BEIRUT – After over four years of siege in the rebel-held suburb of Damascus, the current pro-government offensive and increasing scarcity of vital supplies are likely to be the “last story” from Eastern Ghouta, according to Dr. Annie Sparrow, one of the best-known medical experts on Syria.

Despite repeated requests by the United Nations for humanitarian access and doctors’ appeals for help, the siege in Eastern Ghouta is ongoing and residents have increasingly limited access to food, medicine and supplies needed for shelter. The World Economic Forum’s annual meeting in Davos this year was likely the last chance for the international community to help improve what U.N. Syria envoy Staffan de Mistura said has now become the “epicenter of suffering,” Sparrow told Syria Deeply.

“This is our last opportunity to even talk about [the siege],” said Sparrow, an assistant professor at the Arnhold Global Health Institute at the Icahn School of Medicine at Mount Sinai Hospital, who has contributed to a number of healthcare reports on Syria.

Pro-Syrian government forces began their siege of Eastern Ghouta in 2013, cutting hundreds of thousands of residents off from the rest of the world. Though aid deliveries to the area were always scarce, the situation grew even direr last year when smuggling routes and tunnels were destroyed.

In conjunction with Davos, Syria Deeply spoke to Sparrow about the deteriorating healthcare situation in Eastern Ghouta, the failure to end the siege and what needs to be done to improve the humanitarian situation.

Syria Deeply: You’ve been in contact with health workers in Eastern Ghouta since 2012. What’s the situation like for them now?

Annie Sparrow: The sheer stress is so unimaginable. After so many years of siege and the escalation of the military campaign since November, I’ve never seen such stress, such pressure. It’s so unbearable for the doctors. We used to talk every day, [now] there is no time. We have voice letters [notes, for recording messages] maybe if we’re lucky. Even the surgeons, if they eat anything, they eat there in the operation room. It is crazy. It’s dreadful.

To have this ethical burden, where you have so few medical resources left and you have to decide which patients have the chance of surviving and which patient is going to die because you just can’t keep everyone alive, it’s really the most insane and awful position for a doctor to be in because we are used to being able to treat everyone.

[We] triage according to the medical emergency but we will treat everyone in the end, anyone who has a chance to live will live. You can’t do that anymore; anyone with only a 30–50 percent chance of survival will have to be sacrificed for those who have a higher chance.

If you’re in Douma right now, you’re 500 yards [450m] from the front line. There’s no light at the end of the tunnel. We used to be able to say, “Oh well, [if] there’s no light at the end of the tunnel, then you could walk down and light the bloody thing yourself.” You had to make the light yourself. None of us has ever seen it, where the pressure has escalated to this degree where there is no light, there’s no tunnel.

There’s no way to make any hope. It’s the extinguishing of hope that is so horrible. There’s no way to get an escape route, make a tunnel, negotiate, there’s nothing left to negotiate with. The doctors … have to negotiate with the militias in Ghouta, persuade them to agree to release some more prisoners to the government in order to let a convoy in, which has absolutely no guarantee of containing anything useful.

Syria Deeply: What is now the most urgent need in Eastern Ghouta?

Sparrow: There are maybe 25 patients with dialysis for end-stage renal failure. If they don’t get dialysis supplies within the next few weeks, they will die. Which may sound like a small number, but it’s a lot of human suffering and that extinguishment of hope. I don’t know whether you call hope a human right, but once you extinguish the hope, it’s how you destroy the community.

It’s not a new thing – dialysis has been withheld from the convoys since 2014 … then after that they built the tunnels. That was very prescient because they could tell they weren’t going to achieve this any other way, they couldn’t rely on the government or the U.N. to do anything.

While the tunnels were there they could still get treatment that they really needed. We can’t bribe anything in anymore. In the past, you could still smuggle things in, but you can’t do that anymore. There’s no way in and there’s no way out.

From the beginning, any convoy that went in wasn’t allowed to contain anything useful. Maybe if they send any vaccines in, it will be 10 percent of what is needed. They won’t put anything in that is important for the doctors’ protection like hepatitis B vaccine to protect them from blood-borne disease that spreads much more rapidly in doctors when they’re exposed to so much blood.

They haven’t had any normal saline for years, under the pretense that it could be used to treat terrorists. If you’re a pregnant woman and you have a cesarean section, you need to have saline because your blood pressure will drop. That’s the way it is. In the past, they were told to drink liters of salty water like oral rehydration to try and compensate. But with the price of salt in Ghouta, you can’t get salt in Ghouta anymore.

