Syria. A health care system under attack

2017

More than six years after the start of the war, Syria represents not only the biggest humanitarian disaster of our times, but also the most complex. The highly unstable and unpredictable political-social environment is marked, along with other problems, by heavily restricted access to populations in need, high levels of insecurity, including the constant displacement of front lines, and the wilful targeting of attacks against humanitarian staff.  

The Syrian health care system has been severely weakened in the six-year conflict, there is a chronic shortage of medicines, supplies and equipment, half the health care facilities are shut or only work in part and only a third of health care staff are available to attend to 12.8 million people who require health care in Syria in 2017.  

The military attacks on the Syrian health care system have pushed it to breaking point and the related data paints a grim picture:

  • 478 attacks on 323 centres, of which 90% were perpetrated by Syrian Government forces and their allies and 9% by other armed groups (including Daesh, the Free Syrian Army and the Syrian Islamic Liberation Front).
  • Barrel bombs have been used, despite being banned in UN Resolution 2139, in at least 83 attacks on hospitals.
  • 16% of all health care facilities (hospitals, health centres, health posts and private hospitals) have been completely destroyed and 42% have sustained damages. Although not every city has been affected in the same way, the city of Aleppo has had 40% of its health care infrastructure razed to the ground, while 80% of the infrastructures in Raqqa and Dayz az-Zawar are debilitated.
  • The death toll of health workers stands at 830, 90% of which were perpetrated by the Syrian Government’s forces and its allies.  
  • 65% of health care staff and at least 15,000 of the 30,000 Syrian doctors have fled the country. In the cities ravaged most by the war, such as Aleppo, only 70 of the 6,000 doctors remain.  

In addition to their total or partial destruction, health care facilities are also affected by the destruction of other related infrastructures such as communication channels, the network of electricity or water and sanitation, which negatively impact the delivery of health services.  

Without doubt, the destruction of health facilities and a shortage of health care staff has strongly contributed to the deteriorating health of the Syrian population, which in turn has triggered the reappearance of infectious diseases and the aggravation of non-communicable diseases. One such example is polio, which had almost been completely eradicated but has spread across different provinces (among them Raqqa, Deir Ez-Zor and Homs) due to a vaccine shortage. In the most critical cases, the lack of suitable care has led to death, and in the first three years of the war alone, around 200,000 people died from a lack of basic health care.   

The health care system as a target of war

According to Physicians for Human Rights, the majority of attacks on health care facilities are planned, representing a flagrant violation of international humanitarian law, which is very explicit when it comes to protecting medical missions.

“IHL regulations stipulate that all persons regularly and solely engaged in the operation and administration of civilian hospitals shall be respected and protected”.

(Art. 20, Fourth Geneva Convention, and Art. 9, Protocol II Additional to the Geneva Conventions).

Despite the United Nations’ Resolution 2286 and calls from the UN, civil society organisations and different governments, in Syria the health care infrastructure and health care staff are still military targets. The last spate of attacks took place in September 2017, and, according to the World Health Organisation (WHO), there were different attacks on hospitals and various ambulances in the province of Idlib. The three hospitals in the province, Kafr Nabl, Khan Sheikhoun and Heish hospital, specialising in maternity and infant care, were shut down.   

The humanitarian health care response

Although health care staff are a target of war, humanitarian organisations are still working to offer the population health services. Health care interventions are articulated around basic elements of a health system identified by the WHO: leadership, human resources, medicines and medical supplies, health financing, the management of healthcare information and service delivery.

In 2016, both the WHO and humanitarian health organisations went to great lengths to respond to the health care needs of the population:

  • More than 10 million medical treatments were distributed, and over a third of the supplies needed for these treatments were administered in war-torn areas, controlled by opposition forces and with difficult access.
  • Mobile clinics were organised with health care staff to provide health care to hundreds of thousands of displaced people fleeing besieged zones, for instance neighbourhoods in east Aleppo and Homs.
  • Essential health care was offered to different patients suffering from non-communicable diseases such as diabetes, kidney failure and mental illness.   
  • Health care staff were trained in different areas, for instance carrying out health evaluations, treating injures, mental health, nutrition, immunisation, etc.
  • Millions of children were vaccinated against diseases such as Hepatitis B, measles, German measles, flu, and polio.  

These interventions look to provide a response to the most urgent health care needs among the population and to reactivate basic health services. The support and recovery of the health network is a priority for bolstering the referral system and specialised care, particularly sexual and reproductive health, child health, infectious diseases, chronic disease control, and mental health.  

Nevertheless, there are zones in the country that are extremely difficult to access. Currently, fifteen areas in Syria, where 700,000 people live, are under siege, and it is not uncommon for aid to be obstructed or temporarily interrupted when trying to reach these regions, with medicines from convoys sent to besieged and hard-to-access zones being seized.

Finally, organisations such as Médicos del Mundo and Médicos sin Fronteras are already concentrating part of their health interventions in refugee camps in Syria, providing direct health care, psychosocial support and medicine deliveries through mobile units.