الشعب يريد إسقاط النظام(Ash-shab yurid isqat an-nizam) – “The People want to bring down the regime”. This slogan represents the will of the people of not just one country, but of an international movement in the Middle East and North Africa called the “Arab spring”. Beginning with the Tunisian revolution in 2010, the Arab Spring culminated in the toppling of or major uprisings against longstanding regimes in Tunisia, Libya, Egypt, Yemen, Syria and Bahrain. What started as a relatively peaceful revolution in Tunisia (relative to the others in the list), resulting in the successful ousting of Ex-president Ben Ali, turned more heated when the revolutionary fervour migrated eastwards to similar autocratic authorities of Libya, Egypt, Yemen, and the focus of this article – Syria.
To be more specific, this article talks about on the health care workers of Syria, who have been working in the background during the Syrian Civil War to heal people on both sides of the conflict, and the civilians who happened find themselves in the wrong place at the wrong time. This might seem like a challenging task already, and one might think that the government as well as the opposition leadership would support the health care workers, who are serving an important role for their cause – that of healing the injured. However, what we instead see is the systematic targeting of health professionals in both government controlled and non-government controlled areas of Syria. The Syrian Civil War has truly been a destructive experience, and has brought one of the highest functioning health care systems in the Middle East before commencement of the civil war to its heels. Like the revolutionary fervour of the Arab Spring, what happens in Syria does not stay in Syria, and this article will also highlight the plight of the Syrian refugees: the victims and carriers of communicable and non-communicable diseases that place great burdens not only on themselves but also on the governments of the refugees’ host countries.
For the people who watch the news regularly, most would remember the period during which there was regular reporting of the Syrian refugee crisis, showing pictures and videos of boat-fulls of Syrians making their arduous journey across the Mediterranean. This represents an incredibly dangerous part of the migration journey for any Syrian refugee determined to reach the safe havens of Western Europe like Germany, France, Sweden etc. A lot of people tried, and many boats sunk with their passengers. This poses a question – Why did these people risk their lives crossing the Mediterranean?
It is because the mass exodus of Syrian refugees has posed a very heavy burden on their hosts in the Middle East. There are 3.3 million in Turkey, 600,000 in Jordan, and just over 1.1 million in Lebanon – that’s 1/6 of Lebanon’s population! Although these Syrian refugees have no luxuries to speak of inside the cramped refugee camps or various urban/rural lodgings, they do require quite a lot of expenditure in the way of health maintenance. For example, a survey conducted in 2017 found that 86% of households in Lebanon and 88% of households in Jordan included at least one woman who has had at least one childbirth in the last year. Nearly all of these childbirths happened in health facilities (94% in Lebanon and 98% in Jordan). While this does show the remarkable flexibility of these host countries’ healthcare systems in accommodating the significant influx of extra users, the financial funding for these vital services are do not follow the demand very well – the UN has called for an extra $4.4 Billion funding to be channelled to the neighbouring countries, which in summation host over 5 million Syrian refugees. This under-funding means that the prices of a lot of the services available in the healthcare systems of the host countries may not be affordable for the refugees. Although the UNHCR (United Nations High Commission for Refugees) covers the large majority of the costs, even small contributions demanded from the refugees maybe more than they can pay.
This situation is only made worse by the risks of infectious diseases that comes hand in hand with any mass emigration of people. The unsanitary conditions, poor access to proper healthcare, and the interpersonal contact that occur as a result of moving to foreign places form an unholy trinity that increase the likelihood of outbreaks emerging. Measles, Leishmaniasis and tuberculosis outbreaks have all swept through Syria and onto the neighbouring countries. Even polio, a disease thought to have been eradicated from Syria since 1999 by means of vaccination campaigns, have returned 2 times, most recently in 2017! This is because since the civil war there has been a deterioration of the government polio vaccination programme, with the people in areas controlled by ISIS and other non-government groups being even less accessible to vaccine programmes. The lack of vaccination and public health systems in Syria as a result of the civil war has turned Syria into a breeding ground for various pathogens that are usually well-contained by effective public health services. As these infections leak to the surrounding countries with the refugees they pose a serious risk to these countries’ public health as well.
