After four years of civil war, Syria’s conflict is spiralling further out of control, with devastating consequences for its people.

While video footage of ISIS beheadings and government barrel bombs dominate the media, the collapse of the healthcare system means Syrians are now likely to die otherwise preventable deaths: choking from asthma, bleeding to death during child birth, starving.  

‘Syria is experiencing the worst humanitarian catastrophe this century,’ said Leigh Daynes, Executive Director of Doctors of the World UK, which supports dozens of primary healthcare clinics operating in and around Syria.

‘The misery is unimaginable and made worse by the wilful, illegal targeting of healthcare workers and facilities.’

Over half of the 20-million-strong Syrian population have been forced to flee their homes, often multiple times. More than 7 million are displaced within Syria and 3.6 million have fled the country completely, mostly living in refugee camps in neighbouring countries, causing huge stress to their healthcare systems. More than 200,000 Syrians have been killed, and over a million injured and disabled. A third of these deaths and a half of these injuries occurred in 2014.  

Prior to the war, Syria’s healthcare system was thriving, with hospital and doctor levels equivalent to other middle-income countries such as Brazil, Turkey and China. Life expectancy was 76 years. Over three-quarters of the country’s disease burden was of the Western, non-communicable type (hypertension, diabetes and so forth).

Four years of violence waged with heavy artillery, missiles, barrel bombs, bullets and a fearsome intensity have changed all of that.

The UN estimates that 12.2 million Syrians now require urgent humanitarian assistance, and that almost half of them are children. Of these, 2.5 million children, aged under-five, are at risk of malnutrition. Life expectancy has dropped by two decades.

Child vaccination levels dropped from 90 per cent pre-conflict to 50 per cent in March 2014. As a result, outbreaks of diseases that had long been under control have spread across the land and into neighbouring countries: hepatitis, measles, leishmaniasis, multi-drug-resistant tuberculosis, typhoid and even polio, which had not been seen in the Middle East for 20 years.

An estimated 1,500 women give birth in dire conditions every day. Chronic diseases that can be easily managed with access to medicine and equipment are killing people. The mental-health burden of the conflict is vast and largely untreated.

Overwhelmed by the devastation is a Syrian healthcare system shattered by the deliberate targeting of medics and medical infrastructure.

‘Medical personnel are clearly targeted because they are seen as potential enemies, because they are seen as helping the opposite side,’ says Francesco Volpicella, Doctors of the World’s Syria director.

The NGO Physicians for Human Rights has detailed 233 attacks on 183 medical facilities: 138 with indiscriminate weapons, 32 with barrel bombs. Only 45 per cent of Syria’s public hospitals are fully functioning. In the half of the country not controlled by government forces, the majority of hospitals have been destroyed.

‘This is the worst concerted attack on healthcare in living memory,’ says Leonard Rubinstein, Director at the Bloomberg Center for Public Health and Human Rights at Johns Hopkins University, Maryland.

‘In the decades I’ve been studying this issue in places like Bosnia, Chechnya, Afghanistan and the Gaza Strip, there has been nothing like what has happened in Syria.’

After bombs are dropped in civilian areas, so called ‘secondary attacks’ are sometimes made on rescue workers and paramedics. Six hundred medical personnel have been killed since 2011, 145 of them tortured and executed. The majority of Syria’s doctors have fled the country.

Rubinstein and colleagues interviewed Syrian doctors for a recent report; they told of being tortured to admit working in field hospitals where opposition forces are sometimes treated.

‘They knew that if they refused to admit to this, the torture would get worse,’ said Rubinstein, ‘but if they admitted it, they would be killed.’

Three Security Council resolutions were passed in 2014, calling for an end to attacks on civilians and an increase in aid, but critics have argued they have made little difference.

‘Without action by major governments, these resolutions are little more than empty words and the situation worsens,’ says Leigh Daynes.

There is major agreement that when the war ends, there will need to be a co-ordinated and long-term strategy to rebuild the country’s shattered healthcare system.

‘We will need to be ready to help rebuild much of the healthcare system from scratch,’ says Daynes. ‘It will be a huge job and one that won’t be able to be done without the return of Syrian doctors and healthcare workers – and for that we first need the fighting to stop.’