causes of the syrian civil war essay

Explainer: the Syrian war in one short, easy read

Research Fellow in Conflict Transformation and Social Justice, Queen's University Belfast

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Often described as a “complex web ”, the Syrian war involves numerous actors, dozens of seemingly contradictory alliances and rapidly changing dynamics. But while the war is indeed complicated, making sense of it is crucial to understanding the recent Paris attacks, the refugee crisis in Europe, and the continuing turmoil in the region. Here are the basics – decoded.

How it started

The Syrian “war” began in March 2011, during the Arab Spring, when Syrian president Bashar al-Assad’s government forces launched a violent crackdown against protesters in the city of Daraa . Protests escalated and the regime responds with mass arrests, torture and killings.

In July 2011, the Free Syrian Army (FSA) emerged as the first major rebel group to battle the regime. Comprised largely of defectors from the Syrian armed forces, the FSA’s early successes in seizing military bases and equipment quickly escalated the conflict. By early 2012, it was a full-blown civil war.

How it escalated

Early 2012 also saw the formation of a very different rebel group, Jabhat al-Nusra (the Nusra Front), an off-shoot of the notoriously sectarian group al-Qaeda in Iraq (AQI). Though not the only new group to emerge at this time (the US Defense Intelligence Agency estimates that more than 1,000 rebel groups were operating in Syria by 2013), the Sunni Jabhat al-Nusra quickly changed the dynamic, unleashing suicide bombings and turning the conflict increasingly sectarian.

The Syrian war did not begin as a sectarian conflict, but it quickly became one, especially with the encroachment of regional actors. By mid-2012, the weakening Assad regime was buoyed by direct assistance from long-time (Shia) ally, Iran , and then by fighters from Iran-backed Hezbollah in neighbouring Lebanon.

Meanwhile, seeking the upper hand in their regional cold war with Iran, Sunni Gulf states, such as Qatar and later Saudi Arabia, began supporting Sunni Islamist rebel groups, including Jabhat al-Nusra, with a steady flow of arms and cash.

Meanwhile, the Kurdish minority in north-east Syria, which had so far avoided involvement, declared its own autonomous region in Rojava, in opposition to both Assad and the other rebel groups.

From bad to worse

Exploiting fractures and rivalries among rebel forces, Assad pummelled opposition, militants and civilians alike – and in August 2013 launched a sarin chemical weapons attack on the Ghouta agricultural belt around Damascus. Around 1,400 people were killed. The US president, Barack Obama, previously had identified chemical weapons as a “red line”, but potential air strikes were averted by a deal between the US and Russia in which the US agreed to back off if the Syrian regime, supported by Russia, destroyed its chemical weapons programme .

Indeed, when US airstrikes in Syria did begin the following year, they didn’t target the Syrian regime, but a newly emerged rebel group: the Islamic State in Iraq and Syria (ISIS). Later referred to as Islamic State, and often described by its Arabic acronym, Daesh , it also emerged from AQI, but sought to be independent from al-Qaeda, aiming to establish a caliphate in Syria and Iraq.

Rebuffed by Jabhat al-Nusra leaders and exiled from al-Qaeda in February 2014, ISIS employed brutal tactics and ideologies to – in the apt words of Zach Beauchamp – “out-extremist al-Qaeda in competition for recruits and resources”.

ISIS is winning the extremist PR war and recruits both regionally and internationally, attracting an estimated 30,000 foreign fighters to its ranks by September 2015.

The US, which provides support for some anti-Assad rebels, began airstrikes against ISIS in September 2014. The following year, Russian airstrikes started in support of Assad and were criticised for targeting moderate rebel groups instead of ISIS (now Islamic State).

As Assad hung on, IS gained territory in both Syria and Iraq and grew in reach, in recent weeks claiming responsibility for international attacks against a Russian airliner over Egypt’s Sinai peninsula, a twin suicide bomb attack in Beirut and the Paris attacks .

‘Running out of words’

The Syrian conflict has been described as a civil war, a proxy war and a sectarian war. On one level, the Syrian government, backed by Russia, Iran and Hezbollah, is pitted against the “moderate” rebels, backed by the US-led coalition, Turkey and the Gulf States, with everyone scrambling to contain Islamic State (who also receive funding from the Gulf States). The Kurds are fighting IS and Assad, and are supported by the West, but are also being bombed by Turkey, which is trying to stem a Kurdish uprising within its own borders. Following the latest atrocities – and France’s growing engagement – things could get even more complex.

However you frame it, the war is a humanitarian crisis; more than 220,000 killed, 4.2m refugees , and millions more internally displaced. UN officials briefing the Security Council have said they are “ running out of words ” to describe the horror.

The US and more than a dozen other states, including Saudi Arabia and Iran, have reportedly agreed to a framework that will include a ceasefire and political transition. But steps towards implementation will be slow and difficult.

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Why Is There a Civil War in Syria?

