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Earthquake exacerbates ‘prosthetics crisis’ in Syria’s northwest

IDLIB — Five months ago, Muhammad al-Oqda stood in the […]

10 March 2023

IDLIB — Five months ago, Muhammad al-Oqda stood in the plains around the southern Idlib countryside town of al-Bara, looking out towards his hometown of Kafruma in the distance. He was dreaming of “returning to my home, my land, my livelihood,” in the town he was displaced from when the Syrian regime took control of it in 2020. But that day, a landmine exploded, his right leg was amputated and his dream changed. Today, it is “to get a prosthetic limb.”

Like other displaced people living in camps in Hayat Tahrir al-Sham (HTS)-controlled Idlib, al-Oqda, a 29-year-old father of four, is concerned about poor living and economic conditions. But when he lost his leg, and then his construction job, life became much more difficult. Today, he spends his days bedridden in a camp near the town of Killi. He thinks about his own future, and that of his children, making do with a monthly aid basket, he told Syria Direct

In the early years after the 2011 Syrian revolution, as violence was at its height, local and international medical organizations sought out those like al-Oqda to provide treatment and fit them with prosthetic limbs. Today, getting a prosthesis has become difficult, al-Oqda said. He relies on crutches to move about near his tent, but “can’t find work while in this state.” 

Then came the earthquake that struck Turkey and Syria on February 6, killing at least 3,697 people and injuring 15,000 in Syria. Many of the injured had limbs amputated as a result, due to crush syndrome or other injuries, making the crisis of providing prostheses to those who need them particularly salient. 

“The earthquake is a turning point, without a doubt, because the number of people who need to be fitted with prostheses is greater,” said Hassan Ismail (a pseudonym), a technician at a prosthetics and orthotics center in Idlib. 

“Many of those pulled out from under the rubble suffered from limb crush syndrome, which makes amputation necessary,” Ismail told Syria Direct. He fears a “prosthetics crisis” if donors do not respond to the increased need. “The crisis will be more pronounced three months after the earthquake, when a patient finishes emergency treatment, and is physically capable of installing and using a limb.” 

Read more: Crush syndrome and cancer: Earthquake deals blow to Idlib’s health sector

So far, “for prosthetics centers, the elements of the response are the same as they were before the earthquake disaster,” said Mohamad Katoub, an expert in humanitarian response and relief worker protection in Syria. “Prosthetic limbs are a priority, but the problem is with the donors, in terms of allocating resources for this or not. If the response to this sector continues as it was before the earthquake, we won’t see a notable improvement.” 

Al-Oqda is one of 15,000 people in northwestern Syria who need prosthetic fitting or maintenance, according to Ahmad al-Hamdou, the Idlib director of the National Syrian Project for Prosthetic Limbs (NSPPL), which stopped working at the start of the year after it lost funding. Some 60 percent of those who need a prosthesis do not have one, he said.  

This figure was approximate even before the February 6 earthquake. Syria Direct attempted to obtain an estimate for the number of amputations in northwestern Syria due to the earthquake, but so far there are no such statistics available, several medical sources said. 

Doctor Melhem Ghazi, the head of the Directorate of Hospitals in the HTS-backed Salvation Government, said “the Health Directorate documented 15 cases of limb amputation due to the earthquake over the first two days.” The disaster’s impact on the work of prosthetics centers has yet to become apparent, he told Syria Direct

For eight years, the center al-Hamdou runs in Idlib was one of four prosthetics centers providing free services, in which time it provided more than 5,000 prostheses. When it lost funding, the Salvation Government’s Ministry of Health sought to take it over and place it under its management, but so far “nothing has happened, and the center has stopped providing services,” al-Hamdou said. 

Since 2020, active military operations and shelling in northwestern Syria have gradually decreased. But landmines and unexploded ordnance continue to threaten the lives of residents in both opposition-controlled areas and those the regime has retaken. According to a May 2022 report by the Global Protection Cluster, one out of every two people in Syria is at risk of death or injury due to war remnants. One in three people injured suffered amputation of a limb, while two out of three suffered lifelong injuries. 

