The United Nations estimates the civil war raging in Syria has left more than 2.

5 million people in dire

need of food, water, drugs and medical supplies.

After 18 months of fighting, thousands are dead and thousands more wounded. If past wars are any
indication, the health and well-being of Syrians will likely be affected long after the last guns are fired.

Before the uprising started, Syria boasted nearly 500 hospitals and 70 licensed pharmaceutical
manufacturers that supplied 90 percent of the nations drugs. All that has changed.

Tarik Jasarevic is a spokesman for the World Health Organization (WHO), which recently sent a team of
observers into the embattled city of Homs. He says many hospitals and health centers in Homs have
been badly damaged by shelling. Only six of 12 public hospitals remain open, and eight out of 32 private
hospitals are still in operation-- at greatly reduced capacity.

The 350-bed National Hospital has been completely destroyed, Jasarevic said. Lack of access to health
care facilities, both by patients who need care and health workers who provide care, is one of the main
obstacles being faced.

Staff shortages make matters worse. At least half of all the medical doctors in Homs have left the city,
Jasarevic said. Many of the health facilities are staffed with volunteers who dont have any medical or
health training.
My wife has many sicknesses like increasing glucose, cholesterol, heart problems and high blood
pressure. My kids have problems sleeping. They are always waiting for someone to break
through the front door
Mustafa S., Damascus
Most of Syria's once-prosperous pharmaceutical industry was located in Aleppo, Homs and rural
provinces near Damascus. However, economic sanctions, violence, rising fuel costs and a shortage of
raw materials have forced most of them to shut down.
As a result, there is a critical shortage of life-saving medicines, vaccines, insulin, antibiotics, cancer
drugseven basics like oxygen, nitrogen gas or anesthesia drugs, Jasarevic said.

The disruption of Syrias health care system means surgeries are being postponed and many patients with
chronic health problems are not being treated. Expectant mothers are not getting sufficient pre-natal care,
and children are often skipping life-saving vaccinations.

Human Costs

By late September, the Local Coordinating Committees had documented more than 25,000 dead from the
fighting in Syria. The Syrian Observatory for Human Rights reported a higher figure -- 27,000 dead, with
more than 6,880 of them members of Syrias armed forces and security agencies.

Dr. Anas Al-Kassem is an Ontario-based surgeon and founder of the non-profit Canadian Relief for
Syria (CRS). The group is made up of physicians who travel to the Turkish border with Syria every
month to set up field hospitals and work to get much-needed medical supplies to the area.

Al-Kassem says that while the death toll from the fighting is catastrophic, more attention should be paid
to the many Syrians who survive with debilitating injuries -- and what impact this will have on the
countrys future.

Imagine, every day theres almost 1,000 wounded -- added on top of the 1,000 wounded the day before,
Al-Kassem said. If you have 100,000 disabled, that means a half-a-million dependents will have lost the
persons supporting them.

I think thats going to be the major issue, these disabilities, and the psychological effect is going to be
unbelievable, he said.

Moreover, Al-Kassem says the injuries he sees are getting more severe by the day. Six months ago, he
said, most of the injuries were gunshot wounds, something relatively familiar to doctors and
comparatively easy to treat.

Now that the regime his firing on civilians from the air, Al-Kassem says he is seeing more dramatic
injuries than he has ever seen before -- even during his trauma fellowship in a Canadian medical school.

Sometimes we dont know where to start, what to do, how to survive these patients, Al-Kassem said.
So it is getting very, very impossible. Its a war zone there.

Hidden Wounds

Civilians may not be taking a direct role in the fighting, but they experience war trauma in a number of
indirect ways: Their homes may be bombed. They may be shot at. They may lose family members or be
displaced. They may suffer shortages of food and water. They may be arrested, beaten or raped.

Dr. Elie Karam is founder and director of the Beirut Institute for Development, Research, Advocacy and
Applied Care and an expert on the impact of war on civilian mental health. His studies of the population
of Lebanon after its 16-year civil war demonstrate that war increases the risk of mental problems
including depression, post-traumatic stress disorder (PTSD) and/or problems with impulse control.
Syria, he predicts, will face the same challenges.

