Results of a Nationwide Capacity Survey of Hospitals Providing Trauma Care in War-Affected Syria | Emergency Medicine | JAMA Surgery | JAMA Network
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Figure 1.  Locations of Hospitals in the Survey
Locations of Hospitals in the Survey

Red dots represent locations of hospitals.

Figure 2.  Critical Equipment in Need of Maintenance or Repair
Critical Equipment in Need of Maintenance or Repair
Figure 3.  Support to Syrian Trauma Hospitals
Support to Syrian Trauma Hospitals
Table 1.  Characteristics of Respondent Syrian Trauma Hospitalsa
Characteristics of Respondent Syrian Trauma Hospitalsa
Table 2.  Number of Emergency Services at Syrian Trauma Hospitals
Number of Emergency Services at Syrian Trauma Hospitals
Table 3.  Staffing at Syrian Trauma Hospitals
Staffing at Syrian Trauma Hospitals
1.
United Nations High Commissioner for Refugees. Syria Regional Refugee Response. Inter-Agency Sharing Portal. 2015. http://data.unhcr.org/syrianrefugees/regional.php. Accessed December 9, 2015.
2.
United Nations Office for the Coordination of Humanitarian Affairs, Syrian Arab Republic. 2015. http://www.unocha.org/syria. Accessed December 9, 2015.
3.
 Attacks on health care in Syria continue, defying U.N. resolutions. [press release] New York, NY: Physicians for Human Rights; 2015.
4.
Syrian Center for Policy Research. Syria: Alienation and Violence, Impact of Syria Crisis Report 2014. Damascus: Syrian Center for Policy Research; March 2015.
5.
Cluster  UH.  Health Resources Availability Mapping System (HeRAMS): Health Facilities Report. Gaziantep, Syria: UN Health Cluster; 2014.
6.
Unit  Assistance Coordination. HeFRA SI-2. Gaziantep, Turkey: Assistance Coordination Unit; April 2015.
7.
SPHERE Project.  Sphere Handbook: Humanitarian Charter and Minimum Standards in Disaster Response. 3rd ed. Northampton, England: Belmont Press; 2011.
8.
World Health Organization. Tool for Situational Analysis to Assess Emergency and Essential Surgical Care. http://www.who.int/surgery/en/. Accessed December 9, 2015.
Original Investigation
September 2016

Results of a Nationwide Capacity Survey of Hospitals Providing Trauma Care in War-Affected Syria

Author Affiliations
  • 1Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
  • 2Union of Medical Care and Relief Organizations, Paris, France
  • 3Department of Neurology, University of Alberta, Edmonton, Alberta, Canada
JAMA Surg. 2016;151(9):815-822. doi:10.1001/jamasurg.2016.1297
Abstract

Importance  The Syrian civil war has resulted in large-scale devastation of Syria’s health infrastructure along with widespread injuries and death from trauma. The capacity of Syrian trauma hospitals is not well characterized. Data are needed to allocate resources for trauma care to the population remaining in Syria.

Objective  To identify the number of trauma hospitals operating in Syria and to delineate their capacities.

Design, Setting, and Participants  From February 1 to March 31, 2015, a nationwide survey of 94 trauma hospitals was conducted inside Syria, representing a coverage rate of 69% to 93% of reported hospitals in nongovernment controlled areas.

Main Outcomes  Identification and geocoding of trauma and essential surgical services in Syria.

Results  Although 86 hospitals (91%) reported capacity to perform emergency surgery, 1 in 6 hospitals (16%) reported having no inpatient ward for patients after surgery. Sixty-three hospitals (70%) could transfuse whole blood but only 7 (7.4%) could separate and bank blood products. Seventy-one hospitals (76%) had any pharmacy services. Only 10 (11%) could provide renal replacement therapy, and only 18 (20%) provided any form of rehabilitative services. Syrian hospitals are isolated, with 24 (26%) relying on smuggling routes to refer patients to other hospitals and 47 hospitals (50%) reporting domestic supply lines that were never open or open less than daily. There were 538 surgeons, 378 physicians, and 1444 nurses identified in this survey, yielding a nurse to physician ratio of 1.8:1. Only 74 hospitals (79%) reported any salary support for staff, and 84 (89%) reported material support. There is an unmet need for biomedical engineering support in Syrian trauma hospitals, with 12 fixed x-ray machines (23%), 11 portable x-ray machines (13%), 13 computed tomographic scanners (22%), 21 adult (21%) and 5 pediatric (19%) ventilators, 14 anesthesia machines (10%), and 116 oxygen cylinders (15%) not functional. No functioning computed tomographic scanners remain in Aleppo, and 95 oxygen cylinders (42%) in rural Damascus are not functioning despite the high density of hospitals and patients in both provinces.

