| This is the eighth blog post in a series looking at an array of issues in 2019 related to weapons use, the arms trade and security assistance, at times offering recommendations. |  Iain Overton |
It is a hard truth that explosive weapons have a devastating impact on health – from the direct blast that can tear limbs and families apart, to the widespread destruction of health infrastructure and all the painful reverberations this has. And nowhere else is this truism more evident than in war-torn Syria.
There, according to data by Action on Armed Violence (AOAV), not only has the use of explosive weapons caused at least 79,000 direct casualties - of which about 85% (67,000) were civilians - but it has also devastated state and civilian infrastructure, causing immeasurable harm to healthcare. In Syria, direct casualties from such violence is just the beginning.
Today, with half of Syria’s basic infrastructure non-functioning owing to the war, civilians lack access to energy systems, clean water and other basic essentials – all factors that increase the risk of the spread of disease.[1] At the same time, explosive violence has radically reduced the capacity of health facilities across the country;[2] 60% of health-care services in Syria today lie damaged or destroyed.[3] So, whilst the demand for healthcare is greater than ever, access is significantly reduced and civilians are left ‘dying from injuries and illnesses that are easily treatable and preventable.’[4]
Many medical personnel have also been killed in bombardments; 57% of Syrian medical personnel deaths between March 2011 and December 2017 were caused by explosive weapon use.[5] Others have left; by 2018, with thousands of clinicians having fled the violence, just a third of healthcare workers are said to remain in the beleaguered nation.[6] Such an exodus poses a serious problem. Many physicians are unlikely to return; for some it may be unsafe to do so, for others they may have made a new life elsewhere. In a post-conflict environment, where demand is high and resources are few, medical staff may decide that a better quality of life is to be found in the countries they fled to.[7]
The result of this is that access to care is stretched thin. Doctors’ caseloads have more than doubled,[8] while the lack of staff means there are few specialised services, particularly as donor efforts focus on emergency funding for ‘cost effective intervention’.[9]
Blast survivors are amongst the worst impacted by this reality, faced with highly limited rehabilitation services and considerable difficulties reaching care in the first place. In desperate response to this, living with suppurating wounds and mounting ill-health, many patients have been increasingly misusing antibiotics, a considerable problem in the country even prior to the conflict.[10] Evidence suggests this has likely exacerbated antimicrobial resistance in Syria[11] – causing further significant obstacles for the future.
More than 11.3 million people are said to be in need of health assistance within Syria, including 3 million with injuries and disabilities.[12] A large percentage of those injured are likely to be due to explosive weapons. Amongst 25,000 injured Syrian refugees examined by Humanity and Inclusion, 53% had been injured by such weapons.[13]
In some of the worst impacted areas, the rate of injury and disability is disturbingly high. In a survey of injury and disability across Idlib, Aleppo and Raqqa, as many as 50% of responders were said to be living with some form of disability.[14] The main cause of these injuries were airstrikes (54%), followed by other explosions (28%).[15]
Amputations are common – one doctor commented that Syria will be left with ‘a generation of amputees.’[16] Alongside this, a Humanity and Inclusion report found that, of injured people in Syria, around 8% required an orthopaedic fitting.[17] Furthermore, with the clearance of mines and explosive remnants of war (ERW) predicted to take 50 years, blast injuries are likely to continue to occur long after the conflict ends.[18]
Amputees have life-long healthcare needs: from rehabilitation and tissue management to further associated conditions, such as ectopic bone formations and osteoarthritis. Such conditions are difficult to manage in a developed healthcare system, let alone a post-conflict environment with a severely dilapidated and destroyed healthcare infrastructure.
The ruin of civilian infrastructure in Syria, beyond health infrastructure, will also have long lasting health impacts on the population. Again, with the displacement of skilled construction workers, alongside the sheer level of redevelopment needed, it is likely that such a threat to health will linger for a long time to come. Syria will almost certainly be witness to increased rates of water-borne or similar diseases in the coming years.[19] One study found physical damage to 457 water supply and sanitation infrastructure assets, not including damage to pipe networks.[20]
The mountains of rubble and waste left in the wake of the bombardment has – and will - also provide the perfect habitat for sand flies, leading to severe outbreaks of leishmaniasis; cases there have increased in recent years by a rate of at least 150%.[21] The most common form of leishmaniasis (cutaneous) causes severe skin lesions which can leave scars and inflict serious disability, but there has also been an increase in visceral leishmaniasis, which is often fatal. [22]
The widespread devastation may also herald further health disasters ahead. When explosive weapons destroy buildings, dangerous and toxic substances are often exposed.[23] Little research has been conducted into this harm, and we are only just beginning to understand the consequences. But studies of those exposed to the toxic dust in the collapse of the World Trade Center give stark warnings. By October 2018, over 43,000 people had been diagnosed with a 9/11 related health condition – 10,000 with cancer – and more still are likely to have been affected.[24] This was also in the US, where the medical infrastructure remained intact after the terror attack. In Syria, a lack of safety equipment in clearance operations, a prolonged and widespread exposure due to uncleared waste, and a lack of health infrastructure, only increase the health risks.
