by Dr Abdullah Alhouri
This article is part of our Conflict & Health in the Eastern Mediterranean Series. Read the Series Introduction.
Since 2011, Syria has been ensnared in an armed conflict  which has had a devastating impact on health care services. Most crucially, the foundations of Syria’s health care infrastructure have been destroyed. This has resulted in a dramatic increase in both morbidity and mortality in the country, and it is expected that this will only continue to worsen .
One of the most exacerbating factors behind the national health crisis is the falling numbers of trained health care workers (HCWs), who have often been victims of violence during the conflict and have been consequently forced to leave the country. These HCWs play a vital role in health care delivery during conflict and in the reconstruction of the health care system following a cessation of conflict .
Doctors, and other HCWs, flee because they or their families face the prospect of violent death or the threat of widespread violence. Some HCWs leave looking for a stable environment in which they can live and practice their profession safely. Reports indicate that the number of HCWs is exceptionally high among Syrian immigrants , with the World Health Organization (WHO) estimating that up to 70% of HCWs have left the country. Beyond those lost to migration, 782 medical personnel were reportedly killed between 2011- 2016 . Because of the falling numbers of skilled medical professionals in Syria, the WHO had voiced concerns early in the conflict regarding the quality of current health services and uncertainties regarding how such medical expertise will be rebuilt.
Another important driver of the health crisis is the socioeconomic challenges that negatively affect HCWs currently operating in Syria. Like most Syrians, many HCWs have lost their property and savings. Moreover, their medical facilities are frequently unable to pay them a salary. Consequently, most are living below the poverty line. This has a marked impact on their ability to work and has forced many of them to accept, often without pay, incredibly challenging working conditions.
Furthermore, the quality of health care provided by the remaining HCWs is questionable since many of them experienced long interruptions to their training programmes, with continuous medical education impossible amidst constant conflict. These insufficiently trained physicians have been obliged to treat medical conditions and perform surgeries for which they lack specialization. This is because of the absence of qualified staff and the continued urgency of the situation. Looking for practical solutions to resume medical training and support the remaining HCWs is an important aspect that needs urgent exploration. Without it, there certainly are negative impacts on the quality of care provided to the Syrian people even after a cessation of conflict .
On top of the current situation, what rubs salt into the wound is the spread of Covid-19. The pandemic has created further pressure on Syrian medical staff, who are already exhausted after 10 years of conflict. Over 40,000 cases have so far been detected, and over half of them are in the Northern and North-western parts of the country, areas where health care system has been devastated by direct attacks on hospitals and other health care facilities. Moreover, Coronavirus continues to claim the lives of many Syrian medical staff. For instance, on 16th of February 2021 the Syrian Ministry of health announced that 22 health care providers died due to Covid-19 infection; the actual number could be much higher because of the scarcity of Covid-19 testing.
Despite a continuous deterioration of Syria’s health care system, no actions have been taken to deal with this issue. According to the WHO, more than half of the population in Syria (12 million out of 20 million) require medical attention. Additionally, WHO reported that only 50% of hospitals in Syria are fully functioning, with 25% of hospitals across the country only partially functioning because of a scarcity of medical staff, tools, medications or physical facilities. The remaining 25% are completely out of service. This is the stark reality of the present situation. It is a problem that must be tackled without further delay, because to continue as such will lead only to yet higher rates of mortality and morbidity.
To solve this crisis, several things need to happen. First and foremost, it is important to protect HCWs by enforcing legislation and laws that guarantee their rights and safety, providing them with modern equipment necessary for delivering adequate health care, and attracting them by increasing their salaries. This is the only way to curtail migration of HCWs and to ensure that they are able to practice in a safe work environment.
Second, it is important that the trust between the population and the doctors be restored since the political affiliation of doctors has been a factor affecting the relationship between patients and doctors. For example, patients are reluctant to go to doctors who are known to be part of the opposition because they fear retaliatory persecution by the state in light of the counter-terrorism law passed in July 2012. Therefore, to restore people’s trust, it is crucial to change how belligerents, including the government and the opposition, and individuals look at HCWs and affiliate them with one group or another. This, in turn, is key to increasing the safety of HCW’s.
Third, the international community needs to apply pressure on the Syrian state to force it to respect international humanitarian laws, which sternly prohibits attacks on health care facilities and workers, especially in opposition-held areas. Beyond this, it is also important to support dialogue around protecting health worker and facilities and mechanisms for achieving such protection. Such movements ideally involve civil society leaders, including community and religious leaders, who hold important status in their respective communities and are influential in times of conflict and crisis . In conclusion, the health care system in Syria will continue to deteriorate, perhaps to a point of no return, unless serious actions are taken to ensure the safety and protection of HCWs, their facilities, and their livelihoods.
- Loss, Julika, Yamen Aldoughle, Alexandra Sauter, and Julia von Sommoggy. 2020. “‘Wait and Wait, That Is the Only Thing They Can Say’: A Qualitative Study Exploring Experiences of Immigrated Syrian Doctors Applying for Medical License in Germany”. BMC Health Services Research 20 (1). doi:10.1186/s12913-020-05209-2.
- Omar A. Understanding and Preventing Attacks on Health Facilities During Armed Conflict in Syria. Risk Manag Healthc Policy. 2020;13:191-203
- Bou-Karroum, Lama, Amena El-Harakeh, Inas Kassamany, Hussein Ismail, Nour El Arnaout, Rana Charide, Farah Madi, Sarah Jamali, Tim Martineau, Fadi El-Jardali, and Elie A. Akl. “Health Care Workers in Conflict and Post-conflict Settings: Systematic Mapping of the Evidence.” Plos One 15, no. 5 (2020). doi: 10.1371/journal.pone.0233757.
- Omar, Abdulaziz. “Understanding and Preventing Attacks on Health Facilities During Armed Conflict in Syria.” Risk Management and Healthcare Policy Volume 13 (2020): 191-203. doi:10.2147/rmhp. s237256.
- Karroum, Lama Bou, Amena El-Harakeh, Inas Kassamany, Hussein Ismail, Nour El Arnaout, Rana Charide, Farah Madi, Sarah Jamali, Tim Martineau, Fadi El-Jardali, and Elie Akl. “Health Care Workers in Conflict and Post-Conflict Settings: Systematic Mapping of the Evidence.” SSRN Electronic Journal, 2019. doi:10.2139/ssrn.3458503.
Doctor Alhouri is a medical doctor. He graduated from the University of Jordan- School of Medicine.