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Future Development

The war on Syria’s health system

Omer Karasapan

On February 11, the Syrian Center for Policy Research announced in a report that 470,000 Syrians had been killed in the war and 1.9 million wounded—that’s 11.5 percent of the population and a much higher number than reported previously. The United Nations had cited a number of 250,000 killed until it stopped gathering death statistics 18 months ago. In the meantime, over half of Syria’s population has been displaced with  4.6 million refugees mostly in Jordan, Lebanon and Turkey,  in addition to 900,000 asylum applications by Syrians in Europe since 2011, and 7.6 million internally displaced people.

Life expectancy has dropped from 70 in 2010 to 55 in 2015 and 70,000 of the dead have died from lack of adequate health services and medicines, especially for chronic diseases. Rabie Nasser, the report’s author, noted that “indirect deaths will be greater in the future.” Others have higher estimates. The NGO Save the Children puts the number of deaths from chronic diseases because of a lack of access to treatment and drugs at 200,000. The Syrian American Medical Society (SAMS) cites 300,000.

Before the war, Syria was a middle-income country with relatively good health indicators. “We are seeing many more humanitarian emergencies in middle-income countries where non-communicable diseases are more prevalent,” says the U.N. High Commissioner for Refugees’ (UNHCR) chief medical expert Paul Spiegel, “Not just cancer, but diabetes, renal disease, hypertension, and hypercholesterolemia.” These are manageable but without medicine and treatment, they become deadly. The U.N. also estimates over half-a-million debilitating injuries that will require long-term care. Serious mental health issues affect hundreds of thousands among the displaced and those who have stayed put but only one hospital remains partially functioning.  

According to the World Health Organization, 57 percent of Syria’s public hospitals have been damaged while 37 percent are no longer functioning. Its pharmaceutical industry has been decimated. According to a report by Physicians for Human Rights (PHR), over 15,000 of Syria’s 30,000 or so medical doctors have left the country, with more on the way. Of Aleppo’s 6,000 physicians before the civil war, only 250 remained in July 2013—95 percent had left the city and often the country. Those fleeing included nurses, medical technicians, administrators, ambulance drivers, and others. A November 2015 report, “Aleppo Abandoned,” notes that the city’s opposition-held eastern part saw 45 separate aerial attacks on medical facilities over the past three years.

This tragedy according to many—from the PHR to the UNHCR to others—is due to a deliberate targeting of medical facilities by all sides but most of all by the Syrian government, which has the ability to wage aerial attacks on the whole country. This is a policy of some duration. The U.N. noted that “anti-terrorism laws issued on 2 July 2012 effectively criminalized medical aid to the opposition.” These laws contravene the customary international humanitarian rule that “under no circumstances shall any person be punished for carrying out medical activities compatible with medical ethics, regardless of the person benefiting therefrom.” Hundreds of doctors have been killed, with 139 deaths directly attributable to torture or execution, a number PHR calls conservative since the war prevents accurate reporting.

Needless to say, the fate of doctors in areas controlled or contested by ISIS remains even more perilous. Women doctors are driven away or worse, and male doctors prevented from attending to female patients and vice-versa. Disappearances of medical personnel, Syrian or otherwise, is a constant threat—five doctors from Belgium, Denmark, Peru, Sweden, and Switzerland were taken away by ISIS in 2014; their fate remains unknown.

In areas controlled neither by the government nor ISIS, things have worsened since the beginning of the Russian air campaign. Bombings of medical facilities rose with 12 facilities hit in October 2015 alone. Following an air attack in February 2016 on a hospital in the southern town of Tafas, Doctors Without Borders noted that “despite tireless calls by international organizations for an end to indiscriminate bombing, it appears to have become the new norm.” Two further medical facilities were hit by Russian aircraft on February 15, killing at least 20 and leaving tens of thousands without medical care and further “incentivized” to leave. These attacks depopulate areas controlled by the opposition, putting additional pressure via more refugees on neighboring countries and Europe.  

As the bombing of a Doctors Without Borders hospital in Afghanistan by U.S. aircraft in October 2015 showed, such attacks are not confined to Syria. Israeli forces in Gaza have hit hospitals leading to calls by Amnesty International for investigations to determine if these were part of a deliberate campaign. The same accusations have also been levelled at Saudi Arabia by Doctors Without Borders in the context of its air campaign in Yemen. Other examples from around the world abound.

However, the scale of the systematic destruction of medical facilities in Syria is such that it needs a sharper and more focused response. The situation is dire enough that reaching an agreement in which hospitals can identify themselves as in combat zones abiding by the Geneva Convention and are spared, rather than hide as they do now, would be a big step forward. Then, agreement should be reached to provide aid to all medical facilities in the country, including those in government controlled areas which also face numerous challenges. If this is too big a hurdle for the parties, why even bother talking?

Author

Omer Karasapan

Regional Knowledge & Learning Coordinator, World Bank

This blog was first launched in September 2013 by the World Bank in an effort to hold governments more accountable to poor people and offer solutions to the most prominent development challenges. Continuing this goal, Future Development was re-launched in January 2015 at brookings.edu.

For archived content, visit worldbank.org »

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