Short and Long-Term Health Consequences of the 2013 Sarin Attack in Ghouta, Syria: A Retrospective Descriptive Study of Civilian Survivors

Short and Long-Term Health Consequences of the 2013 Sarin Attack in Ghouta, Syria: A Retrospective Descriptive Study of Civilian Survivors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Short and Long-Term Health Consequences of the 2013 Sarin Attack in Ghouta, Syria: A Retrospective Descriptive Study of Civilian Survivors MHD Bahaa Aldin Alhaffar, Luluwa Zarzar, Anneli Eriksson, Salim Namour This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7267929/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Apr, 2026 Read the published version in Scientific Reports → Version 1 posted 12 You are reading this latest preprint version Abstract Background On August 21, 2013, sarin gas was used as a weapon of war in multiple areas of Ghouta, rural Damascus, Syria, in the largest confirmed chemical weapons attack against civilians in the 21st century. Despite the scale of the attack, little is known about the long-term medical symptoms experienced by survivors. This study aimed to document the lived experiences, short- and long-term physical and psychological consequences of sarin exposure among civilian survivors, more than a decade after the attack. Methods We conducted a retrospective descriptive study based on semi-structured narrative interviews with survivors of the 2013 Ghouta chemical attacks. Participants were selected based on confirmed exposure and willingness to provide detailed accounts of their health status, experiences, and healthcare-seeking behavior. Thematic analysis was used to identify recurrent patterns and outcomes across different domains. Results All participants reported persistent medical symptoms ranging in severity, including chronic respiratory issues, neurological complaints, fatigue, and sensory disturbances. The psychological impact was universal, with widespread reports of anxiety, nightmares, panic attacks, and social withdrawal. Most participants experienced significant disruption to their quality of life and described barriers to accessing healthcare. Conclusions The long-term consequences of sarin exposure in Ghouta extend far beyond the initial event, affecting nearly every aspect of survivors’ lives. These findings highlight the urgent need for sustained medical, psychological, and social support for victims of chemical attacks. Integrating survivor needs into broader frameworks for post-conflict recovery and transitional justice is essential to ensure accountability, recognition, and the right to health. Health sciences/Health care Humanities/Medical humanities Biological sciences/Psychology Social science/Psychology Sarin gas chemical weapons Ghouta attack Syria survivors conflict public health Figures Figure 1 Figure 2 Background Since the beginning of the Syrian revolution in March 2011, Syria has witnessed one of the most devastating humanitarian crises in the modern history [ 1 ]. What began as peaceful demonstrations demanding freedom and dignity quickly escalated into a protracted and complex armed conflict that has reshaped the nation’s demographic, political, and health landscapes [ 2 ]. Over the past fourteen years, the war has been characterized by widespread violence, mass displacement, and severe human rights violations [ 3 ], several reports documented the systematic attacks on civilians, the bombing of critical infrastructure, and targeted attacks on healthcare facilities [ 4 ]. Among the gravest breaches of international humanitarian law is the use of chemical weapons in civilian areas—a tactic that has caused profound physical and psychological harm while remaining largely under-investigated [ 5 ]. Between 2012 and 2019, several attacks using chemical weapons has been documented, even though the exact number varies between different sources [ 6 , 7 ], the number of attacks exceeded hundreds, with civilians comprising 97.6% of the reported fatalities [ 5 ]. Among the most notorious incidents were the sarin gas attack in Al-Ghouta, rural Damascus in 2013 [ 7 ], and the Khan Sheikhoun attack in 2017 [ 7 ]. Investigations by the Organization for the Prohibition of Chemical Weapons (OPCW) confirmed the use of prohibited agents, including sarin, chlorine, and sulfur mustard. These attacks not only caused immediate mass casualties but also inflicted long-term neurological, respiratory, and psychological harm on survivors [ 7 ]. The Ghouta attack, in particular, marked a critical turning point in the Syrian conflict. On August 21, 2013, sarin-filled rockets struck multiple locations in the Damascus suburbs—including Zamalka, Ein-Tarma (East Ghouta), and Moadamiya (West Ghouta)—killing over 1,300 people (the exact number is different between different reports) and leaving thousands with chronic health complications [ 7 ]. This incident represented the largest-scale use of nerve agents since the Iran-Iraq War (1980–1988), crossing a critical “red line” and provoking widespread international condemnation [ 8 ]. Under diplomatic pressure, Syria acceded to the Chemical Weapons Convention (CWC) and dismantled its declared stockpile [ 9 ]. Despite these measures, chemical attacks continued, with chlorine gas gradually replacing sarin as the most frequently used agent. However, geopolitical divisions and the obstruction of investigative efforts done by the Assad regime have impeded accountability, leaving survivors to endure long-term health consequences with limited medical support [ 7 , 9 ]. Sarin (GB, Oisopropyl methyl phosphorofluoridate) was the primary nerve agent used in the Ghouta attack [ 5 ]. It is a highly toxic organophosphate that works by irreversibly blocking acetylcholinesterase (AChE), the enzyme responsible for breaking down the neurotransmitter acetylcholine (ACh) at nerve ending [ 10 ]. The resulting accumulation of ACh leads to overstimulation of the autonomic, neuromuscular, and central nervous systems. Symptoms include excessive secretions, difficulty breathing, slowed heart rate, and pinpointing pupils. Muscle twitching, weakness, and respiratory paralysis may follow, while effects on the brain can trigger seizures, confusion, coma, and, ultimately, death—most often from respiratory failure due to blocked airways and muscle paralysis [ 7 , 10 ]. While the acute effects of sarin exposure are well documented, the long-term health consequences remain poorly understood—particularly in Syria, where mass displacement and years of repression obstructed systematic research [ 11 ]. Frontline medical reports point to persistent neurological damage, chronic respiratory illness, and psychological trauma among survivors, yet little is known about how these conditions shape health-seeking behaviours and access to care [ 11 ]. Political restrictions and insecurity further limited independent investigation, leaving critical medical and scientific gaps [ 12 ]. Despite the scale and gravity of these attacks, documentation has been limited. Deliberate obstruction, disinformation, and suppression of evidence by the Assad regime hindered accountability and denied survivors recognition and care. Since the Assad regime’s fall in December 2024, new opportunities have emerged to investigate and record these long-term impacts [ 13 ]. This study contributes to the scientific understanding of sarin’s enduring effects by examining the lived experiences and medical consequences among Ghouta survivors which support the broader demands for justice, recognition, and reparations. Aim of the research : This study aims to investigate the lived experiences, psychological impact, and the immediate, short, and long-term medical symptoms among the survivors of Al-Ghouta chemical attack. Methodology Study design : This research is a retrospective descriptive study focusing on the survivors of Al-Ghouta attack. Survivors were defined as individuals who directly experienced and survived a major chemical weapons attack, witnessing the event firsthand and being in close proximity to the attack location. The study followed STROBE guidelines for reporting of observational studies [ 14 ]. Study settings and location : Between 2013 and 2019, the number of confirmed chemical weapon attacks in Syria exceeded 300, involving various toxic agents including sarin, chlorine, and sulfur mustard [ 5 ]. These attacks caused hundreds of fatalities and thousands of injuries, primarily affecting civilian populations. Among them, the Ghouta sarin attack stands out as the largest in both scale and lethality, and therefore, was the focus on this study. Figure 1 represents the major attack in Syria between 2013–2019 with zoomed in map on the attack of 2013 in Ghouta. This study was conducted in the aftermath of the fall of the Assad regime on December 8, 2024, a political shift that created new opportunities for the documentation and investigation of previously suppressed war crimes, including the long-term effects of chemical weapons. For over a decade, efforts to study these consequences were largely obstructed by systemic denial, targeted repression, and the destruction of evidence. The collapse of the regime has not only allowed survivors to speak more openly but has also facilitated field-based research efforts in areas previously inaccessible to investigators and human rights workers. Fieldwork was carried out in locations directly affected by the 2013 Ghouta chemical attacks, specifically the neighbourhoods of Zamalka and Ein-Tarma in Eastern Ghouta and Moadamiya in Western Ghouta, Damascus Suburbs Governorate. These areas, situated approximately 16 kilometres apart, were struck in the early hours of August 21, 2013, by rockets filled with sarin gas. According to survivor accounts and OPCW reports, the Zamalka and Ein Tarma strikes occurred between 2:00 and 3:00 AM, while Moadamiya was targeted closer to 5:00 AM [ 15 ]. Participant Inclusion Criteria and Sampling Participants were selected using purposive sampling, targeting individuals with direct and verifiable exposure to the sarin attack in Ghouta. Inclusion criteria required that participants were 1- physically present in the affected areas of Zamalka, Ein Tarma, or Moadamiya during the time of the attack, 2- Witnessed the event firsthand, and 3- Were within close proximity to a confirmed impact site. Eligible participants were identified and contacted through the Association of Victims of Chemical Weapons (AVCW), which maintains a detailed and independently verified database of survivors. Participant eligibility was confirmed by AVCW, and recruitment was further supported by a trusted field responder and survivor based in Zamalka, who facilitated introductions and verified accounts through local networks. Given the qualitative design and use of narrative interviews, no formal sample size calculation was conducted. The final sample consisted of 14 semi-structured narrative interviews were the participants asked to tell his/her story without interfering but only directing towards the overall themes of the study. The participants were selected based on their exposure history, availability, and willingness to participate. Data collection continued until thematic saturation was reached—that is, when no new information or codes were emerging and the interviews began to yield repetitive themes. This approach ensured both analytical depth and representational diversity across proximity, age, and gender dimensions. Interview Guide Development and Data Collection Data collection was guided by a semi-structured interview guide developed specifically for this study. A narrative interview technique was employed, allowing participants to share their experiences freely and with minimal interviewer intervention. This approach was chosen to centre survivor voices, minimize framing bias, and respect the sensitive nature of the topic. The interview guide was informed by existing literature on chemical weapons exposure, toxicological outcomes, and trauma-informed qualitative research [ 16 ]. It was designed to elicit open-ended narratives while maintaining structure around key domains: demographic background, prior medical history, the day of the attack, short- and long-term health symptoms, survival strategies on the day of the attack, and perceived impacts on others (e.g., children, reproductive outcomes). The guide was first drafted in English, then professionally translated into Arabic to ensure cultural and contextual appropriateness [ 17 ]. A pilot focus group was conducted with representative of AVCW to test the relevance, clarity, and emotional safety of the questions. Interviews were conducted between January and April 2025 during field visits to previously targeted locations. All interviews were conducted in Arabic, in private and respectful settings chosen by the participants. Depending on logistical constraints and participant preference, all interviews were held in person, in the same locations were the chemical attacks happened, providing direct contextual relevance to the data collected. Each session began with a written informed consent process, ensuring participants understood the study’s purpose, the voluntary nature of participation, and their rights, including the right to withdraw at any time. Interviews lasted between 20 and 50 minutes. All transcripts and audio files were stored in encrypted, password-protected drives accessible only to the research team, in accordance with GDPR-compliant data protection standards. Data Analysis All interviews were audio-recorded, transcribed verbatim in Arabic, and anonymized during transcription to ensure confidentiality. The transcriptions were then reviewed for accuracy and completeness by the research team and translated to English. A thematic analysis approach was applied, following Braun and Clarke’s six-phase framework: familiarization with the data, generation of initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report [ 18 ]. Initial coding was performed manually in English by two independent researchers trained in qualitative methods. Codes were derived both inductively from the data and deductively from the study objectives. Following the initial coding round, the researchers conducted a cross-checking process to ensure consistency and reliability. Discrepancies in code interpretation were resolved through iterative discussion and consensus, and in cases of ambiguity, a third researcher was consulted. A process of recoding was conducted after initial theme development, allowing for the refinement of code categories and the consolidation of overlapping or conceptually similar codes. Themes were then grouped under broader domains reflecting the lived experiences of chemical attack survivors, including recognition of exposure, short and long-term symptoms, health-seeking behaviour, psychosocial impact, and barriers to care. During analysis of the interviews, medical symptoms were categorized into 1-immediate, 2-short-term, and 3-long-term medical symptoms based on participant narratives. Immediate symptoms occurred directly or within the first hour of exposure; short-term symptoms lasted within hours to two weeks; and long-term effects persisted for months to years. The analysis was conducted manually to retain close engagement with the narrative structure and context. Throughout the process, reflexivity was maintained through analytic memos and debriefing sessions among the research team. Thematic saturation was confirmed when no new codes or themes emerged from additional interviews, supporting the adequacy of the final sample. Following the completion of the thematic analysis, a focus group discussion was held with members of both the current and former leadership of the Association of Victims of Chemical Weapons (AVCW). The aim was to present and validate the preliminary findings, clarify any inconsistencies, and ensure contextual relevance. Feedback received from AVCW was reviewed systematically, and all relevant insights were incorporated into the final analysis and presentation of results. Bias As with all retrospective studies relying on self-reported data, this study is subject to inherent biases—particularly recall bias and information bias. To mitigate these, a purposive sampling strategy was employed, and only verified survivors—identified and cross-checked through the Association of Victims of Chemical Weapons (AVCW)—were included. Interviews were guided by a semi-structured tool with neutral, open-ended prompts to minimize interviewer influence and enhance the reliability of recollections. Additionally, consistency across participant narratives served as a further internal validity check. Ethical Considerations Ethical approval for the study was obtained from the Association of Victims of Chemical Weapons (AVCW), which also served as the data custodian under a formal data-sharing agreement. This agreement outlined strict adherence to confidentiality, data protection, and participant rights. Each participant provided written informed consent prior to the interview, after receiving detailed information about the study’s aims, methodology, potential risks, and safeguards. Participants were given space to ask questions and were informed of their right to withdraw at any time without consequence. All interviews were conducted in private settings, and data were anonymized during transcription. Given the trauma-associated nature of the subject matter, interviews were conducted using a trauma-informed approach. Researchers were trained to recognize signs of psychological distress, and interviews were paused or terminated when participants showed discomfort or emotional triggering. This ethical framework aimed to ensure that participants’ dignity, safety, and autonomy remained central throughout the research process. Results Descriptive analysis of the interviews : This study is based on a total of 14 face-to-face interviews conducted with survivors of the chemical weapons attack that took place in Al-Ghouta, Zamalka. Participants ranged in age from 12 to 60 years, with a mean age of 39. The gender distribution included eight females and six males. In terms of proximity to the chemical attack site, participants reported varying distances, with the closest being approximately 10 meters and the furthest up to 100 meters away. Most participants were within a 30 to 80-meter radius of the impact zone, indicating significant exposure to the chemical agents. All participants described that they were healthy and did not any medical symptoms before the attack. Table 1 presents the main thematic findings from the study. Five overarching themes were identified through the analysis: exposure to the chemical attack and lived experience; immediate medical response and survival strategies; short-term medical symptoms; long-term medical consequences; and psychological impact. Each theme encompassed several subthemes reflecting the complex, layered nature of survivors' experiences—ranging from sensory and social cues during the attack, to improvised medical responses, to chronic physical and psychological sequelae that persist more than a decade later. Table 1 summery of study themes, main results and impact of the victims and survivals of the chemical weapons attack Themes Subtheme Exposure to Chemical Attack and lived experience - Realizing the chemical attack - Sensory cues - Social cues - Seeking health care - Alerting others Immediate medical response, treatment, and survival strategies - Improvised masks - Civilian rescue - Atropine use - Transportation of victims - Seeking shelters - Makeshift tools Immediate and Short-term medical symptoms - Ophthalmological problems - Respiratory symptoms - Gastrointestinal (GI) symptoms - Neurological symptoms Long term medical symptoms - Cardiologic issues - Chronic respiratory issues - Gastrointestinal (GI) distress - Immune dysfunction - Neurologic problems - Ophthalmological problems - Reproductive Health Disorder - Weakness Psychological impact - Post traumatic stress disorder (PTSD) - Bereavement - Grief - Displacement trauma - Loss of family Exposure to Chemical Attack and lived experience : In the initial phase of the interview, participants were asked to recount their experiences during the attack. Nearly all (13 of 14) described the event as sudden and disorienting, with no official warnings or alerts. Most survivors (9 of 14) identified the threat through sensory cues—unusual smells, lack of typical explosion sounds, and visual anomalies. Others (5 of 14) recognized the attack only after observing the reactions of neighbours or community members. The process of realization was gradual, unfolding as a series of sensory, spatial, and social signals rather than clear communication. In this vacuum of structured alerts, people relied on their instincts and one another to interpret the unfolding event. “Its smell was like rotten apples mixed with vinegar… we smelled it and started showing symptoms.” — Participant 2 “We heard a missile without an explosion, and black smoke rose.” — Participant 12 “The closest missile to my house was about 100 meters. Its sound was faint and unlike normal shells.” — Participant 4 “There was black smoke, and it looked different from a typical bombing.” — Participant 11 “We woke up to the neighbours shouting, ‘chemical attack!’ We didn’t understand what was happening. Everyone was shouting and crying.” — Participant 12 “The neighbours knocked on our door yelling ‘chemical attack!’ and we could feel something was wrong with the air.” — Participant 13 “At 1:45 AM, we were using our radios and performing rescue work. Suddenly, around 15 missiles fell. The first three [missiles] didn’t explode in a normal way. When we went to the site, there was a strange smell, and one of the people there started convulsing and foaming at the mouth.” — Participant 1 “We asked our team on the radio what kind of missiles these were—this wasn’t normal.” — Participant 1 Immediate medical response, treatment, and survival strategies : In the absence of organized emergency infrastructure, survivors of the Ghouta chemical attack relied on improvised and community-driven responses. All participants reported using household items—such as vinegar, water, cloth, and onion peels—as makeshift gas masks. Eight out of 14 described the use or administration of atropine, though access was uneven and often improvised. Transport to medical facilities was primarily civilian led, with survivors either carried by neighbours or taken by volunteer drivers to overwhelmed field hospitals. These spontaneous efforts reflect the urgent and chaotic environment in which survival depended on shared knowledge, peer support, and the creative use of limited resources. “We went to the rooftop and tore a piece from my son's shirt. We dipped it in vinegar and water and put it on our faces as masks.” — P13 “We used a mask with a piece of cotton soaked in vinegar and water. We put onion peels inside it, just like we heard from others—it might help.” — P11 “I opened oxygen tanks and administered atropine. I was injecting people, trying to do anything I could.” — P10 “They took us to Kafr Batna. My husband kept helping others the whole time, even though he was exposed himself.” — P12 “Medical volunteers were injecting people with atropine... local health workers were giving treatment, even in houses.” — P4 “Ambulances came from Arbin, from Douma, from across Ghouta. But it was too much... there were too many cases at once.” — P3 Immediate and Short-term medical symptoms : All participants described a sudden onset of acute medical symptoms during the chemical attack, with excessive salivation and foaming reported by 12 out of 14, muscle convulsions by 11, respiratory distress by 11, ophthalmologic symptoms such as burning or blurred vision by 12, and loss of consciousness by 9. These symptoms began within seconds to minutes after exposure and were multisystemic in nature, affecting respiratory, neurological, and visual systems simultaneously. The rapid progression of effects contributed to a sense of helplessness and panic, especially in the absence of medical support. Table 2 “One person convulsed and started foaming at the mouth—we knew then it was chemical.” — P1 “My whole body started shaking uncontrollably. My eyes hurt. I felt like my body wasn’t mine anymore.” — P 13 “The light looked like a thousand suns. Everything was spinning. I felt like I was dying.” — P4 “I started feeling dizzy in the morning. My husband told me I blacked out for hours.” — P 11 “I started vomiting black liquid before anything else. It was like my insides were reacting instantly.” — P12 “My saliva tasted like artificial sweetener, like saccharin. I’ve never tasted anything like it.” — P3 “Our eyes became blurred; for two weeks we couldn’t see properly.” — P2 “My eyes were burning so badly they gave me an injection just for the pain.” — P10 “There was vision loss and shortness of breath—even while carrying people I could barely see through the smoke.” — P5 The short-term medical symptoms lasting days to weeks following the attack, participants continued to experience serious health problems. All survivors reported neurological symptoms, including tremors, confusion, or disorientation. Ophthalmologic issues persisted in 12 participants, while respiratory symptoms remained in 7. Gastrointestinal distress was reported by 6, along with sensory disturbances, temporary loss of consciousness, and involuntary urination. Notably, 2 participants also reported reproductive health complications. These ongoing symptoms disrupted daily functioning, prolonged recovery, and contributed to lasting trauma. Table 2 “If I try to smoke a cigarette now, just one puff makes me cough for an hour.” — P6 “for the next two weeks I had tremors and couldn’t even control my hands” __ P13 “It took my over 10 days until I could move myself, and until now I have nerve problems” __9 “For 15–20 days after the attack I couldn’t see, but then it started improving slowly” __P4 “.. I passed out after few minutes, and I wake up after 7 hours in a different place, I found myself in a different place, in a hospital, and for the next 3 days I couldn’t concentrate, and then I realized that my kids are dead” P__9 Long term medical symptoms : In the months and years following the attack, participants described a wide range of chronic and progressively debilitating conditions. The most commonly reported long-term symptoms were neurological and neuromuscular disorders, present in all participants. These included tremors, nerve pain, and coordination issues. Chronic respiratory problems were reported by 10 out of 14 survivors, while immune dysfunction appeared in 6. Ophthalmologic complications persisted in 8, reproductive health disorders were mentioned by 3, and cardiologic issues by 4. Survivors also reported fatigue and weakness, gastrointestinal distress, and a variety of other persistent symptoms, including cognitive issues and developmental delays in children. Table 2 . These long-term effects severely limited daily functioning, even years after the exposure. These narratives reveal a consistent pattern of multisystem chronic illness, in individuals who were previously healthy, and point toward serious long-term toxicological impacts of sarin exposure. Most survivors explicitly attributed these conditions to the chemical attack, reinforcing the link between exposure and long-term health deterioration. “They get episodes—days where they shake, their nerves hurt. They’re always taking medication for it.” — P5 “Even now, years later, I get tremors in my face, especially around my nose. It comes suddenly and really disturbs me.” — P6 “I lost my eyesight, and my immune system is wrecked.” — P3 “My son still has nerve