Look around the makeshift settlements that have sprung up in northwest Syria, Dr. Mufaddal Hamadeh said, and you’ll be able to tell who’s recently arrived.
They’re “the ones camping on the roads and the ones camping under olive trees [who] are using blankets to create a tent – not even plastic sheets,” said Dr. Hamadeh, president of the Syrian American Medical Society (SAMS).
By contrast, many of those who arrived earlier in the region have put concrete blocks around themselves, or added tin or plastic roofs to ad hoc structures.
More than 900,000 people – perhaps as many as 1 million – have poured into the region since December 1, fleeing a new outbreak of conflict as the Syrian government attempts to retake the Idlib governate. Approximately 80% are women and children.
Numerous humanitarian groups, including SAMS, are on the ground providing help to partners in the area. Nonetheless, there aren’t enough healthcare facilities – or doctors, or medicines – to serve the new arrivals, many of them needing emergency care, medication for chronic disease, a safe place to deliver babies, and treatment for trauma and other mental health issues related to the conflict.
Pre-conflict, Syria had a relatively strong health system and had seen significant improvements in figures like life expectancy and infant and maternal mortality. Children were normally vaccinated.
Idlib and nearby Aleppo, in Syria’s northwest, had a combined 550 health facilities, according to Dr. Alaa Abou Zeid, a WHO emergency health coordinator for the region.
Conflict cut that number in half. “The health system in the northwest was already decimated in the period before the last escalation of conflict,” Dr. Abou Zeid said.
Then, since December 1, an additional 74 health facilities were forced to shut or suspend services. Dr. Abou Zeid estimates that 11,000 patients with conflict-related injuries have been unable to receive urgently needed care.
A major shift
Idlib had already experienced a major population shift before the most recent, cataclysmic development in the years-long conflict.
Before the fighting started, it had had a population of about 1.5 million. During the conflict, even before the recent arrival of hundreds of thousands, its population more than doubled, reaching somewhere between 3 and 4 million, according to WHO spokesperson Hedinn Halldorsson.
The sheer number of newly displaced people “makes it different and more dire as well,” he said. “it puts a lot of pressures on the already strained health services.”
Some health facilities have been attacked – part of a long-running offensive strategy that has drawn international condemnation. Others have fallen into the hands of military forces. Still others have closed as their patient population has fled, leaving whole cities empty.
An ever-changing crisis
In addition, said Karl Blanchet, a professor and co-director of the Health in Humanitarian Crises Center at the London School of Hygiene and Tropical Medicine, it’s hard to offer people reliable information about what’s open and where. A combination of official and informal networks are used to tell people which health facilities are open and safe.
“If you are too transparent, then [the health facilities] become targets,” he said. “It’s happening in a very ad hoc manner.”
That danger, too, means that people are less likely to seek medical care. “If people know that health facilities do get attacked, it definitely doesn’t encourage them to seek health care,” Blanchet said.
Complicating matters, said Halldorsson, is the fact that, for many of the displaced, this isn’t the first time they’re fleeing. “These are people who have been displaced multiple times, so the more you are displaced the more depleted your resources are,” he said.
First and foremost, what’s needed is shelter and basic supplies. Large numbers of the displaced are sleeping in the open in temperatures that have improved but are still frigid at night.
“We are seeing a major spike in children’s deaths due to hypothermia and cold exposure,” said Dr. Hamadeh, citing the example of a father who carried his toddler 5 kilometers to the nearest hospital in freezing conditions, only to find out she had already died.
The ever-changing situation also makes it difficult to know exactly what’s needed on the ground. “It’s highly complex there to have a sense of where to operate and what to do. The needs are huge,” Blanchet said.
However, at least one thing is clear: “The current health needs are unprecedented,” said Dr. Abou Zaid.
Many have been injured by conflict, making emergency care a priority. “In emergency care, you’ve got one crucial variable: It’s time. It’s about being fast,” Blanchet explained. “Many of [the displaced] won’t get access to emergency care in time. The scale is too large.”
Dr. Abou Zaid also expressed concern about the “high presence of non-communicable diseases,” such as diabetes, hypertension, and cancer, that are going untreated. The rough conditions are increasing the risk of respiratory infections, especially for children and the elderly.
And Dr. Abou Zaid said infectious diseases – like measles – are a risk for children, many of whom have gone without vaccinations. The UN has warned of the potential for an outbreak of a disease like the measles.
Not everyone agrees about the severity of the situation. Debarati Guha-Sapir is the director of the Center for Research on the Epidemiology of Disasters and a professor at Brussels’s University of Louvain School of Public Health. “Syrians are a population that have had a good and high standard of health status,” she said. “There are still people with a very decent level of health conditions and vaccination coverage.”
While Syria’s conflict has certainly created greatly increased emergency health needs and other needs, she said, “it’s more of an acute problem.”
The conflict itself, she said, is a greater threat to Syrians – especially children, whom Dr. Guha-Sapir said are disproportionately likely to be killed by bombings – than the public health situation.
Emergency care is greatly needed, she explained, but she was less concerned about issues like infectious disease outbreaks than she was about other humanitarian crises, like that of South Sudan, in which many fled at “absolutely desperate levels of survival.” For example, “if there were to be a major measles outbreak in Syria, I would be very much surprised. Even in the northwest,” she said.
But Blanchet stressed the importance of addressing all different facets of health care. “Health is actually very comprehensive, so if you miss one aspect, it’s going to have some reflecting effect,” he said.
Failing to prevent violence and trauma will create a strain on mental health services, for example. Leaving chronic conditions untreated creates emergencies. When emergency care can’t be provided, infections become more common.
And sources stressed the extraordinary mental health needs of the displaced, many of whom have lost family members and experienced conflict firsthand. Some mental health providers are currently practicing in northwestern Syria, but the demand far outweighs the available treatment.
“There are huge mental health issues that need to be addressed today and that will need to be addressed in the future,” Halldorsson said.
“Mental health is always the last one to be provided. It’s never been on the top of the agenda,” Blanchet said, explaining that while there’s plenty of awareness around the issue, it’s simply too dangerous to send in additional mental health providers.
Dr. Hamadeh recalls meeting a nine-year-old boy, injured from shrapnel, in an Idlib hospital, hours after losing five of his siblings. The boy, he said, seemed completely without emotion.
“I just realized that these guys are totally numb. Loss has become normal life,” he said. “These are all stories that happen to them every day.”
Direct Relief has maintained a strong presence in the region since the Syrian conflict began in 2011, providing 53 shipments and over $118 million in donations, including equipping people in displacement camps with tents and basic supplies. In response to recent developments in the conflict, the organization is preparing to ship a range of medicines, supplies, and hygiene items this week.