By: Julie Marks

Updated: August 25, 2023 | Original: September 14, 2018

The Syrian civil war, which has devastated the entire country of Syria and its neighbors, is a complex conflict that involves several nations, rebel groups and terrorist organizations.

What started as a nonviolent protest in 2011 quickly escalated into full-blown warfare. Since the fighting began, more than 470,000 people have been killed, with over 1 million injured and millions more forced to flee their homes and live as refugees.

Was Arab Spring the spark that ignited the civil war?

Although many complicated motives led to the Syrian civil war, one event, known as the Arab Spring , stands out as perhaps the most significant trigger for the conflict.

In early 2011, a series of political and economic protests in Egypt and Tunisia broke out. These successful revolts, dubbed the Arab Spring, served as an inspiration for pro-democracy activists in Syria.

However, in March of that year, 15 Syrian schoolchildren were arrested and tortured for writing graffiti that was inspired by the Arab Spring. One of the boys was killed.

The arrests sparked outrage and demonstrations throughout Syria. Citizens demanded the release of the remaining children, along with greater freedoms for all people in the country.

But the government, headed by President Bashar al-Assad , responded by killing and arresting hundreds of protestors. Shock and anger began to spread throughout Syria, and many demanded that Assad resign. When he refused, war broke out between his supporters and his opponents.

“The Syrian government must stop shooting demonstrators and allow peaceful protests; release political prisoners and stop unjust arrests; allow human rights monitors to have access to cities like Dara’a; and start a serious dialogue to advance a democratic transition,” U.S. President Barack Obama stated in a 2011 speech.

“Otherwise, President Assad and his regime will continue to be challenged from within and isolated abroad,” Obama said. By July 2011, Syrian rebels formed the Free Syrian Army (FSA), and a civil war was imminent.

Assad’s crackdown is just one of several problems plaguing Syria.

Even before the Arab Spring-inspired incident, many Syrian citizens were dissatisfied over the government’s incompetency, the people’s lack of freedoms and the general living conditions in their country.

Assad became president in 2000 after the death of his father. Several human rights groups have accused the leader of habitually torturing and killing political opponents throughout his presidency.

A lagging economy, high unemployment, government corruption and a severe drought were other issues that generated frustration among people under Assad’s rule.

Another problem was a tense religious atmosphere in the country: Most Syrians are Sunni Muslims, yet Syria’s government is dominated by members of the Shia Alawite sect. Tensions between the two groups is an ongoing problem throughout Syria and other nations in the Middle East.

A diverse mix of characters complicates the situation.

Since the start of the war, the situation in Syria became much more complicated, as other countries and organized fighters have entered the picture.

Essentially, the Syrian government’s main backers are Russia, Iran and Hezbollah (a militia group based in Lebanon). The United States, Saudi Arabia, Qatar, Turkey and other western countries are described as supporters of moderate rebel groups. Many newer rebel groups have emerged since the war began.

The ongoing conflict also encouraged terrorist organizations, such as ISIS and al-Qaeda, to join in on the chaos. These groups are primarily made up of Sunni militants.

The rebels and Assad’s forces have both fought separate battles against ISIS, while also waging war against each other. To further complicate the dynamics, the United States has also led an international bombing campaign against ISIS targets since 2014.

In April of 2017 and 2018, the United States launched military attacks against chemical weapons sites in Syria. Assad’s office spoke out against the 2017 attacks and said in a statement, “What America did is nothing but foolish and irresponsible behavior, which only reveals its short-sightedness and political and military blindness to reality.”

After the 2018 attack, U.S. President Donald Trump told the press: "The purpose of our actions tonight is to establish a strong deterrent against the production, spread and use of chemical weapons. Establishing this deterrent is a vital national security interest of the United States. The combined American, British and French response to these atrocities will integrate all instruments of our national power—military, economic, and diplomatic.”

The conflict has spawned a humanitarian and refugee crisis of massive proportions.

Experts estimate that 13.1 million Syrians need humanitarian assistance, such as medicine or food. Nearly 3 million of these people live in hard-to-reach areas.

More than 5.6 million refugees have fled the country, and another 6.1 million are displaced within Syria. Turkey, Lebanon and Jordan are credited with hosting the most Syrian refugees.

The outlook is grim, with violence continuing.

By September 2018, Assad's forces had reclaimed control of most of the country’s biggest cities, although parts of the country were still held by rebel and jihadist groups and the Kurdish-led SDF alliance. The last remaining rebel stronghold was the north-western province of Idlib. ISIS’s presence in Syria, meanwhile, has been greatly diminished.

Since 2014, the United Nations has hosted nine rounds of mediated peace talks, known as the Geneva II process. Despite this intervention, little progress has been made.

After negotiations failed in 2014, UN mediator Lakhdar Brahimi apologized to the Syrian people in a statement, saying, "Unfortunately, the government has refused, which raises the suspicion of the opposition that, in fact, the government doesn't want to discuss the (transitional governing body) at all," he said.

Both the Syrian government and rebels appear unwilling to agree on terms of peace. If nothing changes, this war-torn area of the world is likely to be the site of more violence and instability.