inflammation. He walks and talks like an old man.” — P11 “We noticed problems with urination. It’s like things stopped working right.” — P1 “We lost so much weight after the attack—me and the kids. We looked like we were starving.” — P12 Psychological impact : In addition to physical harm, the chemical attack left survivors with profound psychological trauma. A significant majority reported symptoms consistent with anxiety, depression, or post-traumatic stress disorder (PTSD). Nightmares were described by 11 participants, and sleep disturbances and grief-related symptoms were reported by 8 each. These effects were closely linked to personal loss, mass casualties, displacement, and the erosion of community structures. The trauma extended beyond the event itself, shaped by the chaos of emergency medical care, the psychological burden of mass burials, and the long-term fragmentation of families. Displacement functioned as both a physical and emotional rupture, often described as a point of no return. These layered experiences underline the urgent need for mental health support, including grief counselling and trauma-informed care, in post-conflict health interventions. “We went through a nightmare. I had a son and daughter—both lost in front of me. I still hear their voices at night.” — P10 “When they took us to the hospital, we saw people lying on the floor, unconscious, children foaming at the mouth. My mind couldn’t process what I was seeing.” — P12 “We were digging mass graves three meters deep. We were layering bodies. There was no time to say goodbye.” — P3 “We were burying the dead quickly in collective graves. There were days when we buried 40 at once.” — P5 “After the strike, we left into the unknown. We had no idea where we were going, just that we had to get away.” — P1 “We were displaced to the north. We’ve only recently returned, and nothing feels the same.” — P2 “We were displaced to the north. My sister left her children with me. She never came back.” — P13 Table 2 Prevalence of Immediate, Short-Term, Long-Term, and Psychological Symptoms Among Survivors of the 2013 Sarin Attack in Ghouta Theme Subtheme Frequency Main results Impact immediate symptoms Excessive salivation & foaming 12 Response driven by instinct and community help; formal care was limited Delayed response, confusion, and fear due to absence of structured alerts loss of consciousness 9 Muscle convulsions 11 ophthalmology symptoms 12 Respiratory Distress 11 Other 3 short term medical symptoms GI distress 6 Symptoms were multisystemic and appeared rapidly after exposure High toxicity confirmed; immediate collapse of physical function Neurologic symptoms 14 ophthalmology symptoms 12 Reproductive Health Disorder 2 Respiratory Distress 7 Sensory details 6 Temporary loss of consciousness 6 involuntary urination 5 Other 4 long term medical symptoms cardiologic issues 4 Chronic symptoms persisted for years and disrupted daily life Long-term disability, need for neurorehabilitation and monitoring chronic respiratory issues 10 GI distress 2 Immune dysfunction 6 Neurologic symptoms 14 ophthalmologic symptoms 8 Reproductive Health Disorder 3 weakness 5 other 7 Psychological Impact symptoms of Anxiety, Depression, or PTSD 12 The psychological trauma was deep and prolonged, rooted in loss and instability Need for integrated mental health and grief support in recovery Sleep disturbances 8 Nightmares 11 Grief 8 Relationship between Proximity, Age, and Severity of Outcomes Survivors' testimonies shed light on how proximity to the chemical strike and age influenced the severity of outcomes. While the study did not apply formal statistical measures, strong narrative patterns suggest that closer distance to the impact site significantly increased both immediate and long-term health complications. In contrast, age appeared to have no protective effect—symptom severity was reported across all age groups. Those within 10 to 30 meters of the strike reported the most acute effects. Participant 1, only twenty meters away, described “witnessing seizures and foaming at the mouth” among others, and later experienced his own persistent neuromuscular dysfunction and cognitive decline. Participant 9, also in close range, recounted “near-total paralysis for ten days” along with lasting memory, vision, and cardiovascular complications. Participant 2, exposed within 30 meters, noted respiratory impairment and long-term visual damage. Conversely, survivors farther from the epicenter experienced milder symptoms. Participant 4, who was about 100 meters away, recalled shortness of breath and visual issues, but emphasized being outside the “deadly radius,” suggesting a localized exposure gradient. These narratives support the view that severity was dose-dependent, with closer proximity increasing toxic load and impairing escape capacity. As for age, no clear correlation emerged. Participant 12, who has a 12-year-old daughter, describe how her daughter suffered vomiting, chronic fatigue, and psychological trauma. Meanwhile, 60-year-old Participant 10 reported visual and respiratory damage along with profound loss, both describing significant, ongoing health deterioration. Similarly, younger adults in their twenties and thirties also reported nerve damage, fertility issues, and chronic pain, undermining assumptions of age-based resilience. Figure N.2 - Severity of Symptoms in Relation to Proximity to Chemical Attack Location Discussion The 2013 sarin gas attack on Ghouta represents one of the darkest chapters of the Syrian war and remains a stark reminder of the intensity and brutality of the decade-long conflict. It was described by the United Nations as “the most significant confirmed use of chemical weapons against civilians since 1988,” [ 19 ]. Despite the magnitude of the attack, very little peer-reviewed research has been published, and to the best of our knowledge, no study has systematically documented the long-term health consequences of chemical weapon exposure during the Syrian war. In this retrospective study, we addressed this gap by investigating the lived experiences, short- and long-term medical symptoms, and psychological impact among civilian survivors of the Ghouta attack. Participants reported a range of persistent physical and psychological symptoms, including respiratory dysfunction, neurological complaints, and mental health disturbances, which they directly attributed to the sarin exposure. These included chronic cough, shortness of breath, chest pain, headaches, sensory deficits, memory problems, anxiety, and episodes of panic or depression—often coexisting and compounding one another. Many participants described a profound deterioration in their overall wellbeing, with symptoms interfering with daily tasks, family roles, and social interactions. The clinical symptoms reported by participants in our study are in strong agreement with those documented in the United Nations Mission report on the 21 August 2013 attack (A/67/997–S/2013/553), which concluded that “survivors reported a rapid onset of extreme breathing difficulties, eye irritation, foaming from the mouth, convulsions, and loss of consciousness.” The report also confirmed that biomedical samples from victims tested positive for exposure to sarin, supporting the validity of the symptomatology described in both our qualitative data and the official investigation [ 20 ]. Moreover, these findings are consistent with earlier case series from the Matsumoto and Tokyo subway sarin attacks, where victims reported longterm somatic and neuropsychiatric symptoms; in the Tokyo cohort, 60–80% of survivors reported ocular and somatic symptoms at 10 years postexposure and 35% met criteria for posttraumatic stress responses [ 21 ]. Additionally, our findings echo studies of Iranian veterans and Kurdish civilians exposed to sulfur mustard, where similar constellations of respiratory, neurological, and psychiatric symptoms were documented years or decades after exposure [ 22 – 25 ]. While toxicological mechanisms differ between sulfur mustard and sarin, the long-term outcomes appear to converge—highlighting the multi-systemic and enduring nature of chemical weapon injury. However, the Syrian case is further complicated by post-attack displacement, economic collapse, and the near-total breakdown of healthcare systems, which have left many survivors without diagnosis, treatment, or recognition [ 1 , 11 , 26 ]. The results of our study showed that the psychological impact of the sarin attack was profound and enduring. Every participant described some form of emotional or psychological distress, often closely intertwined with their physical symptoms. Feelings of fear, helplessness, and anxiety were common, and many reported that these psychological burdens had exacerbated the severity of their chronic health problems. Nightmares, panic attacks, intrusive memories, and hypervigilance were frequently mentioned, alongside social withdrawal and emotional numbness. These findings are consistent with previous studies on chemical warfare survivors, which have documented elevated rates of PTSD, depression, and anxiety long after exposure [ 22 , 24 ], and also similar reductions in qualityoflife scores and moderate depressive symptoms have been documented among Kurdish refugees resettled in Sweden thirty years after the initial attack [ 27 ]. In the Syrian context, where access to mental health care is virtually non-existent, the absence of recognition and support has further intensified the long-term psychological toll [ 28 ]. Our findings also suggest that proximity to the epicentre of the attack may be a critical determinant of symptom severity. Participants who reported being closer to the impact zones consistently described more severe symptoms—ranging from acute respiratory failure and visual disturbances to long-term neurological and psychological sequelae. This pattern supports dose-dependent effects of sarin exposure, as noted in previous studies. In the Tokyo subway attack, for example, symptom severity and biomarker levels of sarin metabolites were significantly higher among individuals in closer proximity to the release site [ 21 , 29 ]. Similarly, after the Matsumoto attack, those residing nearest to the contaminated building experienced the highest mortality and greatest burden of chronic symptoms [ 21 ]. These findings align with toxicological models of nerve agent dispersal, which predict a steep exposure gradient based on distance, ventilation, and terrain [ 30 ]. Notably, the United Nations Mission report (A/67/997–S/2013/553) described similar spatial trends in Eastern Ghouta, where entire families residing near the impact sites were found deceased in confined spaces, often with no visible external injuries, suggesting rapid onset of fatal symptoms due to high-dose exposure. Such spatial clustering of fatalities near the epicentres reinforces the association between proximity and exposure severity in sarin-related mass casualty events [ 20 ]. Access to appropriate healthcare emerged as a major challenge for all participants. Survivors reported years of living with unresolved symptoms—both physical and psychological—without receiving adequate diagnosis, treatment, or follow-up. These barriers mirror those faced by other chemical warfare survivors in conflict-affected settings, such as Halabja, where long-term care needs were similarly unmet [ 24 ]. However, in Syria, the systematic destruction of health infrastructure, ongoing displacement, and political denial of chemical attacks have compounded these difficulties—leaving most survivors without even the basic validation of their suffering [ 31 ]. This study offers one of the first systematic attempts to document the long-term health consequences of chemical weapon exposure among civilians during the Syrian war, drawing directly from the lived experiences of survivors. A key strength lies in its timing—conducted after the fall of the regime—which allowed for open, uncensored testimonies rarely accessible in previous years. The use of a retrospective descriptive design and survivor narratives provided a context-specific understanding of both medical and psychosocial outcomes. However, the study has limitations, including potential recall bias, survivor bias, and challenges in verifying clinical diagnoses due to the destruction/absence of medical records and lack of diagnostic follow-up. Despite these limitations, our study underscores the urgent need for comprehensive, multidisciplinary care for sarin survivors. The persistence of symptoms ten years after exposure emphasises that acute treatment alone is insufficient. Longterm rehabilitation should integrate pulmonology, neurology, ophthalmology and mentalhealth services, as advocated for Halabja survivors. Communitybased psychosocial support and recognition of survivor narratives are essential to address the chronic fear, social isolation and stigma highlighted by participants. International bodies and donor agencies must prioritise funding for chemical weapons survivors, support research into antidotes and neuroprotective therapies, and uphold mechanisms for accountability and reparations. Only by acknowledging and responding to the enduring burden of chemical warfare can we fulfil our ethical obligations to those affected and prevent recurrence, as recognizing and addressing the long-term impact of chemical attacks is not only a medical necessity—it is a foundational step toward meaningful peacebuilding and transitional justice. Conclusion This study provides a documentation of the long-term health impacts of the 2013 sarin gas attack in Ghouta, revealing a persistent burden of physical and psychological consequences and exploring the lived experiences among survivors. The findings underscore the need for sustained, multidisciplinary care and highlight how chemical warfare continues to harm long after the initial exposure. In the context of Syria’s ongoing transition, addressing these harms must be part of any meaningful post-conflict health response and justice process. Survivors’ voices and experiences are essential not only for guiding medical and humanitarian interventions but also for shaping policies that promote accountability, recognition, and lasting peace. Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from Association of Victims of chemical weapons (AVCW), and with a serial number 202502/1. All participants provided informed consent prior to participation. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to confidentiality and security concerns but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contributions MBA, LZ designed the study. LZ conducted the data collection. MBA analysed the data. All authors contributed to the writing and revision of the manuscript and approved the final version. AI use disclosure Artificial intelligence tool (ChatGPT, OpenAI) was used solely for improving grammar, structure, and clarity of the text. All scientific content, data analysis, and interpretation were conceived, conducted, and written by the authors. Acknowledgements This study is dedicated to the victims of the 2013 Ghouta chemical attack and to all those who have suffered from the use of chemical weapons in Syria. We also express our deepest respect to the first responders who risked their lives to save others during and after the attack. Special thanks go to the Association of Victims of Chemical Weapons in Syria for their support and collaboration, and in particular to Anas Al-Khouli, Ibrahim Al-Atiq, Ahmad Hazrouma, Salim Namour, and Manal Al-Hamadi for their trust, guidance, and continued commitment to justice and recognition for survivors. References Alhaffar, M. H. D. B. A. & Janos, S. Public health consequences after ten years of the Syrian crisis: a literature review. Globalization and Health. 2021 2021/09/19;17(1):111. Available at: https://doi.org/10.1186/s12992-021-00762-9 Munzer, A. et al. An analysis of humanitarian and health aid harmonisation over a decade (2011–2019) of the Syrian conflict. BMJ Global Health. ;9(10):e014687. (2024). Available at: https://ghsite-bmj.vercel.app/content/9/10/e014687 Guha-Sapir D, Schlüter B, Rodriguez-Llanes JM, Lillywhite L, Hicks MH-R. Patterns of civilian and child deaths due to war-related violence in Syria: a comparative analysis from the Violation Documentation Center dataset, 2011–16. The Lancet Global Health. 2018;6(1):e103-e10. Available at: https://doi.org/10.1016/S2214-109X(17)30469-2. Muzzall, E., Perlman, B., Rubenstein, L. S. & Haar, R. J. Overview of attacks against civilian infrastructure during the Syrian civil war, 2012–2018. BMJ Glob Health ; 6 (10) (2021). Rodriguez-Llanes, J. M., Guha-Sapir, D., Schlüter, B-S. & Hicks, M. H. R. Epidemiological findings of major chemical attacks in the Syrian war are consistent with civilian targeting: a short report. Conflict and Health. 2018 2018/04/16;12(1):16. Available at: https://doi.org/10.1186/s13031-018-0150-4 Human Rights, W. & Syria A Year On, Chemical Weapons Attacks Persist (Human Rights Watch, 2018). 2018/04/04. Report No.:. Syrian American Medical Society. A New Normal: Ongoing Chemical Weapons Attacks in Syria (Syrian American Medical Society, 2016). Haines, D. D. & Fox, S. C. Acute and Long-Term Impact of Chemical Weapons: Lessons from the Iran-Iraq War. Forensic Sci. Rev. 26 (2), 97–114 (2014). Naqvi, Y. Crossing the red line: The use of chemical weapons in Syria and what should happen now. International Review of the Red Cross. 2019 2019/02/07;99(906):959 – 93. Available at: https://international-review.icrc.org/sites/default/files/906_7.pdf Sidell, F. R., Takafuji, E. T. & Franz, D. R. Chapter 5. In: (eds General, U. S. A. O. T. S. & Borden, I.) Medical Aspects of Chemical and Biological Warfare. Washington, DC: Borden Institute; (1997). Zarocostas, J. Syria chemical attacks: preparing for the unconscionable. The Lancet. ;389(10078):1501. (2017). Available at: https://doi.org/10.1016/S0140-6736(17)30997-2 Charbonneau, L. & Syria Stop Undermining UN Investigation. 2016/10/28 2016. Available at: https://www.hrw.org/news/2016/10/28/syria-stop-undermining-un-investigation Nashwan, A. J. & Swed, S. The fall of Assad: Implications for Syria’s healthcare system. Ethics, Medicine and Public Health. 2025 2025/01/01/;33:101059. Available at: https://www.sciencedirect.com/science/article/pii/S2352552525000180 Vandenbroucke, J. P. et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Med. 4 (10), e297 (2007). Human Rights, W. Attacks on Ghouta: Analysis of Alleged Use of Chemical Weapons in Syria. New York: Human Rights Watch, 2013 2013/09/10. Report No.:. Edelman, N. L. Trauma and resilience informed research principles and practice: A framework to improve the inclusion and experience of disadvantaged populations in health and social care research. Journal of Health Services Research & Policy. ;28(1):66–75. Available at: https://journals.sagepub.com/doi/abs/ (2023). 10.1177/13558196221124740 Beaton, D. E., Bombardier, C., Guillemin, F. & Ferraz, M. B. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa. 1976) . 25 (24), 3186–3191 (2000). Ahmed, S. K. et al. BM, et al. Using thematic analysis in qualitative research. Journal of Medicine, Surgery, and Public Health. 2025 2025/08/01/;6:100198. Available at: https://www.sciencedirect.com/science/article/pii/S2949916X25000222 The White, H. & United Nations Releases Report on the Use of Chemical Weapons in Syria.. The White House Blog (Obama White House Archives). 2013/09/18 (2013). Available at: https://obamawhitehouse.archives.gov/blog/2013/09/18/united-nations-releases-report-use-chemical-weapons-syria United Nations Mission to Investigate Allegations of the Use of Chemical Weapons in the Syrian Arab R. Report on the Alleged Use of Chemical Weapons in the Ghouta Area of Damascus on 21 August 2013. New York: United Nations, 2013 2013/09/16. Report No.:. Sugiyama, A. et al. The Tokyo subway sarin attack has long-term effects on survivors: A 10-year study started 5 years after the terrorist incident. PLoS One . 15 (6), e0234967 (2020). Hashemian, F. et al. Anxiety, depression, and posttraumatic stress in Iranian survivors of chemical warfare. Jama. ;296 5:560-6. (2006). Available at: https://www.ncbi.nlm.nih.gov/pubmed/16882962 Mohammad-Amin, K., Avakh, F., Abdollahi, M., Ezatollah Kordmirza, N. & Alireza, G. Effects of Chemical Warfare Throughout Time on Mental Disorder Symptoms and Brain Executive Functions of Veterans Exposed to Chemical Weapons. Annals of Military and Health Sciences Research. (2023). Available at: https://api.semanticscholar.org/CorpusId:260664359 Moradi, F. et al. Health perspectives among Halabja’s civilian survivors of sulfur mustard exposure with respiratory symptoms—A qualitative study. PLoS ONE. ;14 (2019). Available at: https://api.semanticscholar.org/CorpusId:195260715 Aroniadou-Anderjaska, V. et al. Long-term neuropathological and behavioral impairments after exposure to nerve agents. Ann. N Y Acad. Sci. 1374 (1), 17–28 (2016). Organisation for the Prohibition of Chemical W. Report of the OPCW Fact-Finding Mission in Syria regarding an alleged incident in Khan Shaykhun, Syrian Arab Republic, April 2017 (S/1510/2017). The Hague, Netherlands: Organisation for the Prohibition of Chemical Weapons, 2017 2017/06/29. Report No.:. Moradi, F., Moradi, F., Li, Y., Olin, A-C. & Daka, B. The impact of sulfur mustard on quality of life and mental health in Kurdish survivors in Sweden, thirty years after exposure. Health and Quality of Life Outcomes. 2022 2022/12/20;20(1):165. Available at: https://doi.org/10.1186/s12955-022-02081-y Kakaje, A. et al. Mental disorder and PTSD in Syria during wartime: a nationwide crisis. BMC Psychiatry. (2021). 2021/01/02;21(1):2 Available at: https://doi.org/10.1186/s12888-020-03002-3 Yanagisawa, N., Morita, H. & Nakajima, T. Sarin experiences in Japan: Acute toxicity and long-term effects. Journal of the Neurological Sciences. (2006). 2006/11/01/;249(1):76–85 Available at: https://www.sciencedirect.com/science/article/pii/S0022510X06002917 Satu, M. S. A. U. J. A. R. Jr. Chemical Warfare Agents: Toxicity at Low Levels (CRC, 2001). Haar, R. et al. The cascading impacts of attacks on health in Syria: A qualitative study of health system and community impacts. PLOS Glob Public. Health . 4 (6), e0002967 (2024). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7267929","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":503075262,"identity":"7bb2da10-fcc9-429a-b608-7258069f7f75","order_by":0,"name":"MHD Bahaa Aldin Alhaffar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYBACAwkwZZHAwHyAgeEDkMnGTpwWiQQGtgQGxhkgLcykaGHmAbEJaTGXbn74gaFGIo+/jfnZZ5tf2+T5mBkYP3zMwa3Fcs4xYwmGYxLFEsfYjGfn9t02bGNmYJacuQ2Pw24kAN3GJpHYcL/BmDm35zYjUAsbMy9eLemffzD8k0icf4z9M7Nlz217IrTkmEkwtkkkbjjGY8zM8ON2IkEtljNyyiwS+yQSNx7jKWbsbbid3MbM2IzXL+YS6ZtvfPhmkzjvGPtmhh9/btvOb28++OEjHi1gkABjMLaByQYC6lHAH1IUj4JRMApGwUgBALAzTj2fHDVGAAAAAElFTkSuQmCC","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":true,"prefix":"","firstName":"MHD","middleName":"Bahaa Aldin","lastName":"Alhaffar","suffix":""},{"id":503075263,"identity":"3b0f2d15-e148-4939-9143-4285eb422192","order_by":1,"name":"Luluwa Zarzar","email":"","orcid":"","institution":"Damascus University","correspondingAuthor":false,"prefix":"","firstName":"Luluwa","middleName":"","lastName":"Zarzar","suffix":""},{"id":503075264,"identity":"ef39d0a3-3a53-4fff-ae72-cef9d9acca9e","order_by":2,"name":"Anneli Eriksson","email":"","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":false,"prefix":"","firstName":"Anneli","middleName":"","lastName":"Eriksson","suffix":""},{"id":503075265,"identity":"9f5ada50-ebba-4c1b-858b-17c1ee2e1a1a","order_by":3,"name":"Salim Namour","email":"","orcid":"","institution":"Association of Victims of Chemical Weapons","correspondingAuthor":false,"prefix":"","firstName":"Salim","middleName":"","lastName":"Namour","suffix":""}],"badges":[],"createdAt":"2025-08-01 06:23:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7267929/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7267929/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-026-47135-z","type":"published","date":"2026-04-02T16:00:02+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89642316,"identity":"4f362a32-896e-4563-8277-cf64354fca38","added_by":"auto","created_at":"2025-08-22 08:14:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":231545,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMajor chemical weapon attacks in Syria between 2013-2019\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMap (left):\u003c/strong\u003e Syria map generated in R studio using open source data, open street map, Humanitarian data exchange, available from: Syria Roads (OpenStreetMap Export) | Humanitarian Dataset | HDX.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eZoomed Map (right):\u003c/strong\u003e zoomed in map to rural Damascus generated in R studio using open source data, representing Ghouta attack using sarin on the 21\u003csup\u003est\u003c/sup\u003e of august 2013, visualization of the approximate location based on the details provided from the Association of the victims of chemical weapons Home - Association of Victims of Chemical Weapons\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRed dot:\u003c/strong\u003e chemical weapon attack using Sarin, \u003cstrong\u003eGray circle:\u003c/strong\u003e chemical weapon attack using other agent (sulfur mustard or chlorine).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7267929/v1/5ff862777d892a6e6a16ee84.png"},{"id":89642313,"identity":"1f9a74ff-c408-4eaa-b06f-eeba2bbee1fe","added_by":"auto","created_at":"2025-08-22 08:14:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":44128,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eSeverity of Symptoms in Relation to Proximity to Chemical Attack Location\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7267929/v1/0e92497227e23d60ed40a70e.png"},{"id":106344559,"identity":"e01ff0f4-3cd1-4eb4-9782-610d038a5359","added_by":"auto","created_at":"2026-04-07 16:15:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1241446,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7267929/v1/979763b3-6a04-4925-9b50-f5bc8f659b9d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Short and Long-Term Health Consequences of the 2013 Sarin Attack in Ghouta, Syria: A Retrospective Descriptive Study of Civilian Survivors","fulltext":[{"header":"Background","content":"\u003cp\u003eSince the beginning of the Syrian revolution in March 2011, Syria has witnessed one of the most devastating humanitarian crises in the modern history [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. What began as peaceful demonstrations demanding freedom and dignity quickly escalated into a protracted and complex armed conflict that has reshaped the nation\u0026rsquo;s demographic, political, and health landscapes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Over the past fourteen years, the war has been characterized by widespread violence, mass displacement, and severe human rights violations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], several reports documented the systematic attacks on civilians, the bombing of critical infrastructure, and targeted attacks on healthcare facilities [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Among the gravest breaches of international humanitarian law is the use of chemical weapons in civilian areas\u0026mdash;a tactic that has caused profound physical and psychological harm while remaining largely under-investigated [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBetween 2012 and 2019, several attacks using chemical weapons has been documented, even though the exact number varies between different