Youre going to see a lot of depression, he said. You are you going to see lots of anxiety disorders,
including PTSD, and you are going to have an increase in impulse control disorders.

Refugees vulnerable

The United Nations says more than 250,000 Syrians have fled their homes for refugee camps in Turkey,
Jordan and elsewheremost of them women and children. Studies suggest that refugees suffer from
higher rates of PTSD and depression, particularly if they are disabled.

Children are perhaps the most vulnerable victims of war. Dr. Barry S. Levy of the Tufts University
School of Medicine in Massachusetts has studied the issue of children in war zones and is co-author
of War and Public Health.

Violence begets more violence, he said in an interview with VOA. When a child sees his family killed,
suffers, witnesses atrocities or is uprooted some of them seek revenge and that may go on for years or
even generations.

Reproductive health risks

War stress also contributes to complications in reproductive and sexual health. A 2007 study on male
infertility in Lebanon, for example, found that war may limit access to good obstetric care and assisted
delivery, and this has been shown to lead to an increase in birth defects.

According to the United Nations Population Fund, the bulk of Syrian refugees are women and children.
Women are more likely to be raped, as studies show that the power of rape as a tool of war goes up in
countries where the greatest stigma is attached to a womans honor during peacetime. But according to
the Womens Media Project, which has been tracking reported cases of rape in Syria, sexual violence is
also being perpetrated against men and children.

Post Conflict Health Challenges

The Syrian International Coalition for Health (SICH) is a consortium of organizations and health care
providers who have banded together to address Syrias health care emergency.

