Syria: a healthcare system on the brink of collapse

Most doctors have fled

WHO estimates that some 80 000 doctors have emigrated, leaving just 37 000 in Syria. “Doctors were some of the first departures from Syria because they could afford it and they can find work elsewhere,” said Hanna Kaade, a newly graduated doctor and the first aid and clinics coordinator for the Red Crescent in Aleppo and WHO in northern Syria. “Many of the hospitals have gone out of service because they don’t have the staff, have become military centres, or have just become ruins. The remaining medical centres cannot compensate—we just don’t have the ability to accept the amount of patients we need to.”

With the war still raging there has not been the chance to rebuild medical centres. “There are areas where they’re still under constant bombardment, constant fighting and shelling, where they have developed makeshift hospitals in underground buildings,” Gabbar said. “We don’t have regular access to electricity so we have to buy generators that run off diesel, but then we don’t even have good access to that. We have to ration supplies so that we just provide for the most important areas—theatres and the special care baby unit, for example.”

This leaves a population struggling to receive much needed healthcare. Many have had to flee to neighbouring countries such as Lebanon or Turkey or have had to make the perilous trip to Damascus to get care. “We used to have many patients coming from all across the country, especially the northeastern region, seeking treatment for all kinds of acute and chronic diseases. That is not the case anymore,” said Khaled Alok, a medical student studying in Damascus.

Road closures, checkpoints, and the lack of public transport have changed the patient demographic, yet there are still many to treat. Healthcare workers in rural areas outside of Damascus travel for at least three hours to reach medical centres in the city, everyday running the risk of encountering snipers, roadside explosions, and suicide bombers.

“Even with the high numbers of patients, surgery is being performed in appropriate conditions, and hospitals and outpatient clinics are still running as far as possible,” said Alok.

The state funded system is also under extra pressure because many previously wealthy Syrians now impoverished by war are unable to pay for private services. “64% [of Syrians] used the services that were provided in this country by the private sector and they are not able to sustain this at all. They don’t have money to spend on healthcare,” said Hoff.

Drug shortages

According to WHO, before the outbreak of the war, 90% of drugs in Syria were locally produced. Many pharmaceutical plants have been destroyed, however, and those left are struggling to source raw materials, which has led to a 70% fall in production.1

The Syrian Ministry of Health argues that sanctions imposed by countries such as the United Kingdom and United States hamper humanitarian efforts.2 Imposed in 2011 shortly after the conflict started, they included freezing the assets of the government and a ban of crude oil exports to Europe, which used to provide a fifth of Syria’s gross domestic product.3

Pharmacies now try to control their stock by limiting the amount each patient can buy. Pharmacies have also tried to source drugs from abroad, but often these are unaffordable.1 As a result, many Syrians with chronic health problems have turned to the black market. Drugs are smuggled over borders and sold at inflated prices with the risk that the supply could stop any day.1

Return of polio

Civil war has led to a drop in vaccination rates and the re-emergence of polio, a previously eradicated disease. “There has been recent outbreak in the northeastern regions of Syria, a disease this country has been free of for almost 15 years,” said Alok. Hoff, who is coordinating WHO’s humanitarian effort, said that there have been 22 reports of polio resulting in partial paralysis, although only 10 have been confirmed.4

“There has been a drop in the vaccination coverage from around 90% before the war started to around 60% to 2012,” she said. The United Nations has warned that half a million children, regardless of where they live in Syria, need to be urgently vaccinated against the highly infectious disease, but access to the high risk areas is difficult.5 WHO has vaccinated 60 000 children in a door to door campaign, and there will be subsequent vaccination programmes in Syria and neighbouring countries.

But Hoff is pessimistic: “The vaccination campaign will not be sufficient to deal with this problem . . . the low immunisation coverage is having disastrous effects.” And as millions of displaced Syrians move across and out of the country the risk of polio spreading increases.5

Resolve to carry on

Omar Hakeem works in a field hospital in a besieged suburb of Damascus. He, like many Syrian doctors who remain in the country, shows extraordinary resilience in the face of seemingly insurmountable challenges. “We see children dying of hunger and we see women weeping because they died. We will continue working to heal these people.”

Dani Markabawi has just finished his medical finals in Damascus, at the largest and oldest university in Syria. It has largely remained open, with lectures and teaching still taking place. He says that this resolve is common. “The atmosphere at school and in hospital hasn’t changed. People are trying to preserve the normalcy of their lives to the point that when you step onto campus you forget about the war raging outside.”

Thanks to the spirit of ordinary Syrian people, limited healthcare provision continues. Alok fled his home to live with his grandparents in inner city Damascus so that he could continue studying. He tells of travelling through the night to the sound of gunfire and seeing families walking on the side of the road with all their belongings towards the city. “I thought I would sit and cry, or be paralysed by the shock and fear. Instead, I said ‘bye’ to my grandfather and grandmother, took the regular bus, and headed to University Hospital for Dermatological Diseases, where I had clinic duty that day. I arrived a few minutes late to find the clinic had started and the residents had begun seeing patients.”