Beyond the physical harm, many more Syrians will be left psychologically affected by the bombardment. One Save the Children study found that, among Syrian refugees interviewed, almost all children and 84% of adults reported that bombing and shelling was the number one cause of psychological stress in children.[25]
The outlook for psychiatric care in Syria is dire. With less than 100 psychiatrists across the whole country prior to the crisis and many of those forced to flee, it is certain that most Syrians will be unable to access the psychological support they desperately need.
Overall, the scale of civilian harm and damage to infrastructure has left a health crisis in Syria which is likely to last decades. The lack of infrastructure and staff is unlikely to be quickly remedied, whilst the harm from explosive weapons, both physically and psychologically, will in many cases require lifelong treatment. Such consequences should serve as a warning on the long-term harm from explosive weapons, and states should commit in 2019 to stop using such weapons in populated areas. That is the least that can be done in the name of humanity.
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Iain Overton is Executive Director of Action on Armed Violence
----------
Footnotes
[1] Interview with Omar Sobeh, Hand in Hand for Syria, WASH cluster coordinator, in Gaziantep, Turkey, October 23rd 2018.
[2] Cierra Carafice, ‘Where Do We Go From Here? The Story of Syria's Public Health System’, October 09 2017, Middle East Studies Center.
[3] Speech by Peter Maurer, ‘Even wars have limits: Health-care workers and facilities must be protected’, May 03 2016, ICRC.
[4] WHO, ‘Seven years of Syria’s health tragedy’, March 14 2018.
[5] Raja Abdulrahim, ‘After the Gas and Bombs: The Health Crisis That’s Killing Syria’, April 17 2018, Wall Street Journal.
[6] Interview with Dr Mohamad Katoub, Advocacy Manager at Syrian American Medical Society, August 7th 2018.
[7] See Dathan, J. ‘When the bombs fall silent: the reverberating effects of explosive weapons’, May 2018, Action on Armed Violence.
[8] Interview with Dr Kinda Alhourani and Dr Tarek Al Mousa, Syrian Expatriate Medical Association, in Gaziantep, Turkey, October 22nd 2018.
[9] Interview with Dr Kinda Alhourani and Dr Tarek Al Mousa, Syrian Expatriate Medical Association, in Gaziantep, Turkey, October 22nd 2018.
[10] Interview with Dr Kinda Alhourani and Dr Tarek Al Mousa, Syrian Expatriate Medical Association, in Gaziantep, Turkey, October 22nd 2018.
[11] Esmita Charani, Senior Lead Pharmacist, Imperial College London, Faculty of Medicine, at the Global Health Forum: The impact of conflict on health care, 19 May 2018.
[12] WHO, ‘Seven years of Syria’s health tragedy’, March 14 2018.
[13] Handicap International, ‘Syria, a mutilated future’, May 2016.
[14] Presentation by Keiko Tamura, Head of Programmes, HIHFAD, Child Protection Sub-Cluster meeting in Gaziantep, Turkey, October 23rd 2018.
[15] Presentation by Keiko Tamura, Head of Programmes, HIHFAD, Child Protection Sub-Cluster meeting in Gaziantep, Turkey, October 23rd 2018.
[16] Interview with Dr Mohamad Katoub, Advocacy Manager at Syrian American Medical Society, August 7th 2018.
[17] Anne Garella, ‘‘80,000 people in Syria need a prosthesis or an orthosis’’, Humanity and Inclusion, 2015.
[18] Wilton Park and the Foreign and Commonwealth Office, 2017, ‘Clearance of improvised explosive devices in the Middle East Monday 22 – Wednesday 24 May 2017 | WP1548’.
[19] Interview with Omar Sobeh, Hand in Hand for Syria, WASH cluster coordinator, in Gaziantep, Turkey, October 23rd 2018.
[20] World Bank, 2017, ‘The Toll of War. The economic and social consequences of the conflict in Syria’.
[21] The Lancet, ‘Leishmaniasis unleashed in Syria’, February 2017, Volume 17, pp.144-145.
[22] The Lancet, ‘Leishmaniasis unleashed in Syria’, February 2017, Volume 17, pp.144-145.
[23] Andy Garrity, ‘Conflict rubble: a ubiquitous and under-studied toxic remnant of war’, July 10 2014, Conflict and Environment Observatory.
[24] Erin Durkin, ‘September 11: nearly 10,000 people affected by 'cesspool of cancer'’, September 11 2018, The Guardian.