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Causes and Consequences of The Civil War in Syria

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Last Updated on December 30, 2016 by

Below are a few resources focusing on the causes and consequences of the ongoing (hopefully soon to be recent) civil war in Syria. (‘War and Conflict’ in relation to development is part of the A Level Sociology Global Development topic).

The causes of the civil war in Syria

This Guardian video does a reasonable job of explaining some of the causes of the Syrian Civil War in five minutes. NB it has its critics – see below!

The trigger event which caused the Civil War in Syria was when 1000s of people took the street in January 2011 to demand political reforms (e.g. elections) inspired by ‘ The Arab Spring ‘ – a wave of violent and non-violent protests which had swept across many North African and Middle Eastern Countries in December – January 2012.

The protesters were protesting about the brutal rule of dictator president Assad who had ruled Syria in the interests of a relatively small elite since the year 2000, when he took over from his father, who had ruled the country since the 1970s, having modernised it while brutally repressing any dissent.

Assad’s response to the protests was to violently repress the initially non-violent protests by shooting over a hundred demonstrators. Over the coming months some of these armed themselves and formed small groups of rebels – the ensuing conflict between Assad’s security forces and the rebels resulted in 60 000 deaths in the first 18 months of the conflict.

The root of the conflict can be further traced back to the after math of World War I when France and Britain established the boarders of the Middle Eastern Countries, lumping many different ethnic groups and religions into Syria. The ethnic/ religious breakdown of Syria’s population is approximately 12% Alawites (President Assad’s ethnic group),8% Christians, 3% Shiites, and 74% Sunnis.

NB – The video has an equal amount of likes and dislikes – with many of the commentators pointing to the fact that the video misses out the role of the USA in causing conflict all across the middle east – commentators argue that the US has a long history of arming rebel groups in the Middle East as part of its foreign policy to deliberately destabilise the region.

Who is Fighting Who and Why?

This second video by VOX starts off by pointing out that the war in Syria is a mess, with four main groups involved:

• The Assad/ government forces, backed by Russia and Iran,
• The Rebels, backed by the Saudis, Turkey and the USA,
• The Kurds, also backed by the USA
• ISIS, which established a ‘Caliphate’ in an area which spread across the Syria-Iraq border.

This video focuses more on how the conflict has develop and points to the important fact that Syria has now become a ‘ Proxy War ’ in which other nation states are effectively fighting each other by funding different factions within the conflict, but without being directly involved themselves.

By 2013 money and troops were being funneled to the rebels by Sunni Muslims (e.g. the Saudis) While Iran (Shia Muslims) funneled money and troops to Assad.

In late 2013, the USA stepped into the war when Obama signed a secret deal for the CIA to train and equip the rebels.

In February 2014 ISIS emerges – which focuses on fighting the rebels and the Kurds, not Assad, and the US now has an ongoing dilemma which confuses matters and possibly prevents the US from taking effective action – who is it’s real enemy – ISIS or Assad?

Up until this time, Assad was losing ground to both the rebels and ISIS until September 2015 when Russia stepped in by bombing US backed rebels, and to date (December 2016) it seems like Assad is likely to defeat the rebel forces.

NB – As with the previous video, this also has its critics, so as with all sources, be skeptical of the validity!

Causes of the Civil War in Syria – A Summary 

To my mind, for the purposes of A level Sociology you can simplify the causes of this conflict thus:

• Nasty bad men (dictators) in the middle east don’t allow people to vote and oppress anyone who opposes them.
• People in many middle eastern countries want the right to vote and basically governments who don’t abuse their human rights.
• They use social media to organise and publicise protests – which spread all over the middle east and quickly to Syria
• The nasty dictator, Assad, wants to cling onto power so he kills hundreds of the protesters
• Other nations have a role to play in perpetuating the crisis – Russia and Iran by funding Assad and the USA by funding the rebels.
• NB – Don’t fall into the trap of seeing the USA as backing the ‘good guys’ and supporting democracy versus the bad Russians and crazy Muslims who want to keep the evil dictator Assad in place because that’s in their economic/ ideological interests – the USA has a history of backing ‘evil dictators’ itself, when they support US interests at least. 
• You could further trace all of these problems back to the ethnic and religious divide/ tensions in Syria, which in turn was at least partially created by the French and British when they invented the country by drawing up artificial boarders after World War I.

The Consequences of the Civil War in Syria

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A Timeline of the Syrian Civil War and Refugee Crisis

A timeline of the syrian civil war and refugee crisis .

The Syrian crisis is the world’s worst humanitarian crisis since World War II.

The horrors and atrocities of this conflict have filled our newspapers, TV screens and minds since fighting broke out in 2011.

After 9 years of conflict, let’s take a look back and see how Syria’s civil war and resulting refugee crisis developed.

2011 — The Syrian Conflict Begins

March: Unrest within Syria as the conflict begins to take hold.

