with Adam Coutts, University of Cambridge, and Martin McKee, London School of Hygiene and Tropical Medicine
The conflict in Syria is an escalating humanitarian and public health catastrophe. Civilians are currently caught between two armed factions: the Syrian military loyal to the government of President Bashar Al Assad and the Free Syrian Army opposition. According to the UN, the 2-year long conflict has already resulted in an estimated 60,000 civilian casualties and tens of thousands injured.
As if the direct effects of military force on Syrians were not enough, there has also been a full-scale assault on the health infrastructure. Even if Syrians are able to reach health facilities, which they often cannot because of ground fighting and erratic and unsafe transport, government forces have targeted health-care facilities, health workers, and patients intentionally, as described by independent observers such as Physicians for Human Rights, Amnesty International, and Médecins Sans Frontières.
These deliberate attacks by government forces, which are in addition to collateral damage from attacks on nearby facilities, are having a devastating impact on health-care services. In a report issued on Jan 2 2013, the United Nations Office for the Coordination of Humanitarian Affairs' delegation to Syria found that 35% of hospitals, 10% of health centres, and 40% of the country’s available ambulances have been severely damaged. In major cities such as Aleppo, Hama, and Homs the public health systems have collapsed: disease registration and vaccination programmes have stopped completely and many qualified doctors have fled the country. Only very basic health services exist in the refugee camps of Lebanon, Jordan, and southern Turkey, and some camps have no health services at all. Conditions worsened with the onset of winter. Investigations by journalists reported children dying from exposure to cold and a lack of medical care for physical injuries caused by armed conflict.
Health concerns extend beyond the damage to health services; there are also the health effects of mass displacement. By March 2012, UN agencies had already registered 40, 000 refugees and anticipated that about 96, 500 would require assistance over 6 months. Yet by December 2012, the Office of the United Nations High Commissioner for Refugees reported far higher numbers, with nearly half a million people fleeing the country and more than 2 million internally displaced; it is estimated that 1.1 million people will have fled abroad by June 2013.
There are growing dangers of epidemics. The World Food Programme reports that 2.5 million Syrians are suffering from hunger, with UN agencies struggling to meet the basic daily needs of refugees in camps for shelter, nutrition, and protection. There are credible reports of an increased incidence of tuberculosis in urban areas, and particularly in Aleppo and among refugees in neighbouring countries. Although accurate numbers are not yet available, doctors interviewed recently report that if left unchecked the situation is likely to become 'out of control'. Reports from Aleppo also indicate a resurgence of Leishmaniasis among children.
The most obvious response to the emerging health crisis in Syria is for the violence to stop, yet diplomatic solutions seem elusive. Although a case for armed intervention can be made under the 'responsibility to protect' doctrine, this seems unlikely given Russian opposition. The UN has proposed a massive aid package: to support 4 million civilians inside Syria, 2 million who are internally displaced, and half a million refugees; the Office for the Coordination of Humanitarian Affairs estimates that US$1.5 billion dollars will be needed, which seems ambitious when many potential donors are facing major financial problems. The bulk of these funds comprise the Syrian Humanitarian Assistance Response Plan (SHARP), a $519 million package for projects across a range of humanitarian areas, and a $1 billion Regional Response Plan to assist neighbouring countries in providing support for refugees.
However, questions remain about whether this injection of funds will be enough. The International Rescue Committee argues that the budgets allocated for humanitarian purposes are naive and must be increased from present levels. Moreover, only 3% of the funds requested have so far been provided, making it impossible to deliver an effective health response. It is also unclear how SHARP funding can reach those in most need, particularly when they are in opposition-controlled areas where violence has made it difficult for aid workers to reach refugees.
Few clear alternatives
One possibility is to enhance the effectiveness of aid distribution by tapping local knowledge and newly established networks of civilian councils to deliver public health and civil society projects. The Regional Response Package, which will be discussed at a high-level pledging conference in Kuwait on Jan 30 2013, faces difficulties. Aside from the event being used to further legitimize the newly formed Syrian National Coalition, internal politics, in particular the influence and role of militant Islamists, might hamper the pledging of funds, as too might contradictory goals of government donors and humanitarian agencies.
A quick pragmatic option to assist the hundreds of thousands of injured would be to cover the cost of treatment in neighbouring countries, as was done for Libyans fleeing to Jordan. The health-care systems of Jordan, Turkey, and Lebanon are advanced and could provide such treatment. However, to do so, adequate funding for treatment will be needed from the Regional Response Package and the recipient countries must be persuaded to allow refugees to be treated in their facilities.
The experiences of Afghanistan, Iraq, and Libya show the consequences of failing to address health crises in situations where most international attention is focused on resolution of political and security issues. Once again, the main focus of the international community has been on the latter, while the response to the humanitarian crisis within and outside Syria has been inadequate. As the conflict continues, with little immediate hope for a political solution, the least the international and public health community can do is to take measures to protect the Syrian people, wherever they are.
This article originally appeared in The Lancet, and is republished here with kind permission.