Though Piece

Syria is facing an epic public-health catastrophe: I can’t help wondering where the international health community has been while this medical disaster of biblical proportion has been going on over the last 7 years?  Where has the Lancet organization, the American Medical Association, or the World Health Organization been?

How can any humanist worth their salt stay silent anymore? How can any environmental scientist pretend that climate change or simply the climate supersedes this tragedy?

After the Gas and Bombs: The Health Crisis That’s Killing Syria

The country’s seven-year civil war is systematically destroying its health-care system and fueling a public-health catastrophe

By Raja Abdulrahim
Photographs by Raja Abdulrahim The Wall Street Journal
RAQQA, Syria—This country’s seven-year war is fueling a parallel disaster: a crippling public-health catastrophe.

Some 400,000 Syrians have died from bullets, bombs or torture, including alleged recent gas attacks. More may have died as a result of the breakdown of its health system, and chronic conditions such as diabetes and heart disease have become far more deadly, according reports from the World Bank and World Health Organization.

The regime of Bashar al-Assad has targeted hospitals, clinics and medical personnel in a strategy to destroy the country’s medical infrastructure. Between the fighting and the destruction done to the health-care system, today most people can’t expect to live to 65. Many perish because they can’t get medicine, or reach a hospital.

After Years of Conflict, Syria’s Health-Care System in Shambles.
Syria once had hundreds of hospitals and medicine was inexpensive. After seven years of conflict, the country’s health-care system is devastated. Photo: Ahmed Deeb for The Wall Street Journal

Muhammad Ismail woke his wife and three sons before a late-January sunrise and together they traveled for two hours, over rubble-filled roads and past bombed out hospitals, to join a swarm of the sick seeking treatment at one of Raqqa’s only functioning clinics.

At the facility’s metal gate a sign advertised, “The women doctor is available on Thursday.” A guard directed patients to crowded examination rooms, where privacy was forfeited to meet the crushing demand.

The clinic is one of only two medical facilities operating in this provincial capital city, which has a population of about 70,000. Across the street, victims of mine explosions are rushed into a residential building-turned-emergency room. About a quarter of the victims die on their way, according to Doctors Without Borders, which runs both the emergency room and the clinic.

“No hospital, no doctors, no pharmacies,” said Mr. Ismail, 45.

Inside a Doctors Without Borders clinic in Raqqa, a Syrian boy receives an injection for leishmaniasis, a parasitic skin disease little-known in Syria before the war. Syrians wait for medical care in one of the city’s only functioning clinics.
A Syrian boy receives an injection for leishmania, a parasitic skin disease little-known in Syria before the war.
A Syrian boy receives an injection for leishmania, a parasitic skin disease little-known in Syria before the war.
Syrians from Raqqa wait to be checked at a clinic.
Syrians from Raqqa wait to be checked at a clinic.

Western officials, human-rights groups and a United Nations investigative body accuse the Assad regime and its allies of carrying out most of the attacks on the health system, in an attempt to destroy the infrastructure that supports opposition rebels. The Syrian regime denies purposely attacking health-care facilities.

Hundreds of medical facilities have been bombed out of operation, and thousands of medics either killed or forced to flee. About three quarters of health-care workers have fled the country and more than half of public hospitals and health centers have closed or are only partially functioning, according to the United Nations.

The collapse of the medical sector has deepened the health crisis, accelerating the spread of some infectious diseases, resurfacing others that had been all but stamped out.

In 2008—three years before the conflict began—life expectancy in Syria was 72, according to the World Health Organization. In 2015, that had dropped to 64.5. The independent non-profit Syrian Centre for Policy Research reports an even steeper decline—from 75.9 years in 2010 to an estimated 55.7 in 2015—as a result of both the deaths from violence and indirect causes such as the spread of disease and the collapse of the health system.

A young woman in Idlib died from cancer after she could no longer continue chemotherapy treatment because the road was blocked by a frontline; three patients who died from kidney failure in the span of 10 days because the dialysis machine was out of order in a besieged Damascus suburb; and newborn babies who died from exposure one winter in an Aleppo hospital with blown-out windows, according to family members and doctors.

“The regime has systematically and deliberately attacked health as an enemy in this war,” said Susannah Sirkin, director of international policy for Physicians for Human Rights. “We have never seen anything like this.”

Physicians for Human Rights has corroborated 492 attacks on health care facilities and 847 deaths of medical personnel, including doctors, nurses, dentists and even medical students since the beginning of the war. More than 90% were carried out by the Assad regime or Russia, the group says.

In January, when the French foreign ministry accused the regime of targeting civilians and hospitals in the northwest province of Idlib, the Syrian foreign ministry said France was “exploiting the humanitarian sides to divert attention from the failure of the policies it has adopted towards Syria,” according to Syria’s state media.

