Doctors Without Borders

Photo: An MSF surgeon operates on a patient in northern Syria. Syria 2012 © MSF

Syria: “A War Against Health Workers and Services”
This article originally appeared in French in Le Monde.

In June, Doctors Without Borders/Médecins Sans Frontières-France (MSF) opened a hospital in the Idlib region in northern Syria, an area under rebel control. Located behind the front lines, the hospital has 15 beds and a staff of approximately 50, including 10 international MSF workers. Designed to perform war surgery, the facility also offers medical and surgical emergency care as the front moves further away. MSF’s Belgian and Spanish sections managed two other hospitals in Syria.

Fabrice Weissman, MSF’s operations advisor, returned from a mission in Syria in early December. He was particularly struck by the breadth of the needs and the lack of international response.

What are the conditions facing MSF’s medical staff in the Idlib region? 

As soon as you cross the border, you are vulnerable to aerial bombing by the Syrian air force, even behind battle lines. Hospitals are at particular risk, as they have become one of the government’s preferred targets. As a result, public hospitals are deserted. Temporary field hospitals that do perform surgery tend to be hidden in individual houses and abandoned public facilities or are buried underground. When they are spotted, the doctors change location. 

This makes it difficult to organize medical treatment. Some Syrian medical professionals have gone into exile and dentists and pharmacists are providing emergency medical care. Their skills are improving but they are rarely trained in war surgery, which presents specific complications such as bone infections, and in triaging victims during mass influx of wounded. Even so, they are managing quite well given the conditions and increasing stock-outs of medical supplies such as anesthetics. Syrian doctors from the diasporas are coming to help out, too. 

What struck me most profoundly about this conflict is the way health facilities have became part of the war zone. The Syrian army is waging a war against health workers and services operating in opposition-controlled areas. Using health care denial as a weapon of oppression, the government has de facto transformed health care provision as a weapon of resistance.

Do international humanitarian aid organizations like MSF have a significant presence in Syria?

You don’t see the traditional aid actors—such as the United Nations agencies and the major humanitarian NGOs—in Syria. Acting officially in support of the Syrian government, the UN does not have Damascus’ authorization to provide cross-border assistance into rebel-held areas, which have significantly expanded over the past six months. However, precedents do exist, as in South Sudan in the 1980s, where the UN intervened in areas that were not under the legal government’s control, based on a Security Council resolution or following direct negotiations with the parties. 

With regard to nongovernmental organizations, very limited funds are allocated to those that want to work in rebel-held areas. There’s a paradox here because the European Union and the US support the opposition, but are providing minimal financial and diplomatic support to humanitarian organizations ready to operate in rebel territory. Most international aid is allocated to the government-held areas, through the ICRC, the World Food Program, the UNHCR, all working with the Syrian Arab Red Crescent Society. The needs in the rebel-held areas are not being met. 

However, there is an aid network organized by Syrians in the country and in the diasporas, with the help of neighboring countries and Gulf nations. But it’s not enough. Traditional international aid would be more than welcome to support the efforts of this local network. That would require diplomatic courage on the part of the UN agencies and the states that support them—whether the European Union, the US, Russia, China, and others. 

What needs did you observe on site? 

There are extensive treatment needs in the area of chronic illnesses, which are the primary cause of mortality (specifically diabetes, kidney failure, hypertension and heart problems, and cancer). The organization of medical care has virtually collapsed and there are shortages of specialized medicine, as 90 percent of drugs were produced previously in Syria. Fatal respiratory illnesses are also a source of concern, given winter conditions. Children and the elderly are of course the most vulnerable. The weakest members of the population are experiencing mortality rates and suffering that could be prevented. 

The number of wounded has increased significantly over the last six months as a result of the intensification of fighting (among the 60,000 deaths counted by the UN Human Rights Commission, more than 40,000 occurred since June alone). At the same time, the types of wounds are changing, with growing numbers of people injured by ammunition fragments during aerial and artillery bombing. Among the 500 wounded treated in MSF facilities so far, 70 percent presented extensive soft tissue and bone damage due to shrapnel. Some need major reconstructive surgery that requires hospitalization abroad, in Jordan, Lebanon, or Turkey, where 700 hospital beds are currently dedicated to Syrian patients. On the other hand, we have not seen any illnesses related to the use of combat gas.

Beyond medical assistance, there are other major needs. Daily life has become very difficult. There is a housing crisis resulting from the internal population displacement. The Office for the Coordination of Humanitarian Affairs (OCHA) estimates that some two million people are displaced. Most are living with relatives living further away from the frontlines or in tent camps, most located close to the Turkish border. The conditions in those camps are very precarious, particularly given the arrival of winter, with freezing temperatures at night. There is also an energy crisis. Diesel, which was subsidized before the war, is hard to find and of poor quality. Its price has increased twenty- or thirty-fold, triggering a dramatic increase in transport and food prices. There is an acute shortage of baby formula, milk, and flour. Bread is becoming scarce in several towns. The situation calls for large-scale food assistance by the World Food Program and other humanitarian agencies.