[25] McDonald, A. 2017. ‘Invisible Wounds: The impact of six years of war on the mental health of Syria’s children’, Save the Children. Available at:
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There, according to data by Action on Armed Violence (AOAV), not only has the use of explosive weapons caused at least 79,000 direct casualties - of which about 85% (67,000) were civilians - but it has also devastated state and civilian infrastructure, causing immeasurable harm to healthcare. In Syria, direct casualties from such violence is just the beginning.
Today, with half of Syria’s basic infrastructure non-functioning owing to the war, civilians lack access to energy systems, clean water and other basic essentials – all factors that increase the risk of the spread of disease.[1] At the same time, explosive violence has radically reduced the capacity of health facilities across the country;[2] 60% of health-care services in Syria today lie damaged or destroyed.[3] So, whilst the demand for healthcare is greater than ever, access is significantly reduced and civilians are left ‘dying from injuries and illnesses that are easily treatable and preventable.’[4]
Many medical personnel have also been killed in bombardments; 57% of Syrian medical personnel deaths between March 2011 and December 2017 were caused by explosive weapon use.[5] Others have left; by 2018, with thousands of clinicians having fled the violence, just a third of healthcare workers are said to remain in the beleaguered nation.[6] Such an exodus poses a serious problem. Many physicians are unlikely to return; for some it may be unsafe to do so, for others they may have made a new life elsewhere. In a post-conflict environment, where demand is high and resources are few, medical staff may decide that a better quality of life is to be found in the countries they fled to.[7]
The result of this is that access to care is stretched thin. Doctors’ caseloads have more than doubled,[8] while the lack of staff means there are few specialised services, particularly as donor efforts focus on emergency funding for ‘cost effective intervention’.[9]
Blast survivors are amongst the worst impacted by this reality, faced with highly limited rehabilitation services and considerable difficulties reaching care in the first place. In desperate response to this, living with suppurating wounds and mounting ill-health, many patients have been increasingly misusing antibiotics, a considerable problem in the country even prior to the conflict.[10] Evidence suggests this has likely exacerbated antimicrobial resistance in Syria[11] – causing further significant obstacles for the future.
More than 11.3 million people are said to be in need of health assistance within Syria, including 3 million with injuries and disabilities.[12] A large percentage of those injured are likely to be due to explosive weapons. Amongst 25,000 injured Syrian refugees examined by Humanity and Inclusion, 53% had been injured by such weapons.[13]
In some of the worst impacted areas, the rate of injury and disability is disturbingly high. In a survey of injury and disability across Idlib, Aleppo and Raqqa, as many as 50% of responders were said to be living with some form of disability.[14] The main cause of these injuries were airstrikes (54%), followed by other explosions (28%).[15]
Amputations are common – one doctor commented that Syria will be left with ‘a generation of amputees.’[16] Alongside this, a Humanity and Inclusion report found that, of injured people in Syria, around 8% required an orthopaedic fitting.[17] Furthermore, with the clearance of mines and explosive remnants of war (ERW) predicted to take 50 years, blast injuries are likely to continue to occur long after the conflict ends.[18]
Amputees have life-long healthcare needs: from rehabilitation and tissue management to further associated conditions, such as ectopic bone formations and osteoarthritis. Such conditions are difficult to manage in a developed healthcare system, let alone a post-conflict environment with a severely dilapidated and destroyed healthcare infrastructure.
The ruin of civilian infrastructure in Syria, beyond health infrastructure, will also have long lasting health impacts on the population. Again, with the displacement of skilled construction workers, alongside the sheer level of redevelopment needed, it is likely that such a threat to health will linger for a long time to come. Syria will almost certainly be witness to increased rates of water-borne or similar diseases in the coming years.[19] One study found physical damage to 457 water supply and sanitation infrastructure assets, not including damage to pipe networks.[20]
The mountains of rubble and waste left in the wake of the bombardment has – and will - also provide the perfect habitat for sand flies, leading to severe outbreaks of leishmaniasis; cases there have increased in recent years by a rate of at least 150%.[21] The most common form of leishmaniasis (cutaneous) causes severe skin lesions which can leave scars and inflict serious disability, but there has also been an increase in visceral leishmaniasis, which is often fatal. [22]
The widespread devastation may also herald further health disasters ahead. When explosive weapons destroy buildings, dangerous and toxic substances are often exposed.[23] Little research has been conducted into this harm, and we are only just beginning to understand the consequences. But studies of those exposed to the toxic dust in the collapse of the World Trade Center give stark warnings. By October 2018, over 43,000 people had been diagnosed with a 9/11 related health condition – 10,000 with cancer – and more still are likely to have been affected.[24] This was also in the US, where the medical infrastructure remained intact after the terror attack. In Syria, a lack of safety equipment in clearance operations, a prolonged and widespread exposure due to uncleared waste, and a lack of health infrastructure, only increase the health risks.
