A leading Syrian public health expert, Dr. Fouad M. Fouad, told Syria Deeply that the country’s supply of medications has dwindled to less than 20 percent of what was available before the war. Fouad, who is currently an assistant research professor at the American University of Beirut, was once the director of the Primary Health Care Department in Aleppo. Now he says the supply of medications to treat chronic illnesses such as kidney failure, cancer, diabetes and cardiac diseases has virtually dried up.

Overall, the country’s official and non-official hospital networks are both unsurprisingly in dire straits, said Fouad, who ran mobile clinics across the country before the civil war and has written extensively on the health crises that have emerged from the conflict that has displaced about 10 million people and injured hundreds of thousands.

He spoke to Syria Deeply about the state of the country’s health sector and how it will leave lasting issues in physical and mental health that will challenge Syria for years to come.

Syria Deeply: Based on your research on Syria’s healthcare system, where are the public health services most vulnerable?

Fouad: In principal, the problem inside Syria is caused by the fact that we have several health systems. The first system in place is the principal one, which is affiliated with the Ministry of Health and is part of the regime. The second system exists in areas that are outside the control of the regime. And the third one – if we can call it a healthcare system – exists in the areas under the control of the extremist Islamists. This problem forms a huge challenge for the humanitarian and healthcare response systems, which are functioning and under regime control, and aid is possible. As for the second healthcare system, it has also been possible to deliver some aid through neighbouring countries to the areas that are outside regime control, but it is not enough and far from efficient. The third system, if we can call it a system, is in the areas under the control of the extremist Islamists and there is no chance to deliver aid. We actually don’t know what the problems are that they have.

Syria Deeply: What are some of the biggest problems facing the population today?

Fouad: The healthcare problems were triggered by the collapse of the infrastructure in areas that were under regime control. That led to the spread of contagious diseases, mainly Hepatitis A, diseases related to lack of water sanitation, typhoid, lipidosis, diarrhea. In addition, the services that could be offered and given to women have suffered a lot. We have had cases of unsafe child delivery. The problems resulting from that were numerous including, complications, bleeding and eventually death.

Because the Syrian crisis has taken a longer time, we began to see problems in treating chronic illnesses such as kidney failure, cancer, diabetes, heart operations and others. These illnesses got more complicated because the proper treatment is not available, or is very expensive. Many of the healthcare sector workers have left the country for fear of being targeted or kidnapped. They sought a safe place outside the country, and that placed a bigger burden on the system inside the country.

Syria Deeply: How are people coping? What are some of the creative solutions you’ve seen?

Fouad: In Syria today, we began to see serious problems with the availability of medication. Even the existing medications we had problems with. The medications available to the patients are less than 20% of what was available before the crisis. Many of those who engaged in the past in the medicine production sector are facing a lot of difficulty today. They suffer from disrupted electricity supply, lack of general security and lack of secure movement of their employees and their production and materials. Life and medication became very expensive, hard currency was not available all the time, sanctions were imposed, and there was a lack of safe access to deliver medication to points of need. Many medications disappeared from the markets, including those treating cancers, antibiotics, heart diseases and children’s and women’s diseases. As a result of the above, we started to see a shortage in proper treatment, and the destruction of hospitals and healthcare centers.

As a result, more than 77% of the hospitals have been damaged severely, are non-functional, or it’s very hard for them to operate with full capacity. In the areas that are not under regime control, the healthcare situation is extremely dire and needs help to treat patients in areas such as Idlib, Deir Ezzor and Aleppo. Medication reaches these areas through smuggling, and so often the condition of its safety or preservation are not guaranteed. We really do not know the quality of medication that is being distributed in areas that are outside our control.

More than 15,000 doctors left Syria; many of them were highly qualified and specialized in their fields. Those who are left behind are the young generation who have less experience. As a result, we started to see different problems related to injuries. It is estimated that about 600,000 to 800,000 people have been injured because of the war. Some have their homes destroyed by military attacks, shrapnel or they were in the line of fire.