In May 2016 the UN Security Council adopted a resolution condemning attacks on medical facilities and personnel in conflicts worldwide, and demanding an end to impunity for those responsible. The UN singled out Syria as one of the worst offenders.

Five months after the resolution, as the attacks continued, then British ambassador to the UN Peter Wilson said they amounted to a “calculated dismantling of Syria’s health-care system.”

In February the Syrian regime launched an assault on Eastern Ghouta, a suburb of the capital Damascus. During the five-week offensive attacks on medical facilities there have become a near-daily occurrence.

During one week alone, at least 24 medical facilities were struck by rockets and mortar shells, forcing six out of operation, according to the Syrian American Medical Society.

An destroyed ambulance lies in front of Raqqa's ruined hospital.
An destroyed ambulance lies in front of Raqqa’s ruined hospital.

“Now we are here, direct targeting on us, more injured, lot of civilian people,” anesthesiologist Bassam Bakir said in halting English in a video shot at an underground hospital in Ghouta after one such attack. The camera swung wildly as doctors yelled instructions and treated patients lying on side-by-side gurneys.

“I, I can’t. I don’t know, we have to help these people,” he said.

The city of Raqqa fell out of regime control in early 2013, when it was taken over by anti-government rebels. The following year it was fully captured by Islamic State militants, who made it the defacto capital of their self-proclaimed Islamic caliphate, which also straddled Iraq.

Over the four-year period that Raqqa was under control of these two groups, the city’s three public hospitals were hit numerous times by airstrikes and mortar attacks, first by the Syrian regime and Russia and then last year by the U.S.-led coalition, according to several independent Syrian monitoring groups. Like the Assad regime, Russia has denied attacking hospitals, at one point calling such accusations “figments of the imagination.”

In the final days of the battle last year to capture Raqqa from Islamic State, the U.S.-led coalition struck the city’s national hospital, where militants were holed up.

Army Col. Ryan Dillon, spokesman for the U.S.-led coalition, said he didn’t know how many strikes the coalition carried out on the hospital but that by that point it was being used as a command and control base for Islamic State and not as a hospital.

Now, as residents trickle back to the city and its surrounding countryside after Islamic State’s defeat, the ill and injured face a gaping hole where Syria’s healthcare system had been.

Raqqa’s National Hospital was destroyed during the offensive against Islamic State militants.
Raqqa's National Hospital, the last stronghold of Islamic State, was destroyed during recent fighting there.
Raqqa’s National Hospital, the last stronghold of Islamic State, was destroyed during recent fighting there.
Hospital cots lay abandoned in the yard of Raqqa's National Hospital.
Hospital cots lay abandoned in the yard of Raqqa’s National Hospital.

The January trip made by the Ismail family was the third they’d made within a week to seek treatment for his three sons, who have leishmaniasis, a parasitic skin disease little-known in Syria before the war. The condition, which causes skin lesions, is spread by sand flies that swarm the dead bodies trapped in Syria’s rubble-filled buildings, and the tent camps hosting people displaced by the war.

After hours of waiting in crowded hallways, Mr. Ismail led his youngest son, Abdullah, to the clinic’s examination room, where Mr. Ismail’s wife and other son held him down while a nurse injected each gray skin lesion on the boy’s face and body. Abdullah sobbed and thrashed. His mother looked away.

After his other two sons were treated, the family was told to return after a few days for another round of treatment. As the family left through the swarm of people waiting outside the door, a man took his turn on the examination table to have a leg wound treated, while at the same time a wife and her husband received leishmaniasis injections at the nearby counter.

When Doctors Without Borders first arrived in Raqqa in November, just weeks after the city was fully captured from Islamic State militants, the group didn’t know whether any building was safe to enter, so it set up tents on the side of the road.

Eventually the group took over the clinic that Mr. Ismail’s family visited. They spent days de-mining it and had to rebuild one of the rooms, which had been destroyed in an explosion.

Initially, the group set up an emergency room to treat trauma injuries, but it was quickly overwhelmed by children with chest infections, women with pregnancy complications, and elderly people with heart disease and diabetes.

Across Raqqa’s pockmarked walls, posters for vaccination campaigns compete with posters warning about Islamic State mines hidden in homes.

As millions of Syrians have been displaced and the country’s infrastructure destroyed, childhood vaccinations have been disrupted. “We’ve been seeing measles cases, mumps cases and we’ve been seeing polio cases,” said Jonathan Skillen, a medical team leader with Doctors Without Borders.