Conclusions and Relevance  Syrian trauma hospitals operate in the Syrian civil war under severe material and human resource constraints. Attention must be paid to providing biomedical engineering support and to directing resources to currently unsupported and geographically isolated critical access surgical hospitals.

Introduction

As the Syrian civil war enters its fifth year of fighting, the evolving conflict has claimed hundreds of thousands of lives. The war has resulted in displacement of more than 10.8 million Syrians (4.28 million refugees,1 6.5 million internally displaced2), representing 49% of the estimated prewar population. The urban warfare that has characterized the conflict has resulted in massive degradation of critical infrastructure, including electricity, clean water, sanitation, and public health hospitals. In addition, it has been widely reported that the targeting of health care professionals and medical hospitals3 has led to a severe decline in public health as measured by life expectancy, vaccination coverage, and infant mortality.4

Despite this level of devastation, hospitals continue to function inside Syria to provide acute and emergency care for the remaining population. The destruction of health care facilities through shelling and barrel bombing have forced some hospitals to reconstitute in nondescript, fortified buildings, such as former schools, underground garages, and warehouses. The capacities of the hospitals vary from just a few beds to a few large hospitals with 100 or more beds, from operative centers staffed by a single surgeon to multispecialty surgical units, and from hospitals that lack basic monitoring equipment, such as pulse oximeters, to those with intensive care unit and even tele–intensive care unit capabilities.

To plan for rational resource distribution and public health coverage of the remaining population, clinicians and policymakers need to know the capacity, capabilities, and geographic distribution of critical health resources. The Union of Medical Care and Relief Organizations (UOSSM), in coordination with partner organizations through the Syrian Hospital and Acute Care Committee, conducted a nationwide survey of hospitals that provide secondary surgical care or higher in regions outside the control of the government in Damascus. By identifying and geocoding clinically relevant services and equipment, we seek to create a continually updated functional capabilities map of trauma and essential surgical services in Syria. Such information can be used by clinicians in real time to decide how to treat patients, where to refer those in need of specialty services, and how best to distribute critical resources. To our knowledge, this study represents the first report of this project.

Box Section Ref ID

Key Points

  • Question What is the capacity to provide trauma care in Syria?

  • Finding Ninety-four hospitals provide operative trauma care inside Syria, with 538 surgeons, 378 other physicians, and 1569 nurses of any kind providing care for 12 million people in April 2015 (nongovernment, non–Islamic State territory). There is an unmet need for biomedical engineering support, with large numbers of critical equipment in need of repair, and trauma volume is high, with a mean (SD) of 228 (305) patients presenting monthly to Syrian hospitals.

  • Meaning Hospitals are operating under severe human and material resources constraints to provide trauma care during the Syrian Civil War.

Methods

From February 1 to March 31, 2015, the UOSSM staff conducted a nationwide survey of 94 surgical hospitals inside Syria (Figure 1). The survey was conducted in Arabic, and we collected data from each facility in the following domains: patient volume, services provided, presence and functionality of diagnostic and therapeutic equipment, staffing levels, accessibility of patient transfer and resupply, and funding.

Trained data collectors familiar with hospitals in each region administered the survey. Data collectors visited each facility to directly observe operations and to visually inspect equipment noted, when possible. A regional data supervisor was responsible for collecting records, reviewing results, and visiting a subset of hospitals to verify data collected.

This study of hospitals providing trauma care in Syria was reviewed and approved by the Yale University Institutional Review Board, and no informed consent was deemed necessary because no identifiable information was collected.