sources [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], the number of attacks exceeded hundreds, with civilians comprising 97.6% of the reported fatalities [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Among the most notorious incidents were the sarin gas attack in Al-Ghouta, rural Damascus in 2013 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and the Khan Sheikhoun attack in 2017 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Investigations by the Organization for the Prohibition of Chemical Weapons (OPCW) confirmed the use of prohibited agents, including sarin, chlorine, and sulfur mustard. These attacks not only caused immediate mass casualties but also inflicted long-term neurological, respiratory, and psychological harm on survivors [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe Ghouta attack, in particular, marked a critical turning point in the Syrian conflict. On August 21, 2013, sarin-filled rockets struck multiple locations in the Damascus suburbs\u0026mdash;including Zamalka, Ein-Tarma (East Ghouta), and Moadamiya (West Ghouta)\u0026mdash;killing over 1,300 people (the exact number is different between different reports) and leaving thousands with chronic health complications [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This incident represented the largest-scale use of nerve agents since the Iran-Iraq War (1980\u0026ndash;1988), crossing a critical \u0026ldquo;red line\u0026rdquo; and provoking widespread international condemnation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Under diplomatic pressure, Syria acceded to the Chemical Weapons Convention (CWC) and dismantled its declared stockpile [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Despite these measures, chemical attacks continued, with chlorine gas gradually replacing sarin as the most frequently used agent. However, geopolitical divisions and the obstruction of investigative efforts done by the Assad regime have impeded accountability, leaving survivors to endure long-term health consequences with limited medical support [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSarin (GB, Oisopropyl methyl phosphorofluoridate) was the primary nerve agent used in the Ghouta attack [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It is a highly toxic organophosphate that works by irreversibly blocking acetylcholinesterase (AChE), the enzyme responsible for breaking down the neurotransmitter acetylcholine (ACh) at nerve ending [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The resulting accumulation of ACh leads to overstimulation of the autonomic, neuromuscular, and central nervous systems. Symptoms include excessive secretions, difficulty breathing, slowed heart rate, and pinpointing pupils. Muscle twitching, weakness, and respiratory paralysis may follow, while effects on the brain can trigger seizures, confusion, coma, and, ultimately, death\u0026mdash;most often from respiratory failure due to blocked airways and muscle paralysis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile the acute effects of sarin exposure are well documented, the long-term health consequences remain poorly understood\u0026mdash;particularly in Syria, where mass displacement and years of repression obstructed systematic research [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Frontline medical reports point to persistent neurological damage, chronic respiratory illness, and psychological trauma among survivors, yet little is known about how these conditions shape health-seeking behaviours and access to care [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Political restrictions and insecurity further limited independent investigation, leaving critical medical and scientific gaps [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite the scale and gravity of these attacks, documentation has been limited. Deliberate obstruction, disinformation, and suppression of evidence by the Assad regime hindered accountability and denied survivors recognition and care. Since the Assad regime\u0026rsquo;s fall in December 2024, new opportunities have emerged to investigate and record these long-term impacts [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This study contributes to the scientific understanding of sarin\u0026rsquo;s enduring effects by examining the lived experiences and medical consequences among Ghouta survivors which support the broader demands for justice, recognition, and reparations.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eAim of the research\u003c/span\u003e:\u003c/p\u003e\u003cp\u003eThis study aims to investigate the lived experiences, psychological impact, and the immediate, short, and long-term medical symptoms among the survivors of Al-Ghouta chemical attack.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThis research is a retrospective descriptive study focusing on the survivors of Al-Ghouta attack. Survivors were defined as individuals who directly experienced and survived a major chemical weapons attack, witnessing the event firsthand and being in close proximity to the attack location. The study followed STROBE guidelines for reporting of observational studies [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy settings and location\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eBetween 2013 and 2019, the number of confirmed chemical weapon attacks in Syria exceeded 300, involving various toxic agents including sarin, chlorine, and sulfur mustard [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]. These attacks caused hundreds of fatalities and thousands of injuries, primarily affecting civilian populations. Among them, the Ghouta sarin attack stands out as the largest in both scale and lethality, and therefore, was the focus on this study. Figure\u0026nbsp;1 represents the major attack in Syria between 2013\u0026ndash;2019 with zoomed in map on the attack of 2013 in Ghouta.\u003c/p\u003e\n\u003cp\u003eThis study was conducted in the aftermath of the fall of the Assad regime on December 8, 2024, a political shift that created new opportunities for the documentation and investigation of previously suppressed war crimes, including the long-term effects of chemical weapons. For over a decade, efforts to study these consequences were largely obstructed by systemic denial, targeted repression, and the destruction of evidence. The collapse of the regime has not only allowed survivors to speak more openly but has also facilitated field-based research efforts in areas previously inaccessible to investigators and human rights workers.\u003c/p\u003e\n\u003cp\u003eFieldwork was carried out in locations directly affected by the 2013 Ghouta chemical attacks, specifically the neighbourhoods of Zamalka and Ein-Tarma in Eastern Ghouta and Moadamiya in Western Ghouta, Damascus Suburbs Governorate. These areas, situated approximately 16 kilometres apart, were struck in the early hours of August 21, 2013, by rockets filled with sarin gas. According to survivor accounts and OPCW reports, the Zamalka and Ein Tarma strikes occurred between 2:00 and 3:00 AM, while Moadamiya was targeted closer to 5:00 AM [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipant Inclusion Criteria and Sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were selected using purposive sampling, targeting individuals with direct and verifiable exposure to the sarin attack in Ghouta. Inclusion criteria required that participants were 1- physically present in the affected areas of Zamalka, Ein Tarma, or Moadamiya during the time of the attack, 2- Witnessed the event firsthand, and 3- Were within close proximity to a confirmed impact site.\u003c/p\u003e\n\u003cp\u003eEligible participants were identified and contacted through the Association of Victims of Chemical Weapons (AVCW), which maintains a detailed and independently verified database of survivors. Participant eligibility was confirmed by AVCW, and recruitment was further supported by a trusted field responder and survivor based in Zamalka, who facilitated introductions and verified accounts through local networks.\u003c/p\u003e\n\u003cp\u003eGiven the qualitative design and use of narrative interviews, no formal sample size calculation was conducted. The final sample consisted of 14 semi-structured narrative interviews were the participants asked to tell his/her story without interfering but only directing towards the overall themes of the study. The participants were selected based on their exposure history, availability, and willingness to participate. Data collection continued until thematic saturation was reached\u0026mdash;that is, when no new information or codes were emerging and the interviews began to yield repetitive themes. This approach ensured both analytical depth and representational diversity across proximity, age, and gender dimensions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterview Guide Development and Data Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection was guided by a semi-structured interview guide developed specifically for this study. A narrative interview technique was employed, allowing participants to share their experiences freely and with minimal interviewer intervention. This approach was chosen to centre survivor voices, minimize framing bias, and respect the sensitive nature of the topic.\u003c/p\u003e\n\u003cp\u003eThe interview guide was informed by existing literature on chemical weapons exposure, toxicological outcomes, and trauma-informed qualitative research [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. It was designed to elicit open-ended narratives while maintaining structure around key domains: demographic background, prior medical history, the day of the attack, short- and long-term health symptoms, survival strategies on the day of the attack, and perceived impacts on others (e.g., children, reproductive outcomes). The guide was first drafted in English, then professionally translated into Arabic to ensure cultural and contextual appropriateness [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. A pilot focus group was conducted with representative of AVCW to test the relevance, clarity, and emotional safety of the questions.\u003c/p\u003e\n\u003cp\u003eInterviews were conducted between January and April 2025 during field visits to previously targeted locations. All interviews were conducted in Arabic, in private and respectful settings chosen by the participants. Depending on logistical constraints and participant preference, all interviews were held in person, in the same locations were the chemical attacks happened, providing direct contextual relevance to the data collected. Each session began with a written informed consent process, ensuring participants understood the study\u0026rsquo;s purpose, the voluntary nature of participation, and their rights, including the right to withdraw at any time. Interviews lasted between 20 and 50 minutes.\u003c/p\u003e\n\u003cp\u003eAll transcripts and audio files were stored in encrypted, password-protected drives accessible only to the research team, in accordance with GDPR-compliant data protection standards.\u003c/p\u003e\n\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\n \u003ch2\u003eData Analysis\u003c/h2\u003e\n \u003cp\u003eAll interviews were audio-recorded, transcribed verbatim in Arabic, and anonymized during transcription to ensure confidentiality. The transcriptions were then reviewed for accuracy and completeness by the research team and translated to English. A thematic analysis approach was applied, following Braun and Clarke\u0026rsquo;s six-phase framework: familiarization with the data, generation of initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eInitial coding was performed manually in English by two independent researchers trained in qualitative methods. Codes were derived both inductively from the data and deductively from the study objectives. Following the initial coding round, the researchers conducted a cross-checking process to ensure consistency and reliability. Discrepancies in code interpretation were resolved through iterative discussion and consensus, and in cases of ambiguity, a third researcher was consulted.\u003c/p\u003e\n \u003cp\u003eA process of recoding was conducted after initial theme development, allowing for the refinement of code categories and the consolidation of overlapping or conceptually similar codes. Themes were then grouped under broader domains reflecting the lived experiences of chemical attack survivors, including recognition of exposure, short and long-term symptoms, health-seeking behaviour, psychosocial impact, and barriers to care.\u003c/p\u003e\n \u003cp\u003eDuring analysis of the interviews, medical symptoms were categorized into 1-immediate, 2-short-term, and 3-long-term medical symptoms based on participant narratives. Immediate symptoms occurred directly or within the first hour of exposure; short-term symptoms lasted within hours to two weeks; and long-term effects persisted for months to years. The analysis was conducted manually to retain close engagement with the narrative structure and context. Throughout the process, reflexivity was maintained through analytic memos and debriefing sessions among the research team. Thematic saturation was confirmed when no new codes or themes emerged from additional interviews, supporting the adequacy of the final sample.\u003c/p\u003e\n \u003cp\u003eFollowing the completion of the thematic analysis, a focus group discussion was held with members of both the current and former leadership of the Association of Victims of Chemical Weapons (AVCW). The aim was to present and validate the preliminary findings, clarify any inconsistencies, and ensure contextual relevance. Feedback received from AVCW was reviewed systematically, and all relevant insights were incorporated into the final analysis and presentation of results.