As the Syrian war approaches its eighth anniversary next month, the reality of the nation's revolution-gone-wrong could not be starker. Millions have been displaced inside and outside the country, and upwards of 560,000 have been killed. With President Bashar Al-Assad increasingly seen as the victor of the war, the focus has gradually shifted to reconciliation with his Arab neighbours, with officials regularly trumpeting the desire for reconstruction.
Yet beyond resolving the ongoing military conflict, and the consequent death and destruction it causes, the impact of the war on Syria's health is a battle that will continue for many years to come, says Dr Mohammed Jawad, a PhD candidate researching armed conflict and health at Imperial College, London. "The indirect impact is very wide-reaching, truly devastating and, importantly, really difficult to calculate," he explains. Over 13 million people have been forced to leave their homes and about half have stayed inside Syria, and half have left to other countries. "So even if these 13 million people have never experienced any direct armed conflict-related stresses, like torture or rape or the loss of a loved one, the mere process of being forced to leave your home can have a really tremendous effect on your mental and physical well-being."
The stress of the seven-year war is also likely to create an ongoing impact that will last for years to come, with trauma and anxiety increasing blood pressure and the consequent risk of heart disease. "The stress can even lower the immunological response or your immune system and make you a lot more vulnerable to infectious diseases and even some cancers," Jawad points out.
One of the most brutal hallmarks of the Syrian conflict has been the systematic targeting of hospitals and medical facilities by the Assad regime. In the first six months of 2018, the Syrian government and Russian allied forces attacked hospitals a record 92 times, in clear violation of international law. Witnesses state that drones followed ambulances prior to the bombings to establish hospital locations.
"The amount of damage to hospitals has really been unprecedented," says Jawad. "About half of them are either partially functioning or not functioning at all."
According to the medical researcher, before the war the situation in Syria was markedly different, with the country having made significant progress in the health sector. "It was performing relatively well, pretty much all the major indicators for good health, such as life expectancy, infant mortality, maternal mortality, were all heading in the right direction."
Now, the substantial destruction caused by bombing campaigns has significantly reduced access to healthcare. The violence and lack of opportunities that it brought has also forced half of the country's doctors to leave, restricting Syrians' access to healthcare even further.
With the violence winding down, Damascus has called for refugees in neighbouring countries to return to Syria and help rebuild the country. However, with over one million listed as "wanted" on government databases, the fear of reprisals has prevented many from even considering it.
"Neighbouring Iraq is a good example to see what might happen," suggests Dr Jawad. "They are still very much struggling to have enough human resources to deliver healthcare. There are lots of innovative ways to try to combat that, and I think lots of organisations are now looking at these ways to train people up to deliver healthcare."
Sieges have been a defining strategy in the Syrian conflict, with the regime and international coalition against Daesh both conducting long-term blockades on towns and cities, affecting tens of thousands of civilians. Numerous sieges were conducted in 2018, perhaps most famously on the Damascus suburb of Eastern Ghouta, which had been blockaded for five years. The regime had tightened the siege in the months before the city fell, closing tunnels that were used to smuggle essential items and intensifying shelling. The heaviest day of the bombardment was recorded as 21 February 2018, with the regime launching some 1,658 attacks in just 24 hours.
Even after the bombing has stopped, though, a siege can leave physical and mental scars behind, some of which can be permanent. "Most of the evidence of the long-term impact of a siege comes from World War Two," Jawad points out. "In the siege of Leningrad [now St Petersburg] over a million people in the city starved to death, and the survivors were so heavily restricted in their calorie intake that it did, unfortunately, result in permanent damage to the metabolism."
He has seen studies which report increases in the rate of mental health problems, diabetes, heart disease, cancers and other conditions among survivors of the siege in Leningrad compared with those who lived around the same time but not in the siege area. "Thus," he concludes, "the upcoming generation in Syria is likely to bear the brunt of the impact of siege conditions due to young children and babies possessing a greater dependency on adequate nutrition."
Refugees, without refuge
Those Syrians who have escaped the violence still face threats to their health, often due to the abject poverty that they find themselves in as refugees. Jawad says that there have been many outbreaks of diseases among those who have left their homes. "This is probably due to them being forced to live in overcrowded rooms with lower standards of hygiene, as well as their weakened immune systems." Throw that into the mix with all the mental health issues they are facing, he adds, and there are tremendous knock-on effects. "These include reduced education and employment opportunities, with resultant abject poverty and an inability to afford healthcare for even the most simple of conditions."
From the London-based researcher's experience of working with refugees in Lebanon, it is the government's policy there, which prohibits them from working freely, that poses the greatest threat to refugees' well-being. Harsh circumstances have forced many, including children, into the informal economy, wherein no official wages are set and most receive payment in kind, working in exchange for food and lodgings, for example.
"You need to find ways for people who are affected by conflict to fend for themselves eventually. Employment opportunities could be provided, like those seen in Turkey, for example, where there's a lot more integration, a better chance for doctors to run their own clinics for Syrian refugees, earning a living and breaking that cycle of poverty and bad health."
Although Lebanon has a long history of hosting Palestinian refugees, the treatment of Syrians has been markedly different largely due to the construction of refugee camps. Whilst Palestinian camps will often have a clinic onsite run by a humanitarian agency, Syrians have little infrastructure, relying on tents and makeshift accommodation, often located far from health and medical services.
"In a way that makes them far more vulnerable because they are much harder to reach, you don't know really where they are, where they're living, so it's really difficult to count them. No one knows how many refugees there are in each country now, because a lot of them have just moved in to urban areas. So it's hard to find them and deliver healthcare."
The provision of humanitarian aid is also under fire. Syria was a middle-income country before the war, such that traditional aid models that would provide food and basic medication were largely unnecessary, even for refugees.
"The traditional aid model in Africa would have been focused quite heavily on nutrition to combat malnutrition and malnourishment, but with Syria we actually didn't see that and there's maybe a lot of inefficient use of nutritional services for refugees that weren't really used by them."
Understanding the provision of healthcare in conflict zones is important, not only to deal with the humanitarian fallout from warfare, but also to use it to influence how war is conducted, Dr Jawad argues. "We are getting a lot better at measuring the direct and indirect effects of war on health. In Syria, occasional ceasefires were negotiated, particularly in the east of the country, on the basis of treating an outbreak of polio with vaccination. That's an example of the indirect effect of war causing an infectious disease and humanitarian agencies using that information to put pressure on warring parties to negotiate a ceasefire."
Whilst this offers some hope, the changing nature of warfare suggests that there are also numerous new challenges to be considered. "We are seeing wars lasting for much longer than before, protracted and concentrated in urban areas compared to the traditional cross-border fighting in remote areas," he notes. "What will probably happen is that more people are being exposed to the direct effects of war over a longer period of time which will create a lot more physical and emotional scars for generations to come."