and the Syrian healthcare system has been badly affected by the crisis.2–4 With huge population movements, substantial decreases in vaccination coverage, and deterioration of water and sanitation systems, the risk of epidemic-prone diseases is high. Epidemics pose a threat to health not only within Syria, but also in neighbouring countries. Public health surveillance is crucial 2066
to avert epidemics in emergency situations.5 In September, 2012, with the support of WHO, the Syrian Ministry of Health established an Early Warning Alert and Response System (EWARS) to strengthen the national surveillance system, detect epidemic threats early, respond to and control outbreaks, and monitor epidemic-prone diseases. EWARS is a network of reporting sentinel sites that collect information on a weekly basis. EWARS includes an alert element that signals outbreak at early stages, and it also includes preparedness plans. EWARS is supported by a network of laboratories, a communication network (via mobile phones), and a training component. At the beginning (September, 2012), 104 health centres were designated as sentinel reporting sites for EWARS across 14 governorates in the country. To overcome the problems in centres located in the governorates particularly affected by the conflict, non-governmental organisations’ health facilities and private hospitals and clinics were recruited by WHO in those governorates. By November, 2013, there were 368 reporting sites. Nine diseases were judged to be of high burden and epidemic-prone. A weekly bulletin is produced by EWARS and posted on WHO country office and Ministry of Health websites. EWARS is established and functional. It has succeeded so far in mitigating the consequences of many outbreaks, responding to a nation-wide measles outbreak, a typhoid outbreak in Deir ALZour, and the present polio outbreak. We declare that we have no conflicts of interest.
*Ghada Muhjazi, Hyam Bashour, Nidal Abourshaid, Hani Lahham [email protected] WHO Surveillance of Communicable Diseases, Damascus, Syria (GM); Damascus University, Damascus, Syria (HB); and Ministry of Health Damascus, Syria (NA, HL) 1
The UN Refugee Agency. Syria regional refugee response. http://data.unhcr.org/syrianrefugees/ regional.php (accessed Dec 3, 2013).
2
3 4
5
WHO. Health: Syrian Arab Republic 2013. http://www.who.int/hac/syria_ dashboard_6june2013_final_small_.pdf (accessed Dec 3, 2013). Garfield R. Health professionals in Syria. Lancet 2013; 382: 205–06. Médecins Sans Frontières. Syria two years on: the failure of international aid so far. http:// doctorswithoutborders.tumblr.com/ post/44944097430/syria-two-years-on-thefailure-of-international (accessed Dec 3, 2013). WHO. Outbreak surveillance and response in humanitarian emergencies: WHO guidelines for EWARN implementation. 2012. http:// whqlibdoc.who.int/hq/2012/who_hse_gar_ dce_2012_1_eng.pdf (accessed Dec 3, 2013).
Improving medical research in the Arab world Arab nations’ medical research output and broad impact are weak according to the 2013 Scimago Institutions Rankings report 1 (of the 2740 universities and research institutions worldwide, only 60 were from Arab countries), which echoes the Scimago Journal and Country Rank (1996–2012), 2 and the 2013 Shanghai Ranking (appendix).3 Arab institutions were linked with 76 417 reports published between 1996 and 2012, which is only 4% of medical research reports by US-based institutions (table). Medical research publication from institutions from all Arab countries is almost half of that from Turkey, almost the same as that from Israel, and double that from Iran, but with a lower H index4 average (table). Promotion of medical research in Arab countries needs serious efforts and several strategic goals must be agreed on by all stakeholders— scientists and decision makers. The strategy should include upgrading research infrastructure and equipment, providing sufficient funds and high-quality training, as well as promoting excellence. Additionally, Arab scientists working abroad should be seen as an asset. China has already shown the way by recruiting qualified www.thelancet.com Vol 382 December 21/28, 2013
whereby benefits and burdens are fairly distributed. Hölldobler and Wilson’s illustration of the ant colony is fitting: just as ants cooperate within their own colony but compete with new colonies when they are introduced, so must individual health-care providers learn to cooperate within a wider setting of competition, without an inherent need for a hierarchy or a market.5 We declare that we have no conflicts of interest.
