Two years ago, at the beginning of the violence in Syria, I was asked to write a blog in the British Medical Journal on behalf of Medecins Sans Frontieres. As a medical-humanitarian organisation, we were particularly outraged by the way in which public health facilities were being infiltrated by security forces. Patients wounded in demonstrations were pulled out of hospitals and doctors treating the wounded in makeshift clinics were tortured and imprisoned. These were colleagues, pursuing our common ethical obligations in our normally privileged places of work, the hospital.
Because we were unable to obtain permission from the government in Damascus to work directly on the ground, we started to support networks of colleagues with medical supplies and training in what became known as clandestine clinics, a term that carries a certain forbidden romantic connotation.
But they were not romantic at all, they were bloody and dirty places where poorly trained medical staff did their best to save the wounded with little equipment and limited medical supplies.
Later we opened our own makeshift trauma hospitals in the north of the country in areas controlled by the opposition. Normally we work on all sides and negotiate with all parties in a conflict, but without permission from the government, this has proven impossible.
In Syria we have worked at the edge of our capacities and at the limits of our principles, crossing borders and finding a space to work in this increasingly complex and dangerous place.
When I wrote that blog there was much expectation that shuttle diplomacy by the then United Nations-League of Arab States Joint Special Envoy for the Syrian crisis, Kofi Annan, would result in a peace accord and that influential alliances of neighbouring states, global leaders in the West and in the Gulf would negotiate an end to the civil war.
Two years later, Syria is the worst place on the planet to live. We can assume this because everyone has started to leave, Syria is haemorrhaging people at the rate of 5000 to 6000 a day. The conflict has taken its toll; an estimated 100,000 people have been killed. That's more or less 100 people a day for the last 2 years who are direct victims of the violence. There are also an unmeasurable number of indirect victims because of the collapse of the public health system: women without care in childbirth, children no longer vaccinated, adults without treatment for their chronic ailments like diabetes and hypertension. Essential medicines are in short supply, electricity is cut and there are food and fuel shortages.
This flood of people fleeing Syria is being received into refugee settlements and camps in the four neighbouring countries; Jordan, Iraq, Turkey and Lebanon who are now host to 1.5 million Syrians. Nobody willingly chooses to move to another country where you don't know anyone and where you are reliant on the support of international organisations and welfare. It's the absolute last option to move into a refugee camp.
While Medecins Sans Frontieres continues to negotiate for access through Damascus, for now it is only possible to work in opposition-controlled areas where we run five hospitals. Our offer of care now extends beyond emergency trauma care to respond to today's realities: obstetrics, vaccinations and chronic care. We are doing more than most other organisations but it's simply not enough. The gap between what is needed on the ground and what we are able to provide is widening. Medecins Sans Frontieres has been critical of the humanitarian response both inside and outside Syria. It's not sufficient. The international aid effort is failing and falling further behind each day.
Ultimately, the solution will not come from a group of foreign doctors. International and regional bodies, the UN and the Security Council are paralysed by indecision. These institutions, created and mandated to limit the madness of war, are crippled by the incalculable permutations and associated risks of any assertive action they take today. Meanwhile, the entire region begins to shake, another day, another 100 lives and another 5000 refugees ... just another day in Syria.
I have worked in some pretty ugly spots, but coming away from Syria I was really disturbed, less by the conflict and what I was seeing in the clinics than by what seemed to be almost a mass psychosis in the population. You could read it in their faces, manifest in some as profound sadness and in others as intense rage and anger. I left Syria wondering what the recovery of this country will look like. The international community must take action now to put in place the conditions for that recovery to happen and the humanitarian response must be massively scaled up to cope with the enormous needs inside and outside Syria.
Dr Greg Elder is the deputy director of operations for medical-humanitarian organisation Medecins Sans Frontieres. He joined the organisation in 2001 and has worked in Sudan, Timor, Thailand, Nigeria, Somalia, Haiti and Ethiopia.