In an article in the forthcoming issue of the Avicenna Journal of Medicine, SICH member Mazen
Kherallah and co-authors warn that Syrias health care should not be allowed to collapse altogether, as
has occurred in other regional conflicts. Kherallah says SICH will meet in Geneva next month to discuss
how to protect lives and reduce disease, malnutrition and disabilities in Syria -- and to empower Syrias
health care system so that it can meet war-related health care challenges in the future.
They crossed the border at dead of night, a 12-week-old baby in her mother's arms. They tiptoed through
a minefield, squirmed through barbed wire. The cost: 15,000 Syrian pounds; the reason: an unexplained
sickness that had overcome the infant.
In a bare room on the Turkish side of the border, where the sole piece of furniture is an old television set,
the little girl was wheezing and breathing heavily. "We were very scared, but we had no choice," said the
father, who asked that the family's names be withheld. "In Qamishli [north-eastSyria] nobody could help,
so we decided to come to Turkey. She has breathing problems."
She is not alone. Doctors and aid workers on both sides of the Turkey-Syria border are raising the alarm
about a public health emergency careering out of control and spreading across southern Europe as the tide
of human misery from Syria inexorably heads north.
According to doctors struggling to cope with minimal state help in the frontier region, measles and other
infectious diseases such as cutaneous leishmaniasis [which causes skin sores] have started to appear on
both sides of the border. The World Health Organisation has already raised an alert about the revival of
polio in northern Syria. All were previously illnesses under control in the neighbouring countries.
"Communicable diseases like measles, typhoid or TB are now popping up in Turkish cities," said Dr
Ramazan Kaya, a member of the Chamber of Medical Doctors in Mardin, south-eastern Turkey, and
specialist for internal diseases at the Nusaybin state hospital.
He underlined a sharp increase of typhoid and dysentery patients on the Turkish side over recent months.
"We are very worried by this development. So far, our warnings have fallen on deaf ears in Ankara."
"Turkey shares an 850km border with Syria," said Dr Cengiz Gnay, secretary of the Chamber of Medical
Doctors in Diyarbakir, the country's south-eastern capital. "Every day, people cross these borders
unchecked in both directions, be they refugees, smugglers or others. We cannot be sure if any of these
people are ill. And some of them might travel on to other Turkish cities, to Istanbul or Ankara, and from
there on to Europe. It is time that the world paid attention to the terrible humanitarian drama unfolding in
Syria."
The situation appears particularly acute in the north-east, heavily populated by Syrian Kurds who are
under attack both by the Damascus regime and by the Islamist militants of Jabhat al-Nusra and other al-
Qaida affiliates. They have quarantined the region, blocking the delivery of aid supplies and urgently
needed medicines. Medical staff and aid workers with recent access to the region say medical stocks have
vanished, that medical equipment is antiquated and obsolete.
"Qamishli might possibly be the world's biggest open air refugee camp right now," said Kaya. "Sanitary
conditions are dismal. Water is no longer chlorinated, rubbish isn't collected anymore.
"Syria is known to have had very good healthcare. Since the beginning of this conflict, the system has
started to break down, and it is getting worse by the day. There are shortages of everything medicine,
vaccines, medical equipment."
The sick baby's father said Qamishli was now flooded by Kurds from surrounding villages displaced by a
wave of recent attacks by Islamist groups such as Jabhat al-Nusra or the Islamic State in Iraq and the
Levant.
The European Union's most senior official in charge of the world's biggest humanitarian aid budget,
Kristalina Georgieva, urged the international community to insist on access for health professionals to the
blocked region, in the same way that the regime was forced to open up to chemical weapons inspectors.
"The importance of access cannot be stressed enough," the commissioner in Brussels told the Guardian.
"We urge the international community to demand access for health professionals in the same way we got
access for chemical inspectors to work in Syria. There have to be loud and clear calls to both sides of the
conflict that the targeting of healthcare professionals and facilities must not continue."
A recent WHO report said 60% of Syrian hospitals have either been damaged or completely destroyed
during the conflict. Large numbers of doctors have fled the country. The Turkish doctors say the situation
in the north-east, as well as in Kobani and Afrin, is exacerbated by the Syrian regime's deliberate neglect
of regions with a predominantly Kurdish population. "The Assad regime has ignored the country's
Kurdish population for a long time, excluded them from all development and investment," said Dr
Mehmet Demir, head of the Chamber of Medical Doctors in Batman, south-eastern Anatolia. "Most of the
equipment is from the 1950s machines you might usually find at a scrapyard."
Demir was in the Qamishli region of northern Syria a week ago.
"What I saw in the small clinics is inhumane, a tragedy," he said. "Surgery is performed without
anaesthetics. Desperate Syrian doctors told us that for most operations now they have to rely on luck
