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AOAV: all our reportsHealth and explosive violenceReverberating effectsSyria case study

The reverberating health effects of explosive weapon use in Syria

·        Life expectancy in Syria dropped by over 20 years according to the Syrian Centre for Policy Research, from 75.9 years in 2010 to 55.7 in 2015.

·        More than 800 healthcare workers have been killed in attacks on medical facilities since 2012.

·        The number of physicians in Syria has decreased by 67.5%.

·        The percentage of children under the age of one lacking immunisation for measles has more than doubled.

·        There were just 85 psychiatrists in Syria prior to the war. The number today is far lower.

The impact of explosive weapons on the health of the Syrian people and on healthcare in Syria is almost indescribable. Life expectancy dropped by over 20 years, according to the Syrian Centre for Policy Research, from 75.9 years in 2010 to 55.7 in 2015. It is a worsening fuelled by both direct violence and the indirect impact on health and healthcare.

The direct impact of explosive weapons to human bodies is very complex and for survivors such injuries are almost invariably lifelong. Dr Emily Mayhew, a medical historian at Imperial College London, says of blast injuries: ‘Blast alters everything: the way cells heal, the way skin scars, the way bones grow back, the way brains operate. Blast affects pain, memory, resilience, every basic human process of life.’[i]

In short, the impact that explosive violence has had on health and healthcare in Syria, both directly and indirectly, has been profound.

Infrastructure and personnel
In Syria, explosive violence has left health facilities almost completely non-functional, with 60% of health-care facilities either damaged or destroyed. The make-shift hospitals that have been created are often poorly staffed; it is estimated that about three-quarters of health-care workers have fled. According to the group Physicians for Human Rights, more than 90% of attacks on healthcare facilities and medical personnel have been carried out by the Assad regime or Russia.

In total, 57% of Syrian medical personnel deaths between March 2011 and December 2017, were caused by explosive violence. In 2017, 36 of the 38 documented attacks on medical facilities were caused by explosive weapons – 31 using airstrikes, three using barrel bombs and two using mortars, whilst 44 of the 51 deaths of civilian health professionals were caused by such weapons. By February 2018, health facilities were being bombed at a rate of one every 24 hours. More than 800 healthcare workers have been killed in attacks on medical facilities since 2012.

According to Dr Katoub, Advocacy Manager at the Syrian American Medical Society (SAMS), in 2011 there were approximately 40,000 physicians in Syria; by mid-2018 there were just 13,000.[ii] In the North-West of the country there is just one physician per 2,600 people.[iii]

The damage to health infrastructure and harm to medical personnel has meant that, according to Dr Tedros Adhanom Ghebreyesus, WHO Director-General, Syrian civilians are ‘dying from injuries and illnesses that are easily treatable and preventable.’ This has been amplified by the collapse of the pharmaceuticals industry, with medicine production having declined by 90% since 2010.[iv] This has resulted in a scarcity of medication and the development of a black market, preventing access for treatable and chronic diseases, especially among the poor.[v]

With just a third of Syria’s physicians left in the country, it’s also worth considering whether healthcare professionals will return post-conflict. There is a general consensus that though many may say they wish to return to Syria, their home, when the conflict ends, many will not; for many, returning would either be too dangerous or they have built lives elsewhere they might not wish to then leave.

Prosthesis being adjusted at IPHS in Gaziantep, Turkey

This distance between stated intent (to return) and reality (to create a new life elsewhere) is not unique to Syria. AOAV’s wider work on post-conflict environments has repeatedly found that a scarcity of medical personnel is a common complaint. The extreme demands on doctors and other medics, along with the instability of post-conflict environments, mean that many know they can find a better quality of life in another country, and many do.

Illness and disease
Since the onset of conflict in Syria in 2011, the percentage of infants under the age of one lacking immunisation for measles has more than doubled during the course of the conflict, with 20% lacking such in 2011 to 46% by 2014. That rate stood at 33% in 2017 following concerted efforts to reach children in difficult-to-access areas. Similar results are also seen for a shortfall in immunisations for DTP (a combination of vaccines against three infectious diseases –  diphtheria, tetanus and pertussis). There has also been over a sevenfold rise in confirmed outbreaks of measles, with 733 cases confirmed in Syria in 2017, compared to 85 in 2016. This might also be a tip of an iceberg – measles outbreaks are thought to have affected thousands of children in 2017, with infections reported in all 14 governorates.

A risk of contracting a variety of diseases is also heightened by the destruction caused by explosive weapons. Leishmaniasis, for instance, is a disease transmitted by the bite of tiny sand flies and which, in the case of cutaneous leishmaniasis, can cause severe skin lesions – also known as the ‘Aleppo boil’. Rubble and debris caused by the explosive weapons have provided the sand fly with a perfect habitat. The incidence of that disease was estimated to have increased by at least 150% in 2014 alone, with between 25,000-40,000 cases per year prior to the war and over 100,000 cases seen in 2014. And though the situation is thought to have improved in recent years, evidence also points to an increase in visceral leishmaniasis too – a disease which is ‘almost always fatal’.