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBias\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAs with all retrospective studies relying on self-reported data, this study is subject to inherent biases\u0026mdash;particularly recall bias and information bias. To mitigate these, a purposive sampling strategy was employed, and only verified survivors\u0026mdash;identified and cross-checked through the Association of Victims of Chemical Weapons (AVCW)\u0026mdash;were included. Interviews were guided by a semi-structured tool with neutral, open-ended prompts to minimize interviewer influence and enhance the reliability of recollections. Additionally, consistency across participant narratives served as a further internal validity check.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eEthical approval for the study was obtained from the Association of Victims of Chemical Weapons (AVCW), which also served as the data custodian under a formal data-sharing agreement. This agreement outlined strict adherence to confidentiality, data protection, and participant rights.\u003c/p\u003e\n \u003cp\u003eEach participant provided written informed consent prior to the interview, after receiving detailed information about the study\u0026rsquo;s aims, methodology, potential risks, and safeguards. Participants were given space to ask questions and were informed of their right to withdraw at any time without consequence. All interviews were conducted in private settings, and data were anonymized during transcription.\u003c/p\u003e\n \u003cp\u003eGiven the trauma-associated nature of the subject matter, interviews were conducted using a trauma-informed approach. Researchers were trained to recognize signs of psychological distress, and interviews were paused or terminated when participants showed discomfort or emotional triggering. This ethical framework aimed to ensure that participants\u0026rsquo; dignity, safety, and autonomy remained central throughout the research process.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eDescriptive analysis of the interviews\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThis study is based on a total of 14 face-to-face interviews conducted with survivors of the chemical weapons attack that took place in Al-Ghouta, Zamalka. Participants ranged in age from 12 to 60 years, with a mean age of 39. The gender distribution included eight females and six males. In terms of proximity to the chemical attack site, participants reported varying distances, with the closest being approximately 10 meters and the furthest up to 100 meters away. Most participants were within a 30 to 80-meter radius of the impact zone, indicating significant exposure to the chemical agents. All participants described that they were healthy and did not any medical symptoms before the attack.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the main thematic findings from the study. Five overarching themes were identified through the analysis: exposure to the chemical attack and lived experience; immediate medical response and survival strategies; short-term medical symptoms; long-term medical consequences; and psychological impact. Each theme encompassed several subthemes reflecting the complex, layered nature of survivors' experiences\u0026mdash;ranging from sensory and social cues during the attack, to improvised medical responses, to chronic physical and psychological sequelae that persist more than a decade later.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003esummery of study themes, main results and impact of the victims and survivals of the chemical weapons attack\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThemes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubtheme\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExposure to Chemical Attack and lived experience\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Realizing the chemical attack\u003c/p\u003e\u003cp\u003e- Sensory cues\u003c/p\u003e\u003cp\u003e- Social cues\u003c/p\u003e\u003cp\u003e- Seeking health care\u003c/p\u003e\u003cp\u003e- Alerting others\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eImmediate medical response, treatment, and survival strategies\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Improvised masks\u003c/p\u003e\u003cp\u003e- Civilian rescue\u003c/p\u003e\u003cp\u003e- Atropine use\u003c/p\u003e\u003cp\u003e- Transportation of victims\u003c/p\u003e\u003cp\u003e- Seeking shelters\u003c/p\u003e\u003cp\u003e- Makeshift tools\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eImmediate and Short-term medical symptoms\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Ophthalmological problems\u003c/p\u003e\u003cp\u003e- Respiratory symptoms\u003c/p\u003e\u003cp\u003e- Gastrointestinal (GI) symptoms\u003c/p\u003e\u003cp\u003e- Neurological symptoms\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLong term medical symptoms\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Cardiologic issues\u003c/p\u003e\u003cp\u003e- Chronic respiratory issues\u003c/p\u003e\u003cp\u003e- Gastrointestinal (GI) distress\u003c/p\u003e\u003cp\u003e- Immune dysfunction\u003c/p\u003e\u003cp\u003e- Neurologic problems\u003c/p\u003e\u003cp\u003e- Ophthalmological problems\u003c/p\u003e\u003cp\u003e- Reproductive Health Disorder\u003c/p\u003e\u003cp\u003e- Weakness\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePsychological impact\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Post traumatic stress disorder (PTSD)\u003c/p\u003e\u003cp\u003e- Bereavement\u003c/p\u003e\u003cp\u003e- Grief\u003c/p\u003e\u003cp\u003e- Displacement trauma\u003c/p\u003e\u003cp\u003e- Loss of family\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eExposure to Chemical Attack and lived experience\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e In the initial phase of the interview, participants were asked to recount their experiences during the attack. Nearly all (13 of 14) described the event as sudden and disorienting, with no official warnings or alerts. Most survivors (9 of 14) identified the threat through sensory cues\u0026mdash;unusual smells, lack of typical explosion sounds, and visual anomalies. Others (5 of 14) recognized the attack only after observing the reactions of neighbours or community members. The process of realization was gradual, unfolding as a series of sensory, spatial, and social signals rather than clear communication. In this vacuum of structured alerts, people relied on their instincts and one another to interpret the unfolding event.\u003c/p\u003e\u003cp\u003e\u003cem\u003e \u0026ldquo;Its smell was like rotten apples mixed with vinegar\u0026hellip; we smelled it and started showing symptoms.\u0026rdquo; \u0026mdash; Participant 2\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We heard a missile without an explosion, and black smoke rose.\u0026rdquo; \u0026mdash; Participant 12\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The closest missile to my house was about 100 meters. Its sound was faint and unlike normal shells.\u0026rdquo; \u0026mdash; Participant 4\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There was black smoke, and it looked different from a typical bombing.\u0026rdquo; \u0026mdash; Participant 11\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We woke up to the neighbours shouting, \u0026lsquo;chemical attack!\u0026rsquo; We didn\u0026rsquo;t understand what was happening. Everyone was shouting and crying.\u0026rdquo; \u0026mdash; Participant 12\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The neighbours knocked on our door yelling \u0026lsquo;chemical attack!\u0026rsquo; and we could feel something was wrong with the air.\u0026rdquo; \u0026mdash; Participant 13\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;At 1:45 AM, we were using our radios and performing rescue work. Suddenly, around 15 missiles fell. The first three [missiles] didn\u0026rsquo;t explode in a normal way. When we went to the site, there was a strange smell, and one of the people there started convulsing and foaming at the mouth.\u0026rdquo; \u0026mdash; Participant 1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We asked our team on the radio what kind of missiles these were\u0026mdash;this wasn\u0026rsquo;t normal.\u0026rdquo; \u0026mdash; Participant 1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eImmediate medical response, treatment, and survival strategies\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eIn the absence of organized emergency infrastructure, survivors of the Ghouta chemical attack relied on improvised and community-driven responses. All participants reported using household items\u0026mdash;such as vinegar, water, cloth, and onion peels\u0026mdash;as makeshift gas masks. Eight out of 14 described the use or administration of atropine, though access was uneven and often improvised. Transport to medical facilities was primarily civilian led, with survivors either carried by neighbours or taken by volunteer drivers to overwhelmed field hospitals. These spontaneous efforts reflect the urgent and chaotic environment in which survival depended on shared knowledge, peer support, and the creative use of limited resources.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We went to the rooftop and tore a piece from my son's shirt. We dipped it in vinegar and water and put it on our faces as masks.\u0026rdquo; \u0026mdash; P13\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We used a mask with a piece of cotton soaked in vinegar and water. We put onion peels inside it, just like we heard from others\u0026mdash;it might help.\u0026rdquo; \u0026mdash; P11\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I opened oxygen tanks and administered atropine. I was injecting people, trying to do anything I could.\u0026rdquo; \u0026mdash; P10\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They took us to Kafr Batna. My husband kept helping others the whole time, even though he was exposed himself.\u0026rdquo; \u0026mdash; P12\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Medical volunteers were injecting people with atropine... local health workers were giving treatment, even in houses.\u0026rdquo; \u0026mdash; P4\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Ambulances came from Arbin, from Douma, from across Ghouta. But it was too much... there were too many cases at once.\u0026rdquo; \u0026mdash; P3\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eImmediate and Short-term medical symptoms\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eAll participants described a sudden onset of acute medical symptoms during the chemical attack, with excessive salivation and foaming reported by 12 out of 14, muscle convulsions by 11, respiratory distress by 11, ophthalmologic symptoms such as burning or blurred vision by 12, and loss of consciousness by 9. These symptoms began within seconds to minutes after exposure and were multisystemic in nature, affecting respiratory, neurological, and visual systems simultaneously. The rapid progression of effects contributed to a sense of helplessness and panic, especially in the absence of medical support. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;One person convulsed and started foaming at the mouth\u0026mdash;we knew then it was chemical.\u0026rdquo; \u0026mdash; P1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My whole body started shaking uncontrollably. My eyes hurt. I felt like my body wasn\u0026rsquo;t mine anymore.\u0026rdquo; \u0026mdash; P 13\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The light looked like a thousand suns. Everything was spinning. I felt like I was dying.\u0026rdquo; \u0026mdash; P4\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I started feeling dizzy in the morning. My husband told me I blacked out for hours.\u0026rdquo; \u0026mdash; P 11\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I started vomiting black liquid before anything else. It was like my insides were reacting instantly.\u0026rdquo; \u0026mdash; P12\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My saliva tasted like artificial sweetener, like saccharin. I\u0026rsquo;ve never tasted anything like it.\u0026rdquo; \u0026mdash; P3\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Our eyes became blurred; for two weeks we couldn\u0026rsquo;t see properly.\u0026rdquo; \u0026mdash; P2\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My eyes were burning so badly they gave me an injection just for the pain.\u0026rdquo; \u0026mdash; P10\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There was vision loss and shortness of breath\u0026mdash;even while carrying people I could barely see through the smoke.\u0026rdquo; \u0026mdash; P5\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe short-term medical symptoms lasting days to weeks following the attack, participants continued to experience serious health problems. All survivors reported neurological symptoms, including tremors, confusion, or disorientation. Ophthalmologic issues persisted in 12 participants, while respiratory symptoms remained in 7. Gastrointestinal distress was reported by 6, along with sensory disturbances, temporary loss of consciousness, and involuntary urination. Notably, 2 participants also reported reproductive health complications. These ongoing symptoms disrupted daily functioning, prolonged recovery, and contributed to lasting trauma. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If I try to smoke a cigarette now, just one puff makes me cough for an hour.