rather than skills. Pharmacies are pretty much empty everywhere."
According to the WHO, local production of medicines has collapsed by up to 70% since many
pharmaceutical plants have been substantially damaged. Prior to the start of the conflict in March 2011,
90% of medicines in Syria were produced inside the country.
"The impact of this conflict on the health situation in Syria is horrible," Georgieva added. "Access for
humanitarian aid workers inside Syria has not improved despite an extremely dramatic deterioration of
conditions inside the country. The government needs to ensure that medical supplies get in and that health
professionals can operate freely, that hospitals and health facilities are rebuilt. Only one fourth to one
third of the health teams that could have been active in Syria are actually operating because of the lack of
access."
For those who have escaped into Turkey, only those who are transferred to the country's official refugee
camps receive medical checks and vaccinations. But thousands prefer to lodge with family members all
over the country, or move on to bigger cities in search of work or a route to Europe.
For women facing pregnancy complications, it is almost impossible to receive emergency obstetric care.
Turkish doctors say figures for cot deaths and women dying during childbirth have exploded. People with
treatable chronic illnesses such as diabetes, kidney and cardiovascular diseases receive no professional
care.
Local officials in Nusaybin claim that Turkey deliberately keeps aid from going to Syrian Kurds, and that
Turkish aid organisations ignore the north-east.
"Turkey refuses to open its borders. They refuse to help the Kurds," said Ayse Gkkan, Nusaybin's mayor
from the pro-Kurdish Peace and Democracy party (BDP). Her party has been collecting donations of
food, clothing and medicines from all over Turkey, but she stressed that it was like the proverbial drop in
the ocean.
"We try and send aid everywhere we can," said Hseyin Oru, deputy head of the Humanitarian Relief
Foundation (IHH), a Turkish NGO delivering aid to Syria. "But we are already overstretched. The
situation is bad everywhere in Syria, and we barely manage to meet maybe 1% of what is required. Syria
has been abandoned by the world, and we have been abandoned trying to help Syria."
All doctors are alarmed that previously good Syrian immunisation programmes have all but to ground to a
halt in the country's north.
"Vaccination deliveries have stopped. I have seen at least three cases of polio in Qamishli," said Kaya.
"Measles are now very common, and has made its way across the border."
Demir agreed: "This year we registered measles patients in the Batman region. We cannot be sure where
the infections originated, but Syrian patients were the first to be treated for the illness."
In their small Nusaybin home, the newly arrived family hopes that their baby daughter will soon get
better.
"We will try to make a life for ourselves here," said the father. "And we hope that one day she can return
to a happier, peaceful Syria."
As refugees flee across the borders of war-torn Syria, they leave behind a rapidly crumbling health system
with too few physicians, too little medicine and too many hospitals that have been abandoned or
destroyed. But in the camps and cities theyre running to, basic health care and essentials can be equally
elusive. Simple necessitieslike running water or heating fuelare scarce as well. Meanwhile, as the
conflict intensifies, the number of refugees flocking into the surrounding countries rises, too. Currently
estimated by the U.N. to be around 1 million, Syrian refugees are expected to triple by the years end.
Because of difficulties entering the country, addressing public health needs within Syrian borders has
proved challenging if not impossible for foreign aid workers. Still, the Bloomberg Schools Center for
Refugee and Disaster Response (CRDR) researchers are determined to try. Theyre launching injury
surveillance at health facilities in Aleppo, in northwestern Syria, and working with NGOs providing
humanitarian assistance in Syria to better understand the countrys greatest health needs. To answer that
same question about Syrias refugee community, Bloomberg School researchers and students are actively
working in the camps and cities in the nearby countries. The idea is to look at the current state of refugee
populations in the region so that we can better inform donors and providers of humanitarian assistance
about what is most needed, says Shannon Doocy, PhD, an associate professor in International Health.
Doocy is launching two studiesone in Syria and one in refugee host countries.
The Syria-based study is still in its infancy and is moving slowly, explains Tom Kirsch, MD, MPH, an
associate professor in International Health and Emergency Medicine, and a co-investigator of Doocys
studies. The government is at active war with various groups, he says, and they dont want outsiders
within their boundaries.
For now, that leaves researchers focused on refugees in the surrounding countries, where they are
witnessing firsthand refugee conditions, whether in tent settlementswhere the nights are cold and toilets
are sometimes nonexistentor, as Alicia Hernandez witnessed, camping out in unfinished buildings.
One place that particularly stayed with me was a construction site, recalls Hernandez, an MPH student
and a registered nurse, who recently returned from Lebanon. It was extremely remote, a large concrete