Another predictable consequence of bombings is that of increased rates of water-borne diseases, and other maladies related to poor hygiene. However, due to the quick and effective responses from Water, Sanitation and Hygiene (WASH) teams in Syria, it seems that the severity of the outbreaks expected from such conflicts have been avoided. According to the Syrian Relief Network, ‘the major problem is not disease outbreaks but the provision of health care and its accessibility.’

Nevertheless, a contamination of water sources and a widespread loss of access to clean water has meant that the rates of disease have increased.[vi] This has been exacerbated by a decrease in educational access, with children not learning hygiene practices typically taught in school.[vii]

Overall, children in cities torn apart by bombs are particularly at risk of illness and disease. In a 2017 study using data collected by Qatar Red Crescent in May 2015, it was found that of 1,002 children assessed in homes and IDP camps across Northern Syria, 29% were suffering from a respiratory illness or disease (including 23% with a respiratory infection), 17% with a digestive illness or disease (10% had diarrhoea or bloody diarrhoea and 4% were malnourished), and 19% had a neurological illness or disease (including 7% with meningitis).[viii]

Access to treatment

With profound shortages of trained personnel and functioning health facilities, as well as with damage to transport infrastructure and rising poverty, medical treatment throughout Syria has become ever harder to access. According to doctors from the Syrian Expatriate Medical Association (SEMA) there is a ‘severe lack of specialised care’, such as gynaecologists or orthopaedic surgeons, throughout the country, a reality not eased by the fact that donors tend to focus on funding emergency care for ‘cost-effective intervention’.[ix] Those in north-west Syria, for instance, have to seek care in Turkey for many specialist treatments, but many are unable to undertake such a journey due to logistics and poverty. In addition, quality of care is said to have decreased as doctors’ caseloads have more than doubled.[x]

In particular, blast injury survivors are most impacted by the chaos and the disruption to health services that war creates. Many of those interviewed for this report talked of limited access to rehabilitation, with the injured and disabled expressing particular trouble doing such.

Due to ongoing explosive violence and instability, follow-up care is also notoriously difficult. In many cases, patients have been forcibly displaced before they could attend doctor’s follow-up appointments, and so have subsequently been unable to continue treatment.[xi] Others have been unable to seek medical assistance due to the costs of treatment or the logistics in accessing such.

Recognising such challenges, Hand in Hand for Aid and Development (HIHFAD) have begun mobilising multisectoral teams to provide evaluation, care, equipment and training for the treatment of patients.[xii] Perhaps the most concerning thing is that HIHFAD have reported that, on follow-up, 25% of those injured that they have assisted had been further injured in on-going fighting. Such continued violence also displaced 13% of all respondents and killed one patient.

An imam who lost his leg in an airstrike receives treatment at IPHS in Gaziantep, Turkey.

Amongst the refugees and NGO organisations interviewed by AOAV, many Syrian refugees struggled to access services, particularly those lacking appropriate documents. They also faced language barriers, economic concerns, fear and stigma, which all could further prevent them from seeking treatment from both physical and psychological health conditions. In Turkey, for example, if you don’t possess a right-to-remain document, then you risk being reported to the police on visiting a hospital or other healthcare facilities.[xiii]

The level of need amongst Syrian refugees, as well as cuts in donor funding and political uncertainty regarding refugees in some host countries, has also meant that humanitarian agencies are struggling to cope. At the International Pitying Hearts Society (IPHS) a lack of funding has forced them to close their clinics in Syria and in some Turkish border areas. Their clinic in Gaziantep has a waiting list for prosthetics for more than 2,000 people.[xiv]

In Lebanon and Jordan, one survey found that almost a quarter of refugees interviewed had a disability (22.9% in Jordan and 22.6% in Lebanon). Of these, a quarter in Jordan and over half (57.5%) in Lebanon needed specialised services, but had been unable to access them.[xv]

Such a lack of treatment has meant Syrians are often faced with incorrect treatment or self-treatment. Whilst self-treatment can be useful if the patient is informed, as organisations like HIHFAD have tried to ensure, patients and carers all too often make ill-informed treatment choices. For example, many Syrians are said to be purchasing over-the-counter antibiotics, self-prescribing and overusing antibiotics. This, in turn, has increased antimicrobial resistance (AMR) in Syria.[xvi]

In this regard, the injuries caused by explosive weapons pose a particular concern. As one review of antimicrobial resistance concluded: ‘the war trauma produced by the heavy weaponry used in this conflict has led to an exponential increase in the number of infection-prone high-risk injuries such as contaminated open wounds and fractures.’ Many of those self-prescribing antibiotics often do so incorrectly, such as failing to finish the course, while the constant movement of refugees raises the risk that certain strains of AMR may spread. When compared to local populations, the rates of AMR are notably higher, and the strains different, among refugee populations. One German study, for instance, found an increased prevalence of antibiotic resistant genes (ARGs) in refugees from Syria, Iraq and Afghanistan compared to local Germans.

