Tuesday, 1 October 2019

Syria’s economic struggle

Image result for http://www.synaps.network/ War by other means Syria’s economic struggle

 'War has both gutted Syria’s economy and reconfigured the economic activity that remains. While swathes of the country have been destroyed and depopulated, others have absorbed their people, businesses, and economic capacity. Dozens of businesspeople across Syria testified to this chaotic transfer of wealth, which has spurred limited economic growth even as it introduces new forms of socioeconomic dysfunction.

 Syria’s coastal cities are perhaps the starkest and most consequential embodiment of this trend. Having remained comparatively stable throughout the war, the cities of Latakia and Tartous absorbed wave upon wave of displaced people from Homs, Aleppo, and Idlib—an influx that both strained and buoyed the region’s economy in a time of stagnation. A hotel manager in Tartous—whose economy has for decades relied on tourists visiting the coast’s Mediterranean beaches—stressed the paradox: “The period from 2012 to 2017 was a bad time for tourism. But even so, all the hotels and resorts were rented out by displaced families.”

 Newcomers included traders and industrialists from Aleppo and Homs—two erstwhile transit hubs and manufacturing centers laid low by siege and bombardment. Such individuals frequently brought their small- and medium-sized businesses with them, palpably accelerating the region’s economic activity. A resident of Latakia described how a street that comprised only shuttered shops before 2011 now buzzes with activity, thanks to Aleppans who rented and re-opened every last storefront.

 This upsurge in commercial activity marks a major historical shift, as Syria’s economic center of gravity had long been distributed along the north-south axis from Aleppo to Damascus. That shift has triggered multiple disruptions, not least in the form of competition between the newly arrived and pre-war laborers and businesspeople: “Carpenters from Homs and Aleppo work harder and are more experienced than the locals here,” said a Homs native who moved his furniture shop to Tartous in 2013. “So they compete with the locals and often push them out of the labor market.”

 Another fault-line divides established elites and wartime profiteers seeking to launder their wealth in the regular economy. This particular schism takes on an unmistakable sectarian hue, as predominantly Alawi nouveaux riche break into markets historically controlled by Sunnis and Christians. Yet this shift also fuels pragmatic collaboration, in a symbiotic relationship where longstanding business figures contribute their expertise while upstarts supply fresh cash and connections to the security apparatus. A Christian restaurant owner in Tartous city summed up this dynamic, in a tone that conveyed his own sectarian bent:

 “Historically, Sunni families have run Tartous’ restaurants, coffee shops, and hotels. Christians ran wine stores as well as those restaurants serving alcohol. In the last two years, more and more Alawi security officers and militia leaders bought restaurants, cafes, and wine shops from Sunnis and Christians.

 I’ll leave Syria someday soon and expect to sell my shop to an Alawi. I’ve received multiple offers from Alawis already. They have plenty of money to buy it, but can’t run it like I do: I have much experience making high quality food and wine, and these people have money only. As a result, you see Alawi officers buying up restaurants but keeping Sunnis and Christians as managers and chefs, while most of the waiters and cleaning staff are young Alawis.”

 Although some coastal Alawis have successfully cashed in on Syria’s conflict economy, most have been plunged into misery and work menial jobs simply to get by. A community that was downtrodden before the war has been further impoverished by Syria’s overall economic malaise, as well as the death, disappearance, or debilitation of countless young men who formed the backbone of the régime’s security apparatus. The result is a complex tapestry of inequality and frustration: While the coast’s established business owners chafe at rising competition from displaced people, an expanding Alawi underclass finds itself more neglected than ever—despite sacrificing tremendously in defense of the régime.

 Those displaced from Homs and Aleppo also converged on the city of Hama, in central Syria. The latter was largely spared by the conflict, and thus took on growing importance as an administrative hub: As the provincial capitals of Idlib and Raqqa fell from government control, Damascus relocated those cities’ state offices (along with staff and resources) to Hama, which thus became the de facto capital of three provinces. Meanwhile, the city’s strategic positioning—at a crossroads between areas controlled by the régime, the rebels, and the Kurdish Autonomous Administration—rendered it a hub for transit and trade. An Aleppan industrialist, speaking from his factory just south of the city, recounted his own move:

 “I came to Hama in early 2014 when the clashes in Aleppo reached [the industrial zone of] Sheikh Najjar. Hama is a stable city with a perfect location. I know hundreds of traders and industrialists who were displaced from Aleppo and restarted their businesses here. Lots of traders from Homs, Idlib, and Raqqa also opened companies in Hama and now buy their materials from Hama-based suppliers.”