structure set back about a mile from the road. One lone family with children was staying there. Even in
the daytime it felt like being in an ice cube. They had to walk at least 30 minutes to a water source and
only had one large, flat mat for the five of them to sleep on.
The actual camps, she continues, often lacked proper sanitation facilities. Most camps used one central
tap as the water source for camps of up to 150 people, Hernandez says. Almost no one was treating the
water before consuming it for lack of money, resources or knowledge how. No one had proper latrines.
Hernandez surveyed the displaced Syrian citizens about their health and medical needs. She is using the
information gathered to devise a training manual for community health educators. A majority of those she
encountered were children and womenmany of them pregnantwho desperately needed basic
necessities like blankets.
MPH student Jonathan Strong has a different focus: elderly refugees and their greater burden of chronic
diseases such as diabetes or heart failure. Strong surveyed elderly Syrian refugees in Lebanon. Many lack
access to affordable, basic health care, making their chronic diseases difficult to manage. The high cost
of health care there poses a huge public health challenge, Strong says. Many of the Syrian refugees I
spoke to in Lebanon are forgoing necessary medical care due to cost.
Both Strong and Hernandez visited the region for work supported by Caritas Lebanon Migrant Center.
While their projects are nearing completionHernandezs training manual has been drafted and Strong is
analyzing the completed studies and compiling the resultsDoocys work is just beginning.
Once her studies are complete, she hopes the information she gathered can guide aid groups assisting
refugees and those remaining in Syria.
The death toll in Syria's ongoing civil war may now be as high as 100,000. As the violence
mounts, another emergency is looming: a public health crisis across the region.
That's the conclusion of a new study published by the British medical journal The Lancet.
Syria's health care system is near collapse. Outbreaks of disease are on the rise in the
country, and refugees sheltered beyond the border are also at great risk.
One medical clinic in a poor neighborhood in Beirut is always busy. The two-story building
is up a narrow street of cinder-block homes. Syrian refugees have moved in, adding to the
crowding and the caseload, Dr. Abdul Kader Abbas says. He says he's treated 758 Syrian
families here many already sick when they arrived in this densely packed neighborhood.
"With the additional numbers," Abbas says, "we are afraid that any disease could spread
easily in such circumstances." That's the same warning spelled out in the
latest Lancet report.
Seventy percent of Syria's medical professionals have fled the country. Public health
researchers Dr. Adam Coutts and Dr. Fouad Fouad say there has been a dramatic rise in
communicable disease.
For example, Coutts says, there were 7,000 cases of measles in northern Syria in the past
few months after a vaccination program was disrupted by war, and the list is growing to
include TB, leishmaniasis, typhoid and cholera, which will come up during the summer
months.
Leishmaniasis is spreading so fast among the displaced people inside of Syria that it is now
called the "Aleppo boil" for the running skin sores transmitted by sand fleas. Fouad says
with the collapse of Syria's health care system, many Syrians have not had any medical care
or medicine for more than two years.
When you consider chronic diseases like diabetes, Type 1 and 2, and cancer, Fouad says,
you start to see that more people are dying of disease rather than war.
Disease moves easily across boundaries along with the refugees. Coutts and Fouad warn
this could lead to a public health crisis for the entire region. By the end of this year, the
Syrian refugee population is expected to reach more than 3 million.
In Jordan, the patient load in hospitals has jumped 250 percent in the past five months.
Lebanon's health system is under strain with more registered refugees than any of its
neighbors.
"With this huge influx of refugees now in Lebanon," Fouad says, "the number will come to
change the whole system."
One expected change is in the school system. U.N. officials estimate that when school starts
in the fall, Syrians will outnumber Lebanese kids in the country's public schools. That
worries Hayda Mohammed Al Jeeshi, the nurse at the health care center.
She says many Syrian kids missed childhood vaccinations before they fled to Lebanon and
that puts Lebanese children at much greater risk. The measles outbreak that started in
northern Syria is now showing up among the refugee community in Lebanon.
Scrambling to care for one of the world's largest refugee populations is another burden of
the Syrian war. The U.S. government has upped its contribution to host countries to more
than $800 million, with an additional $300 million pledged this month for food, shelter and
health care.
"Diseases don't care whether you're for Assad, or against Assad, or uninterested in politics,"
says Anne Richard, the U.S. assistant secretary of state for refugees, who was in Lebanon
this week. "It strikes everyone, as an equal opportunity."
BEIRUT, Lebanon The public health disaster in Syria has been a long time coming. In three years of
violent conflict, 125,000 have been killed and millions displaced. The recent outbreak of polio has
focused the worlds attention, and the international response is welcome. Yet this crisis was both