Preliminary analyses were presented to a focus group of nongovernmental organizations and other health staff from inside Syria for their comment at a conference in Gaziantep, Turkey, in April 2015. The focus group noted that the collected data overestimated the number of surgical subspecialists in Syria. The lack of consistent notation of level of effort, in terms of days per week of subspecialist availability, prevented the accurate identification of subspecialists because many provided services at more than 1 facility. Furthermore, despite the distinction in the initial survey between subspecialists with certification and surgeons providing subspecialty treatment (eg, vascular repair) without official certification, such distinctions were not consistently observed by the hospitals themselves. As a result, data supervisors resurveyed hospitals regarding the presence or absence of surgeons as a group and nonsurgeon physicians as a group, along with their respective level of effort and training.

Key clinical services (eg, ability to provide blood transfusion or physiotherapy for injured patients) were evaluated with respect to their presence and availability (eg, full time, part time, or not reported) at each facility. Only services that were fully functional were considered present. For example, if a hemodialysis machine was present but another critical component, such as dialysate or a dialysis technician, was missing, then this service was coded as not available.

The status of critical diagnostic and therapeutic equipment was recorded in the survey to characterize the functionality and distribution of medical equipment (Figure 2). For each class of equipment, the total number present at each facility and the number of functional and nonfunctional devices were recorded to establish the need for biomedical engineering support at Syrian trauma hospitals. Devices were grouped by function to establish the ability at each facility to perform specific services. For example, operating theaters were assessed to identify whether they had a functioning operating theater light, operating table, suction, cautery, anesthesia device, and ability to monitor patients intraoperatively.

Survey responses were recorded digitally in Microsoft Excel spreadsheets (Microsoft Corporation) then exported to STATA statistical software, release 14 (StataCorp), for analysis. Out of concern for hospital safety, hospitals were georeferenced using coordinates that did not represent exact location but were within neighborhoods or subdistricts of the actual hospital. Results were mapped for spatial display and analysis. No identifying information was collected on individual patients, and all health service data collected were summary in nature.

Results

In all, 94 hospitals that provided operative trauma care services responded to the survey; their characteristics are reported in Table 1. Almost all hospitals were open and staffed 7 days a week (mean [SD], 6.9 [0.3] days), with 80 (85% of all hospitals and 89% of those reporting) reporting operating hours greater than 12 hours daily (the maximum category). The provinces with the greatest number of responses were Rural Damascus (25 [27%]) and Dar’a (19 [20%]) in the south and Idleb (21 [22%]) in the north, reflecting density of surgical hospitals and ease of accessibility for data collectors in these regions.

Hospitals reported a great degree of functional and geographic isolation. Although the mean distance was 18.7 km to the nearest similar facility and 10.5 km to the referral facility, the large SDs reported reflected several hospitals with much further distances from nearby centers. Quiz Ref IDIn addition, 24 hospitals (26%) reported having to use smuggling routes for patient transfers, 47 hospitals (50%) reported domestic supply routes (within Syria) that were never open or open less than daily, and 65 hospitals (68%) reported international supply routes (to nearest border) that were never open or open less than daily. The mean distance from each facility to where they received supplies was 32 km, with many hospitals densely clustered; however, some hospitals were geographically isolated as represented by the SD of 65 km.

Eighty-eight hospitals (98%) reported having a surgical emergency department, and 86 (91%) reported having fully functioning emergency surgical capabilities. One in 6 hospitals (16%) functioned as an emergency surgical center only and reported having no adult inpatient ward to monitor patients postoperatively. Quiz Ref IDFurthermore, although 63 hospitals (70%) reported the ability to bank whole blood, only 7 hospitals (7%) reported functional transfusion services capable of separating and storing blood constituents and cross-matching blood for transfusion (Table 2). Outpatient services were limited, with 31 hospitals (38%) with fully functional outpatient clinics, 18 (20%) with physiotherapy services for injured patients, and 10 (11%) with ability to provide renal replacement therapy.

Availability of surgical subspecialty services could not be analyzed because many hospitals reported the presence or absence of a specialist without specifying his or her level of effort. In April 2015, there were 538 surgeons of any type (mean, 5.5 specialists and 0.8 surgical trainees per facility) and 378 nonsurgical physicians (mean, 2.8 specialists and 0.9 residents) working at 94 surgical hospitals surveyed throughout Syria (Table 3). Allied health care professionals were present in greater numbers, with 1569 nurses (mean, 9.8 professional nurses and 7.2 trainee nurses per facility) and 1043 technicians (mean, 9.6 professional technicians and 2.7 trainee technicians per facility) in this study. Quiz Ref IDThe mean (SD) number of emergency patients per surgeon per month was 41 (54). The mean (SD) number of emergency patients per physician per month was 26 (35). The mean (SD) nurse to physician ratio was 1.71 (1.2). A total of 44 health care professionals (49%) received in-hospital training or continuing medical education.