May:   Families begin to flee their homes in search of safety. The first refugees begin to arrive in Turkey.

2012 — First Refugee Camp Opens in Jordan

July: The Za’atari refugee camp opens in Jordan close to the Syrian border.

Although initially opened as a temporary arrangement, the camp becomes home to tens of thousands of Syrian refugees. 

Reaching over 100,000 refugees in its first year. Today it is the largest camp hosting Syrian refugees and is home to more than 70,000 refugees.

2013 — As Conflict Intensifies, The Number of Children Affected Increases

March: Syrian refugee numbers reach the 1 million mark.

2014 — Syrian Refugees Become the World’s Largest Refugee Group

June: The total number of Syrian refugees passes the 3 million mark, with Syrians becoming the largest refugee group in the world.

Tens of thousands try to escape the conflict by attempting the dangerous passage to Europe by sea.

2015 — A World in Shock as Refugee Crisis Makes Headlines

July: Official UN figures show over 4 million Syrian refugees.

September: The world in shock after images are released of a 2-year-old Syrian toddler Aylan Kurdi who washed up on a Turkish beach after attempting to reach Greece.

2016 — Syria Torn Apart By War

July-August: UNICEF rushes much-needed relief and vital support to children caught up in the biggest flashpoints of the war to date. The battle for Aleppo — Syria’s largest city.

September: A bombing campaign causes death and destruction in Aleppo. An estimated 200 airstrikes hit the city.

2017 — One of the Deadliest Years For Children

March: More than 5 million people have now fled conflict in Syria. Official UNICEF figures show 910 children were killed in Syria in 2017.

July: An agreement is reached on curbing violence in southwest Syria during the G20 meeting in Hamburg, Germany. The ceasefire will take effect in July.

2018 — Children Continue to Suffer 

March: During the first three months of 2018, more than 1,000 children have been killed or injured in Syria. 

November: As winter fast approaches, UNICEF prepares winter campaigns to deliver winter clothes and supplies to children affected.

2019 — Refugees Battle Winter Storms and Conflict 

January to February: Winter storms bring further misery to refugees living in camps, and temporary shelters across Syria, Lebanon, Turkey, and Jordan. Now, they must battle snow, rain, heavy winds, and freezing temperatures.

October: US withdraws troops from northern Syria, prompting Turkey to attack US Kurdish allies in the area.

2020 — Children and Families Flee Violence in North West Syria 

January: More than 500,000 children have been displaced, and 77 children killed or injured, as a result of intense violence in northwest Syria since 1 December 2019.

March 15: The 9th anniversary of the Syrian civil war and the resulting Syrian refugee crisis.

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• Civil War Essays

The Syrian Civil War Essay

The Syrian Civil War began unofficially in March 2011 when the public began protests against the Assad regime with Bashar al-Assad as the President. It was officially declared as civil war by the International Red Cross at the end of 2012. The government is receiving support from Russia while the protestors, known as the Free Syrian Army (FSA) have the support of US, Saudi Arabia, Turkey, Qatar and Iran (CBC, 2014).

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The war has led to hundred thousands of causalities in such a short time period. Refugees camps have sprung up around the boundaries of Syria and these refugees have been exposed to the worst conditions. The economy of the country is severely impacted as it is facing international isolation.

Despite the strong ramifications of the war, both sides are adamant in their position and argue that their position is the right one. The FSA argues that it has a right to a democratic government. The government has not been elected by the people. Moreover, the government has been unable to provide the people with the promised economic and political improvement. The root cause of the uprising is unemployment, dictatorship, and corruption. The FSA point out that the government has been violent in the way that it has tried to curb the uprising. The millions of people who had died are mainly the innocent public.

The Assad regime, on the other hand, argues that civil war is not the solution. The FSA has taken up a violent stance in the entire situation. The regime argues that the entire situation could have been approached in a more politically correct manner. The regime has no other option but to strike back. The government has not treated innocent people harshly. It is only the insurgents who had been punished and the government has to take a strong stance against civil war.

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In the personal-social context, the actions of the FSA can be looked from two perspectives. The actions of the FSA are wrong when considered to be taken for individual advantage but FSA is aiming for the improvement of the society. Even the government argues that it is not attacking FSA for personal reasons but to bring about peace in the region. The government here has a privilege over the people because it has power but then again it is also at a disadvantage because it has been criticized for misusing its power. The privilege of power comes with a disadvantage of becoming unpopular.

CBC (2014) Syria’s civil war: key facts, important players, Retrieved from http://www.cbc.ca/news2/interactives/syria-dashboard/ [Accessed 13 September 2014]

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The Syrian Civil War

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The Syrian conflict: a case study of the challenges and acute need for medical humanitarian operations for women and children internally displaced persons

• Rahma Aburas 1 ,
• Amina Najeeb 2 ,
• Laila Baageel 3 &
• Tim K. Mackey   ORCID: orcid.org/0000-0002-2191-7833 3 , 4 , 5  

BMC Medicine volume  16 , Article number:  65 ( 2018 ) Cite this article

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After 7 years of increasing conflict and violence, the Syrian civil war now constitutes the largest displacement crisis in the world, with more than 6 million people who have been internally displaced. Among this already-vulnerable population group, women and children face significant challenges associated with lack of adequate access to maternal and child health (MCH) services, threatening their lives along with their immediate and long-term health outcomes.