\u0026rdquo; \u0026mdash; P6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;for the next two weeks I had tremors and couldn\u0026rsquo;t even control my hands\u0026rdquo; __ P13\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It took my over 10 days until I could move myself, and until now I have nerve problems\u0026rdquo; __9\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;For 15\u0026ndash;20 days after the attack I couldn\u0026rsquo;t see, but then it started improving slowly\u0026rdquo; __P4\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;.. I passed out after few minutes, and I wake up after 7 hours in a different place, I found myself in a different place, in a hospital, and for the next 3 days I couldn\u0026rsquo;t concentrate, and then I realized that my kids are dead\u0026rdquo; P__9\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eLong term medical symptoms\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eIn the months and years following the attack, participants described a wide range of chronic and progressively debilitating conditions. The most commonly reported long-term symptoms were neurological and neuromuscular disorders, present in all participants. These included tremors, nerve pain, and coordination issues. Chronic respiratory problems were reported by 10 out of 14 survivors, while immune dysfunction appeared in 6. Ophthalmologic complications persisted in 8, reproductive health disorders were mentioned by 3, and cardiologic issues by 4. Survivors also reported fatigue and weakness, gastrointestinal distress, and a variety of other persistent symptoms, including cognitive issues and developmental delays in children. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. These long-term effects severely limited daily functioning, even years after the exposure. These narratives reveal a consistent pattern of multisystem chronic illness, in individuals who were previously healthy, and point toward serious long-term toxicological impacts of sarin exposure. Most survivors explicitly attributed these conditions to the chemical attack, reinforcing the link between exposure and long-term health deterioration.\u003c/p\u003e\u003cp\u003e\u0026ldquo;They get episodes\u0026mdash;days where they shake, their nerves hurt. They\u0026rsquo;re always taking medication for it.\u0026rdquo; \u0026mdash; P5\u003c/p\u003e\u003cp\u003e\u0026ldquo;Even now, years later, I get tremors in my face, especially around my nose. It comes suddenly and really disturbs me.\u0026rdquo; \u0026mdash; P6\u003c/p\u003e\u003cp\u003e\u0026ldquo;I lost my eyesight, and my immune system is wrecked.\u0026rdquo; \u0026mdash; P3\u003c/p\u003e\u003cp\u003e\u0026ldquo;My son still has nerve inflammation. He walks and talks like an old man.\u0026rdquo; \u0026mdash; P11\u003c/p\u003e\u003cp\u003e\u0026ldquo;We noticed problems with urination. It\u0026rsquo;s like things stopped working right.\u0026rdquo; \u0026mdash; P1\u003c/p\u003e\u003cp\u003e\u0026ldquo;We lost so much weight after the attack\u0026mdash;me and the kids. We looked like we were starving.\u0026rdquo; \u0026mdash; P12\u003c/p\u003e\u003cp\u003e\u003cb\u003ePsychological impact\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eIn addition to physical harm, the chemical attack left survivors with profound psychological trauma. A significant majority reported symptoms consistent with anxiety, depression, or post-traumatic stress disorder (PTSD). Nightmares were described by 11 participants, and sleep disturbances and grief-related symptoms were reported by 8 each. These effects were closely linked to personal loss, mass casualties, displacement, and the erosion of community structures.\u003c/p\u003e\u003cp\u003eThe trauma extended beyond the event itself, shaped by the chaos of emergency medical care, the psychological burden of mass burials, and the long-term fragmentation of families. Displacement functioned as both a physical and emotional rupture, often described as a point of no return. These layered experiences underline the urgent need for mental health support, including grief counselling and trauma-informed care, in post-conflict health interventions.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We went through a nightmare. I had a son and daughter\u0026mdash;both lost in front of me. I still hear their voices at night.\u0026rdquo; \u0026mdash; P10\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When they took us to the hospital, we saw people lying on the floor, unconscious, children foaming at the mouth. My mind couldn\u0026rsquo;t process what I was seeing.\u0026rdquo; \u0026mdash; P12\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We were digging mass graves three meters deep. We were layering bodies. There was no time to say goodbye.\u0026rdquo; \u0026mdash; P3\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We were burying the dead quickly in collective graves. There were days when we buried 40 at once.\u0026rdquo; \u0026mdash; P5\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;After the strike, we left into the unknown. We had no idea where we were going, just that we had to get away.\u0026rdquo; \u0026mdash; P1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We were displaced to the north. We\u0026rsquo;ve only recently returned, and nothing feels the same.\u0026rdquo; \u0026mdash; P2\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We were displaced to the north. My sister left her children with me. She never came back.\u0026rdquo; \u0026mdash; P13\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003ePrevalence of Immediate, Short-Term, Long-Term, and Psychological Symptoms Among Survivors of the 2013 Sarin Attack in Ghouta\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubtheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMain results\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eImpact\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003eimmediate symptoms\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExcessive salivation \u0026amp; foaming\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eResponse driven by instinct and community help; formal care was limited\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eDelayed response, confusion, and fear due to absence of structured alerts\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eloss of consciousness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMuscle convulsions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eophthalmology symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRespiratory Distress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003e\u003cb\u003eshort term medical symptoms\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGI distress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003eSymptoms were multisystemic and appeared rapidly after exposure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003eHigh toxicity confirmed; immediate collapse of physical function\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNeurologic symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eophthalmology symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReproductive Health Disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRespiratory Distress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSensory details\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTemporary loss of consciousness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003einvoluntary urination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003e\u003cb\u003elong term medical symptoms\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ecardiologic issues\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003eChronic symptoms persisted for years and disrupted daily life\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003eLong-term disability, need for neurorehabilitation and monitoring\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003echronic respiratory issues\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGI distress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eImmune dysfunction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNeurologic symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eophthalmologic symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReproductive Health Disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eweakness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003ePsychological Impact\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003esymptoms of Anxiety, Depression, or PTSD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eThe psychological trauma was deep and prolonged, rooted in loss and instability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eNeed for integrated mental health and grief support in recovery\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSleep disturbances\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNightmares\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrief\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eRelationship between Proximity, Age, and Severity of Outcomes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSurvivors' testimonies shed light on how proximity to the chemical strike and age influenced the severity of outcomes. While the study did not apply formal statistical measures, strong narrative patterns suggest that closer distance to the impact site significantly increased both immediate and long-term health complications. In contrast, age appeared to have no protective effect\u0026mdash;symptom severity was reported across all age groups.\u003c/p\u003e\u003cp\u003eThose within 10 to 30 meters of the strike reported the most acute effects. Participant 1, only twenty meters away, described \u003cb\u003e\u0026ldquo;witnessing seizures and foaming at the mouth\u0026rdquo;\u003c/b\u003e among others, and later experienced his own persistent neuromuscular dysfunction and cognitive decline. Participant 9, also in close range, recounted \u003cb\u003e\u0026ldquo;near-total paralysis for ten days\u0026rdquo;\u003c/b\u003e along with lasting memory, vision, and cardiovascular complications. Participant 2, exposed within 30 meters, noted respiratory impairment and long-term visual damage. Conversely, survivors farther from the epicenter experienced milder symptoms. Participant 4, who was about 100 meters away, recalled shortness of breath and visual issues, but emphasized being outside the \u0026ldquo;deadly radius,\u0026rdquo; suggesting a localized exposure gradient. These narratives support the view that severity was dose-dependent, with closer proximity increasing toxic load and impairing escape capacity.\u003c/p\u003e\u003cp\u003eAs for age, no clear correlation emerged. Participant 12, who has a 12-year-old daughter, describe how her daughter suffered vomiting, chronic fatigue, and psychological trauma. Meanwhile, 60-year-old Participant 10 reported visual and respiratory damage along with profound loss, both describing significant, ongoing health deterioration. Similarly, younger adults in their twenties and thirties also reported nerve damage, fertility issues, and chronic pain, undermining assumptions of age-based resilience.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFigure N.2\u003c/b\u003e \u003cem\u003e- Severity of Symptoms in Relation to Proximity to Chemical Attack Location\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe 2013 sarin gas attack on Ghouta represents one of the darkest chapters of the Syrian war and remains a stark reminder of the intensity and brutality of the decade-long conflict. It was described by the United Nations as \u0026ldquo;the most significant confirmed use of chemical weapons against civilians since 1988,\u0026rdquo; [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Despite the magnitude of the attack, very little peer-reviewed research has been published, and to the best of our knowledge, no study has systematically documented the long-term health consequences of chemical weapon exposure during the Syrian war. In this retrospective study, we addressed this gap by investigating the lived experiences, short- and long-term medical symptoms, and psychological impact among civilian survivors of the Ghouta attack.\u003c/p\u003e\u003cp\u003eParticipants reported a range of persistent physical and psychological symptoms, including respiratory dysfunction, neurological complaints, and mental health disturbances, which they directly attributed to the sarin exposure. These included chronic cough, shortness of breath, chest pain, headaches, sensory deficits, memory problems, anxiety, and episodes of panic or depression\u0026mdash;often coexisting and compounding one another. Many participants described a profound deterioration in their overall wellbeing, with symptoms interfering with daily tasks, family roles, and social interactions. The clinical symptoms reported by participants in our study are in strong agreement with those documented in the United Nations Mission report on the 21 August 2013 attack (A/67/997\u0026ndash;S/2013/553), which concluded that \u0026ldquo;survivors reported a rapid onset of extreme breathing difficulties, eye irritation, foaming from the mouth, convulsions, and loss of consciousness.