Quiz Ref IDThere were large numbers of nonfunctional critical diagnostic equipment (eTable 1 in the Supplement). Importantly, 12 fixed x-ray machines (23%), 11 portable x-ray machines (13%), and 13 computed tomographic scanners (22%) were not functioning (eTable 2 in the Supplement). In addition, 21 adult ventilators (21%), 5 pediatric ventilators (19%), 14 (10%) anesthesia machines, and 116 (15%) oxygen cylinders were not functioning (eTable 2 in the Supplement). There were no functioning computed tomographic scanners in hospitals reporting from the Aleppo province, and 95 oxygen cylinders (42%) in the Rural Damascus province are nonfunctional, despite the high density of surgical hospitals and critically high number of patients in both areas.

Laboratory diagnostic services were limited. Overall, although most hospitals (82 [87%]) reported the ability to determine hematocrit or hemoglobin levels and to conduct crude ABO testing for blood type, both crucial in patients with hemorrhagic injuries, 27 hospitals (29%) could not crossmatch blood, and fewer than one-third have the ability to screen for viral contamination with hepatitis or human immunodeficiency virus.

Health information management is rudimentary, with most discharged patients generating no record other than basic demographics and patient disposition. Only 63 hospitals (70%) surveyed reported having health records that were electronic and analyzable in some form. Eight hospitals (9%) reported not maintaining any health record at all (eTable 3 in the Supplement).

Trauma hospitals in Syria are severely resource constrained, with only 28 (30%) reporting full support for staff payroll and 11 (12%) reporting adequate financial support for supplies and medical consumables (Figure 3). An additional 46 (49%) and 63 (67%) reported partial support for salary and supplies, respectively.

Discussion

The results of this study, to our knowledge, provide the most comprehensive report of the functional status of hospitals providing trauma care in Syria and illustrate the gaps in human and material resources that can guide policymakers in allocating scarce resources for major trauma care in Syria. Two other hospital surveys were conducted in Syria in 2014-2015 but with a slightly different focus, specifically, the Health Resources Availability Management System (HeRAMS)5 and the Health Facilities Rapid Assessment (HeFRA).6 Each of these surveys assessed the capacity and functional status of health hospitals but tended to group functions (eg, laboratory) rather than report discrete functions (eg, transfusion services), specific services (eg, neurosurgical), or specific equipment (eg, computed tomographic scanner or incubator) that may be a critical resource and have direct clinical significance. The HeRAMS survey provided data on a wide variety of parameters for all types of health care hospitals inside Syria by surveying nongovernmental organizations on behalf of hospitals they support. The HeFRA survey conducted field visits to hospitals directly to assess functionality, case load, and infrastructure. Despite the existence of these surveys, the lack of detail regarding clinical characteristics of hospitals hampered the use of their findings in guiding acute trauma and surgical care in the field. Clinicians remained in the dark as to how to access critical services or where to transfer patients to receive specialty care. This issue is especially problematic given the high degree of insecurity involved in transferring patients in an active war zone and where communication among hospitals is the exception, not the rule.

Although it is difficult to ascertain the precise number of trauma hospitals operating in Syria, the HeRAMS survey identified 135 hospitals providing secondary or tertiary trauma surgical service,5 and the HeFRA survey identified 101 hospitals with at least 1 operating theater.6 Use of such broad inclusion criteria without ascertaining the degree to which these hospitals were providing actual trauma care overestimates the capacity for trauma care in Syria. Both previous surveys (HeRAMS and HeFRA), as well as this study, provide data on hospitals in the extreme north and south of Syria (accessible from bordering countries). Although the HeFRA survey provided more details about hospitals in eastern Syria (currently under Islamic State control), it does not contain data on hospitals in the interior of the country. Assuming all hospitals recorded in prior surveys were still functional at the time of this study, our survey can be estimated to cover 69% to 93% of known hospitals in regions outside government control.