 A textiles trader and Hama native echoed this point, noting the irony that locals often seem to benefit from new arrivals even as they resent them:

 “My profits increased more than tenfold during the war. Every day, there are traders and shop owners from Raqqa and Idlib who come to buy garments and textiles in bulk to sell in their hometowns. My brother has a real estate office and most of his clients are displaced people. My brother-in-law has a big ice cream shop, which also mostly sells to displaced people. Everyone here is making money off the displaced, even while complaining about them.”

 This uneasy growth represents, in part, the inheritance of Hama’s bloody history. The city bore the brunt of the régime’s repression of a Muslim Brotherhood-led insurgency in the 1980s, and still bears the scars. This legacy helped deter Hamwis from fully casting their lot with the 2011 uprising, and continues to shape a tense relationship between original residents and newcomers—many of whom are civil servants employed by the state. “Hamwis don’t trust these outsiders,” remarked a grain trader and member of a deep-rooted Hama family. “They consider them loyalists and informants.” Political sensibilities overlap with social schisms between Hama’s urban, conservative population and displaced constituencies that tend to be more rural and secular. “The people of Hama are very religious,” added the same trader. “The newcomers are Sunni like us, but they’re not devout.”

 Those tensions are further informed by a historic strain of competition between Hama and Homs, which lies just 45 kilometers to the south. In a striking mirror-image of the present, it was Hama’s destruction allowed Homs to flourish in the 1980s and 1990s. Today, Homs—which was at the vanguard of Syria’s 2011 uprising—remains economically paralyzed following its own ruinous showdown with the régime. Some Homsis look bitterly at their northern neighbor, which has profited from the very war for which they paid dearly.

 Meanwhile, Homs itself has been reorganized in ways that add to many residents’ frustration. As the régime’s siege and military campaign flattened swathes of the city’s predominantly Sunni western quarters and commercially vital old souq, Homs’ internal center of gravity shifted toward its mostly Alawi eastern quarter. The latter has witnessed its own miniature boom, as fighters and militia leaders have sought to reinvest their spoils. An NGO worker from an Alawi neighborhood described the area’s transformation:

 “Eastern Homs has thrived, but in a very brittle way. It’s mainly militia figures who open a shop with the few thousand dollars they made looting, despite having no idea how to run a shop. They go out of business and are replaced by someone else who doesn’t know, either. The whole system is based on theft, but at this stage there’s nothing left to steal. So decline is coming.”

 Much of Syria’s wartime growth feels similarly ephemeral, as entrepreneurs rush to spend ill-gotten gains in response to rapidly changing demands. “Just as trade and services produce quick money,” remarked a Syrian economist, “construction is absorbing a lot of cash—but that will create a bubble.” By contrast, Syria’s industrial sector—integral to any large-scale recovery—has bleak prospects, for lack of investment, expertise, and government support. “Industry will be a hellish sector to work in for years to come,” added the same economist. “Reviving the industry would take partnerships between the nouveaux riche and those old industrialists with expertise.” For now, many of the latter remain in exile.

 Amid this economic free-for-all, Syria’s state—far from providing structure or guidance—contributes to the turmoil. A degraded and cash-strapped government abstains from all but the most perfunctory forms of governance, focusing instead on funding itself in ways that push the country deeper into a downward spiral. At the heart of Syria’s crumbling state is its embattled bureaucracy, which is so severely underpaid and under-resourced that civil servants can only live by taking on multiple jobs and engaging in diversifying forms of petty corruption. At best, well-intentioned government employees do their jobs inadequately as a result. A government firefighter described his situation:

 “The government wants soldiers, not employees. They don’t really care how ordinary citizens are living. Our salaries don’t exceed 20,000 pounds [approximately 40 dollars], so really we’re working for God more than anything else. I’m the leader of a fire brigade and I still have to work as a taxi driver and depend on support from my family. Everyone in the brigade has another job.

