A healthcare crisis
Medical students and doctors in Syria face huge challenges
The Syrian conflict has become one of the worst humanitarian disasters of this century. Incredibly though, there remains a continuing resolve by medical students to finish their training even as the healthcare infrastructure deteriorates. Over the past two years students have faced greater challenges than many of us will face in our entire lives. Louna Dreihi, a medical student at Damascus University, describes a situation that is all too familiar. “I have been many times only metres or minutes from my death, with many of us also staying away from [our] families, praying day and night for them to stay safe and alive.” Having begun in March 2011 as a revolution driven by the hope of the Arab Spring, the Syrian civil war has since deteriorated into a stalemate between President Assad’s regime and tentatively allied opposition forces.
Elizabeth Hoff, World Health Organization representative to Syria for the past 12 months, says that WHO estimates that the conflict has claimed 115 000 lives and injured more than 575 000. This makes it one of the most pressing health crises in the world today, and one where no end is in sight. Hoff told the Student BMJ: “The health situation has drastically deteriorated over the last few months, with an estimated 6.5 million displaced within Syria. There are critical gaps in essential healthcare delivery.”
Figures from WHO tell of a situation reaching a pivotal point. As of June 2013, 60% of public hospitals have been affected by the conflict, 38% of which are consequently out of service. Lack of fuel and electricity has forced many hospitals to operate in almost impossible conditions, with patients paying the price as the number of people seeking medical services grows. In regions heavily affected by the conflict, such as Homs, more than 70% of hospitals are out of service.
WHO is trying to alleviate the situation by working with 36 non-governmental organisations to provide humanitarian assistance. Unfortunately, their efforts have not always been straightforward. “We have difficulties in delivering supplies outside of Damascus. We have had two shipments hijacked on the way to Aleppo,” says Hoff. These setbacks are not uncommon and make providing care in Syria a precarious task. However, luckily in this case all was not lost. “What we’ve found is that they were used in the opposition controlled areas. The medicines were not lost; they were just diverted and still used for health purposes.” This speaks of the desperation for medical resources, which are now in short supply.
Access to healthcare
When the conflict began, many fled in search of safety to relatives and friends in neighbouring countries. WHO estimates that 80 000 doctors have emigrated leaving only 37 000 in Syria. “Doctors were some of the first departures from Syria because they could afford it and they can find work elsewhere,” says Hanna Kaade, a newly graduated doctor and the first aid and clinics coordinator for the Red Crescent in Aleppo 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.”
To make matters worse, many patients who would previously travel from regions such as Aleppo to Damascus to seek treatment are no longer able to do so. “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 any more,” says Khaled Alok, a medical student studying in Damascus. Road closures, checkpoints and the lack of public transport have changed the demographic of patients, yet there are still many to treat. Healthcare workers, many of whom live in rural areas outside of Damascus, travel for long hours to reach medical centres with journeys that can take at least three hours. Everyday they run the risk of encountering snipers, roadside explosions, and suicide bombers.
Alok explains that the state funded healthcare system is still providing as much care as it can. “Even with the high number of patients, surgeries are still being performed in appropriate surgical conditions, and hospitals and outpatient clinics are still running as much as possible.” The state funded system will also find itself under extra pressure, as many previously wealthy Syrians—now impoverished by war—are unable to pay for private health 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 out of pocket money to spend on healthcare,” says Hoff.
Shortage of medicine
Before the outbreak of the civil war, 90% of medicines in Syria were produced locally, according to WHO. But now, substantial damage to pharmaceutical plants means local production of medicines has been reduced by 65-70%. Aleppo, a region based in northern Syria, was home to many of the pharmaceutical plants but now many have been destroyed and those that are left are struggling to source the raw materials.
