Syria once had one of the best-developed healthcare systems in the Arab world. But as the war wears on, millions of civilians find themselves in desperate need of medical care, facing limited options as doctors have been forced to flee and few medical supplies reach local populations, particularly in opposition-held territory.
Human-rights groups say that systematic and deliberate attacks on medical personnel and facilities have become the norm. Doctors are sometimes forced to work in secret, moving hospitals to underground locations in factories, farms, houses and even caves to avoid ongoing barrel bombing and shelling of their facilities. There they are forced to work with little or no access to electricity or medical supplies; patients suffering from critical wounds are being treated without anesthesia, while doctors perform emergency surgeries in makeshift conditions.
Physicians for Human Rights, an advocacy group, published a report earlier this year documenting the deaths of 526 medical personnel, “43 percent of whom were specifically targeted” by their killers. The report said that 99 percent of the killings were committed by government forces.
Dr. Annie Sparrow, a pediatrician at New York’s Mount Sinai Hospital with extensive field experience in and around Syria, tells Syria Deeply that few specialists remain in Syria, with only two surgeons and one obstetrician left in Deir Ezzor province. A recent New York Times report claims that there are only 13 surgeons left in the city of Aleppo.
“An appalling situation is just going to get worse,” Sparrow says.
She spoke to Syria Deeply about the ongoing attrition and targeting of Syria’s doctors, and the rapidly deteriorating public healthcare system inside Syria.
Syria Deeply: From a medical perspective, what is happening inside Syria today? To what extent are we seeing the collapse of the healthcare infrastructure?
Sparrow: As I’ve worked on this catastrophic war over the last 18 months, I’ve seen more and more doctors leave who thought they would stay until the bitter end. Most of these doctors are so unbelievably dedicated that I never expected them to leave.
There is an ongoing attrition of doctors in Syria and their plight is a testament to how bad the situation has gotten.
They’ve been forced out by the combination of the ongoing war, ongoing attacks on hospitals, and the danger and difficulty of being a doctor inside Syria.
Inside Syria, doctor’s hands are tied because they can’t move safely between health points. Under Assad, it’s hard to move anywhere. In besieged areas, they can’t get in or out. Under ISIS, there are about 17 checkpoints between Deir Ezzor and Aleppo and doctors have to get through every one of these checkpoints.
Since the start of U.S.-led coalition strikes on ISIS, Assad has continued the barrel bombing of many cities in Syria, including IDP camps and schools. There is a psychological massacre going on. People who were already living in squalid tents facing cold and miserable conditions now live with the fear that even a refugee camp can be bombed.
There is a lot more trauma and a lot less drugs available in Syria now. I’ve watched operations where kids have absolutely no anesthesia, anesthetics, and no sedation while they undergo removal of shrapnel and the resetting of broken limbs. Civilians in besieged areas are now facing the second winter or third winter without fuel or electricity. It’s horrific.
Syria Deeply: Many Syrians are dying because of lack of access to medical care. How are chronic diseases becoming silent killers inside Syria?
Sparrow: It’s very hard to count the number of people dying from infectious diseases, non-communicable and chronic diseases because we just don’t hear about it.
The doctors that I teach are often medical or dental students who are forced to become doctors because they are the only ones left in country. So many doctors who could leave have, and there are very few specialist doctors left. Chronic diseases – cancer, diabetes, kidney failure and heart disease – require specialist attention, yet there are not doctors or drugs. In Deir Ezzor, for example, there are only two surgeons and one obstetrician.
In the regime areas, the conditions are also dreadful. They don’t have the ability to repair or upgrade medical equipment in regime hospitals, where they are also suffering from electricity and water cuts.
The lack of clean water is one of the biggest problems in Syria. There is very little access to safe water and electricity to fuel generators or run water treatment facilities, let alone to cook a meal. A kilogram of sugar now costs $10 in eastern Ghouta, and it costs under $1 in Damascus.
Syrians need safe water like nothing else; water is now filled with all different types of diseases. We are seeing the emergence of unheard diseases, like rare tropical diseases (malaria and other parasites) that we’ve never seen in Syria before. There is a horrible disease called Myiasis in eastern Ghouta, which is a reflection of how bad the water situation is and the appalling living conditions. All of these diseases are amplified by a lack of clean water and electricity, with kids and the elderly particularly vulnerable to them. Compound all of these problems together and the end result is a very fragile and precarious population.
Syria Deeply: How large is the threat of communicable and infectious diseases inside Syria? To what extent have epidemics spread from Syria to surrounding countries? How are they being spread?
Sparrow: Syria is the epicenter of the measles and polio epidemic. We saw the rise of measles and the first case of polio in the beginning of 2013. Polio seems to be under control now, although it is difficult to know for sure under such conditions. But we’ve seen over 10,000 cases of measles this year. We’ve seen the arrival of leishmaniasis, thousands of cases of tuberculosis, and reported outbreaks of typhoid in the summer.