 The state bought our fire suits through a corrupt contractor, and you can tell the suits are basically plastic. In a serious fire I think they would melt on our bodies. We only have one driver for our firetruck, so if he’s not around when we need him, there’s nothing we can do.”

 This deterioration has diverse and far-reaching implications for an economy originally built on socialist principles and which still relies on intensive state intervention in sectors such as industry, energy, trade and agriculture. Even in some areas it has controlled throughout the conflict, the state has retreated from a host of essential functions such as providing key subsidies and ensuring core municipal services like waste management. A state-employed agronomist remarked on the declining support to agriculture on the Syrian coast:

 “Greenhouse farmers in Latakia and Tartous are mostly from families with ties to the army, security services, and loyalist militias. Those farmers have been calling for the government to supply them with heating oil, chemical fertilizers, and pesticides. The government has given them nothing.”

 Where the state retains positive economic functions, it does so in selective and self-serving ways. In 2019, for example, Damascus reasserted its traditional role in purchasing wheat at fixed prices from private farmers, despite the latter’s concentration in areas controlled by the Kurdish Autonomous Administration. This move—and its extensive coverage by state media—was eminently political, reflecting Damascus’ effort to reestablish economic influence in northeastern Syria while reducing its own reliance on imported wheat. In another telling example, a resident of the Damascus suburb of Harasta noted that his neighborhood, unlike many others, had been cleared of rubble and now enjoys free, 24-hour electricity. Indeed, it is adjacent to the strategically vital M5 highway and contains or abuts multiple military sites. A top-tier régime crony is rumored, moreover, to have slated the area for redevelopment.

 As the state retreats, citizens are left to navigate an ad hoc process of privatization in which the government intervenes to extract resources—in an extreme version of Syria’s liberalization drives in the 1990s and 2000s. Municipal councils in Douma and other ruined areas of Eastern Ghouta provided a stark illustration in late 2018: “If people want to remove rubble, they must rent bulldozers from the municipality at their own expense,” said a real estate broker from Damascus. “The municipality deals only with the main roads. Municipal workers are known to damage buildings by removing rubble carelessly, so people prefer to do it themselves anyway.”

 The bureaucracy’s shrinking capacity coincides with its growing propensity for graft. Syrians from all walks of life—including civil servants themselves—consistently grumble about a metastasizing culture of corruption. They occasionally joke that Syrian society is now responsible for subsidizing the state, in a stark reversal of the Baath régime’s socialist roots. A factory owner described this dynamic, and the resulting disruptions:

 “Government employees now meddle in everything. A low-level employee from the Electricity Directorate can walk into my factory and inspect every inch of it without giving a reason. The same is true of employees dealing with water, phone lines, taxes, health, environment, local administration, and customs.

 Just a few days ago, four employees from customs came to my factory shouting and demanding to see our entire facility, even the kitchen. I asked why they were being so rude; they responded that they have the authority to check anything and arrest anyone. Eventually I paid a bribe. Before that, a committee from the Environment Directorate came to the factory to check if we were using harmful substances. If I hadn’t bribed them, they could easily have fabricated a report and shut my factory down.”

 The state’s extractive tendencies extend from the bottom to the top. Even as government bodies have largely ceased to function as architects of economic policy, they continue to interfere in sectors that present opportunities to siphon money back into state coffers. “The régime is making life harder for everyone,” said one businessman. “As a manufacturer, I was recently required to purchase a million stickers from the government to place on my products to prove they were made in Syria. It cost me 14 million pounds [approximately 30,000 dollars] at a time when I’m already struggling to break even.”

 These simultaneous processes of withdrawal and interference are particularly evident in the import-export sector. As Syria has become increasingly isolated and unproductive, exports have plummeted and reliance on imports from neighboring states as well as from Russia, Iran, and China has deepened. Among other problems, this trade imbalance piles onto the shortage of foreign currency reserves created by American and European sanctions.