While several health and humanitarian aid organizations are working to improve the health and welfare of internally displaced Syrian women and children, there is an immediate need for local medical humanitarian interventions. Responding to this need, we describe the case study of the Brotherhood Medical Center (the “Center”), a local clinic that was initially established by private donors and later partnered with the Syrian Expatriate Medical Association to provide free MCH services to internally displaced Syrian women and children in the small Syrian border town of Atimah.

Conclusions

The Center provides a unique contribution to the Syrian health and humanitarian crisis by focusing on providing MCH services to a targeted vulnerable population locally and through an established clinic. Hence, the Center complements efforts by larger international, regional, and local organizations that also are attempting to alleviate the suffering of Syrians victimized by this ongoing civil war. However, the long-term success of organizations like the Center relies on many factors including strategic partnership building, adjusting to logistical difficulties, and seeking sustainable sources of funding. Importantly, the lessons learned by the Center should serve as important principles in the design of future medical humanitarian interventions working directly in conflict zones, and should emphasize the need for better international cooperation and coordination to support local initiatives that serve victims where and when they need it the most.

Peer Review reports

The Syrian civil war is the epitome of a health and humanitarian crisis, as highlighted by recent chemical attacks in a Damascus suburb, impacting millions of people across Syria and leading to a mass migration of refugees seeking to escape this protracted and devastating conflict. After 7 long years of war, more than 6 million people are internally displaced within Syria — the largest displacement crisis in the world — and more than 5 million registered Syrian refugees have been relocated to neighboring countries [ 1 , 2 ]. In total, this equates to an estimated six in ten Syrians who are now displaced from their homes [ 3 ].

Syrian internally displaced persons (IDPs) are individuals who continue to reside in a fractured Syrian state now comprising a patchwork of government- and opposition-held areas suffering from a breakdown in governance [ 4 ]. As the Syrian conflict continues, the number of IDPs and Syrian refugees continues to grow according to data from the United Nations High Commissioner for Refugees (UNHCR). This growth is continuing despite some borders surrounding Syria being closed and in part due to a rising birth rate in refugee camps [ 5 , 6 ]. This creates acute challenges for neighboring/receiving countries in terms of ensuring adequate capacity to offer essential services such as food, water, housing, security, and specifically healthcare [ 4 , 7 , 8 ].

Though Syrian refugees and IDPs face similar difficulties in relation to healthcare access in a time of conflict and displacement, their specific challenges and health needs are distinctly different, as IDPs lack the same rights guaranteed under international law as refugees, and refugees have variations in access depending on their circumstances. Specifically, there are gaps in access to medical care and medicines for both the internally displaced and refugees, whether it be in Syria, in transit countries (including services for refugees living in camps versus those living near urban cities), or in eventual resettlement countries. In particular, treatment of chronic diseases and accessing of hospital care can be difficult, exacerbated by Syrian families depleting their savings, increased levels of debt, and a rise in those living in poverty (e.g., more than 50% of registered Syrian refugees in Jordan are burdened with debt) [ 9 ].

Despite ongoing actions of international humanitarian organizations and non-governmental organizations (NGOs) to alleviate these conditions, healthcare access and coverage for displaced Syrians and refugees is getting worse as the conflict continues [ 4 , 10 ]. Although Syria operated a strong public health system and was experiencing improved population health outcomes pre-crisis, the ongoing conflict, violence, and political destabilization have led to its collapse [ 11 , 12 , 13 ]. Specifically, campaigns of violence against healthcare infrastructure and workers have led to the dismantling of the Syrian public health system, particularly in opposition-held areas, where access to even basic preventive services has been severely compromised [ 14 , 15 , 16 , 17 ].

Collectively, these dire conditions leave millions of already-vulnerable Syrians without access to essential healthcare services, a fundamental human right and one purportedly guaranteed to all Syrian citizens under its constitution [ 4 ]. Importantly, at the nexus of this health and humanitarian crisis are the most vulnerable: internally displaced Syrian women and children. Hence, this opinion piece first describes the unique challenges and needs faced by this vulnerable population and then describes the case study of the Brotherhood Medical Center (the “Center”), an organization established to provide free and accessible maternal and child health (MCH) services for Syrian IDPs, and how it represents lessons regarding the successes and ongoing challenges of a local medical humanitarian intervention.