Mahmood Abu Ahmad walks the streets of Raqqa calling to parents to have their children vaccinated at a clinic run by Doctors Without Borders. Babies wait for vaccinations.
Mahmood Abu Ahmad, a former science teacher, calls for the people in Raqqa to get their chldren vaccinated.
Mahmood Abu Ahmad, a former science teacher, calls for the people in Raqqa to get their chldren vaccinated.
Syrian infants wait to be vaccinated.
Syrian infants wait to be vaccinated.

The posters for the vaccination campaigns are not enough to get the word out in Raqqa, so every weekday morning Mahmood Abu Ahmad, a former science teacher, takes to the city’s muddy streets with a megaphone. “Vaccines for kids, from ages one day to five years old,” he calls out. “Available every day.”

Men on megaphones commonly rove Syrian streets selling everything from olive oil to vegetables. As Mr. Ahmad walked through one neighborhood recently, wearing an arm band labeled MSF, the French acronym for Doctors Without Borders, men and women peeked out with curiosity. The man with a megaphone gave on-the-spot medical advice, and occasionally delivered soft reprimands.

“Has he gotten any vaccines?” Mr. Ahmad asked a woman standing in her doorway holding an 8-month-old baby wearing a light blue onesie with the letters, “MVB,” for “Most Valuable Baby.”

“No,” Hajar al-Ahmad said, as her baby nibbled on her black hijab. She explained that her family had recently returned home after having fled to a camp during a battle for control of the city.

“He needs to get vaccinated,” Mr. Ahmad said. “What’s his name?”


“Ok. If I don’t find his name on the list of vaccinated children, I’m going to come back,” he warned her with a smile.

As he walked away, past a water tower that Islamic State blew up, Mr. Ahmad admitted he doesn’t actually remember the names of the children. He hopes the empty threat is enough to get parents to vaccinate them.

The situation is even more dire in the tent camps hosting nearly a million across Syria.

About 35 miles north of Raqqa, many of the city’s former residents are still stuck in the Ain Issa camp, a sea of white tents spread across a large dirt expanse, which houses some 17,500 people. Residents get drinking water from large tanks. Bathrooms and showers are located in trailers.

A Syrian doctor checks a child at mobile clinic run by Kurdish Red Crescent at a camp outside Raqqa.
A Syrian doctor checks a child at mobile clinic run by Kurdish Red Crescent at a camp outside Raqqa.

Camp life comes with its own medical problems. Crowding and poor sanitation cause respiratory infections and waterborne illnesses to spread easily. In the winter, families must choose between risking a fire from their gas-fired space heaters or being cold in their tents. Children sometimes burn themselves on the heaters, too.

In recent months, a newborn baby died and another child passed away from meningitis, according to the camp manager.

Diabetics taking insulin must find a way to keep the medicine cold, in a place with little to no electricity. Some have resorted to burying the insulin bottles underground or stashing them in the shade to keep them cool, said Ahmad Dbais, a doctor with the Union of Medical Care and Relief Organizations, a France-based charity that supports medical care in several opposition-held parts of Syria.

The Kurdish Red Crescent runs the camp’s trailer clinic and pharmacy, housed in a small concrete building with two signs: one banning cell phones, the other forbidding guns.

Camp resident Hajar Ali Sleiman, 37, went to the clinic one recent morning and along with a group of frustrated women waited for two hours for it to open. It never did.

Ms. Sleiman, who is pregnant, takes hormones to protect the lining of her uterus and prevent another miscarriage. She knew that trying to get the medicine free-of-charge at the camp pharmacy was an exercise in futility.

“Every time I came they would tell me there is no medicine and they’d send us away,” she said.

A Syrian boy buys medicines from a private pharmacy in Ain Issa, a town north of Raqqa.
A Syrian boy buys medicines from a private pharmacy in Ain Issa, a town north of Raqqa.

One of the few remaining physicians in the area is Dr. Fayiz Karabait, a family doctor in the nearby town of Ain Issa. He recently began treating patients in a small trailer clinic supported by the Kurdish Red Crescent. His tiny exam room has only a stethoscope and blood pressure gauge.

On a recent afternoon, Dr. Karabait ran out of prescription pads as a line of waiting patients snaked around the back of the trailer. His nurse assistant, Jawahir al-Khabri, found an empty antibiotic box and ripped it into pieces they could use for jotting down prescriptions.

One of the last patients of the day was Shahrazad Al-Malham, who walked into the cramped exam room with her sick 4-year-old son, Ismail, his hair a mess of dusty unruly brown curls. After a brief exam of the boy, who had an upset stomach, Dr. Karabait began writing a prescription on the back of one of his final pieces of the box.

“We don’t have the money to buy it,” Ms. Malham protested.

“May God provide,” Dr. Karabait said, handing her the chit of paper.

As Ms. Malham walked out of the trailer, the doctor called out after her: “Forgive us.”

Write to Raja Abdulrahim at