The emerging Syrian health crisis.

The conflict in Syria is an escalating humanitarian and public health catastrophe. Civilians are currently caught between two armed factions: the Syrian military loyal to the government of President Bashar al-Assad and the Free Syrian Army opposition. According to the UN, the 2-year long conflict has already resulted in an estimated 60 000 civilian casualties and tens of thousands injured. As if the direct effects of military force on Syrians were not enough, there has also been a full-scale assault on the health infrastructure. Even if Syrians are able to reach health facilities, which they often cannot because of ground fighting and erratic and unsafe transport, government forces have targeted health-care facilities, health workers, and patients intentionally, as described by independent observers such as Physicians for Human Rights, Amnesty International, and Médecins Sans Frontières. These deliberate attacks by government forces, which are in addition to collateral damage from attacks on nearby facilities, are having a devastating impact on health-care services. In a report issued on Jan 2, 2013, the United Nations Office for the Coordination of Humanitarian Affairs’ delegation to Syria found that 35% of hospitals, 10% of health centres, and 40% of the country’s available ambulances have been severely damaged. In major cities such as Aleppo, Hama, and Homs the public health systems have collapsed: disease registration and vaccination programmes have stopped completely and many qualified doctors have fled the country. Only very basic health services exist in the refugee camps of Lebanon, Jordan, and southern Turkey, and some camps have no health services at all. Conditions are worsening with the onset of winter. Investigations by journalists report children dying from exposure to cold and a lack of medical care for physical injuries caused by armed conflict. Health concerns extend beyond the damage to health services; there are also the health effects of mass displacement. By March, 2012, UN agencies had already registered 40 000 refugees and anticipated that about 96 500 would require assistance over 6 months. Yet by December, 2012, the Office of the United Nations High Commissioner for Refugees had reported far higher numbers, with nearly half a million people fleeing the country and more than 2 million internally displaced; it is estimated that 1·1 million people will have fled abroad by June, 2013. There are growing dangers of epidemics. The World Food Programme reports that 2·5 million Syrians are suffering from hunger, with UN agencies struggling to meet the basic daily needs of refugees in camps for shelter, nutrition, and protection. There are credible reports of an increased incidence of tuberculosis in urban areas, and particularly in Aleppo and among refugees in neighbouring countries. Although accurate numbers are not yet available, doctors interviewed recently report that if left unchecked the situation is likely to become “out of control” (Coutts A, unpublished). Reports from Aleppo also indicate a resurgence of leishmaniasis among children (Coutts A, unpublished). The most obvious response to the emerging health crisis in Syria is for the violence to stop, yet diplomatic solutions seem elusive. Although a case for armed intervention can be made under the “responsibility to protect” doctrine, this seems unlikely given Russian opposition. The UN has proposed a massive aid package: to support 4 million civilians inside Syria, 2 million who are internally displaced, and half a million refugees; the Office for the Coordination of Humanitarian Affairs estimates that US$1·5 billion dollars will be needed, which seems ambitious when many potential donors are facing major financial problems. The bulk of these funds comprise the Syrian Humanitarian Assistance Response