Physical
According to the World Health Organisation (WHO), more than 11.3 million people are in need of health assistance in Syria, including three million living with injuries or disabilities. In 2016, the Syrian Center for Policy Research (SCPR), estimated that 11.5% of the country’s population have been killed or injured since the crisis erupted in March 2011.[xvii] And, as explosive weapons injure more people than they kill, along with medical advances in traumatic injury care, it is a truth that more Syrians will have survived bomb blasts, albeit often with complex injuries. In most modern conflicts, the number of wounded is more than double those killed – though this is, of course, dependent on the availability of healthcare.[xviii]

There are numerous physical health consequences caused by explosive weapons. Blast injuries, for instance, greatly increase the risk of developing chronic health conditions such as hypertension, diabetes, coronary artery disease and chronic kidney disease.[xix]

Among the 25,000 Syrian refugees with injuries examined in a 2016 report from Humanity and Inclusion (formerly ‘Handicap International’), 53% had been harmed by explosive weapons. Of these, 89% had permanent or temporary physical impairment. 47% had fractures or complex fractures, including open fractures of the lower and/or upper limbs. 15% had undergone amputation.

In some areas, the rate of injury and disability to Syrian civilians was even higher. In a survey across Idlib, Aleppo and Raqqa, between 40-50% were estimated to be living with a disability.[xx] The main cause of injuries across these areas were airstrikes (54%), followed by other explosions (28%). Impairments associated with mobility and self-care were by far the most prevalent.

Such blast injuries require long-term healthcare, particularly when it comes to the issue of prostheses. Another survey conducted with patients in north-west Syria estimated that almost half of those injured by the conflict were expected to have a permanent impairment.[xxi] Amputations are, sadly, commonplace – one doctor commented that Syria will be left with ‘a generation of amputees.’[xxii] While the NGO Humanity and Inclusion reports that of approximately one million injured people in Syria, around 8% required an orthopaedic fitting.

After losing his leg in an airstrike in Aleppo, this man is receiving treatment at IPHS in Gaziantep, Turkey.

Clearly, such amputees have life-long healthcare needs: from rehabilitation and tissue management to further associated conditions, such as ectopic bone formations and osteoarthritis. Such conditions are difficult to manage in a developed healthcare system, let alone in a post-conflict environment with a dilapidated and destroyed healthcare infrastructure. Moreover, as many injuries are borne by children, there is an even greater demand on healthcare to address their needs.

Psychological
The psychological harm caused by the Syrian conflict is one area where considerable study has been undertaken in recent years. A Save the Children study found that, among Syrian refugees interviewed, almost all children and 84% of adults said bombing and shelling was the primary cause of psychological stress. 71% of interviewees said children were increasingly suffering from symptoms of toxic stress and PTSD.

These psychological conditions are expected to have lasting consequences. As the report concluded, ‘daily exposure to the kind of traumatic events that Syria’s children endure… will likely lead to a rise in long-term mental health disorders’. In children, the psychological stress of bombardment manifests itself in a variety of ways, often with significant behavioural changes and psychosomatic symptoms. In some cases, the impact is so great that children turn to substance abuse, self-harm, or even suicide attempts.

Overall, according to the World Health Organisation, about ‘one in 30 people in Syria is suffering from a severe mental health condition and at least one is suffering from a mild to moderate mental health condition as a result of prolonged exposure to violence.’

Syria is clearly unable to treat such numbers effectively. In 2009, prior to the war, it was reported there were just 85 psychiatrists in the whole country.[xxiii] If we assume a similar decrease in psychiatrists as with physicians there would be less than 30 psychiatrists for the entire country – though some interviewed reported far less.[xxiv]

In response to this, humanitarian agencies have begun training medical personnel to manage some psychological conditions, but with many patients needing long-term specialist care, such ad hoc responses fail to offer a comprehensive solution.

