The five-year civil war in Syria has killed 400,000 Syrians, injured countless others, and displaced half of the country’s 22 million residents.
It’s also completely ravaged the country’s health care system. Helicopters drop barrel bombs filled with shrapnel and nails onto hospitals. Doctors report they don’t have enough coffins to bury the dead.
In Aleppo, a city of 300,000, there are just nine places left to seek health care, and only seven ambulances. There is one neurologist and one cardiologist.
“We’ve never seen anything like what’s going on in Syria,” said Susannah Sirkin, a policy expert with Physicians for Human Rights who works with doctors in Syria. “It’s the destruction of an entire advanced health care system.”
A suicide bombing Tuesday at the Jableh National Hospital in Syria’s Latakia province killed more than 40 patients and family members and wounded dozens of others. An emergency doctor and two nurses were killed.
The attack was only the latest in a series of violence that has taken a toll, both directly and indirectly, on Syria’s health care system since 2011. More than 725 medical personnel have been killed. Twelve health centers supported by Doctors without Borders have been completely destroyed.
“We’re still working, but the whole staff is afraid of a repeat of what has happened with the [other hospitals],” Dr. Abo El Ezz, a general surgeon in Aleppo, said in a telephone interview.
Airstrikes have made seeking treatment for common injuries like broken bones all but impossible, doctors say. Patients in Syria feel incredibly hesitant to seek care at a hospital.
“They’re places of death, not places that are saving lives,” said Sirkin.
“Our staff is constantly afraid of the hospital being bombed,” said Dr. Abo Louai, a pediatrician in Aleppo who said he has to work for up to 20 days at a time, often in back-to-back shifts. The hospital where he works is in the process of building a wall around its perimeter as a last-ditch effort to protect patients and health care professionals from deadly attacks.
Militants are increasingly trying to maximize the impact of individual attacks, bombing health care facilities once, waiting for first responders and emergency personnel to rush to the scene, and then bombing them again.
“They strike again to compound the death toll,” said Matthew Parsons, a researcher with Physicians for Human Rights who spends hours every day meticulously tracking attacks on the health care system in Syria. His tracking shows so-called “double-taps” have gained steam as a tactic since October 2015.
An attack on a hospital in the city of Idlib in February was particularly brutal. Militants targeted a facility supported by Doctors Without Borders once, then again 15 minutes later to target first responders. That wasn’t the end of the assault, though, Parsons said.
Militants knew the victims of the first two attacks would be taken to another facility — the closest one left standing — half an hour north of Idlib. Forty-five minutes later, that facility was attacked. A fourth bomb exploded half an hour after.
Similar tactics have been deployed in other regions. A new report from the World Health Organization, released Thursday, details 594 attacks on health care worldwide between January 2014 and December 2015.
The attacks are in clear violation of the Geneva Conventions, which are supposed to protect health care as a basic human right, even in times of war.
“It’s a really, really insane violation of international humanitarian law,” said Parsons.
The doctors left in Syria are a hodgepodge of survivors. In Aleppo, one of the largest cities in the region, there were fewer than 25 general physicians and 27 surgeons as of July 2015, according to the Syrian American Medical Society, a humanitarian group.
Since then, attacks have continued to tear Aleppo apart. The number of doctors left in Syria has surely fallen since then, Parsons said.
Many of the doctors aren’t being paid anything close to a normal salary. Financial aid from nongovernmental organizations goes to patient care and supplies, first and foremost; salaries fall to the bottom of the priority list.
Experts say many doctors aren’t even fully licensed — they’re medical students who have had to learn on the job.
“They’re working days without sleep, without eating, while they watch the destruction of their communities,” said Sirkin. “They have to make the very difficult decision every day if they’re going to go into work and risk being killed, or stay home with their families, or flee.”
Outside aid from organizations including Doctors Without Borders, the International Committee of the Red Cross, and Physicians for Human Rights keeps shelves stocked with basic medical supplies. Anything more sophisticated is exceedingly hard to come by.
“At one point, there was only one MRI left in all of Aleppo,” Parsons noted.
Frequent power outages have also hindered the delivery of care. If doctors are lucky, they have two or three hours of power a day, Parsons said. They’re often dependent on backup generators to keep the lights on in operating rooms.
“When there’s a raid, we’re terrified, and we’re confused,” said Dr. El Ezz. Hospitals in the country, he said, are teeming with injured patients and staffed by exhausted, helpless doctors and nurses.
Other doctors echoed that sentiment — they’re hanging on by a thread, and patients are, too.
“Things are good right now, thank God,” Dr. Abo Louai said. But, he added, it was good only in the sense that patients and doctors hadn’t been attacked.
Last month, after an attack on a field hospital in Aleppo killed 30 and left at least 60 others wounded, Dr. El Ezz published a blog post in which he reflected on the destruction of the city he calls home.
“The city is bleeding,” he said. “Shelling and bombardments have destroyed everything. No life is left.”