Of course it is not just a matter of treating and isolating people with infectious diseases for the host countries – plenty of refugees have other non-infectious problems. These often chronic problems are also more costly in their treatment than their infectious counterparts – where as you only need to have a proper antibiotic regimen for a case of tuberculosis you need extensively planned regimens of chemotherapy for cancers, or a constant supply of insulin for diabetes. It may surprise you that non-communicable diseases, obesity associated diseases being among them, is the leading cause of death in the Arab world. It may also surprise you that of the Syrian refugee women from the West Bank of Palestine, 30% are overweight, 39% are obese, and 7% are extremely obese. The refugee’s obese condition is not due to over-nutrition – alas, quite the opposite, for the food insecurity of the refugees have pushed people away from the expensive fruits and vegetables to the less scarce supplies of carbohydrate and fat rich foods, resulting in the gaining of weight.
The problem of obesity is a central risk factor to a massive web of different non-communicable diseases – diabetes, depression, heart attacks, metabolic syndromes and so on and so forth. However, it is not the only risk factor experienced by the refugees fleeing Syria. The very act of having to uproot your family and leave the house you grew up in is a very stressful process, and so are the various experiences the refugees have on the road. Some refugees have to walk hundreds of miles only to be turned away at security check points because they lack documentation. Some refugees are insulted by foreigners and are powerless to do anything. Some refugees lost loved ones on the roads or at the sea. The powerlessness of these refugees means the psychological and emotional stress they experience are constant, and they live in constant uncertainty of what might happen tomorrow. Although they have to be concerned more about the immediate future, doubtless many of them also wonder if they might see the loved ones they may have separated from during the trip again; They might think of their home, and wonder if it has since been replaced by a bomb crater. It is unfortunate, and troubling, to think that the refugee health services are too thinly stretched to provide adequate treatments for non-communicable diseases in the host countries, for none require them more than these refugees.
“Turkish authorities have estimated that 55% of the 3 million Syrian refugees there need mental health care, while half of those families believe they need psychological support. In Germany, which has taken in almost 270,000 Syrian refugees, one study estimates 50% have mental health issues and have been victims of violence. Resources to address mental health are scarce, but experts say immediate treatment is needed to avoid long term damage.”
So far I have only talked about the experience of refugees outside of Syria, but as you can imagine, the situation is only more dire inside the war-torn homeland of these refugees. Before the Syrian uprising – and consequentially the civil war – the Syrian health system have been making very respectable progress in improving its health outcomes on a population wide level. Life expectancy from birth was 56 years in 1970 and by 2009 this has increased to 73.1 years. Similar remarkable improvements were achieved in infant mortality and childhood mortality. It also had the leading Pharmaceutical industry in the Middle East. There were issues with the equity, transparency and manpower supply of Syrian healthcare, but the Syrian people didn’t revolt because of their healthcare system.
The civil war changed all that, and undermined years of progress in the health sector. Ironically, the government seem to be instituting a policy of war on its own healthcare infrastructure – one of the few achievements that the regime could actually be proud of before the war started. The rationale behind this decision portrays the unspoken belief of the Al-Assad regime that the enemy are within the population which it tries to control. The regime has many enemies in Syria, comprising of ISIS, other jihadist groups like Hayat Tahrir Al-Sham, and various anonymous tribal resistance groups. The war in Syria is a political struggle for some, a religious struggle for others, and a quick power trip for those who have grudges against others to settle. In the end, all these people struggle for peace, yet due to the presence of so many different factions of competing interests, encouraged by international support, peace is still very far off. As such, many sides of the civil war actively prevent the assistance of suspected enemies among the injured and the sick – in other words, civilians – by health professionals. Unfortunately, the Al-Assad regime is not alone in its terrorization of the healthcare system, but it is the most readily accessible one in terms of data collection.