There is a crisis in human resources for health in Syria, but that burden is unevenly distributed across hospitals in this survey. Although the original survey instrument collected data on subspecialty coverage, variability in the way these data were collected precluded their analysis. Instead, analysis was limited to surgeons and other physicians each taken as a group. Future surveys should take care to narrowly define human resource categories and to explicitly gather information on the percentage of effort in the form of days per week of coverage for each specialty.

In addition, 25% to 30% of health care professionals in each region are physicians in training. Many have performed a large number of emergency procedures during the past 4 years. There is a need for a provisional competency-based certification that can certify proficiency in certain critical functions so that these health care professionals may be better integrated into the health care system as a whole. For example, a resident in vascular surgery or a specialist in general surgery who has become proficient at bypass grafting of traumatically injured vessels may be provisionally credentialed under such a scheme and could be recognized officially as a person to whom patients in need of specialty surgery could be referred. Degree- and diploma-based certification cannot be the rule in this emergency situation in which human resources for health are so severely strained. More granular competency-based training and certification are urgently needed in Syria.

Although many hospitals in the north and south of the country reported adequate numbers of total surgeons, geographically isolated hospitals in the central region had critical shortages of personnel in all categories. Hospitals reported provision of some specialty services (eg, orthopedic) despite a lack of specialists. Thus, it was unclear whether in these instances there were specialists who provided care on an intermittent basis or whether a limited spectrum of services (eg, splinting or external fixation) were being provided by nonspecialists. Future surveys should more carefully define key services (eg, emergency obstetric surgery, emergency general surgery for appendicitis) and document who routinely provides these services.

Quiz Ref IDThe mean nurse to physician ratio of 1.71:1 is just more than half the recommended ratio of 3:1 to 4:1 and much lower than the 5:1 ratio in the SPHERE minimum guidelines for humanitarian response.7 This ratio is an overestimate of true functional capacity of these hospitals because many nurses in this calculation are laypersons who have received little training within hospitals to provide basic nursing tasks and do not have the full repertoire of skills of a professional nurse. This critical shortage is exacerbated by the extreme conditions under which physicians and nurses operate inside Syria.

In addition, there is an unmet need for biomedical engineering in Syria. Large numbers of critical diagnostics and therapeutic devices are nonfunctional. Some are degraded and simply require routine maintenance, such as the replacement of a fuse. Given the critical needs for life-saving equipment and the exorbitant expense and risk of transporting goods into and around Syria, hospitals in Syria urgently need biomedical engineering support for the repair and maintenance of existing medical devices. This support may be more cost-effective than additional procurement. Such support would leverage existing devices and allow local redistribution to more effectively cover hospitals and populations inside Syria.

This survey highlighted a lack of transfusion services in Syria. Blood banks exist but are not uniformly distributed across Syria. Despite available crossmatching capability, anecdotal evidence indicates that the procedure is simply not performed. Although blood transfusions take place daily in astounding numbers, it is almost entirely locally donated whole blood, with few hospitals having the human resources or technical capacity for separation, storage, and testing of blood products. Indeed, in the April 2015 focus group discussion, it became apparent that stock-outs and supply-chain disruptions forced many hospitals to transfuse blood without even rudimentary testing for viral contamination of hepatitis or human immunodeficiency virus. Future efforts should focus on ensuring safety of patients receiving transfused blood in Syria.

Although these results give an important view of the capabilities of trauma hospitals inside Syria, future surveys should seek to add additional details regarding hospitals’ ability to provide key emergency surgical services as outlined in previously standardized instruments, as in the World Health Organization Tool for Situational Analysis to Assess Emergency and Essential Surgical Care.8

As in any cross-sectional survey, these results reveal the situation of Syrian hospitals at a single point in time. In highly dynamic situations, such as the Syrian Civil War, with mobile populations and heavy warfare in urban centers, human and physical resources are likely to have changed—even by the time of this article’s publication. Nevertheless, the results of this study can help guide future interventions to improve surgical services in the country. Future iterations of this survey may add information about trends over time.

