Bombs, Bullets, and Lack of Health Care Has Killed 470,000 Syrians

When the death toll from Syria's increasingly bloody war is discussed, it is sometimes broken down by perpetrator — the regime, ISIS, the rebels — sometimes by method of death – sniper, being crushed by the rubble of one's home after a barrel bomb has been dropped on it, or being killed in a car bomb attack.

But this figure often does not cover the thousands of deaths that have occurred indirectly due to the war.

Far less visible than trauma injuries, chronic illnesses are killing thousands of Syrians with otherwise treatable problems.

A new report released today by the Syrian Center for Policy Research puts the overall death toll at 470,000, and states that 11.5 percent of the country's citizens have been killed, wounded or maimed since the start of the conflict. Previously the most accepted death toll was 260,000, provided by the Syrian Observatory for Human Rights. The UN itself stopped counting in 2014.

But obtaining accurate data in this murky war is extremely difficult. A 2014 report conducted by Save the Children estimated that, since 2011, more than 200,000 Syrians died of "treatable chronic diseases such as cancer, asthma and diabetes – double the number killed by violence."

Related: The UN Says a Syrian Regime Siege of Aleppo Would Be a Total Catastrophe

"Everyone can recognise trauma injuries, which are so obvious because of airstrikes and bombings and the conflict," said Dr. Abdulkarim Ekzayez, Save the Children's programme coordinator for Syria, in a Skype interview from southern Turkey. "But actually, from my perspective as a medical specialist, the risk of other public health risks are even greater than the trauma and the injuries."

Before the 2011 Syrian uprising descended into all-out war, Syria boasted an enviable healthcare system — all treatment, including primary, secondary and specialized care, was free, for all Syrians.

Since then, the healthcare system has been destroyed. Hospitals and medical workers have been deliberately targeted, largely by the regime, and there has been a huge exodus of doctors.

By the end of 2015, at least 700 medical staff had been killed, according to Physicians for Human Rights and some 240 medical facilities had been attacked, many repeatedly.

Medicine is also scarce, especially in besieged areas.

In Eastern Ghouta, just outside of the capital Damascus, two patients have died from kidney failure in the last week alone, having been unable to receive the necessary dialysis treatment due to the regime's blockade of the area, according to Dr. Anas, a surgeon at the Unified Medical Office in Douma, who only gave his last name.

Related: Another Doctors Without Borders Hospital Has Been Bombed in Syria

Anas said that one man Saed Aldura, was in his mid-20s. The relatives of the other patient requested that he remain anonymous.

"We have another two patients who are suffering. They will die soon if they do not have a dialysis session," Anas said by Skype.

Widney Brown, programme director at Physicians for Human Rights, predicts that "significant numbers" are dying due to chronic illnesses such as kidney failure, alongside others such as high cholesterol, heart diseases, and diabetes.

"They were manageable diseases, and now you have people dying when they would not have otherwise," she said.

"When you destroy the healthcare system, then people die not just of injuries related directly to the conflict."

The Douma medical center has also run out of drugs to treat tuberculosis, from which 143 people are suffering in the Eastern Ghouta area, Anas said.

The regime, he said, keeps refusing or delaying shipments.

In terms of human resources, Aleppo city had around 5,000 trained physicians before the war. Now, no more than 30 remain, Save the Children's Ekzayez said, since many have fled to neighboring countries, or the Gulf. "So you can imagine the huge shift."

Ekzayez himself was a doctor in Aleppo, shuttling between the regime and opposition-held sides of the city until 2013. But it was too dangerous, and eventually he had to get out.

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"It was so difficult, especially for medical staff, because they were accused from each side of helping people on the other side," he said.

If the war were to end tomorrow, "You'll have to rebuild the healthcare infrastructure, pretty much from scratch," said Brown.

Brown says that many of the doctors who fled have been denied the right to work, so they are becoming "deskilled."

It is, "really tragic, they had such a good healthcare system before. And such well-trained doctors, so many of whom have left or been killed."

The most immediate step, Brown says, will be to bring back those doctors who were practicing, "and get them back up to speed… and get those whose education was interrupted the training they need. A lot of them are in limbo. Many are practising in field hospitals, but this is not recognised."

Those who do return will arrive to a different Syria, one scarred by war, and with a whole host of new medical problems.

They will have to deal with health issues which are "outside of their purview," Brown says.

Around one million Syrians are living under siege, according to the latest information from Siege Watch, published this week. The opposition has demanded that these sieges be lifted before any serious talks can be held with the regime. But it is not as simple as just lifting the sieges, Brown stressed.

Malnourishment is not cured overnight, but can lead to long term health complications, including stunted growth in children, and weakened immune systems.

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"If sieges were lifted tomorrow … I think we will see chronic illnesses among young people because of these compromised immune systems," Brown said.

Ekzayez is most concerned with the threat posed by contagious diseases, many of which are spreading rapidly, especially in areas with dense populations and poor sanitation, such as refugee and camps for internally displaced people.

Syria's once rigid vaccination program has also collapsed in opposition-held areas, and so all children born over the last five years have missed their routine immunization shots.

Polio re-emerged in Syria in late 2013, after having been eradicated over a decade previously. Mass vaccination campaigns have since been carried out by various actors, including Save the Children, but it remains a threat, Ekzayez said.

In five facilities which Save the Children supports in northwest Syria, some 200 to 300 new typhoid cases are reported each week. Whooping cough, measles, and hepatitis B are also dangers, and for all of these, vaccines are currently unavailable.

Of the many thousands of people held in regime prisons, while the psychological complications are perhaps more obvious, there will be physical side-effects also, Brown says, related to joint and muscle problems from restricted movement.

Related: The Syrian Regime Is Systematically Exterminating Prisoners, UN Inquiry Says

"And some percentage of the population will experience PTSD," she adds, which has both physical and psychological aspects.

Even before the war is over, the trauma of living through it, or fleeing and living in exile, can contribute to physical symptoms, said Sam Taylor at Medecins Sans Frontiere.

In an MSF clinic in Jordan, there is a three-month waiting list for chronic illnesses such as heart disease and hypertension.

"What civilians are exposed to inside Syria and the trauma of having to flee and being a refugee is causing diseases, such as heart disease and hypertension among patients who did not have it before," Taylor said, stressing the need for simultaneous mental health care.

"In order for our patients to heal… you have to have mental health care."