Ill-suited prosthetics

Four years ago, Hassan Haj Ahmad, 44, had part of his left foot amputated due to complications from diabetes, and managed to get a prosthesis two years later. But several months ago, Haj Ahmad, who lives in the northwestern Idlib town of Abu Talha, had to have more of the same leg amputated. He needs an adjustment to his old prosthesis to suit his new condition, but has so far been unable to do so, he told Syria Direct

Unable to find a public center or charity to perform the adjustment, he contacted a private prosthetics center and explained his situation. To modify the limb, it turned out, required “changing the mold and silicone filling, for $400, of which I only have $10,” he said. 

As a result, Haj Ahmad is back in the same situation he was in before he was fitted with his prosthesis, “sitting, staying at home again, my movement limited to between the bed and bathroom.” 

Al-Hamdou, of the shuttered Idlib prosthetics center, said “prostheses need regular maintenance, which is normal, and that requires prioritizing providing parts and materials.” But given the funding crisis for this sector, “there are more than 1,500 unserved patients in Idlib who need limb maintenance or replacement.” 

For children in particular, the need to adjust or replace prosthetic limbs is particularly prominent. “A child needs a limb replacement periodically, approximately every eight months, because of growth and anatomical changes,” prosthetics technician Ismail said. 

In July 2022, the Salvation Government’s Ministry of Health began licensing prosthetics manufacturing centers. Today, Idlib has 10 such centers, four of which provide free services, according to Ghazi, including one Ministry-affiliated center in Sarmada city opened in June 2021, and another set to open soon in the provincial capital. 

Still, the free centers do not cover all of amputees’ needs, and fees at private centers “are not commensurate with the income of people in the area,” al-Hamdou said. “The most simple piece in manufacturing the prosthetic costs $100, the mold costs $150 and the silicone filling costs up to $250.” 

Lack of staff and funding

When al-Hamdou’s prosthetics center in Idlib was operating, it received patients who were seeking maintenance for limbs that were manufactured in private centers, he said. He attributed that to “a lack of experience, and a number of experienced technicians leaving to work in funded centers in the areas controlled by the Syrian National Army in the Aleppo countryside.” 

Abdulsalam al-Omar (a pseudonym), who lives in the Atma displacement camps, was one of those patients. He had to refit his prosthesis at the center in the northern Idlib town of Aqrabat last year because “the old limb, which I got at a private center for $700, didn’t match my condition,” he said. 

Ghazi agreed, saying “securing qualified technicians to work in this field” is a problem, while a lack of funding remains one of the biggest challenges. 

“The prosthetics sector is constantly suffering from funding cuts,” technician al-Ismail said. As a result, after years of work, these centers “have not risen to the level of meeting the needs of amputees, which are much greater than the centers’ capacity.”

In the early years of the war, prosthetics centers “relied on support provided by humanitarian organizations and institutions, but recently they rely upon limited grants,” Ismail said. While some injured people are able to receive services at private centers free of charge, as “organizations or individuals pay the costs,” they are “a few cases,” he added. 

Another challenge is that funders seek to distribute allocated sums to the largest number of patients. This can impact some of the injured, such as those with amputations to their upper limbs, because the prosthetics are more expensive, according to Ismail. “Twenty below-the-knee amputations can be served for the cost of installing one upper limb,” he said. 

Prosthetics centers “receive specific funds, some from specialized organizations such as Humanity and Inclusion, or from individual donors,” Katoub said. “Government and United Nations (UN) funding in this sector is low, especially with funding cuts,” he added.

Katoub attributed the weak funding for prosthetics projects to “the structure of the emergency response, and the percent of need covered by funding.” The food sector is the only one that is covered by more than 50 percent, while only 26 percent of the health sector is covered under the 2022-2023 Humanitarian Response Plan, according to the Financial Tracking Service of the UN Office for the Coordination of Humanitarian Affairs (OCHA). 

Still, the decline in funding also comes alongside a decline in military operations and bombardment in Syria, al-Hamdou said. He criticized any linking of support for the prosthetics sector with military escalation by donors and organizations, particularly as some amputations result from unexploded ordnance, or health conditions such as diabetes.

This report was originally published in Arabic and translated into English by Mateo Nelson.

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