Beyond the physical harm, many more Syrians will be left psychologically affected by the bombardment. One Save the Children study found that, among Syrian refugees interviewed, almost all children and 84% of adults reported that bombing and shelling was the number one cause of psychological stress in children.[25]
The outlook for psychiatric care in Syria is dire. With less than 100 psychiatrists across the whole country prior to the crisis and many of those forced to flee, it is certain that most Syrians will be unable to access the psychological support they desperately need.
Overall, the scale of civilian harm and damage to infrastructure has left a health crisis in Syria which is likely to last decades. The lack of infrastructure and staff is unlikely to be quickly remedied, whilst the harm from explosive weapons, both physically and psychologically, will in many cases require lifelong treatment. Such consequences should serve as a warning on the long-term harm from explosive weapons, and states should commit in 2019 to stop using such weapons in populated areas. That is the least that can be done in the name of humanity.
----------
Iain Overton is Executive Director of Action on Armed Violence
----------
Footnotes
[1] Interview with Omar Sobeh, Hand in Hand for Syria, WASH cluster coordinator, in Gaziantep, Turkey, October 23rd 2018.
[2] Cierra Carafice, ‘Where Do We Go From Here? The Story of Syria's Public Health System’, October 09 2017, Middle East Studies Center.
[3] Speech by Peter Maurer, ‘Even wars have limits: Health-care workers and facilities must be protected’, May 03 2016, ICRC.
[4] WHO, ‘Seven years of Syria’s health tragedy’, March 14 2018.
[5] Raja Abdulrahim, ‘After the Gas and Bombs: The Health Crisis That’s Killing Syria’, April 17 2018, Wall Street Journal.
[6] Interview with Dr Mohamad Katoub, Advocacy Manager at Syrian American Medical Society, August 7th 2018.
[7] See Dathan, J. ‘When the bombs fall silent: the reverberating effects of explosive weapons’, May 2018, Action on Armed Violence.
[8] Interview with Dr Kinda Alhourani and Dr Tarek Al Mousa, Syrian Expatriate Medical Association, in Gaziantep, Turkey, October 22nd 2018.
[9] Interview with Dr Kinda Alhourani and Dr Tarek Al Mousa, Syrian Expatriate Medical Association, in Gaziantep, Turkey, October 22nd 2018.
[10] Interview with Dr Kinda Alhourani and Dr Tarek Al Mousa, Syrian Expatriate Medical Association, in Gaziantep, Turkey, October 22nd 2018.
[11] Esmita Charani, Senior Lead Pharmacist, Imperial College London, Faculty of Medicine, at the Global Health Forum: The impact of conflict on health care, 19 May 2018.
[12] WHO, ‘Seven years of Syria’s health tragedy’, March 14 2018.
[13] Handicap International, ‘Syria, a mutilated future’, May 2016.
[14] Presentation by Keiko Tamura, Head of Programmes, HIHFAD, Child Protection Sub-Cluster meeting in Gaziantep, Turkey, October 23rd 2018.
[15] Presentation by Keiko Tamura, Head of Programmes, HIHFAD, Child Protection Sub-Cluster meeting in Gaziantep, Turkey, October 23rd 2018.
[16] Interview with Dr Mohamad Katoub, Advocacy Manager at Syrian American Medical Society, August 7th 2018.
[17] Anne Garella, ‘‘80,000 people in Syria need a prosthesis or an orthosis’’, Humanity and Inclusion, 2015.
[18] Wilton Park and the Foreign and Commonwealth Office, 2017, ‘Clearance of improvised explosive devices in the Middle East Monday 22 – Wednesday 24 May 2017 | WP1548’.
[19] Interview with Omar Sobeh, Hand in Hand for Syria, WASH cluster coordinator, in Gaziantep, Turkey, October 23rd 2018.
[20] World Bank, 2017, ‘The Toll of War. The economic and social consequences of the conflict in Syria’.
[21] The Lancet, ‘Leishmaniasis unleashed in Syria’, February 2017, Volume 17, pp.144-145.
[22] The Lancet, ‘Leishmaniasis unleashed in Syria’, February 2017, Volume 17, pp.144-145.
[23] Andy Garrity, ‘Conflict rubble: a ubiquitous and under-studied toxic remnant of war’, July 10 2014, Conflict and Environment Observatory.
[24] Erin Durkin, ‘September 11: nearly 10,000 people affected by 'cesspool of cancer'’, September 11 2018, The Guardian.
[25] McDonald, A. 2017. ‘Invisible Wounds: The impact of six years of war on the mental health of Syria’s children’, Save the Children. Available at:
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