Additionally, the Syrian Ministry of Health argues that sanctions imposed by countries such as the UK and US are hampering their humanitarian effort. The sanctions, imposed in 2011 shortly after the beginning of the conflict, have included the freezing of the assets of Syrian government bodies and the banning of crude oil exports to the European Union. This ban has had a massive effect on Syria’s economy, as oil exports to the EU provided 20% of Syrian gross domestic product before the civil war. Lama Al Hayek, a medical student at Damascus University, agrees. “Some medicines and medical substances [are] not available in hospitals as a result [of economic sanctions]. It makes a hard job even harder.”
Alok repeats those claims. “We never had a problem obtaining medications before, with most of them locally produced and sold at very cheap prices in comparison with neighbouring countries. The same goes for all kinds of medical supplies and equipment: we never had any shortage in the market until the beginning of this conflict.” The shortfall in medicines has led to pharmacies trying to control their stock by limiting the amount each customer can buy. The pharmacies have also tried to source drugs from abroad, but they are too expensive for many Syrians, who have been affected by the fluctuating value of the Syrian pound, high food prices, and rising unemployment. As a result many Syrians with chronic health problems have turned to the black market. Drugs are smuggled over borders, sold at inflated prices with the risk that the supply might stop on any given day.
Return of polio
The outbreak of civil war has driven vaccination rates down, resulting in the re-emergence of a previously eradicated disease. “There has been [a] recent outbreak of polio in the northeastern regions of Syria, a disease this country has been free of for almost 15 years,” says Alok. Hoff, who is coordinating the WHO humanitarian effort, reports that there have been 22 cases of polio that have resulted in partial paralysis, although only 10 cases have been confirmed.
“There has been a drop in the vaccination coverage from around 90% before the war started to around 60% to 2012,” says Hoff. 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 low. WHO has initiated a vaccination effort to curb the rise in polio cases. They have vaccinated 60 000 children in a door to door campaign, and there will be several subsequent vaccination programmes over the coming months in both 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.” Moreover, the risk of polio spreading is high as millions of Syrians move across and out of the country every day.
Medical students and doctors resolve to carry on
With the healthcare system on the brink of collapse and people struggling with daily life, it is even more remarkable that students are continuing to study and work. Damascus University is the largest and oldest university in Syria. It has remained largely open with lectures and teaching still taking place. Before the conflict started, many students lived at home in the suburbs of Damascus, travelling in several kilometres to study, but have since moved into the inner city.
Dani Markabawi has just finished his medical finals at Damascus University. “When this whole thing started in Damascus more than a year ago, I started having panic attacks at first, and even considered leaving the country. But with one year remaining for me to graduate I decided to stay. I saw many clashes erupting [on route to university].” Markabawi says this resolve to carry on is a common one. “The atmosphere at school and in hospital hasn’t changed, as people are trying to preserve the normalcy of their lives—to the point that when one steps into campus he instantly forgets about the war raging outside.”
Thanks to this undeniable spirit of ordinary Syrian people, limited health care 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 always thought if I lived to see a day like that one, I would sit and cry, or be paralysed by the shock and fear we lived through. Instead, I said ‘hi’ to my grandfather and grandmother, and left instantly, took the regular bus, and headed to University Hospital for dermatological diseases, where I had a clinic duty that day. I arrived [a] few minutes late to find the clinic had started, and the residents had begun seeing patients.”Keir Stone-Brown, fourth year medical student1, intercalated degree in science journalism2
1University of Manchester1, City University London2
Correspondence to: Keir.Stone-Brown.firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
- IRIN. Syria: healthcare system crumbling. 2012. www.irinnews.org/report/97011/syria-healthcare-system-crumbling.
- Syria: effects of conflict and sanctions on public health. J Public Health 2013;35:195-9.
- BBC News. Q and A: Syria sanctions. BBC News. March 2012. www.bbc.co.uk/news/world-middle-east-15753975.
- Eichner M, Brockmann SO. Polio emergence in Syria and Israel endangers Europe. Lancet 2013. www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2962220-5/fulltext.
- Doucet L. Battle to stop Syria polio outbreak. BBC News. November 2013. www.bbc.co.uk/news/world-middle-east-24823258.
Cite this as: Student BMJ 2013;21:f7007