 Damascus has coped with this pressure by micromanaging the flow of imports, concentrating rights with select individuals and ratcheting up various fees. In the most striking example, the much-anticipated reopening of Syria’s border crossing with Jordan in late 2018 ushered in a brief uptick in trade which was quickly stifled by a reported eight-fold increase in dues on trucks transiting from Jordan. From Damascus’ perspective, such restrictions limit private importers’ ability to expend foreign currency and increase prospects for high-level corruption. Yet they also cancel out the revenues from partial trade normalization, while undermining the very exporters Syria needs to bring in foreign currency. An exporter of foodstuffs described his difficulties:

 “The Central Bank now demands that we sell back our dollars to the government at the [artificially strong] official exchange rate of 435 pounds. In the gray market, the rate is 615 pounds—and that’s the rate at which we buy all our raw materials. That means we lose almost 200 pounds on every dollar. We are working for a government that gives us nothing in return: no subsidies, no materials, nothing.”

 By and large, Syria’s most vital economic allies are only adding to these structural failures. On one side, Moscow and Tehran are vital to keeping Syria’s economy afloat, through desperately needed shipments of fuel and wheat alongside an overall strengthening of trade relations as all three countries seek to circumvent Western sanctions. Cheaply-made Russian and Iranian products have gradually permeated Syrian markets. China has remained a key trading partner, but likewise has shown no tangible movement toward large-scale investments.

 On the contrary, Russia and Iran look to recoup their expenditure in Syria by appropriating growing shares of its remaining assets, in a process that amounts to mortgaging the country’s economic future. Most striking is Russia’s deepening influence over Syria’s oil, gas, and phosphate resources. An oil engineer from Homs described this process:

 “In early 2018, Russian companies started entering Syria’s oil and gas sector. Those companies signed contracts with the Syrian government whereby they will invest in and operate oil and gas fields, taking about 25 percent of the profits—while previously the Syrian government ran everything and took all the revenues. Russia wants to monopolize this sector and pushes the government not to issue contracts to any non-Russian companies.”

 Syria’s seaports also represent prime real estate for Russian and Iranian encroachment. In early 2019, Syrian authorities granted a Russian company a 49-year lease on the commercial port of Tartous, drawing criticism even from loyalists who accused Damascus of giving away vital economic infrastructure. Tehran has reportedly been vying for a similar role, through discussions between the Syrian government and an Iranian company seeking to take over management of Latakia’s seaport. If successful, this takeover would both entrench Iran’s economic influence and invite new sanctions-related woes. A manager with an international shipping company described the risks:

 “The Iranian bid for the port puts the Syrian government in a difficult position. It’s very hard for the government to say no, but it’s impossible for them to say yes: Giving an Iranian company control of the port is like shooting yourself in the head, because Western companies cannot deal with the Iranians. They would immediately have to stop shipping there.”

 Syria’s hollowing out goes beyond jaw-dropping figures on death, destruction, conscription, and displacement: It has eroded society’s very ability to regenerate what was lost.

 Syria’s agricultural sector provides a window into Syria’s self-perpetuating downward spiral. Rural communities across Syria have proven remarkably adaptable throughout the war and small-scale agricultural production has shown signs of bouncing back faster than more capital-intensive spheres like industry and energy. Yet farmers from Deraa to Homs to Hassakeh underscore the enduring challenges posed by plummeting human capital—from unskilled laborers to specialized professionals. A farmer in rural Hama lamented crippling emigration:

 “You can’t have farming without farmers. I would guess that a third of our village has left. And the situation remains unstable, so people are continuing to leave. I personally plan to emigrate with my family in the coming months. Most others have similar plans. I can’t honestly say that I think anyone will be left in a few years. If emigration continues at this pace, it will wipe out the area’s agriculture entirely.”

 An ongoing brain drain has likewise pared down government institutions—responsible for bolstering agriculture and other key sectors—in ways that further complicate the prospects for recovery. “Our qualified accountants and managers left for Turkey, the Gulf states, and Europe,” said an employee with Syria’s Agricultural Bank, a government entity extending loans and subsidies to farmers. “Low government salaries discourage university graduates from coming to work for state-run banks, when they could make double in the private sector. New employees are mostly the widows and daughters of martyrs.”

 “I have no dreams or plans,” said a third-year student in Damascus University’s Faculty of Agricultural Engineering. “My only dream is to avoid military service. Male graduates have two options: Join the army or leave the country.”