To work in the Syrian healthcare system in the current time takes a lot of guts and a lot of commitment. There is a lot of intimidation against people working in healthcare as a result of the violence that has been discharged against some of the healthcare facilities. The acts of violence committed that resulted in the deaths of medical personnel include bombings, shootings, tortures, and executions. However, in the aftermaths these acts are not investigated and the guilty brought to justice. In fact although there are statistics on the numbers of different types of attacks, the perpetrators of these acts are hardly known. Nonetheless, in some cases these acts are clearly coordinated by established authorities – the Russian jets most likely knew they were targeting hospitals, the rebel mortar teams most likely weren’t shelling on random, and a few poorly sourced chemical terrorists most likely didn’t get their supply of Sarin nerve gas from the internet. As a result, many health professionals have relocated and separated the different departments of the hospitals as to make it harder for the attackers to find them, and if they do, to minimise the effect they can have on hospital service. However, the targeting of health service is so efficient that some areas cannot sustain the health service in the face of these attacks – such as in eastern Aleppo in November 2016.
As a result of these persistent, deadly attacks, the majority of the medical professionals of Syria have followed the emigration of refugees from Syria. In 2009, there were 29,927 doctors in Syria but by 2015 15,000 doctors had left the country. Turning the guns on the remaining healthcare staff has only worsened their situation, as now the staff not only have to manage the impossible influx of patients, but also contemplate the possibility of dying on the job. You can try to ignore the latter of the two concerns, but it becomes virtually impossible when you hear the sound of explosions just a few yards from the clinic, and are confronted with the consequences of what might happen to you in front of your own eyes. “After a barrel bomb falls we start dancing, the Arabian dancing. We are not dead, and if nobody is dead among us, we start dancing.” says a health worker.
This shortage of willing medical staff has created serious voids in the staffing of hospitals. Thus, working in Syria would be every medical student’s dream, and every medical student’s nightmare. The inexperienced students are given jobs that would normally require many more years of training and experience. However, due to the fact that there would otherwise be no one to do the operation and the patient would literally die, these students are given the best description of the surgery within the limited time available, and rushed off to the operating theatre. If the operation is a success, then the patient lives, and if he dies, then the medical student can at least have reconciliation in their ignorance. Perhaps President Bashar Al-Assad wouldn’t mind stepping into the clinic once in a while and use his ophthalmologist training to help in some operations – I’m sure the staff would all be there to greet him.
The present state of Syria’s healthcare is quite unlike anything I could possibly imagine. The lack of anaesthetics for operations, the amount of amputations one has to do, the need to ration everything available must exhaust the best of physicians. What about the civilians? The primary healthcare system is basically non-existent, so if you don’t have an emergency you probably won’t be treated in the hospital (and going to the pharmacist may not necessarily be the best alternative) and if you have emergency you just have to hope you can get to the hospital soon enough. What about the pregnant women? Obstetrics is one of the sectors in the shortest supply, and pregnant women in rural areas would have to walk strenuous distances to give birth in a healthcare context. It is no wonder that some women are caught out and have to give birth on their way to the hospital, with out professional help, hygiene or dignity.
“Everything is allowed in a field hospital. You can put the intravenous line in with alcohol – we do it all the time. You can do operations without sterilised materials, without anaesthesia machines.” – a healthcare staff working in a field hospital in Syria.
What about the future? When Syria finally becomes united under one political leadership, how can it reconcile with the healthcare services which it sought to tear apart? How can it repair its infrastructure and undo the chronic health problems imposed upon the population as a result of the civil war? These are very tough questions for Syria in the future, and one can only hope that the sectarian tensions currently rampant in Syria and its neighbours will not lead to too much delays in projecting the country’s efforts towards rebuilding instead of destroying, in realms of healthcare as well as beyond.