Syria: effects of conflict and sanctions on public health

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Syria: effects of conflict and sanctions on public health
Journal of Public Health Advance Access published November 23, 2012
                                                                                                                     Journal of Public Health | pp. 1–5 | doi:10.1093/pubmed/fds090

Syria: effects of conflict and sanctions on public health
Kasturi Sen1, Waleed Al-Faisal2, Yaser AlSaleh3
 Wolfson College, (CR) University of Oxford, Linton Road, Oxford OX2 6EH, UK
 Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
 Health Care, Ministry of Health(F), Damascus, Syrian Arab Republic

    A B S T R AC T

    The past 18 months have witnessed considerable turmoil in countries of the MENA region. The Syrian Arab Republic (SAR) is one such
    country, currently in the midst of a civil war. This report draws attention to some of the recent achievements of its health services, where,
    despite a dearth of published materials, the country achieved remarkable declines in maternal mortality and infant mortality rates. Its

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    health sector now faces destruction from on-going violence compounded by economic sanctions that has affected access to health care,
    to medicines and to basic essentials as well as the destruction of infrastructure. This paper draws attention to the achievements of the
    country’s health services and explores some of the consequences of conflict and of sanctions on population health. Readers need to be
    mindful that the situation on the ground in a civil war can alter on a daily basis. This is the case for Syria with much destruction of
    health facilities and increasing numbers of people killed and injured. We retain however our focus on the core theme of this paper which
    is on conflict and on sanctions.

    Keywords health services, morbidity and mortality, public health

Introduction                                                                                    WHO (WHO –EMRO) and additional online sources on
                                                                                                sanction effects from the ICRC, the UN and WHO.
For more than 16 months, the Syrian Arab Republic (SAR)
                                                                                                Peer-reviewed papers were accessed through Google-scholar
has been in turmoil with violence escalating on a daily basis.
                                                                                                and Medline searches, using key words, Syria and population
At the time of writing, the United Nation (UN) has declared
                                                                                                health, public health, sanctions and included a series of
the country in a state of civil war; whilst the army struggles
                                                                                                reports from the WHO and the UN.
to maintain its credibility in facing the opposition, civilians
are trapped with high casualties from both sides. Financial
and political support for a change in regime means that the                                     Background
possibilities of a political solution are increasingly remote.1
In this volatile environment and as concerned public health                                     Syria is a lower middle income country with a population of
physicians and scholars, we wish to highlight some of the                                       22.3 million and a per capita income of $3900 in 2009 and a
achievements of health services in Syria that would have                                        land area of 185 180 km2.3,4 Limited contact with western
guaranteed the country fulfilling the health Millennium                                          researchers resulted in a lack of awareness of its achievements
Development Goals (MDG). We discuss in particular the                                           in health status. The progress and capacity of its health ser-
gains in health status made due to the efforts of public                                        vices is now in real jeopardy from the violence of a protracted
health professionals. We also examine the possible conse-                                       war and from economic sanctions. There is a growing danger
quences of sanctions and the current crisis on the future of                                    that a combination of war and sanctions will affect health
public health delivery in Syria.2                                                               service delivery with potentially irreversible consequences for
   For this purpose we rely on secondary data from the                                          the population, already evident in its early stages.5 – 7
Ministry of Health (MOH) and the Central Bureau of
Statistics (CBS) combined with the information from the
World Health Organization (WHO) Observatory (including                                           Kasturi Sen, Member of Common Room, Wolfson College
World Health Statistics 2010), the Population Reference                                          Waleed Al-Faisal, Associate Professor of Public Health
Bureau and the regional National Health Accounts from the                                        Yaser AlSaleh, Former Ministry of Health Advisor

# The Author 2012, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved                                                               1
2      J O U R NA L O F P U B L I C H E A LT H

Public health achievements: some key                                        health amounting to $79 per annum (2008) compared with
features                                                                    Jordan ($246) and Egypt ($200).7,8
                                                                               Table 2 shows MMR trends in Syria over two decades
Syria achieved substantial improvements in population
                                                                            compared with those of Jordan and Egypt. The MMR for
health over the past decades. Contributory factors include
                                                                            Syria are lower despite low investment and an absence of
access to maternal and child health services through com-
                                                                            donor input. This suggests that the health sector was largely
prehensive primary health care, health promotion and edu-
                                                                            self-sufficient until a bi-lateral agreement with the European
cation supported by a network of Women’s Committees,
                                                                            Union (EU) in 2003.12 These health outcomes were achieved
better nutrition through food subsidies and an acknowledg-
                                                                            through an integrated approach to health services including
ment of the need to address the social determinants of
                                                                            primary, secondary and tertiary care and one where institu-
health, largely unknown to the region. Some of the achieve-
                                                                            tional deliveries constituted . 90% of all deliveries.7,8
ments of the health system may be summarized as the
                                                                               Despite past economic pressures and isolation, Syria
                                                                            could credit itself with improved living standards, together
                                                                            with greater citizen awareness of health issues, strengthened
† Comprehensive vaccination coverage                                        by improvements to infrastructure, access to clean water,