Syria: a health crisis of the vulnerable

Critically, women and children represent the majority of all Syrian IDPs and refugees, which directly impacts their need for essential MCH services [ 18 ]. Refugee and internally displaced women and children face similar health challenges in conflict situations, as they are often more vulnerable than other patient populations, with pregnant women and children at particularly high risk for poor health outcomes that can have significant short-term, long-term, and inter-generational health consequences [ 10 ]. Shared challenges include a lack of access to healthcare and MCH services, inadequate vaccination coverage, risk of malnutrition and starvation, increased burden of mental health issues due to exposure to trauma, and other forms of exploitation and violence such as early marriage, abuse, discrimination, and gender-based violence [ 4 , 10 , 19 , 20 ]. Further, scarce medical resources are often focused on patients suffering from acute and severe injury and trauma, leading to de-prioritization of other critical services like MCH [ 4 ].

Risks for women

A 2016 United Nations Population Fund (UNFPA) report estimated that 360,000 Syrian IDPs are pregnant, yet many do not receive any antenatal or postnatal care [ 21 , 22 ]. According to estimates by the UNFPA in 2015, without adequate international funding, 70,000 pregnant Syrian women faced the risk of giving birth in unsafe conditions if access to maternal health services was not improved [ 23 ]. For example, many women cannot access a safe place with an expert attendant for delivery and also may lack access to emergency obstetric care, family planning services, and birth control [ 4 , 19 , 24 , 25 , 26 , 27 , 28 ]. By contrast, during pre-conflict periods, Syrian women enjoyed access to standard antenatal care, and 96% of deliveries (whether at home or in hospitals) were assisted by a skilled birth attendant [ 13 ]. This coverage equated to improving population health outcomes, including data from the Syrian Ministry of Health reporting significant gains in life expectancy at birth (from 56 to 73.1 years), reductions in infant mortality (decrease from 132 per 1000 to 17.9 per 1000 live births), reductions in under-five mortality (from 164 to 21.4 per 1000 live births), and declines in maternal mortality (from 482 to 52 per 100,000 live births) between 1970 and 2009, respectively [ 13 ].

Post-conflict, Syrian women now have higher rates of poor pregnancy outcomes, including increased fetal mortality, low birth weights, premature labor, antenatal complications, and an increase in puerperal infections, as compared to pre-conflict periods [ 10 , 13 , 25 , 26 ]. In general, standards for antenatal care are not being met [ 29 ]. Syrian IDPs therefore experience further childbirth complications such as hemorrhage and delivery/abortion complications and low utilization of family planning services [ 25 , 28 ]. Another example of potential maternal risk is an alarming increase in births by caesarean section near armed conflict zones, as women elect for scheduled caesareans to avoid rushing to the hospital during unpredictable and often dangerous circumstances [ 10 ]. There is similar evidence from Syrian refugees in Lebanon, where rates of caesarean sections were 35% (of 6366 deliveries assessed) compared to approximately 15% as previously recorded in Syria and Lebanon [ 30 ].

Risks for children

Similar to the risks experienced by Syrian women, children are as vulnerable or potentially at higher risk during conflict and health and humanitarian crises. According to the UNHCR, there are 2.8 million children displaced in Syria out of a total of 6.5 million persons, and just under half (48%) of Syrian registered refugees are under 18 years old [ 1 ]. The United Nations Children’s Fund (UNICEF) further estimates that 6 million children still living in Syria are in need of humanitarian assistance and 420,000 children in besieged areas lack access to vital humanitarian aid [ 31 ].

For most Syrian internally displaced and refugee children, the consequences of facing lack of access to essential healthcare combined with the risk of malnutrition (including cases of severe malnutrition and death among children in besieged areas) represent a life-threatening challenge (though some studies have positively found low levels of global acute malnutrition in Syrian children refugee populations) [ 24 , 32 , 33 , 34 ]. Additionally, UNICEF reports that pre-crisis 90% of Syrian children received routine vaccination, with this coverage now experiencing a dramatic decline to approximately 60% (though estimating vaccine coverage in Syrian IDP and refugee populations can be extremely difficult) [ 35 ]. A consequence of lack of adequate vaccine coverage is the rise of deadly preventable infectious diseases such as meningitis, measles, and even polio, which was eradicated in Syria in 1995, but has recently re-emerged [ 36 , 37 , 38 ]. Syrian refugee children are also showing symptoms of psychological trauma as a result of witnessing the war [ 4 , 39 ].

A local response: the Brotherhood Medical Center

In direct response to the acute needs faced by Syrian internally displaced women and children, we describe the establishment, services provided, and challenges faced by the Brotherhood Medical Center (recently renamed the Brotherhood Women and Children Specialist Center and hereinafter referred to as the “Center”), which opened its doors to patients in September 2014. The Center was the brainchild of a group of Syrian and Saudi physicians and donors who had the aim of building a medical facility to address the acute need for medical humanitarian assistance in the village of Atimah (Idlib Governorate, Syria), which is also home to a Syrian displacement camp.

Atimah (Idlib Governorate, Syria) is located on the Syrian side of the Syrian-Turkish border. Its population consisted of 250,000 people pre-conflict in an area of approximately 65 km 2 . Atimah and its adjacent areas are currently generally safe from the conflict, with both Atimah and the entire Idlib Governorate outside the control of the Syrian government and instead governed by the local government. However, continued displacement of Syrians seeking to flee the conflict has led to a continuous flow of Syrian families into the area, with the population of the town growing to approximately a million people.