*Barnabas J Gilbert, Mahiben Maruthappu, Laurence Leaver, Muir Gray [email protected]; University of Oxford, Oxford OX2 6HG, UK (BJG, LL, MG); and Harvard University, Cambridge, MA, USA (MM) 1
2 3 4
5
Davis J. What were you doing while the NHS was being destroyed? Nov 13, 2013. http:// www.theguardian.com/commentisfree/2013/ nov/13/nhs-being-destroyed-labour (accessed Nov 15, 2013). The Lancet. The NHS: free and caring or a market commodity? Lancet 2013; 382: 571. Sullivan R. The Cost Disease. Lancet Oncol 2013; 14: 295. Hellowell M. The role of public-private partnerships in health systems is getting stronger. Commonwealth Health Partnerships, 2012. Hölldobler B, Wilson EO. The ants. Cambridge, MA: Springer-Verlag, 1990.
See Online for appendix
An early warning and response system for Syria The conflict in Syria has continued for more than 2 years: many Syrians have fled to escape the fighting (more than 5 million people have been internally displaced and about 2 million refugees are in neighbouring countries),1 and the Syrian healthcare system has been badly affected by the crisis.2–4 With huge population movements, substantial decreases in vaccination coverage, and deterioration of water and sanitation systems, the risk of epidemic-prone diseases is high. Epidemics pose a threat to health not only within Syria, but also in neighbouring countries. Public health surveillance is crucial 2066
to avert epidemics in emergency situations.5 In September, 2012, with the support of WHO, the Syrian Ministry of Health established an Early Warning Alert and Response System (EWARS) to strengthen the national surveillance system, detect epidemic threats early, respond to and control outbreaks, and monitor epidemic-prone diseases. EWARS is a network of reporting sentinel sites that collect information on a weekly basis. EWARS includes an alert element that signals outbreak at early stages, and it also includes preparedness plans. EWARS is supported by a network of laboratories, a communication network (via mobile phones), and a training component. At the beginning (September, 2012), 104 health centres were designated as sentinel reporting sites for EWARS across 14 governorates in the country. To overcome the problems in centres located in the governorates particularly affected by the conflict, non-governmental organisations’ health facilities and private hospitals and clinics were recruited by WHO in those governorates. By November, 2013, there were 368 reporting sites. Nine diseases were judged to be of high burden and epidemic-prone. A weekly bulletin is produced by EWARS and posted on WHO country office and Ministry of Health websites. EWARS is established and functional. It has succeeded so far in mitigating the consequences of many outbreaks, responding to a nation-wide measles outbreak, a typhoid outbreak in Deir ALZour, and the present polio outbreak. We declare that we have no conflicts of interest.
*Ghada Muhjazi, Hyam Bashour, Nidal Abourshaid, Hani Lahham [email protected] WHO Surveillance of Communicable Diseases, Damascus, Syria (GM); Damascus University, Damascus, Syria (HB); and Ministry of Health Damascus, Syria (NA, HL) 1
The UN Refugee Agency. Syria regional refugee response. http://data.unhcr.org/syrianrefugees/ regional.php (accessed Dec 3, 2013).
2
3 4
5
WHO. Health: Syrian Arab Republic 2013. http://www.who.int/hac/syria_ dashboard_6june2013_final_small_.pdf (accessed Dec 3, 2013). Garfield R. Health professionals in Syria. Lancet 2013; 382: 205–06. Médecins Sans Frontières. Syria two years on: the failure of international aid so far. http:// doctorswithoutborders.tumblr.com/ post/44944097430/syria-two-years-on-thefailure-of-international (accessed Dec 3, 2013). WHO. Outbreak surveillance and response in humanitarian emergencies: WHO guidelines for EWARN implementation. 2012. http:// whqlibdoc.who.int/hq/2012/who_hse_gar_ dce_2012_1_eng.pdf (accessed Dec 3, 2013).
Improving medical research in the Arab world Arab nations’ medical research output and broad impact are weak according to the 2013 Scimago Institutions Rankings report 1 (of the 2740 universities and research institutions worldwide, only 60 were from Arab countries), which echoes the Scimago Journal and Country Rank (1996–2012), 2 and the 2013 Shanghai Ranking (appendix).3 Arab institutions were linked with 76 417 reports published between 1996 and 2012, which is only 4% of medical research reports by US-based institutions (table). Medical research publication from institutions from all Arab countries is almost half of that from Turkey, almost the same as that from Israel, and double that from Iran, but with a lower H index4 average (table). Promotion of medical research in Arab countries needs serious efforts and several strategic goals must be agreed on by all stakeholders— scientists and decision makers. The strategy should include upgrading research infrastructure and equipment, providing sufficient funds and high-quality training, as well as promoting excellence. Additionally, Arab scientists working abroad should be seen as an asset. China has already shown the way by recruiting qualified www.thelancet.com Vol 382 December 21/28, 2013