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† Improved levels of literacy ( particularly among women)                   expanding public healthcare systems and local production of
† Plans to address a rising incidence of non-communicable                   .90% of medicines.4 The integration of health care has
  diseases (NCDs) through partnership with local                            been a significant factor for the country to be on target to
  communities                                                               meet the health MDGs (Fig. 1).9,13
† A re-organization of services in 1998 to increase the local
  level control as part of the process of decentralization
† Steps towards systematization of data and trends through
  the Health Metrics Network and the Syrian National                        Public health services: changes
  Health Accounts.3,8                                                       implemented to structure
                                                                            Progress in public health was achieved through the provision
The following two tables highlight a declining infant mortal-               of free health care to citizens, with a ceiling on charges for
ity rate (IMR) and a greatly improved maternal mortality rate               private providers. The right to comprehensive health cover-
(MMR).                                                                      age is guaranteed by the Constitution of Syria despite exter-
   Table 1 shows significant declines in IMR from 132 per                    nal pressures to fully commercialize the health sector,5,10,11
100 000 live births in 1970 to 14 in 2010; and in MMR                       .80% of beds remained in the public sector and a fee-
from a high of 482 per 100 000 live births in 1970 to 45 in                 for-service system is applied for outpatient services. Health
2010. The decrease is a notable achievement, given the rela-                services were facing a restructure owing to a major agree-
tively low per capita income and public expenditure on                      ment with the EU in 2003, which was subsequently inte-
health services.9 – 11                                                      grated into the 10th Five-Year Plan (2006 – 2010). But
   Syria appears to be somewhat of an outlier for health out-               despite the changes resulting from this agreement the core
comes in the region in relation to per capita expenditure on                of health care remained in the hands of the MOH, an

    Table 1 Essential health indicators: IMR, MMR, Syria, 1970– 2010         Table 2 MMR comparatively with other countries of the region over
    (actual) and 2015 (projected to MDGs)                                    1990 – 2008

                              1970 1993 2002 2003 2004 2010 2015             Year          Egypt               Syria               Jordan

    IMR per 100 000 live      132      33    24   18.1   17.1   14     12    2008           82 (51 –130)          46 (20– 100)      59 (35 – 100)
    births                                                                   2005           90 (56 –150)          50 (22– 110)      66 (38 – 120)
    U5 MR per 100 000         164      44    29   20.2   19.3   16     13    2000          110 (69 –180)          58 (26– 130)      79 (46 – 140)
    live births                                                              1995          150 (94 –240)          77 (34– 180)      95 (55 – 170)
    MMR per 100 000           482    107     71   65.4   58     45     32    1990          220 (130 –350)      120 (52– 290)       110 (64 – 210)
    live births
                                                                             Source: maternal mortality 1990 –2008—WHO, UNICEF –WB,
    Source: Ministry of Health, Damascus, Syria, CBS (2010).                 MM estimation. Inter-Agency group.
S YR I A , P U B LI C H E A LT H , CI V I L WA R , S A N C T I O N S   3

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Fig. 1 Syria: total health spending and IMR in 2006 comparing with other low- and middle-income countries. Source: compiled from Gap-minder: www. (2012).

enduring feat in an epoch of commercialization and privat-                 Product. Their consequences, particularly for population
ization that has permeated the whole region.12 – 14                        health, are having a serious impact.14,15
   Whilst there is a growing trend towards the commercial-                    Economic sanctions have caused the USD exchange rate
ization and fragmentation of services in Syria by province,                value of the Syrian Pound (SP) in the market to rise from
the health indicators of the country with an emphasis on                   45 to .70 SP with ramifications for the whole economy.
managing risk and attention to preventive services remained                Table 3 highlights the cost of basic essentials such as
a credit to the public sector. The country’s health services               cooking oil and gas, milk and eggs. These have doubled and
have mainly stood apart in a fragile picture of public health              tripled over the past year, halving the purchasing power of
in the region where there is a strong emphasis on high-tech                salaries which in turn are affected by the loss of parity of
tertiary care with a general lack of preparedness for the                  the SP. The combination of price increases and the loss of
growing incidence of non-communicable disease.9,13,15 – 19                 value of income has had a devastating effect upon families
There is a risk also that Syria will abandon its legacy of inte-           especially among those with children, pregnant women and
grated care.                                                               elderly people unable to access health services or to pur-
   Despite weaknesses in the trajectory of current health ser-             chase essential food and medicines owing to escalating
vices, health professionals in Syria with support from the re-             costs.7,15,16
gional office of the WHO (EMRO) were able to provide                           The collapse of the exchange rate increased the cost of
more than adequate health care for citizens. Over the past                 health services and in particular of medicines mostly borne
year and more recently, a full-blown civil war as well as eco-             out-of-pocket. The costs of medicines to treat NCDs, for
nomic sanctions is having serious consequences for popula-                 example, are seriously affected.7,14 – 16 The value of salaries
tion health and the health system as we document in the                    has been eroded with thousands of job losses in the service
final section.                                                              sector (tourism in particular) which was booming prior to
                                                                           the conflict.
                                                                              Sanctions have also led to interruptions in power supply
Sanctions and effects
                                                                           for several hours per day in many areas. These expose vul-
Since May 2011, Syria has faced economic sanctions of                      nerable people to extreme winter and summer temperatures
which imports of crude oil and most exports and project                    and undermine the vaccines cold chain supplies contributing
investments form a major part of Syria’s Gross Domestic                    to interruptions in the vaccination programme. In the
4      J O U R NA L O F P U B L I C H E A LT H