 Compounding this issue is the degradation of the education sector, which has itself been drained of human and financial resources while sinking deeper into its own cycle of corruption and mediocrity. “Instructors have very low salaries, so they’re focused on finding bribes or gifts to support their families,” said the same student. “Some will sell students the answers to an exam in exchange for a smartphone or a bottle of whisky.” A professor in the same faculty added:

 “Since 2011, about a third of my faculty’s professors left the country. Young professors fled to avoid military service. Older, experienced professors emigrated because they found better opportunities abroad, or simply to get their conscription-aged sons out of Syria. Graduation rates are very low, because male students don’t want to graduate: They deliberately fail in order to delay military service.”

 This pattern, whereby the gutting of Syria’s work force is reinforced by the degradation of essential support structures, is replicated across all sectors. A plastics manufacturer in Aleppo’s industrial zone of Sheikh Najjar described his predicament:

 “Factory owners are trying to reopen, but face huge challenges—from the shortage of electricity and fuel to the lack of trained working hands. All the experienced workers have been displaced to rebel-held areas or Turkey. When I talk with other industrialists, they tell me they want to reopen but they can’t find male workers—and, when they do, security services come and arrest them. Before 2011, I had two hundred workers. Today I have twenty men and a few women and children who work in cleaning, packing, and making tea and food for what’s left of the crew.”

 Indeed, the devastation of Syria’s male work force has had the transformative side-effect of thrusting women—and, to a lesser extent, children—into the forefront of economic activity, as families find ways to make ends meet in the absence of male breadwinners. Women have thus assumed an expanding role in virtually every sphere, from the civil service to manual labor to entrepreneurship. “Women play an increasingly prominent role in small-scale business, start-ups, and NGOs,” said an academic in Damascus:

 “It’s less risky for a woman to be in such a position: She’s not at risk of conscription and can move more easily across checkpoints. Meanwhile, 70 percent of those employed at my university are women.

 I’m fearful for the sustainability of this development in the long-run. On one hand, small-scale businesses run by women are largely dependent on funding related to foreign aid programs—they aren’t self-sustaining. On the other, society’s view of these changes is worrying. Men will admit that women working is, for now, the only choice. But there’s this perception that the issue is out of their hands, which exacerbates tensions within families and society. So there’s still much work to be done on this front.”

 Moreover, Syria’s continued stagnation places women at the center of an economy in which most can aspire to little more than survival. The imperative to fight for even a minimal stream of income often locks women and men alike into a sort of wartime limbo, where they cannot so much as return to the hometowns from which they were displaced. A woman in the Damascus suburb of Jaramana explained that she would like to return to her hometown of Qadam, but remains anchored to Jaramana by the need to keep working:

 “I currently live off cleaning jobs, in a school during the week and in private homes on weekends. I can’t return to Qadam because I won’t be able to find such work there. If I did go back, I would have to commute to Jaramana via three different buses, so would spend all my time and money on the road.”

 Syria’s sprawling complex of foreign-funded aid programs aims to rein in such hardship, including through a wide range of capacity building and employment-generating interventions. Such programs, however, often incur unintended side-effects: Well-paid jobs with UN agencies or NGOs tend to suck talent out of other sectors and into a job market whose very existence depends on political decisions taken in faraway capitals. In the process, the aid sector has created another tier of wartime nouveaux riche, whose high salaries are as integral to Syria’s fragile economy as they are galling to the majority who remain mired in poverty.'

Image result for 200 hundred syrian pounds

Under Siege Inside Idlib — The Last Rebel Stronghold In Syria

Idlib Syria

 'Mohammed Sadder was sitting outside with his eldest son in the midday heat when a shell from government-held territory tore through the air and struck his family home.

 His wife, mother, and daughter had been laying out lunch on the living room floor.

 The 62-year-old dug through the dust and rubble, yelling out for any signs of life from his family inside. When he found his wife and mother, they were badly injured, but his 5-year-old daughter Islam had been killed.

 Later that evening, with his wife and mother in the hospital, Mohammed carried Islam’s body a few hundred yards down the road to a hill where hundreds of other bodies are buried. He dug her grave with his bare hands, and collapsed next to the small mound of dirt, not wanting to leave her side.

 Since late April, the Syrian régime and its Russian allies have launched near-daily airstrikes and shelling throughout the province of Idlib, the last rebel stronghold left after 8 years of bitter civil war. While Syrian President Bashar al-Assad claims he is targeting rebel terrorist groups, it’s clear that civilians like Mohammad are bearing the brunt of a relentless and indiscriminate bombing campaign.

