In Aleppo province, there are currently only 30 doctors serving 300,000 people, according to a report earlier this year from SAMS and Johns Hopkins University.

The shortage of doctors is just part of the fallout of a regime campaign of bombings “deliberately” targeting medical staff and facilities in rebel-controlled areas of the country, says Dr. Carlos Francisco, the Doctors Without Borders (Médecins sans Frontières) head of mission in Syria.

According to data from MSF, 55 percent of hospitals in Syria have been damaged or destroyed during the course of the conflict, most of them targets of regime airstrikes. 

‘Every day it is getting worse because we see every day the medical institutions are targeted and damaged and medical staff are killed or they are fleeing.’ Francisco tells Syria Direct’s Joseph Adams and James Bowker.

“When you see that one building in May, that everyone knows is a hospital, was attacked three times in two days… the entire area was damaged, and is considered unsafe. So when you ask if the [regime is] deliberately targeting or no, I say yes.”

Q: We've noticed reports bemoaning a lack of supplies as well as old and broken equipment. Yet we also recently read a story about a Syrian expatriate doctor who was brought into Aleppo to perform a brain surgery at a local hospital under rebel control. If a visiting surgeon can be brought in to perform a complex operation, what is preventing the entry of equipment and other necessities?

In Aleppo and Idlib, we're dealing with the normal supply issues you would expect in an ongoing war. We regularly send supplies requested by local hospitals, and we usually manage to deliver them. But sometimes, either trouble crossing at the border (with Turkey), or fresh fighting, prevents supplies from arriving on time.

One of the main problems we have actually is maintaining more specialized medical equipment, not only in terms of parts and labor, but in finding specialized technicians who can train local staff on the proper use and maintenance of medical devices so they stay in working order.

In terms of training staff, this is obviously another problem. After four and a half years of war, most senior and highly trained staff have either fled, or have been injured, or even killed. In a recent 2015 MSF assessment of the state of Syria's medical cadre, we found that of the 2,500 doctors were originally working in Aleppo at the start of the conflict, in areas now under the control of the opposition, less than 100 remain.

The problem is not only a lack of doctors, but a lack of technical skills. The risks Syria's doctors and medical staff bear every day, their resourcefulness and commitment to service, are extraordinary and undeniable. Yet after four and a half years, many highly skilled doctors have long left the country. So there are few doctors and medical staff still working in Aleppo, and those that are, often lack many essential technical skills -universities, nursing schools, none are currently operating, which prevents medical staff and doctors from learning and practicing the skills they need.

Q: Are you directly involved with assisting hospitals in the city of Aleppo?

In [rebel-held] east Aleppo, we have a support program. I think we are supplying 11 medical institutions. In northern Aleppo and the countryside, we are supporting a total of 41 medical institutes; mainly hospitals, but also health centers, medical points, ambulance assistance and blood banks.

I would like to highlight another problem: The strategy of armed actors targeting medical facilities. We are collecting data, which shows that 55% of the hospitals in Syria have been damaged or destroyed during these four years of war. Some examples: In East Aleppo in May and June, in the area controlled by the opposition, we saw a campaign of barrel bombs in the city that affected a large number of hospitals and their capacity.

Out of 37 hospitals in Aleppo governorate, 10 of them, 30 percent were damaged by barrel bombs. Amongst this 30 percent affected by barrel bombs are the five biggest hospitals, giving the most specialized trauma and life-saving support. All of them were closed at least for several days until they managed to re-organize, or in some cases to find new locations.

They were not only hospitals, but medical points; the blood bank was also damaged. The ambulance organization system was also targeted and some of the ambulances and medical staff were lost. This is not only in Aleppo.

At the beginning of August we saw a similar campaign in Idlib. In three days, nine hospitals were targeted by aerial strikes and three medical staff were killed. I wanted to point out those specific data to give you an idea how difficult it has been and how damaged the medical institutions in the areas controlled by the opposition. 

At MSF, we estimate that it will take between 20 and 30 years to recover the medical capacity before the war. Every day it is getting worse because we see every day the medical institutions are targeted and damaged and medical staff are killed or they are fleeing.

Q: Does this seem like a deliberate targeting of the medical infrastructure in these cities, or are these random strikes?

When you see that one building, that everyone knows is a hospital, in May, a hospital that we are supporting, was attacked three times in two days. Some of the barrel bombs hit the hospital, the others landed within 15, 20 meters around the hospital. The hospital was directly damaged by some of the barrel bombs, and indirectly by all of the barrel bombs.

Aside from that, the entire area was damaged, and is considered unsafe. So when you ask if they are deliberately targeting or no, I say yes. When you see the pattern, you can see that they are the target.

Not all the areas in Aleppo city are targeted with the same pattern. And we see that not only hospitals, but markets and other areas of population concentration are targeted.

We see for instance that one of the strategies is barrel bombing in one populated area and then 20 minutes later when the ambulances are there, they drop more barrel bombs. In Idlib, they were not barrel bombs but missiles from jets, so that’s clear that the hospitals were directly targeted.

Would you say that the major cause of medical shortages are these airstrikes? Or is it the general fighting? If the airstrikes disappeared tomorrow, would you be able to see progress in the ability to provide care?

That's a very good question. If airstrikes ended tomorrow, for sure it would be easier for everyone to provide and receive medical care. Places would be safe for the medical staff and patients, and if there were not the risk of those attacks the hospitals would be better prepared. Any improvement in the war, if we can guarantee that the hospitals are not targeted, would be much better.

It's not only that hospitals cannot provide medical assistance, it is also difficult for patients when they are exposed to barrel bombs or snipers or fights, its difficult for them to get that medical assistance.

Imagine a vaccination campaign for measles where we need to gather people. In Aleppo city it’s impossible, you cannot gather people anyway because they will become a target.

So the barrel bombs kill in two ways; either with the direct result of the blast, or because people with diseases can't get to health centers for fear of being targeted themselves.

What we see with all war and conflicts, and in Syria, is that when the medical assistance worsens, people don't die only because of direct trauma, but because the medical assistance they are getting and the medical status of the population is worsening.

In Idlib, one of the facilities that was targeted in August was the dialysis center. You can imagine, given all the time until the hospital managed to get the dialysis service running again the situation of all those people suffering who need it.