    Table 3 Prices of essential goods before and after sanctions                whose numbers escalate by the day and who are fleeing
                                                                                from violence, are increasingly facing dismal conditions
    Item                         Price before sanctions Price after sanctions   which include limited access to basic essentials such as food
                                 (SP)                    (SP)                   and water, compounded by the psycho-social impact (espe-
                                                                                cially on children) of dislocation, living with fear and uncer-
    Gas (one cylinder)           250                     800
                                                                                tainty and without any well-established routine activities.
    Mazoot (1 litre)              13                      30
    Vegetable ghee (Aseel)       615                     675
    (4 kg)                                                                      Sanctions: do they work?
    Cheese 1 kg                   80                     180                    Western governments have long used sanctions and eco-
    Yogurt 1 litre                35                     100                    nomic embargoes as a means of promoting democracy but
    Sugar 1 kg                    50                      65
                                                                                have often failed to acknowledge their effects on civilians
    Cow ghee 1 kg                290                     350
                                                                                despite mounting evidence.14,16,18 – 20 The most recent inter-
    Milk 1 litre                  20                      55
                                                                                national sanctions against Syria were intended to prevent
    Vegetable oil 1 litre         60                     100
    Rice 1 kg                     40                     160
                                                                                conflict but have not deterred the inflow of arms, damaging

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    Eggs 30                       80                     200
                                                                                the economy and health services both of which are intrinsic-
    Tea 250 g                     30                      45                    ally linked.5,14,16,21
    Tomatoes 1 kg                 15                      50                       Sanctions in general have caused controversy because eco-
                                                                                nomic embargoes inevitably affect all parts of an economy
    From                including households. They affect the cost of living, the prices
    1208 (adjusted to May 2012 rates for rice and milk).                        of medicines (which households have to purchase) and the
                                                                                price of utilities such as electricity and water.5,14,15,22 All of
                                                                                these have a direct effect on population health. Such actions in
                                                                                principle contravene the charter of the UN Covenant for
longer term, this will lead to the loss of gains made in infec-
                                                                                Economic Social and Cultural Rights because they cause
tion prevention and control in diseases such as poliomyelitis,
                                                                                major disruption to food, pharmaceuticals and sanitation
and contribute to a rise in morbidity and mortality among
   Sanctions have prevented the entry of essential medical
supplies into the country, including those for cancer, dia-
betes and heart disease, which are not produced locally and
is having an impact upon the thousands dependent upon                           Since the devastation caused to population health by sanc-
such medication to treat long-term conditions.5,14,16,17 There                  tions in Iraq,4,18,20 there have been regular challenges from
are reports that many current refugees into countries bor-                      public health professionals, moral philosophers, human
dering Syria are seeking treatment for urgent chronic condi-                    rights lawyers among others to their use on the grounds
tions.5,14,16,17 The harm to health indicators will remain                      that they are tantamount to ‘collective punishment’ and
hidden as the consequences will only become evident over a                      therefore against international law.5,6,23 [Concerns about
longer period in time.                                                          sanctions were also expressed by the UN’s Committee on
   It is well known that cold weather is especially difficult                    Economic, Social and Cultural Rights as early as 1997. In an
for vulnerable groups such as older people, but in this case                    extensive discussion the Committee noted that trade sanc-
it is aggravated by the difficulties of obtaining oil for                        tions almost always have a dramatic impact on the rights
heating. As the price index (Table 3) shows, the cost of                        recognized in the Covenant on Economic Social and
heating oil increased 2-fold in the past year alone. Cold                       Cultural Rights frequently causing “significant disruption in
weather in the absence of heating will increase droplet and                     the distribution of food, pharmaceuticals and sanitary sup-
respiratory tract infections among the most vulnerable.                         plies.” (Para 3 in http:/,
There are indications that these are on the rise following a                    GENERAL,,,47q7079eO,O.html).] It is not yet clear in
bitterly cold winter in 2011 –2012. In the long run, an in-                     which of these categories Syria will fall into, but the rising
crease in mortality and morbidity, from respiratory tract                       deficiencies to health system infrastructure from a range of
infections among older people and children is likely. It will                   sweeping deprivations already suggest catastrophic effects to
lead also to a loss in gains made towards increasing life ex-                   population health in the years ahead.5,6,22 [Navi Pillay,
pectancy and decreasing child mortality rates. Refugees,                        Commissioner for Human Rights for the UN, reported gross
S YR I A , P U B LI C H E A LT H , CI V I L WA R , S A N C T I O N S   5

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