\u0026rdquo; The report also confirmed that biomedical samples from victims tested positive for exposure to sarin, supporting the validity of the symptomatology described in both our qualitative data and the official investigation [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Moreover, these findings are consistent with earlier case series from the Matsumoto and Tokyo subway sarin attacks, where victims reported longterm somatic and neuropsychiatric symptoms; in the Tokyo cohort, 60\u0026ndash;80% of survivors reported ocular and somatic symptoms at 10 years postexposure and 35% met criteria for posttraumatic stress responses [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Additionally, our findings echo studies of Iranian veterans and Kurdish civilians exposed to sulfur mustard, where similar constellations of respiratory, neurological, and psychiatric symptoms were documented years or decades after exposure [\u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. While toxicological mechanisms differ between sulfur mustard and sarin, the long-term outcomes appear to converge\u0026mdash;highlighting the multi-systemic and enduring nature of chemical weapon injury. However, the Syrian case is further complicated by post-attack displacement, economic collapse, and the near-total breakdown of healthcare systems, which have left many survivors without diagnosis, treatment, or recognition [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe results of our study showed that the psychological impact of the sarin attack was profound and enduring. Every participant described some form of emotional or psychological distress, often closely intertwined with their physical symptoms. Feelings of fear, helplessness, and anxiety were common, and many reported that these psychological burdens had exacerbated the severity of their chronic health problems. Nightmares, panic attacks, intrusive memories, and hypervigilance were frequently mentioned, alongside social withdrawal and emotional numbness. These findings are consistent with previous studies on chemical warfare survivors, which have documented elevated rates of PTSD, depression, and anxiety long after exposure [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and also similar reductions in qualityoflife scores and moderate depressive symptoms have been documented among Kurdish refugees resettled in Sweden thirty years after the initial attack [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In the Syrian context, where access to mental health care is virtually non-existent, the absence of recognition and support has further intensified the long-term psychological toll [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur findings also suggest that proximity to the epicentre of the attack may be a critical determinant of symptom severity. Participants who reported being closer to the impact zones consistently described more severe symptoms\u0026mdash;ranging from acute respiratory failure and visual disturbances to long-term neurological and psychological sequelae. This pattern supports dose-dependent effects of sarin exposure, as noted in previous studies. In the Tokyo subway attack, for example, symptom severity and biomarker levels of sarin metabolites were significantly higher among individuals in closer proximity to the release site [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Similarly, after the Matsumoto attack, those residing nearest to the contaminated building experienced the highest mortality and greatest burden of chronic symptoms [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These findings align with toxicological models of nerve agent dispersal, which predict a steep exposure gradient based on distance, ventilation, and terrain [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Notably, the United Nations Mission report (A/67/997\u0026ndash;S/2013/553) described similar spatial trends in Eastern Ghouta, where entire families residing near the impact sites were found deceased in confined spaces, often with no visible external injuries, suggesting rapid onset of fatal symptoms due to high-dose exposure. Such spatial clustering of fatalities near the epicentres reinforces the association between proximity and exposure severity in sarin-related mass casualty events [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccess to appropriate healthcare emerged as a major challenge for all participants. Survivors reported years of living with unresolved symptoms\u0026mdash;both physical and psychological\u0026mdash;without receiving adequate diagnosis, treatment, or follow-up. These barriers mirror those faced by other chemical warfare survivors in conflict-affected settings, such as Halabja, where long-term care needs were similarly unmet [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, in Syria, the systematic destruction of health infrastructure, ongoing displacement, and political denial of chemical attacks have compounded these difficulties\u0026mdash;leaving most survivors without even the basic validation of their suffering [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study offers one of the first systematic attempts to document the long-term health consequences of chemical weapon exposure among civilians during the Syrian war, drawing directly from the lived experiences of survivors. A key strength lies in its timing\u0026mdash;conducted after the fall of the regime\u0026mdash;which allowed for open, uncensored testimonies rarely accessible in previous years. The use of a retrospective descriptive design and survivor narratives provided a context-specific understanding of both medical and psychosocial outcomes. However, the study has limitations, including potential recall bias, survivor bias, and challenges in verifying clinical diagnoses due to the destruction/absence of medical records and lack of diagnostic follow-up.\u003c/p\u003e\u003cp\u003eDespite these limitations, our study underscores the urgent need for comprehensive, multidisciplinary care for sarin survivors. The persistence of symptoms ten years after exposure emphasises that acute treatment alone is insufficient. Longterm rehabilitation should integrate pulmonology, neurology, ophthalmology and mentalhealth services, as advocated for Halabja survivors. Communitybased psychosocial support and recognition of survivor narratives are essential to address the chronic fear, social isolation and stigma highlighted by participants. International bodies and donor agencies must prioritise funding for chemical weapons survivors, support research into antidotes and neuroprotective therapies, and uphold mechanisms for accountability and reparations. Only by acknowledging and responding to the enduring burden of chemical warfare can we fulfil our ethical obligations to those affected and prevent recurrence, as recognizing and addressing the long-term impact of chemical attacks is not only a medical necessity\u0026mdash;it is a foundational step toward meaningful peacebuilding and transitional justice.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides a documentation of the long-term health impacts of the 2013 sarin gas attack in Ghouta, revealing a persistent burden of physical and psychological consequences and exploring the lived experiences among survivors. The findings underscore the need for sustained, multidisciplinary care and highlight how chemical warfare continues to harm long after the initial exposure. In the context of Syria\u0026rsquo;s ongoing transition, addressing these harms must be part of any meaningful post-conflict health response and justice process. Survivors\u0026rsquo; voices and experiences are essential not only for guiding medical and humanitarian interventions but also for shaping policies that promote accountability, recognition, and lasting peace.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from Association of Victims of chemical weapons (AVCW), and with a serial number 202502/1. All participants provided informed consent prior to participation. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to confidentiality and security concerns but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eMBA, LZ designed the study. LZ conducted the data collection. MBA analysed the data. All authors contributed to the writing and revision of the manuscript and approved the final version.\u003c/p\u003e\n\u003cp\u003eAI use disclosure\u003c/p\u003e\n\u003cp\u003eArtificial intelligence tool (ChatGPT, OpenAI) was used solely for improving grammar, structure, and clarity of the text. All scientific content, data analysis, and interpretation were conceived, conducted, and written by the authors.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThis study is dedicated to the victims of the 2013 Ghouta chemical attack and to all those who have suffered from the use of chemical weapons in Syria. We also express our deepest respect to the first responders who risked their lives to save others during and after the attack. Special thanks go to the Association of Victims of Chemical Weapons in Syria for their support and collaboration, and in particular to Anas Al-Khouli, Ibrahim Al-Atiq, Ahmad Hazrouma, Salim Namour, and Manal Al-Hamadi for their trust, guidance, and continued commitment to justice and recognition for survivors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlhaffar, M. H. D. B. A. \u0026amp; Janos, S. Public health consequences after ten years of the Syrian crisis: a literature review. Globalization and Health. 2021 2021/09/19;17(1):111. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12992-021-00762-9\u003c/span\u003e\u003cspan address=\"10.1186/s12992-021-00762-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMunzer, A. et al. 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R. \u003cem\u003eJr. Chemical Warfare Agents: Toxicity at Low Levels\u003c/em\u003e (CRC, 2001).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaar, R. et al. The cascading impacts of attacks on health in Syria: A qualitative study of health system and community impacts. \u003cem\u003ePLOS Glob Public. Health\u003c/em\u003e. \u003cb\u003e4\u003c/b\u003e (6), e0002967 (2024).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sarin gas, chemical weapons, Ghouta attack, Syria, survivors, conflict, public health","lastPublishedDoi":"10.21203/rs.3.rs-7267929/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7267929/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eOn August 21, 2013, sarin gas was used as a weapon of war in multiple areas of Ghouta, rural Damascus, Syria, in the largest confirmed chemical weapons attack against civilians in the 21st century. Despite the scale of the attack, little is known about the long-term medical symptoms experienced by survivors. This study aimed to document the lived experiences, short- and long-term physical and psychological consequences of sarin exposure among civilian survivors, more than a decade after the attack.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a retrospective descriptive study based on semi-structured narrative interviews with survivors of the 2013 Ghouta chemical attacks. Participants were selected based on confirmed exposure and willingness to provide detailed accounts of their health status, experiences, and healthcare-seeking behavior. Thematic analysis was used to identify recurrent patterns and outcomes across different domains.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAll participants reported persistent medical symptoms ranging in severity, including chronic respiratory issues, neurological complaints, fatigue, and sensory disturbances. The psychological impact was universal, with widespread reports of anxiety, nightmares, panic attacks, and social withdrawal. Most participants experienced significant disruption to their quality of life and described barriers to accessing healthcare.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe long-term consequences of sarin exposure in Ghouta extend far beyond the initial event, affecting nearly every aspect of survivors\u0026rsquo; lives. These findings highlight the urgent need for sustained medical, psychological, and social support for victims of chemical attacks. Integrating survivor needs into broader frameworks for post-conflict recovery and transitional justice is essential to ensure accountability, recognition, and the right to health.\u003c/p\u003e","manuscriptTitle":"Short and Long-Term Health Consequences of the 2013 Sarin Attack in Ghouta, Syria: A Retrospective Descriptive Study of Civilian Survivors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-22 08:14:12","doi":"10.21203/rs.3.rs-7267929/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-07T14:22:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-11T15:49:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-03T11:50:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68509961158401883451884336772963735996","date":"2025-12-01T08:41:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334309798546689208241249128204486160940","date":"2025-12-01T05:26:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-27T14:55:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318827342520641950292340448791635302894","date":"2025-11-27T14:37:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-25T18:51:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-13T10:17:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-05T05:07:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-02T09:15:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-08-01T06:20:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6ad1871f-a338-491b-86df-7a8e5009d040","owner":[],"postedDate":"August 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":53442738,"name":"Health sciences/Health care"},{"id":53442739,"name":"Humanities/Medical humanities"},{"id":53442740,"name":"Biological sciences/Psychology"},{"id":53442741,"name":"Social science/Psychology"}],"tags":[],"updatedAt":"2026-04-07T16:11:55+00:00","versionOfRecord":{"articleIdentity":"rs-7267929","link":"https://doi.org/10.1038/s41598-026-47135-z","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-04-02 16:00:02","publishedOnDateReadable":"April 2nd, 2026"},"versionCreatedAt":"2025-08-22 08:14:12","video":"","vorDoi":"10.1038/s41598-026-47135-z","vorDoiUrl":"https://doi.org/10.1038/s41598-026-47135-z","workflowStages":[]},"version":"v1","identity":"rs-7267929","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7267929","identity":"rs-7267929","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}