In Absentia: describing the toll of war on health in Syria

In our line of work we rely on numbers. The number of patients treated in the clinics, the number of children with pneumonia, or diarrhoea or severe malnutrition, the number of patients admitted to the hospital, the number of patients undergoing emergency surgery, the number of babies born, the number of children vaccinated, the number of people counselled.

The numbers guide us to where the needs are, what is making people sick, how difficult it might be to reach health care by how late and sick the patients are when they present to hospital, and the number of deaths and where and when they happen. These are all ways of measuring how the health system is performing.  They paint a picture from which we can describe, interpret and then plan how best to reach a population’s health needs. We can adjust medical interventions in order to treat more people, to reduce disease burden and avert death. The central tenant is to provide health care, alleviate suffering and provide comfort to people. Not just those patients directly in front of us, but everyone around them. Numbers are important; without them we cannot effectively do our job.

In New Zealand we are fortunate that we have the information we need to allocate resources effectively. In war-torn Syria, patients are besieged and in inaccessible areas. True numbers are unknown, those that we do see paint a picture so bleak, the size and scale of the emergency health response seems unimaginable.

For six long years, war has waged across Syria, resulting in an unprecedented 4.8 million people becoming refugees. The responsibility to care for this refugee population falls largely to Syria’s neighbours.  Inside Syria, the United Nations High Commission for Refugees have some overwhelming numbers. They report that 13.5 million people are in direct need of medical and humanitarian assistance. More than six million have been forced from their homes and are now internally displaced due to shifting battle lines, armed groups and militia; and 4.3 million people are categorised as ‘’hard to reach’’ - a humanitarian euphemism used when getting information from communities is limited and as a result the likelihood of the population accessing sufficient protection, food, shelter, water or healthcare is extremely low.

The effects of war are not limited to frontlines or battle grounds. Indiscriminate bombings of civilians, hospitals and cities, cause catastrophic blast injuries, permanent disability and deaths. War has insidiously crept into every consultation room, every hospital bed, health post and clinic in areas indirectly affected by the Syrian crisis over the last six years.

MSF has tried to maintain operations throughout the country over the course of the conflict. Despite repeated requests for access to work in government-held areas, we have not been able to secure authorisation to do so. We can therefore only provide direct assistance and deploy teams in opposition-held territories and can mainly speak of what we see in those locations. These medical programmes are not classic by our definition. They have been forced to start and stop as the fighting draws near. They have been relocated after hospitals have been damaged by shells and mortar, or when the populations are forcibly displaced. These projects and hospitals operate all the time under impossible conditions with new staff, new systems, rapidly changing security management and dramatic variability of the availability of medicines and supplies as unpredictable border controls change from week to week. It is no easy feat to provide meaningful healthcare care in such an environment.

What we can describe from the numbers and experience generated from these programmes is indicative of a grave medical situation and looming public health crisis. At the most practical level, there are not enough doctors, nurses or midwives in northern Syria. Most have fled, many have been killed, and the future health workers have long since had their studies disrupted. There are not enough functioning health facilities at primary, secondary or tertiary level. There are also not enough medical supplies making their way across the international borders.

In regards to the population’s health, we see gains in child health outcomes demonstrated in pre-war Syria slowly slipping away. Vaccination rates are at an all-time low – with MSF’s survey of children in Northern Syria revealing only 17% had received their complete childhood immunisation schedule by the time they had reached the age of five.  We know that Syrian children still do not receive the pneumococcal vaccine, which would considerably reduce to the incidence of paediatric pneumococcal pneumonia infections, a vital prevention strategy where antibiotics and access to clinics and hospital care in conflict settings is fraught. We have witnessed multiple and recurrent outbreaks of polio, measles and typhoid plaguing the children across the country causing severe illness and contributing to entirely preventable deaths.  We have seen children born through the course of the conflict with congenital abnormalities or common paediatric problems who die or remain uncared for because the services and specialised care they need no longer exists or is inaccessible to them.

Women’s access to functioning reproductive health care services is too low. It is so low hardly any women are attending routine antenatal care. Women in labour are forced to deliver at home as the birthing services no longer exist. There is evidence that those few functioning facilities that do offer emergency obstetric surgery have seen a significant surge in the number of women electing to have unindicated caesarean sections, at great financial cost and unnecessary risk, rather than accept the risk of delivering at home. All around is evidence of worsening malnutrition among infants, as formula milk costs exceed what families can afford and poor infant feeding practices due to lack of support and education programs. 

The absence of health facilities means that those people living with chronic diseases such as diabetes, heart disease, renal disease, thalassemia, epilepsy and asthma, report experiencing unabated symptoms. These group of patient’s long term disease progression, life expectancy and the later catastrophic burden on the future health system is yet to be seen.

There are many people suffering from the psychological effects of trauma, grief, loss, depression and anxiety, with very few places to get care. Many mothers tell us their children are angry or withdrawn, or have resumed bed wetting. Husbands and wives fight more than before. Hope is diminished, and people remain uncertain and fearful of the future.

For six years, the war has robbed the Syrian people of their right to health care. Poor politics and failed diplomacy has enabled the war to continue remorselessly and kept borders closed, taking away the rights of the Syrian people to flee the horrors and preventing medical humanitarian actors like MSF to access and support those most in need.  

MSF doesn’t have all the numbers. We just see those suffering and dying in front of our eyes. Many more individuals and families will continue to suffer unless this war stops. One more life is too many, collectively we need to do more to not only stop the war but to help those who are suffering.