In addition to the Center, there are multiple healthcare centers and field hospitals serving Atimah and surrounding areas that cover most medical specialties. These facilities are largely run by local and international health agencies including Medecins Sans Frontieres (MSF), Medical Relief for Syria, and Hand in Hand for Syria, among others. Despite the presence of these organizations, the health needs of IDPs exceeds the current availability of healthcare services, especially for MCH services, as the majority of the IDPs belong to this patient group. This acute need formed the basis for the project plan establishing the Center to serve the unique needs of Syrian internally displaced women and children.

Operation of the Center

The Center’s construction and furnishing took approximately 1 year after land was purchased for its facility, a fact underlining the urgency of building a permanent local physical infrastructure to meet healthcare needs during the midst of a conflict. Funds to support its construction originated from individual donors, Saudi business men, and a group of physicians. In this sense, the Center represents an externally funded humanitarian delivery model focused on serving a local population, with no official government, NGO, or international organization support for its initial establishment.

The facility’s primary focus is to serve Syrian women and children, but since its inception in 2014, the facility has grown to cater for an increasing number of IDPs and their diverse needs. When it opened, facility services were limited to offering only essential outpatient, gynecology, and obstetrics services, as well as operating a pediatric clinic. The staffing at the launch consisted of only three doctors, a midwife, a nurse, an administrative aid, and a housekeeper, but there now exist more than eight times this initial staff count. The staff operating the Center are all Syrians; some of them are from Atimah, but many also come from other places in Syria. The Center’s staff are qualified to a large extent, but still need further training and continuing medical education to most effectively provide services.

Though staffing and service provision has increased, the Center’s primary focus is on its unique contribution to internally displaced women and children. Expanded services includes a dental clinic 1 day per week, which is run by a dentist with the Health Affairs in Idlib Governorate, and has been delegated to cover the dental needs for the hospital patients . Importantly, the Center facility has no specific policy on patient eligibility, its desired patient catchment population/area, or patient admission, instead opting to accept all women and children patients, whether seeking routine or urgent medical care, and providing its services free of charge.

Instead of relying on patient-generated fees (which may be economically prohibitive given the high levels of debt experienced by IDPs) or government funding, the Center relies on its existing donor base for financing the salaries for its physicians and other staff as well as the facility operating costs. More than an estimated 300 patients per day have sought medical attention since its first day of operation, with the number of patients steadily increasing as the clinic has scaled up its services.

Initially the Center started with outpatient (OPD) cases only, and after its partnership with the Syrian Expatriate Medical Association (SEMA) (discussed below), inpatient care for both women and children began to be offered. Patients’ statistics for September 2017 reported 3993 OPD and emergency room visits and 315 inpatient admissions including 159 normal deliveries and 72 caesarean sections, 9 neonatal intensive care unit cases, and 75 admissions for other healthcare services. To better communicate the clinic’s efforts, the Center also operates a Facebook page highlighting its activities (in Arabic at https://www.facebook.com/مشفى-الإخاء-التخصصي-129966417490365/ ).

Challenges faced by the Center and its evolution

The first phase of the Center involved its launch and initial operation in 2014 supported by a small group of donors who self-funded the startup costs needed to operationalize the Center facility’s core clinical services. Less than 2 years later, the Center faced a growing demand for its services, a direct product of both its success in serving its targeted community and the protracted nature of the Syrian conflict. In other words, the Center facility has continuously needed to grow in the scope of its service delivery as increasing numbers of families, women, and children rely on the Center as their primary healthcare facility and access point.

Meeting this increasing need has been difficult given pragmatic operational challenges emblematic of conflict-driven zones, including difficulties in securing qualified and trained medical professionals for clinical services, financing problems involving securing funding due to the shutdown of banking and money transferring services to and from Syria, and macro political factors (such as the poor bilateral relationship between Syria and its neighboring countries) that adversely affect the clinic’s ability to procure medical and humanitarian support and supplies [ 40 ]. Specifically, the Center as a local healthcare facility originally had sufficient manpower and funding provided by its initial funders for its core operations and construction in its first year of operation. However, maintaining this support became difficult with the closure of the Syrian-Turkish border and obstacles in receiving remittances, necessitating the need for broader strategic partnership with a larger organization.

Collectively, these challenges required the management committee and leadership of the Center to shift its focus to securing long-term sustainability and scale-up of services by seeking out external forms of cooperation and support. Borne from this need was a strategic partnership with SEMA, designed to carry forward the next phase of the Center’s operation and development. SEMA, established in 2011, is a non-profit relief organization that works to provide and improve medical services in Syria without discrimination regarding gender, ethnic, or political affiliation — a mission that aligns with the institutional goals of the Center. Selection of SEMA as a partner was based on its activity in the region; SEMA plays an active role in healthcare provision in Idlib and surrounding areas. Some other organizations were also approached at the same time of this organization change, with SEMA being the most responsive.