These data are only representative of the 94 hospitals that responded to the survey. Estimates from other surveys of health care facilities indicate the presence of 110 to 150 surgical centers that provide any form of trauma care.5,6 Findings may only be generalizable for regions such as the north and south of the country, where most respondent hospitals exist. The results have limited generalizability to isolated hospitals in the center of the country. Furthermore, hospitals in the east of Syria that once reported data to this hospital committee and that are now in regions controlled by the self-proclaimed Islamic State are no longer reliably reached by data collectors. As such, little can be predicted from these data as to the current state of those hospitals.

Patient volumes reported by hospital administrators were not in line with documentation from trauma data reported independently by those hospitals. Actual observed trauma patient volumes (for 59 hospitals where such data were available) were thus used to calculate the mean number of patients per clinician. Future surveys should focus on drawing from clinical records and generating reliable estimates of patient volume and derived measures of patients per clinician and for planning resource distribution.

Conclusions

Trauma hospitals inside Syria continue to provide massive amounts of trauma and emergency surgical care every day. Human resources are strained, and additional study is needed to more carefully map the availability of critical medical services and resources in the country. There is a need for competency-based training and credentialing to allow a number of partially trained specialists to be accessed by the community for subspecialty care. Finally, there is an unmet need for biomedical engineering that can access the untapped resource of idle life-saving equipment.

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Article Information

Accepted for Publication: March 28, 2016.

Corresponding Author: Hani Mowafi, MD, MPH, Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave, Ste 260, New Haven, CT 06519 (hani.mowafi@yale.edu).

Published Online: June 22, 2016. doi:10.1001/jamasurg.2016.1297.

Author Contributions: Dr Mowafi had access to all the data in the study and takes full responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Mowafi, Alnahhas, Allodami, Mahameed, Koly, Aldbis, Saqqur, Al-Kassem.

Acquisition, analysis, or interpretation of data: Mowafi, Hariri, Alnahhas, Ludwig, Mahameed, Koly, Zhang.

Drafting of the manuscript: Mowafi, Alnahhas, Ludwig, Mahameed, Koly, Aldbis, Saqqur, Zhang.

Critical revision of the manuscript for important intellectual content: Mowafi, Hariri, Alnahhas, Allodami, Mahameed, Koly, Al-Kassem.

Statistical analysis: Hariri, Ludwig, Mahameed, Koly, Zhang.

Obtained funding: Mowafi, Aldbis, Al-Kassem.

Administrative, technical, or material support: Mowafi, Alnahhas, Allodami, Mahameed, Koly, Saqqur, Al-Kassem.

Study supervision: Mowafi, Allodami, Koly, Al-Kassem.

Conflict of Interest Disclosures: Drs Hariri, Alnahhas, Allodami, Mahameed, Koly, Aldbis, Saqqur, and Al-Kassem reported being affiliated with the UOSSM and working inside Syria. No other disclosures were reported.

Funding/Support: Funding for the analysis and interpretation of the data and preparation, review, and approval of the manuscript was provided by Yale University. Funding for the design and conduct of the study and collection and management of the data was provided by the UOSSM.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
United Nations High Commissioner for Refugees. Syria Regional Refugee Response. Inter-Agency Sharing Portal. 2015. http://data.unhcr.org/syrianrefugees/regional.php. Accessed December 9, 2015.
2.
United Nations Office for the Coordination of Humanitarian Affairs, Syrian Arab Republic. 2015. http://www.unocha.org/syria. Accessed December 9, 2015.
3.
 Attacks on health care in Syria continue, defying U.N. resolutions. [press release] New York, NY: Physicians for Human Rights; 2015.
4.
Syrian Center for Policy Research. Syria: Alienation and Violence, Impact of Syria Crisis Report 2014. Damascus: Syrian Center for Policy Research; March 2015.
5.
Cluster  UH.  Health Resources Availability Mapping System (HeRAMS): Health Facilities Report. Gaziantep, Syria: UN Health Cluster; 2014.
6.
Unit  Assistance Coordination. HeFRA SI-2. Gaziantep, Turkey: Assistance Coordination Unit; April 2015.
7.
SPHERE Project.  Sphere Handbook: Humanitarian Charter and Minimum Standards in Disaster Response. 3rd ed. Northampton, England: Belmont Press; 2011.
8.
World Health Organization. Tool for Situational Analysis to Assess Emergency and Essential Surgical Care. http://www.who.int/surgery/en/. Accessed December 9, 2015.
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