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.

With global attention focused on the fight against jihadi groups like the Islamic State (ISIS), the Syrian regime has continued its use of barrel bomb attacks on civilians.

In an address to the U.N. Security Council last week, Kyung-wha Kang, the United Nations deputy emergency relief coordinator, once again accused the Syrian regime of “using explosive barrel bombings against civilians in Syria.” It came in spite of a resolution calling for an end to the indiscriminate employment of weapons.

“Barrel bombs, crudely made drums of explosives dropped from helicopters, are so imprecise that the Syrian air force doesn’t dare drop them near the front line for fear of hitting its own troops,” Ken Roth, executive director of Human Rights Watch, told Syria Deeply.

“If we could stop the barrel bomb, it’s hard to think of anything else that would make a greater difference in stopping the slaughter of civilians and destruction of civilian institutions in civilian areas,” he added.

Roth spoke to Syria Deeply about the devastating effect barrel bombs are having on the civilian population in Syria.

Syria Deeply: You’ve tracked the use of barrel bombs, and prior to that the use of missiles on civilian areas. What’s the state of play now?

Roth: The barrel bombs are continuing and indeed they are the principal reason why civilians are dying in Syria today. Everybody is focused on ISIS. ISIS is terrible, civilians are suffering under ISIS, but if you stand back and say, what is the principal tool being used to slaughter civilians? It’s the barrel bomb. Initially, governments don’t really want to talk about this, because they are so focused on ISIS and don’t want to do anything that would undermine the Assad government’s ability to hang on and theoretically fight back against ISIS. People don’t seem to recognize that the barrel bomb is not a military weapon. It is so imprecise that the Syrian air force doesn’t dare drop it near the front line for fear of hitting its own troops.

Barrel bombs, for those who don’t know, are typically an oil drum or some large canister filled with explosives and metal fragments that serve as shrapnel. It is dumped from a helicopter hovering at a very high altitude to avoid anti-aircraft fire. From that altitude, it can’t be aimed with any precision whatsoever – it can simply be dumped into a neighborhood, and it is neighborhoods that barrel bombs are dumped on because of the need to stay away from the front line. If you ask what is enabling the pro-regime forces to hold on, it’s now the barrel bomb.

It is a terror and an anti-civilian tool. Part of Assad’s strategy is to make life as miserable as possible for the civilians living in opposition-held areas. It’s designed to kill many and terrify the rest so they will flee and gradually depopulate the area, to make it harder for the rebels to hang on.

Syria Deeply: What’s the size and scope of the problem?

Roth: If you talk to Syrians, the things that they fear the most are the barrel bombs. You hear stories of people who move their families closer to the front line (meaning they are braving snipers and artillery) because they feel safer there, where the barrel bombs won’t be dropped. Barrel bombs are hitting hospitals, schools and various civilian institutions in opposition-held areas of Aleppo and other areas. If we could stop the barrel bomb, it’s hard to think of anything else that would make a greater difference in stopping the slaughter of civilians and destruction of civilian institutions in civilian areas.

Syria Deeply: What’s the advantage to the regime of using these particular forms of weaponry in this particular conflict?

Roth: This goes back to the beginning. Assad from the start chose not to fight this war under the Geneva Convention, which in essence dictates that you only shoot at the other side’s combatants, and you do everything you can to minimize harm to civilians. He threw those rules out the window. He has been fighting a war strategy of war crimes aimed in large part at the civilian population. The barrel bombs, used for a good year now or longer, are just the latest, cruelest, largest manifestation of this strategy.

Syria Deeply: What’s your hope for the pressure that can be applied to induce behavior change in the regime when it comes to the use of barrel bombs?

Roth: What I’ve found in discussions with Western governments, Russian officials and even Iranian officials … for various reasons they don’t want to restrict the military weapons available to the Syrian government. The major Western governments are focused at this stage on fighting ISIS, and Russia and Iran are focused on bolstering Assad. None of them have an immediate interest in stopping the barrel bombs. I’ve had to explain the lack of military relevance of this weapon. When they hear that, then they are willing to step back. I’ve received some positive response from both Moscow and Tehran on this point.

In terms of Western governments, they are afraid of the barrel bomb issue for a separate issue – they don’t want to take on the broader issue of the Syrian government’s use of conventional weapons to attack civilians. Having come close to the brink of military involvement via the chemical weapons issue, and having been focused on other issues with Russia and Iran, the West simply hasn’t wanted to bring this up. There is no avoiding the fact that Ukraine is the top issue in Moscow, and potential nuclear weapons is the top issue in Tehran, but there should be bandwidth to take on the barrel bomb issue as well. Especially since Russia and Iran shouldn’t have any interest in the barrel bomb attacks continuing – they aren’t necessary to the Assad regime’s survival.

I’m guardedly optimistic that if we can highlight the devestation being caused by the barrel bombs and the lack of military utility, we can make a difference. One factor with the West is that so far they are pursuing only a military strategy against ISIS. To some extent they are trying to stop the flow of arms, weapons and personnel to ISIS, but they aren’t really taking on the ideological appeal of ISIS – part of it is religious and the idea of a caliphate, but a big part of it is that ISIS can represent itself as the only force that is effectively trying to stop the Assad regime’s slaughter of civilians. The West shouldn’t be giving that argument to ISIS. There have to be ways to address the barrel bombs – Assad’s primary tool for killing civilians. It’s the right thing to do in humanitarian terms, but it is also important to help undercut ISIS’s ideological appeal.

Syria Deeply: The U.N. has called for an end of the use of barrel bombs. What would it take to create actual accountability and enforce change?

Roth: The U.N. Security Council has talked about barrel bombs in generic terms. It hasn’t made any efforts to follow up on that broad language with concrete pressure on Damascus to stop. We need to go beyond ritualistic condemnation and upholding of the Geneva Conventions, and focus on pressure on Damascus to stop. We’ve seen that when serious pressure is applied, they do stop. It’s time for that pressure to be applied to stop the barrel bombs.