Background: Syrian health system capacity has been devastated by a decade of conflict distinguished by frequent attacks on healthcare facilities and workers. The chronic nature of complex emergency created substantial gaps in formal training for what remains of the health system, leaving already impaired infrastructure vulnerable to the arrival of Covid-19 in mid-2020 to areas of Northwest Syria- the region now relies on ~600 physicians, few with critical care training, in 9 remaining hospitals with 197 ventilators to support a population of 4.5 million experiencing up to an estimated 1,500 new infections daily.

Purpose: In September 2021, regional leaders representing the Syrian Board of Medical Specialties and the Health Directorate of Northwest Syria (Idlib and Aleppo) contacted MedGlobal, a US-based humanitarian organization founded and run by a network of global health practitioners from academic medical centers, to help address educational gaps and support the local Covid-19 response.

Description: The intervention began with a network of experienced global health practitioners from US based academic institutions with a series of telephone calls with health representatives to complete an informal survey of health system capabilities, educational needs, and other areas for academic support. Within 10 days, a multipronged intervention was delivered beginning with a participant skill assessment survey to inform content development, with event announcement through local networks. Materials were translated into Arabic and distributed beforehand in low-bandwidth electronic formats. Lectures were supplemented with a synthesis of up-to-date treatment regimens, organized into context appropriate protocols informed by our experience in other conflict-affected settings. A special emphasis was placed on adaptations learned from other resource-strained sites including (1) creation of specialized task shift teams (eg. “prone teams”) composed of informally trained personnel to offload nursing staff shortages and (2) adapted ARDSNet training in the Kigali modification to the Berlin Criteria for the diagnosis and management of acute respiratory distress syndrome. A recording was made on a public streaming website of the intervention and materials in high and low data versions to preserve access for participants for download, reference, and share. 92% rated the relevance of the intervention as very good or excellent. Respondents reported uncertainty around baricitinib and dexamethasone use, ventilator modes, non-invasive mechanical support, as well as gaps in basic critical care management; 96.2% requested additional lectures. The most highly rated innovations were (1) a description of the “prone team” of auxillary staff and (2) the Kigali modification to the Berlin Critieria for the diagnosis of acute respiratory distress syndrome which corrects the Horowitz Index with SpO2 monitoring in settings where arterial blood gas measurements are unavailable.

Conclusions: Our experience in multiple sites over the course of the Covid-19 pandemic suggests a neglected area for humanitarian intervention is context-adapted educational support to health systems, and particularly, health education in conflict-affected settings. Our innovation, as described here, are context-adapted educational materials, particularly for heavily relied upon informal health staff. We urge the early generation and dissemination of these materials for health systems with disrupted educational infrastructure.