Since the Center-SEMA partnership was consummated, the Center has received critical support in increasing its personnel capacity and access to medicines, supplies, and equipment, resulting in a gradual scale-up and improvement in its clinical services. This now includes expanded pediatric services and the dental clinic (as previously mentioned and important, as oral health is a concern for many Syrian parents and children). The Center also now offers caesarean deliveries [ 41 ]. However, the Center, similar to other medical humanitarian operations in the region, continues to face many financial and operational challenges, including shortage of medical supplies, lack of qualified medical personnel, and needs for staff development.

Challenges experienced by the Center and other humanitarian operations continue to be exacerbated by the ongoing threat of violence and instability emanating from the conflict that is often targeted at local organizations and international NGOs providing health aid. For example, MSF has previously been forced to suspend its operations in other parts of Syria, has evacuated its facilities after staff have been abducted and its facilities bombed, and it has also been subject to threats from terrorist groups like the Islamic State (IS) [ 42 ].

The case study of the Center, which evolved from a rudimentary medical tent originally located directly in the Atimah displacement camp to the establishment of a local medical facility now serving thousands of Syrian IDPs, is just one example of several approaches aimed at alleviating the suffering of Syrian women and children who have been disproportionately victimized by this devastating health and humanitarian crisis. Importantly, the Center represents the maturation of a privately funded local operation designed to meet an acute community need for MCH services, but one that has necessitated continuous change and evolution as the Syrian conflict continues and conditions worsen. Despite certain successes, a number of challenges remain that limit the potential of the Center and other health humanitarian operations to fully serve the needs of Syrian IDPs, all of which should serve as cautionary principles for future local medical interventions in conflict situations.

A primary challenge is the myriad of logistical difficulties faced by local medical humanitarian organizations operating in conflict zones. Specifically, the Center continues to experience barriers in securing a reliable and consistent supply of medical equipment and materials needed to ensure continued operation of its clinical services, such as its blood bank, laboratory services, operating rooms, and intensive care units. Another challenge is securing the necessary funding to make improvements to physical infrastructure and hire additional staff to increase clinical capacity. Hence, though local initiatives like the Center may have initial success getting off the ground, scale-up and ensuring sustainability of services to meet the increasing needs of patients who remain in a perilous conflict-driven environment with few alternative means of access remain extremely challenging.

Despite these challenges, it is clear that different types of medical humanitarian interventions deployed in the midst of health crises have their own unique roles and contributions. This includes a broad scope of activities now focused on improving health outcomes for Syrian women and children that are being delivered by international aid agencies located outside of the country, international or local NGOs, multilateral health and development agencies, and forms of bilateral humanitarian assistance. The Center contributes to this health and humanitarian ecosystem by providing an intervention focused on the needs of Syrian women and children IDPs where they need it most, close to home.

However, the success of the Center and other initiatives working to end the suffering of Syrians ultimately relies on macro organizational and political issues outside Atimah’s border. This includes better coordination and cooperation of aid and humanitarian stakeholders and increased pressure from the international community to finally put an end to a civil war that has no winners — only victims — many of whom are unfortunately women and children.

Abbreviations

the Brotherhood Women and Children Specialist Center

Internally displaced persons

Maternal and child health

Medecins Sans Frontieres

Non-governmental organizations

Outpatient department

Syrian Expatriate Medical Association

United Nations Population Fund

the United Nations High Commissioner for Refugees

The United Nations Children’s Fund

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Joint Masters Program in Health Policy and Law, University of California - California Western School of Law, San Diego, CA, USA

Rahma Aburas

Brotherhood Medical Center for Women and Children, Atimah, Syria

Amina Najeeb

Department of Anesthesiology, University of California, San Diego School of Medicine, San Diego, CA, USA

Laila Baageel & Tim K. Mackey

Department of Medicine, Division of Global Public Health, University of California, San Diego School of Medicine, San Diego, CA, USA

Tim K. Mackey

Global Health Policy Institute, San Diego, CA, USA

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We note that with respect to author contributions, all authors jointly collected the data, designed the study, conducted the data analyses, and wrote the manuscript. All authors contributed to the formulation, drafting, completion, and approval of the final manuscript.

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This community case study did not involve the direct participation of human subjects and did not include any personally identifiable health information. Hence, the study did not require ethics approval.

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Amina Najeeb and Laila Baageel, two co-authors of this paper, were part of the foundation of the Center, remain active in its operation, and have a personal interest in the success of the operation of the clinic. The remaining authors declare that they have no competing interests.

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Aburas, R., Najeeb, A., Baageel, L. et al. The Syrian conflict: a case study of the challenges and acute need for medical humanitarian operations for women and children internally displaced persons. BMC Med 16 , 65 (2018). https://doi.org/10.1186/s12916-018-1041-7

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DOI : https://doi.org/10.1186/s12916-018-1041-7

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