Syria Deeply: Why haven’t U.N. agencies been able to fill the gap left by the destruction of smuggling routes?

Sparrow: The elephant in the room that is still not being addressed is how is the U.N. still working with the government? By working with the government, it legitimizes the government and makes it OK for donors. The biggest donors for the World Health Organization are Norway, the U.K., the U.S., European countries, Japan. The WHO says they need hundreds of millions of donors, for health alone … how can it still justify asking when it clearly, demonstrably, cannot get a single thing in [to Eastern Ghouta] that’s useful?

Insulting is not the right word, but when you send in a convoy that is full of empty jerry cans and some strips of water treatment tablets … this is not useful. Don’t send it. Don’t pretend you’re sending something useful when this is just worse than useless. You’re not sending any surgical supplies, you’re not allowed to send sutures, you’re not allowed to send fluids.

Two years ago I had an argument at Davos with [former head of the United Nations Office for the Coordination of Humanitarian Affairs] Stephen O’Brien. He knew it was impossible [to get supplies to Eastern Ghouta] but he said, “You shouldn’t be talking about this, you’re compromising the Four Towns Agreement and our ability to get supplies in.” [I said] Who told you that lice were the biggest problem? They don’t need any more scabies medication, they don’t need any more useless medicines, they don’t need any more clothes. Don’t pretend that you’re sending something useful when you’re not.

Syria Deeply: What are the current options to improve the humanitarian situation?

Sparrow: In Turkey, you can have a conversation to ask [Turkish president Recep Tayyip] Erdogan to ask [Russian president Vladimir] Putin to put the pressure on Assad to stop the airstrikes on civilians, to allow some convoys in, or to allow the hundreds of patients out, but none of that is happening.

It’s not helpful that we don’t have an international consensus … people have had Syria fatigue for two or three years now.

The U.N. still justifies working with the government. If it didn’t, then we might see international members actually withdraw that funding and start to fund the groups that are still working on the ground or supporting those working on the ground, whether it’s SAMS [Syrian American Medical Society] or MSF [Medecins Sans Frontieres]. That is the only way to mitigate the misery and possibly even get the government to behave better.

Syria Deeply: Do you expect any progress to come out of this year’s Davos for Ghouta or for aid in general in Syria?

Sparrow: Four years ago, with the polio outbreak … my role was to explain the work of thousands of healthcare workers across northern Syria who were vaccinating kids and getting the job done with the help of the Turkish government and support of the CDC [Centers for Disease Control and Prevention]. That led Bill Gates to take the trouble to find out about this and he started to fund cross-border Syrian efforts. That was really terrific and [the Gates Foundation] has continued vaccination efforts for those routine childhood diseases that we can prevent so easily.

The polio epidemic that has now spread to Raqqa and elsewhere, that’s still not under control, is vaccine-derived polio. That is emblematic of a community … that is under-immunized, undernourished and very vulnerable, where a vaccine-derived polio virus can take up and spread.

Syria is very vulnerable in general. Syria is so incarcerated, there’s a whole scene of Syria where it’s very difficult for anyone to get in or out. So we’re not seeing the same concerns of “refugees might spread these terrible diseases, therefore we should get on and help keep them in Syria,” which is a pragmatic, political way of thinking. Because it’s so contained within Syria, we’re not actually understanding the gravity of what this means.

Even though Ghouta is the worst of the worst, the whole of Syria is in this abysmal public health crisis that is not getting any better and it can’t get any better. There are things that we should do, like ease the medical sanctions so that you can import medical equipment, but the U.N. should be downsizing its presence in Damascus to focus more on cross-border efforts because those are the efforts that are still reaching the people who need it most. At the moment, it’s generally not interested.

I think that’s the bit that really kills all of us, watching the disintegration of Ghouta. I’m watching it and thinking, why? How is it possible that we can still be talking about this? How is it possible that our standards are now so low that we think it’s OK to talk about deleting [aid from] convoys and we don’t say “lift the siege already.”

This is Syria’s last chance. After this, there are no more chances to put any more pressure on … after Ghouta falls.

The views expressed in this article belong to the author and do not necessarily reflect the editorial policy of Syria Deeply.

These responses have been lightly edited for length, sense and clarity.