 More than 700 civilians, including 300 children, have been killed since the latest offensive began. More than 400,000 more have been displaced in the same time frame, according to the United Nations. Meanwhile, the Syrian Civil Defense teams work round the clock to help struggling families move away from neighborhoods that are still being shelled.

 “It’s an indescribable fear,” said Rajaa Hamdu Kazmuz, a mother of seven. The fighting continues even as Russian, Turkish and Iranian leaders have agreed to multiple ceasefires to end the violence in Idlib Province.

 Kazmuz and her seven children spent the last few weeks sleeping in a makeshift bunker beneath their house, hoping to escape the worst of it until the next lull in fighting. But the shelling has only ramped up in recent weeks, and she’s looked on in horror as several of her neighbors have been killed. They’re currently living without electricity, and basic goods have become hard to get hold of. Her children are afraid to even walk outside.

 So they packed up their belongings in mid-September and drove 60 miles towards Turkey, praying that Syrian President Bashar al-Assad’s bombs wouldn’t reach them there.

 But they’ll face another set of roadblocks on the Turkish border, where displaced Syrians have flooded in by the thousands in recent months. Facing the mounting humanitarian emergency on his border, President Recep Erdogan has warned global leaders that he’ll throw his country’s gates open, sparking fears that another refugee crisis could reach Europe’s borders.

 But few solutions appear readily available. On September 19, the UN voted on a resolution to work towards a peaceful resolution in war-battered Idlib, but China and Russia, killed it, all but assuring the violence in Idlib will continue indefinitely.

 Those in Idlib who cannot afford transport to safer areas, have resigned themselves to their fate.

 The day after burying his 5-year-old daughter, Mohammed shoveled out enough rubble so he could sleep in a corner of what’s left of his home.

 “Where would we go?” he asked, “I don’t even have enough for a cab fare... We’ll clean it up and continue living here.” Pointing to a grave adjacent to his daughter’s, he added, “That’s my spot. If Allah wills it.”

Idlib Syria

‘We’re staying’: The doctors refusing to flee Idlib’s deadly front line

 'The blood forms pools on the floor of a whitewashed operating room. Two men pose for a photo with their table of metal instruments, unable to smile.

 It’s late at night after a long day of airstrikes on Syria’s northwestern Idlib province. The two doctors have been operating on the wounded for hours.

 “This is from a day where we were working from early morning until late at night, treating injuries,” said Dr. Haitham Diab.

 Diab is a surgeon in one of the few hospitals close to the front lines in Idlib that is still operational. He said it was hit by an airstrike in July, but the damage was minor.

 In another photo, Diab can be seen crouched down in a corner of the hospital in a set of wrinkled green scrubs, exhausted. Packages of medicine, gauze, and other supplies lie stacked on metal shelves to his side.

 Diab is among the healthcare workers still doing their job in the midst of a four-month air, artillery, and land campaign waged by Syrian government and allied Russian forces in and around rebel-held Idlib – areas home to an estimated four million people.

 Despite the dangers, many doctors are working under fire with limited supplies, even as more patients need help.

  At the peak of the bombing last month in the southern part of Idlib where he works, Diab said the hospital’s 20 doctors were performing some 40 emergency operations every day.

 Civilians and civilian infrastructure, including hospitals and health clinics, have been hit hard by the offensive.

 Several doctors said the places where they work have been bombed, including the hospital where Diab operates alongside Shaker al-Hamido.

 After an airstrike hit just outside their house several months ago, al-Hamido, a doctor from southern Idlib, said he sent his wife and toddler-aged children north to the Syrian-Turkish border so they could stay somewhere safer.

 “Of course I’m afraid,” he said, but he continues to live and work in the area.

 Among the bombed hospitals are those that voluntarily registered their coordinates with a UN-run no-strike list, which was shared with Russia, Turkey, and the United States as part of a deconfliction mechanism supposed to prevent such facilities from being targeted.

 Al-Hamido and Diab said their hospital had shared its location with the UN.

 The UN says a total of 51 medical facilities – such as hospitals, ambulance points and clinics – have been damaged as a result of attacks since the offensive began.