These diseases are not easy to diagnose in Syria; there is a complete breakdown of the healthcare system, so there are no laboratories that can diagnose them.
But we are also seeing the ongoing rise of infectious diseases across Syria’s borders, which are amplified by terrible living conditions and the stigma the diseases carry.
We’ve seen measles spread to Lebanon where there were a couple thousand cases last year and several hundred cases this year. We’ve seen outbreaks of typhoid in Syria, Lebanon and Jordan, and polio in Iraq.
Measles is the biggest indicator of infectious diseases because, besides smallpox, it is the most contagious disease on the planet. When we see measles outbreaks we know there are huge holes in the immunization coverage of kids.
Very few refugees living in neighboring countries will come forward if they have infectious diseases because of the fear and stigma attached to them. Refugees get blamed for carrying infectious diseases to neighboring countries. The appalling conditions they live in foster the spread of diseases like measles – with every case of measles you can infect 8-12 people.
Syria Deeply: What steps and obstacles do you face when trying to deliver medical aid to Syrian civilians? How does the plethora of armed opposition government, and jihadists groups controlling different areas and checkpoints, obstruct delivery of aid?
Sparrow: In the besieged areas, they do not allow the passage of basic medical items, food, vaccines and healthcare equipment. Every now and then a dribble of aid is let in, but it’s entirely inadequate in terms of what’s needed.
In the north, under areas in ISIS control, they have been known to let vaccination and medical aid through, but are suspicious of any form of documentation about it, which is a requirement from international NGOs who want complete transparency, accountability and documentation.
Vaccinators that are already operating in difficult conditions and are risking their lives daily to bring aid to people across the country have to overcome added barriers of suspicion [from groups like ISIS], and deal with requirements from international NGOs that don’t reflect the reality on the ground.
The tragedy of the death of 17 children as a result of a measles campaign in September has been a major setback because the measles campaign stopped everywhere in the country except Deir Ezzor, and the polio campaign hasn’t recommenced.
We have babies born who aren’t vaccinated, and kids who haven’t been vaccinated at all since the beginning of the revolution. They don’t even have the flu vaccine now.
This is taking place in a context where there were already significant barriers to delivering aid and medical care. There is no humanitarian space in Syria. Doctors have been criminalized, terrorized, and they are exhausted. They don’t have the capacity to deal with basic operations, let alone ongoing chlorine attacks or the emergence of new tropical diseases they have never seen before.
Syria Deeply: Doctors themselves are now targets of physical violence, arrests and harassment. Who is targeting doctors? How and why are they being attacked?
Sparrow: The regime continues to target doctors. In the north, there have been many attacks in Aleppo, Idlib and Raqqa on hospitals and clinics. These attacks take the form of barrel bombs, shelling and targeted missiles. You can no longer run trauma hospitals. Doctors are dispersed over a wider area, so they are trying to bring services to people but they no longer have sophisticated hospitals to go to. They are moving hospitals underground because of the sustained and systematic targeting of hospitals. The [regime] detects where people and hospitals are going by using heat imagery, so the only way to withstand that is to build hospitals in basements, one or two floors down. It becomes very difficult for patients to stay overnight.
It’s a very successful strategy, because as the war goes on the needs are greater, whether it’s chronic diseases, trauma, infectious disease, malnutrition, preventable and infectious diseases etc. There were 50,000 cases of leishmaniasis in Aleppo in the last six months alone, which gives you an idea of the scale of the problem.
Syria Deeply: Looking to the immediate future, what are you most concerned about? What are the long-term ramifications of a breakdown of the healthcare system in Syria?
Sparrow:My fear is that the Syrians that are left face increasingly difficult and punitive conditions, where there simply isn’t access to healthcare. When there is access to healthcare, its completely inadequate because they don’t have the basic antibiotics and medicine to treat basic infections and chronic diseases, let alone standard vaccinations and the specialized healthcare that is needed to deal with the appalling war trauma.
Historically, the opposition areas have always been the most vulnerable, especially the besieged areas that are now facing the second or even third winter without adequate water, fuel and electricity, but regime areas are also facing increasingly difficult conditions. More people are trying to leave but are facing barriers because Lebanon and Jordan are closing their borders.
There is a new level of vulnerability and crisis in terms of the public health situation and it can only get worse. There is endless deterioration and a descent into a public health nightmare, compounded by the ongoing barrel bombs and chlorine attacks.
It’s very difficult to describe the true nature of this public health crisis because we can’t see it; we don’t know what it feels like to not have access to clean water or to be too terrified to drink it. We are going to see an increase in the death toll due to previously treatable diseases, and an appalling situation is just going to get worse.