BEIRUT – With the capture of eastern Aleppo by government forces and their allies and the forced displacement of tens of thousands of people, the health situation in the formerly besieged city has deteriorated even further into a kind of “hell,” medical professionals told Syria Deeply.
Eastern Aleppo’s medical sector had already suffered greatly under a government blockade that started in July. The siege and the subsequent systematic targeting of the city’s medical facilities and staff rendered its health sector completely unable to cope with the latest onslaught.
The global nonprofit organization Physicians for Human Rights has documented 400 attacks on medical facilities in Syria throughout the conflict, with more than 90 percent allegedly perpetrated by the Syrian government or its Russian backers.
Health experts added that towns and villages in the surrounding countryside and nearby city of Idlib have done their best to welcome evacuees, but do not have the resources to settle and sustain such large numbers, believed to be nearly 40,000.
They also warned the current crisis unfolding in Aleppo could soon be repeated in these other areas. “This is only the beginning of the end. We’ll see the same crisis play out as some of these other conflicts reach end stages,” said David Scales, of the Cambridge Health Alliance.
Syria Deeply spoke with various public health experts about the crisis.
Syria Deeply: Alongside the broader humanitarian crisis, what is the public health situation on the ground in Aleppo? What are you hearing about access to medicine and care?
Dr. Ahmad Tarakji, president, Syrian American Medical Society: Siege and bombardment campaigns destroyed health infrastructure in eastern Aleppo. For the last week, people have been dying on the streets. The ability to rescue, evacuate and treat people was and is very limited. Our medical staff tried to collect leftover medical supplies and teams, and opened a few medical points. They were only able to handle limited injuries on a smaller scale. Today, after the evacuation was aborted, shelling resumed. Only a handful of medical professionals are left in eastern Aleppo, and with close to no resources, people are dying slowly even from moderate injuries. Needless to say that there is not any ability to treat children, women and people with chronic diseases.
David Scales, physician, writer, resident at Cambridge Health Alliance: After months of siege, access to any medications or care for chronic diseases is minimal. [There is] a general difficulty in being able to treat patients for any condition. This being due to restricted movement, the lack of supplies, the lack of trained healthcare personnel and adequate infrastructure. What makes this sadder is that Aleppo used to be the center of the Syrian pharmaceutical industry. Many generic medications were made in the metropolitan area, and the destruction there means that it will be years before this industry gets back on its feet. The problems people in the siege are facing are only an amplified version of the problems people in other parts of Syria are facing.
Syria Deeply: What are the emerging health concerns coming out of Aleppo now?
Dr. Fouad Fouad, research professor at the faculty of health sciences at American University of Beirut: Injuries come first. People are under bombing, people are under collapsing buildings, they are buried under the rubble. Second is mental health. Third are childhood conditions. Then there are the elderly. In terms of public health, this is hell.
Tarakji: Tens of thousands of people went in the streets waiting for their evacuation. The buses and ambulances provided to them are enough to evacuate 1,000 at a time. So even in maximum capacity they will need to work constantly for a week to allow everybody out. The regime will not allow enough buses and ambulances in, and Aleppo is cold this time of the year. Once they arrive in the western countryside of Aleppo, then our teams will receive them. The patients will be assessed and triaged between surgery services, ICU, mental health, maternity, etc. Complicated cases are sent to Turkey for further treatment because of the limited resources. In the first group of evacuated patients, one third were children. We prepared eight hospitals to receive the patients, five of them are SAMS hospitals, and 17 mobile clinics, also we are working on increasing the telemedicine capacity.
Syria Deeply: Are you seeing or hearing about cases of malnutrition, or new cases of infectious disease?
Scales: We are unlikely to hear about these until public health surveillance can be done, and the siege/war makes that exceedingly difficult. So no news does not necessarily mean good news. Malnutrition is a huge concern, but I haven’t seen data that can tell us what kinds of malnutrition nor what prevalence. As the population of Aleppo gets evacuated we will learn more about it, but given how bad the siege and bombings have been, I am highly concerned. There is also the factor of starting to feed very malnourished people. Starting to eat again after having severe caloric restriction can lead to drastic changes in electrolytes, some dangerous enough to cause heart problems (cardiac arrhythmias). This is called “refeeding syndrome” and usually requires hospitalization and frequent blood tests to monitor this. Doctors will be watching the evacuees for this, but in such a resource poor setting (even in Idlib, where most of the evacuees are going), further morbidity can be expected.
Syria Deeply: What else do you think people need to know about what’s happening, specifically in public health?
Scales: To me, the biggest fact is that while Syria pops up in the news on occasion with iconic images of children washed up on beaches or in ambulances, dusty and bleeding, the public health crisis is slow, grinding and has no iconic, representative photos that bring this issue to the forefront. If you see public health as social determinants of health, which I do, then every child unvaccinated, every mother who gets no prenatal care, every kid who can’t go to school creates a generation of Syrians whose health will be drastically reduced, who will die sooner compared to before the war, even if the killing stops tomorrow. Public health is infrastructure like potable water, it is communication between healthcare professionals and analyzing data about disease transmission and vulnerable populations. There’s an old political science paper called ‘Civil Wars Kill and Maim People – Long After the Shooting Stops.’ It looked at how the destruction in public health and other infrastructure during civil wars led to higher rates of mortality for years even after a war ended. In Syria, we’re just watching that play out in real time. So we really don’t know how bad the public health situation is in much of the country, particularly in heavily hit regions of Aleppo. But what we do know is that it will take a generation to build the system back up again – long after everyone has forgotten the name Aylan Kurdi.
Fouad: It’s a shame. What is the role of U.N. agencies including WHO, UNICEF, UNHCR, all these agencies that should guarantee safe exit for people? What we see now are the Russians, the Syrian regime managing the whole issue. Where are the U.N. agencies that should be telling us the condition of the people evacuating? We need to know what is going on in eastern Aleppo, what’s going on for people who leave and what will their conditions be when they reach their destination? We need to be sure what the guarantees are for people to leave and be safe.
Tarakji: In addition to increased awareness, it will be great to encourage people to donate to certain active organizations. The resources to deal with the crisis are very limited and we, literally, count on every dollar to help. For most of us, the current source of support are the individual fellow citizens.
Syria Deeply: Do you think the situation will get better, in terms of access to care, for those who’ve left what were the rebel-held areas?
Scales: In the short run, yes. Those in eastern Aleppo are being evacuated to Idlib, where there are still a number of field hospitals in operation. So, compared to the utter deprivation that the population was facing after five months of siege in east Aleppo, their health access is likely to improve. But this is similar to saying that refugees fleeing the country are better off – yes, they are less at risk of imminent death and have somewhat better access to medical care, but they are still incredibly vulnerable as internally displaced people. Indeed, evacuation is little consolation as the regime will next turn their sights to Idlib, which remains under rebel control. It is a matter of time until the humanitarian crisis extends there. So fleeing from Aleppo is less of an ‘evacuation to safety’ situation than an ‘out of the frying pan, into the fire’ type of situation.
Fouad: These are all responses to emergencies, but not long-term. Not just in Aleppo but in many places, including even Lebanon, Turkey or Jordan, long-term response or long-term strategy is not present. I think that right now there is a huge need, and U.N. agencies such as WHO, UNHCR, UNICEF, UNDP, all those who are working inside Syria and even regional offices and headquarters, it’s time now to show some sort of commitment for people’s lives. This is an unprecedented event since the Second World War. We’ve been watching the bombing of Syria for three weeks, and till now there’s no serious movement to prevent that. So at least now we need some sort of serious commitment to help people.