The vote by the British parliament on 3 December for air strikes on Syria has consequences for the already catastrophic humanitarian and medical situation in Syria and surrounding countries. The four and a half year conflict has already led to considerable destruction of health infrastructure, hospitals, and clinics, and has resulted in the death of at least 679 health workers. 
An estimated 12 million people are displaced without adequate healthcare, shelter, or food.  Official figures are lacking, but an estimated 180,000 civilians (included 20,000 children) have been killed as a direct result of the conflict ; one million people have been injured, and 200,000 have died because of lack of healthcare.
The recent escalation of violence, including Russian airstrikes, has destroyed several hospitals in the past few weeks alone. [4, 5] The destruction of healthcare in Syria has not been accidental with all parties culpable, [6,7] however: government forces have been responsible for most of such attacks. 
A recent Physicians for Human Rights report on Aleppo, one of the cities most affected by the conflict, highlighted that more than two thirds of hospitals are not functioning, with 95% of doctors either killed or having fled the country.  Since October 2015, more than 200,000 civilians in Aleppo province have been forced to flee their homes and move to other parts of the country in search of safety as a direct result of increased air strikes. The areas to which they flee are unsafe, and camps and aid trucks near the borders have been targeted by air strikes in recent weeks. Though British air strikes may not target Aleppo or its surroundings, other areas where civilians remain, or to which civilians have fled, may be affected.
More air strikes will compound the damage to remaining infrastructure and lead to further displacement of civilians, and to more injuries, and deaths. Air strikes will also make the provision of medical and humanitarian care ever more difficult and dangerous. Any increase in violence will lead to already overstretched medical and humanitarian agencies being unable to meet the needs of the civilian population. These agencies are unable to focus on medium or long term development in Syria because the immediate humanitarian crisis will always take priority. This means that traumatised civilians will have little or no hope of overcoming their difficulties. People in besieged areas will bear the heaviest burden with no possibility of avoiding airstrikes. Civilians in these areas are already short of medical aid and food supplies, few aid agencies are able to access them, and few health workers remain to treat injured people.
Medical facilities rely on generators powered by fuel for electricity. Air strikes which target oil refineries will reduce the availability of fuel, driving up prices and hence the running of costs of the few remaining health facilities.
Doctors who remain in Syria fear any increase in air strikes. Rami Kalazi, a neurosurgeon in Aleppo, told us that it is hard to know who is bombing but that he has concern that more air strikes could contribute to the shelling of health facilities and civilians. He says that the facility he works in has already been attacked 35 times by different parties. It is under-resourced, and they often work without electricity, water, or fuel and, like other health workers, he simply wants all attacks to end. An orthopaedic surgeon working in Idlib province told us that at least 30 bombs fell during a single air strike in December, lasting 40 minutes, and which took place while he was operating on an injured patient. The blasts shattered glass and windows, even though the facility in which he was working was not a direct target.
Both doctors pledge to continue providing much needed care to injured civilians, even though their own lives are at risk. Dr Kalazi told us that bombing by any party, regardless of intention, will continue to cause suffering and difficulties for civilians and those seeking to help them.
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2. Baker E, Heisler M. Aleppo Abandoned. A case study on health care in Syria. Physicians for Human Rights. November 2015.
3. The main conflict parties who are killing civilians in Syria: Civilian’s death toll up to the end of October 2015. [accessed 7th December 2015]
4. SAMS Foundation. Press Release: Two Medical Staff killed in Russian airstrikes on Sarmin. 22nd October 2015.
5. Syria: Barrel bombing of MSF-supported hospital kills seven. Medicin sans frontiers. 1st December 2015.
6. Implementation of Security Council resolutions 2139 (2014) and 2165 (2014) [accessed 7th December 2015]
7. Baker E, Brown W. Doctors in the Crosshairs: Four Years of Attacks on Health Care in Syria. Physicians for Human Rights. March 2015. [accessed 7th December 2015]
Aula Abbara is a member of the medical team of Hand in Hand for Syria and infectious diseases/general internal medicine registrar, London.
Omar Gabbar is a member of the medical team of Hand in Hand for Syria and Consultant Orthopaedic Surgeon in Leicester.
Rola Hallam is the medical director of Hand in Hand for Syria and a consultant anaesthetist at the Royal Free Hospital, London.
Competing interests: None declared.