 At least 14 sites hit by the end of July had shared their coordinates as part of the UN mechanism, according to a tally provided by the Syrian American Medical Society, or SAMS, a US-based group that supports medical facilities in rebel-held areas in Syria.

 Eleven of those sites match incidents recorded by the Armed Conflict and Location & Event Data Project (ACLED), a group that monitors and maps conflict.

 The UN’s emergency aid coordination body, OCHA, which runs the deconfliction system, declined to verify the detailed listings, saying the parties to the conflict were responsible for their conduct under international humanitarian law (IHL) and investigating violations.

 Civilian infrastructure, and medical facilities in particular, enjoy special protection under IHL regardless of whether or not they were “deconflicted”.

 From 27 April to 15 September 2019, ACLED’s latest information, records 69 incidents affecting health workers and patients in northwestern Syria, mainly aerial bombing and shelling by Syrian government and allied Russian forces.

 The Syrian American Medical Society has provided a partial list of strikes on sites whose coordinates were on the UN’s no-strike (or “deconfliction”) list through the end of July.

 Among the hospitals bombed out of service this year was one situated outside Ma'arat al-Nu'man, a town in southern Idlib province. Wassel Aljork, a general surgeon, treated patients there until an airstrike hit it several months ago.

 The hospital, which once served more than 100,000 residents of the surrounding countryside, according to Aljork, is now a pile of rubble.

 When he and other doctors went to survey the wreckage, they found that none of their equipment could be salvaged.

 After the bombing, Aljork left his nearby hometown, where he ran a makeshift clinic out of his house, and headed north. He now works in a hospital near the border with Turkey, where hundreds of thousands of people have fled in search of safety.

 The UN announced earlier this month that it would launch an investigation into attacks on hospitals and other civilian sites, although some doubt how effective it can be.

 “An investigation won’t stop the attacks, but at least it might put some pressure,” says Mohamad Katoub, a doctor and spokesperson for SAMS. The organisation supports some 43 healthcare facilities in Idlib province, according to its website. “We have many concerns about the safety of our medical staff,” he added.

 Some facilities have been built to survive bombardment. Dr. Ahmad al-Bayoush, who specialises in internal medicine, spoke earlier this month as missiles flew overhead. His hospital was moved underground, he explained, to protect it from the bombs.

 Still, the hospital has been hit once already and al-Bayoush worries it could happen again: “The missiles are still flying over us,” he said.

 Those who fled north leave behind dozens of ghost towns in their wake, according to a report published in May by REACH, an organisation that analyses humanitarian data.

 But civilians are still living in southern Idlib; mostly people too poor to afford the cost of transportation out of the area.

 And doctors are running low on supplies to treat them, including some basic medicines like antibiotic creams. “There’s a lot we’re running out of, for surgeries [and] for medical exams,” said Diab. “We’re just working with what we’ve got.”

 The shortages can be deadly. Last month, a man arrived in the operating room having lost his legs in an airstrike. His stomach had been torn open by the blast.

 “We didn’t have enough blood on hand to give him,” said Diab, recalling how the patient died while his wife and children were outside the room. “They were waiting to hear any good news,” he said.

 Al-Hamido said the scale of patients’ injuries is so severe there is often little he can do to save them, even when supplies are on hand.

 One patient sticks in his mind in particular: a pregnant mother who arrived in the operating room in May, after a bomb left her head riddled with shrapnel. The wounds were too deep to save the mother, so al-Hamido and other staff performed a Caesarean section on her in an attempt to save the baby. Despite their efforts, both the mother and child died soon after.

 “I couldn’t save anyone,” al-Hamido said. “I sat down and cried like a child.”

 “This psychological pressure – it’s going to kill us,” he said.

 As pro-government forces continue bombing the area, he and others say they fear what could be in store for southern Idlib, where they work.

 Last month, the Syrian army took the city of Khan Sheikhoun, along a key highway in to the south in Idlib, and doctors worry about their fate if there is a further advance northwards.

 They fear further bombs on their hospitals, but also possible government arrest.

 Late one night, after a shift at the hospital, Diab said he was determined to stay, regardless.

“What else can we do? There is a lot of bombing still happening,” he said. “We’re staying here. As long as there are still people [getting injured], we’ll continue working.” '

Al-Zerbeh Primary Health Center in southern Aleppo after an airstrike on 30 August 2019.