In refugee communities, challenges in accessing psychological support were similar to those reported for accessing physical health support. In addition, there existed added societal stigma relating to mental health disorders, and disquiet at a ‘western approach’ offered towards psychological care.[xxv]

It is also of note that refugees often face further trauma in their countries of refuge, which can exacerbate existing psychological conditions. Citizen’s Assembly, an NGO in Istanbul, reported that of the refugees using their services, 90% have PTSD or depression. Additionally, the insecurities that many refugees face, including issues over registration, difficulties in finding suitable shelter, insecure job prospects and xenophobia, create further stress and anxiety that can exacerbate pre-existing mental health problems.[xxvi]

Conclusion
Extensive damage to the Syrian health service has placed a serious strain upon the population, with children and victims of explosive violence at most risk. Health system infrastructure may take years to be rebuilt, while the loss of key medical personnel could take a generation to remedy. Whilst this is the case, those living with illness and injury will continue to suffer – many of the injured will have complex needs and will require a lifetime of care, particularly the young people who have been injured in the conflict. It is also likely that casualties will continue due to the level of explosive contamination, discussed further in other sections of this research.

To read the full report, key findings, other sections, or another related articles, interviews and videos, please see here.

 

[i] Mayhew, E. 2017. A Heavy Reckoning: War, Medicine and Survival in Afghanistan and Beyond. Wellcome Collection.

[ii] Interview with Dr Mohamad Katoub, Advocacy Manager at Syrian American Medical Society, August 7th 2018.

[iii] Interview with Dr Mohamad Katoub, Advocacy Manager at Syrian American Medical Society, August 7th 2018.

[iv] World Bank, April 2017, ‘MENA Economic Report: The Economics of Conflict Reconstruction in MENA’.

[v] World Bank, April 2017, ‘MENA Economic Report: The Economics of Conflict Reconstruction in MENA’.

[vi] Interview with Omar Sobeh, Hand in Hand for Syria, WASH cluster coordinator, in Gaziantep, Turkey, October 23rd 2018.

[vii] Interview with Omar Sobeh, Hand in Hand for Syria, WASH cluster coordinator, in Gaziantep, Turkey, October 23rd 2018.

[viii] Gerlant van Berlaer et al. 2017 ‘Diagnoses, infections and injuries in Northern Syrian children during the civil war: A cross-sectional study’, PLoS One, Vol 12(9).

[ix] Interview with Dr Kinda Alhourani and Dr Tarek Al Mousa, Syrian Expatriate Medical Association, in Gaziantep, Turkey, October 22nd 2018.

[x] Interview with Dr Kinda Alhourani and Dr Tarek Al Mousa, Syrian Expatriate Medical Association, in Gaziantep, Turkey, October 22nd 2018.

[xi] Presentation by Keiko Tamura, Head of Programmes, HIHFAD, Child Protection Sub-Cluster meeting in Gaziantep, Turkey, October 23rd 2018.

[xii] Presentation by Keiko Tamura, Head of Programmes, HIHFAD, Child Protection Sub-Cluster meeting in Gaziantep, Turkey, October 23rd 2018.

[xiii] Interview with representatives from Citizen’s Assembly, in Istanbul, Turkey, November 1st 2018.

[xiv] Interview with Osama, Media Relations, at the International Pitying Hearts Society (IPHS), in Gaziantep, Turkey, October 25th 2018.

[xv] Presentation by Claire O’Reilly, the Rehabilitation Policy Advisor at Humanity and Inclusion and Co-lead for the Physical Rehabilitation & Disability Working Group, Syria Health Cluster (WHO), in Gaziantep, Turkey, September 2018..

[xvi] Esmita Charani, Senior Lead Pharmacist, Imperial College London, Faculty of Medicine, at the Global Health Forum: The impact of conflict on health care, 19 May 2018.

[xvii] Syrian Center for Policy Research, 2016. ‘Confronting Fragmentation: 2015’.

[xviii] Shehan Hettiaratchy, Lead Surgeon and Major Trauma Director, Imperial College London, at the Global Health Forum: The impact of conflict on health care, 19 May 2018.

[xix] Mayhew, E. 2017. A Heavy Reckoning: War, Medicine and Survival in Afghanistan and Beyond. Wellcome Collection.

[xx] Presentation by Keiko Tamura, Head of Programmes, HIHFAD, Child Protection Sub-Cluster meeting in Gaziantep, Turkey, October 23rd 2018.

[xxi] Presentation by Claire O’Reilly, the Rehabilitation Policy Advisor at Humanity and Inclusion and Co-lead for the Physical Rehabilitation & Disability Working Group, Syria Health Cluster (WHO), in Gaziantep, Turkey, September 2018.

[xxii] Interview with Dr Mohamad Katoub, Advocacy Manager at Syrian American Medical Society, August 7th 2018.

[xxiii] Interview with Dr Mohamad Katoub, Advocacy Manager at Syrian American Medical Society, August 7th 2018.

[xxiv] Interview with Dr Mohammad Abo Hilal, Syria Bright Future, in Gaziantep, Turkey, October 22nd 2018.

[xxv] Interview with Dr Mohammad Abo Hilal, Syria Bright Future, in Gaziantep, Turkey, October 22nd 2018.

[xxvi] Interview with representatives from Citizen’s Assembly, in Istanbul, Turkey, November 1st 2018.