Vanessa Cramond was the Médecins Sans Frontières Medical Emergency Manager for Syria and shares her experiences.
“In our line of work we rely on numbers. The number of patients treated in the clinics, the number of patients admitted to the hospital and undergoing emergency surgery, the number of babies born, the number of children vaccinated, the number of people counselled. The numbers guide us to where the needs are, what is making people sick, how difficult it might be to reach health care by how late and sick the patients are when they present to hospital, and the number of deaths and where and when they happen. These are all ways of measuring how the health system is performing. They paint a picture and from that we can describe, interpret and plan to reach a populations health needs. It is all with the aim to provide health care, to alleviate suffering and provide comfort to people. It is not just those patients directly in front of us, but also the health of everyone around them. The numbers are important; they help us do our job.
So imagine we don’t have the numbers because we can’t reach most people; they are besieged in inaccessible areas. The few numbers we have rarely tell the full story, and if they do, they paint a picture so bleak that the size and the scale of the emergency health response needed seems unimaginable. This is the reality of trying to support the health of people living in war torn Syria in the sixth year of conflict.
"War has also insidiously crept into every consultation room, every hospital bed and every health post and clinic in the areas indirectly affected by the Syrian crisis over the last six years"
For six long years, war has waged across Syria, resulting in an unprecedented 4.8 million people becoming refugees. The responsibility to care for this refugee population falls largely to Syria’s neighbours. Inside Syria, the United Nations High Commission for Refugees have some overwhelming numbers. They report that 13.5 million people are in direct need of medical and humanitarian assistance. More than six million have been forced from their homes and are now internally displaced due to shifting battle lines, armed groups and militia; and 4.3 million people are categorised as ‘’hard to reach’’ - a humanitarian euphemism used when getting information from communities is limited and thus the likelihood of the population accessing sufficient protection, food, shelter, water or healthcare is extremely low. The effects of war have not been limited to frontlines or battle grounds. It does not only comprise of indiscriminate bombings of civilians, hospitals and cities causing catastrophic blast injuries and deaths. War has also insidiously crept into every consultation room, every hospital bed and every health post and clinic in the areas indirectly affected by the Syrian crisis over the last six years.
Médecins Sans Frontières has tried to maintain operations throughout the country over the course of the conflict. Despite repeated requests for access to work in government-held areas, we have not been able to secure authorisation to do so. We can therefore only provide direct assistance and deploy teams in opposition-held territories and can mainly speak of what we see in those locations. Our projects have been forced to start and stop as the fighting draws near. They have been relocated after hospitals are damaged by shells and mortar, or when the populations are forcibly displaced. These projects and hospitals operate all the time under impossible conditions with new staff, new systems, rapidly changing security management and dramatic variability of the availability of medicines and supplies as unpredictable border controls change from week to week. It is no easy feat to provide meaningful healthcare care in such an environment.
What we can describe from the few numbers and experience generated from these programs, is indicative of a grave medical situation and looming public health crisis. At the most practical level, there are not enough doctors, nurses or midwives in northern Syria. Most have fled, many have been killed, and the future health workers have long since had their studies disrupted. There are not enough functioning health facilities at primary, secondary or tertiary level. There are also not enough medical supplies making their way across the international borders. For six years, the war has robbed the Syrian people of their right to health care. Poor politics and failed diplomacy has enabled the war to continue remorselessly and kept borders closed, taking away the rights of the Syrian people to flee the horrors and preventing medical humanitarian actors like Médecins Sans Frontières to access and support those most in need.
We don’t have all the numbers. We don’t know how many people have suffered unnecessary or died due the direct or indirect effects of this ugly and protracted war. And we don’t know how many individuals and families will continue to suffer in the years to come. But what we do know unequivocally and unreservedly is that it is simply far too many.”
A version of this article was first published in the New Zealand Medical Journal