We do not have information about those who have permanent disabilities, such as the loss of a hand or a leg.

Studies say at least 100,000 suffer from huge disabilities, and will form an economic and social burden, and will be in need of continued services. Many of them have left the job market and need financial support. Therefore, we should provide services for them very soon.

Syria Deeply:: What has been the impact on women?

Fouad: In most wars, and long-term wars, women are affected badly. So often the husband leaves home either to make a living, or to carry arms to fight. The woman becomes the head of the family, and this places a huge burden. This aspect is ignored most of the time, and physiological health becomes a secondary concern. But this is a major element that we have to pay attention to, as it could lead to further complications for a whole generation.

Women are exposed more to problems also because they take care of children, work hard and get a lack of proper nutrition. In addition to that, when an area is besieged, or when goods become very expensive or unavailable, children are those who are affected most.

Syria Deeply: We’ve heard that pregnancy is on the rise in Syria. How are women managing to give birth in such dire circumstances?

Fouad: Child deliveries are conducted most of the time under unsafe conditions, especially in areas where the war is still raging. Unsafe deliveries are also taking place in remote areas that are far from health services or transport routes and areas that have seen influxes of refugees. We hear of complications, premature deliveries, bleeding and lack of first aid emergency services, which eventually leads to deaths.

One of the most important problems women face in wars is actually the availability of proper services.

When women flee to an area whether locally or abroad, the host community often does not provide proper shelter and services. This is what happened when people fled from Idlib, for example, to areas inside Syria or in Lebanon.

Syria Deeply: You ran mobile clinics in Syria before the war. Could they be deployed in a situation like this to provide care? What other flexible methods could work?

Fouad: This is a very important subject when we have a crisis, and when we have areas that are not receiving any services, we can work with different forms of mobile clinics. But this could only work if the area is secure and accessible.

We can also use new technology. For example, we can diagnose and deliver the service through the internet, or smartphones. This applies in cases where a consultation is needed but the physician cannot reach the area in need, provided that the area actually has technological services and equipment such as a laptop, etc.

This kind of tele-clinic is effective for diagnosis and health education, but it is not very effective in areas of treatment, where you need a mobile clinic. But there is a strong need to use the technology of mobile clinics in refugee areas and informal settlements. An example of that is Lebanon, where you have gatherings of refugees or settlements. In this case, mobile clinics are very important, and serve several communities.

Syria Deeply: What is the most basic thing that could be done to improve public health provision today?

Fouad: We have to distinguish and talk on two levels: one is Syrians inside Syria, and the other one is Syrians in neighbouring countries.

For the Syrians inside Syria, the most important element is that there should be coordination between workers in the healthcare sector. If I work to provide a service in a certain area, I need to work with the people who are in charge of distributing the services in this region.

Organizing and managing the service is very important so we do not end up having an overlap or waste.

Coordination, actually, is only possible in secure areas. But security is not the only element. One important element to a better healthcare is funding.

In addition to that, we need an innovative approach to treat health problems. When we have a problem with the vaccination of children, for example, we need to educate a number of people about that at the same time.

When we talk about healthcare outside Syria, it should be comprehensive, especially in hosting countries and communities. When you provide services and aid to the refugees, and you exempt the hosting communities from the aid, you are actually increasing tension. For example in Lebanon, 80% of the national healthcare services that are being offered are private. Therefore, we have to develop the healthcare services in a balanced and equal way.

In areas outside regime control, there is lack of information about the kind of healthcare problems that we face or may face. If we have a problem with diarrhea or polio, the evaluation of these problems is left to the estimation of average people who so often have no experience. We need to know who is providing medical aid and who decides how to distribute it. Unfortunately, there aren’t enough efficient personnel with medical backgrounds to prioritize. As a result we have seen some tragic deaths resulting from medical complications and vaccines.

Health management is really an important issue in the area of healthcare. Mismanagement could lead to tragic results and could be worse than corruption.