predictable and preventable.
The collapse of the health system and a lack of basic sanitation in opposition-held areas have created
prime conditions for outbreaks of vaccine-preventable diseases. Syria eradicated polio 14 years ago; the
fact that it has returned represents more than a breakdown of health care during civil war. It is
symptomatic of how the international community, in its response to the crisis, has neglected public health.
Immunization coverage in what are now mainly opposition areas was already below accepted standards in
2011, but the situation has deteriorated. Data on routine immunization from the World Health
Organization reveal that over the past two years a large proportion of the Syrian population has gone
without vaccination.
Across Syria, coverage went down to 60 percent in 2012, and was as low as 50 percent in the embattled
eastern city of Deir al-Zour, a front line between government and rebel forces. The latest W.H.O. figures
from 2013 show that the level is now down to 36 percent in largely rebel-held Deir al-Zour Province,
although it has remained at 100 percent in government-controlled areas such as the western stronghold of
Tartus.
Given these conditions, it was no surprise to medical practitioners that a polio outbreak occurred. The
question is why the international community did not prepare better for this eventuality. A disturbing part
of the answer is that the United Nations itself has aggravated the situation.
Like other United Nations agencies, the World Health Organization works directly with the Syrian
government. The W.H.O.s Syria office is in the Ministry of Health building in Damascus; many of its
staff members are former ministry employees. A recent Reuters report on how the Assad government uses
red tape and threats to prevent the provision of aid in opposition areas has raised doubts about the ability
of the W.H.O. to act with impartiality.
The W.H.O., working with the Syrian government, excluded Deir al-Zour from a polio vaccination drive
that began in December 2012. According to the W.H.O., the province was not included in the campaign
as the majority of its residents have relocated to other areas in the country. Ten months later, this was the
province where polio re-emerged.
There is no evidence that most of the provinces one million residents had, in fact, migrated. The United
Nations World Food Program continued to distribute food there throughout 2012 and 2013 (with
occasional interruptions because of worsening security conditions). In December 2012, the agency
reached 69,000 people in Deir al-Zour.
Last month, an investigation by the German weekly newsmagazine Der Spiegel charged the W.H.O. with
obstructing the testing of polio samples from the Deir al-Zour region. These samples had been presented
by an agency working under the aegis of the Syrian National Coalition. It took nearly a month to get the
test results positive for poliomyelitis and then only from an independent provider in Turkey. By
that time, thousands of displaced people had moved within Syria or fled as refugees to neighboring
countries, most likely spreading the disease.
The latest draft of a W.H.O. situation report for Syria reveals that it took three months for the W.H.O. and
the Syrian Health Ministry to confirm a polio case detected in Aleppo in July 2013. It was then some
weeks before a nationwide vaccination campaign began.
The consequences of these delays and failures now reach well beyond Syrias borders. Lebanon and
Jordan, where a large proportion of Syrian refugees have fled, are particularly at risk. Their public health
systems are already overloaded and underfunded. Unicef figures for immunization from the Lebanese
Health Ministry indicate that only 77 percent of the population had been routinely covered for polio in
recent years, placing thousands of Lebanese children at risk. If the Unicef figures are correct, then this
would be far too low to keep an introduced infection at bay, said Professor Martin Eichner, a disease
expert at the University of Tbingen, Germany. With 4,000 Syrian refugees a day leaving the country,
and the majority entering Lebanon, the virus is already in Lebanon or they will get it sometime soon.
There is also no discernible plan for delivering vaccination coverage to the hundreds of tented settlements
that house as many as 200,000 Syrian refugees across Lebanon.
The emergency is not limited to polio. While Syrias polio outbreak has been making headlines, other
communicable diseases like hepatitis A, the parasitic infection leishmaniasis, typhoid and measles have
all been rising. Chronic and noncommunicable diseases such as diabetes, hypertension and cancer have
also been silently killing Syrians by the tens of thousands. We know from previous crises that up to 80
percent of excess deaths are attributable to wider health conditions during and after a conflict.
The situation is extremely challenging, but humanitarian agencies in the region should be independent
and transparent. There are very real challenges for United Nations staff members working in Syria, but
the World Health Organization must respond to the claims that it refused to test the Deir al-Zour polio
samples, explain why it took three months to confirm a suspected case in July 2013 and give a better
account of why the area was excluded from its vaccination drive. Anything short of this disclosure risks
causing more preventable deaths, not just in Syria but across the entire region.