On the tenth anniversary of the onset of the Syrian conflict, we—members of The Lancet–American University of Beirut Commission on Syria—recognise the devastating impacts of this unresolved conflict, which we will detail in a forthcoming report of this Commission, and call on all parties to end the ongoing suffering of the people of Syria. The conflict in Syria has caused one of the largest humanitarian crises since World War 2, with extensive deaths, displacement, and destruction along with multidimensional health effects. More than 585 000 people have died in this conflict.1Syria Observatory for Human RightsSyrian Revolution nine years on: 586 100 persons killed and millions of Syrians displaced and injured.https://www.syriahr.com/en/157193/Date: March 15, 2020Date accessed: March 11, 2021Google Scholar Child life expectancy in Syria has dropped by a shocking 13 years.2World Vision InternationalFrontiers EconomicsToo high a price to pay: the cost of conflict for Syria's children.https://www.wvi.org/emergencies/syria-crisis-response/syria10/cost-conflict-syrias-childrenDate: March 4, 2021Date accessed: March 10, 2021Google Scholar More than half of Syria's pre-conflict population remains displaced, including 6·2 million internally displaced persons (IDPs)3UNHCRSyria: internally displaced people.https://www.unhcr.org/sy/internally-displaced-peopleDate accessed: March 11, 2021Google Scholar and 6·7 million refugees,4Todd Z By the numbers: Syrian refugees around the world. PBS Frontline.https://www.pbs.org/wgbh/frontline/article/numbers-syrian-refugees-around-world/Date: Nov 19, 2019Date accessed: March 11, 2021Google Scholar both the highest numbers for any country. There is widespread destruction within Syria; by 2017 in three Syrian cities alone, over 1·2 million housing units were damaged and more than 400 000 were destroyed.5World Bank GroupSyria damage assessment of selected cities: Aleppo, Hama, Idlib. Phase III March 2017. World Bank Group, Washington, DC2017http://documents1.worldbank.org/curated/en/530541512657033401/pdf/121943-WP-P161647-PUBLIC-Syria-Damage-Assessment.pdfDate accessed: March 11, 2021Google Scholar This extensive damage is largely due to heavy use of explosive weapons, particularly in urban settings, resulting in high contamination with explosive remnants of war.6Carter CenterUsing conflict data to help demining efforts in Syria.https://www.cartercenter.org/news/features/p/conflict_resolution/using-conflict-data-for-demining-in-syria.htmlDate: Aug 31, 2020Date accessed: March 11, 2021Google Scholar Conflict actors have committed violations of international law on “an epic scale”;7Amnesty International UKSyria: “flagrant war crimes” being committed in Eastern Ghouta.https://www.amnesty.org.uk/press-releases/syria-flagrant-war-crimes-being-committed-eastern-ghoutaDate: Feb 21, 2018Date accessed: March 10, 2021Google Scholar UN Secretary-General António Guterres said on March 10, 2021, Syria's “people have endured some of the greatest crimes the world has witnessed this century”.8UN NewsTen years on, Syrian crisis “remains a living nightmare”: UN Secretary-General.https://news.un.org/en/story/2021/03/1086872Date: March 10, 2021Date accessed: March 11, 2021Google Scholar The health sector is not spared. Weaponisation of health care, including attacks on health-care facilities and targeting of health-care workers, has been a defining feature of this conflict.9Fouad FM Sparrow A Tarakji A et al.Health workers and the weaponisation of health care in Syria.Lancet. 2017; 390: 2516-2526Summary Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 10International Rescue CommitteeA decade of destruction: attacks on health care in Syria.https://www.rescue.org/sites/default/files/document/5648/adecadeofdestructionattacksonhealthcareinsyria.pdfDate: March 2, 2021Date accessed: March 10, 2021Google Scholar A new timeline of attacks on health-care facilities against conflict events from Physicians for Human Rights (PHR) shows how such attacks have been used as a war strategy.11Physicians for Human RightsA 10-year timeline of attacks on health care in Syria.https://phr.org/our-work/resources/syria-ten-years/Date: March 11, 2021Date accessed: March 11, 2021Google Scholar Half of the 113 public hospitals and more than half of the 1790 public health centres in Syria are either partly functioning or not functioning at all as of November, 2020.12WHOWHO Syria. Summary of key indicators.https://applications.emro.who.int/docs/SYR/EMRLIBSYR266E-eng.pdfDate: November 2020Date accessed: March 11, 2021Google Scholar Residents fear accessing or living near health facilities because of attacks.10International Rescue CommitteeA decade of destruction: attacks on health care in Syria.https://www.rescue.org/sites/default/files/document/5648/adecadeofdestructionattacksonhealthcareinsyria.pdfDate: March 2, 2021Date accessed: March 10, 2021Google Scholar PHR has documented the killing of 923 health workers in Syria since 2011 and systematic detention and torture of health workers who had provided aid to protesters.13Physicians for Human Rights“My only crime was that I was a doctor”. How the Syrian Government targets health workers for arrest, detention, and torture.https://phr.org/our-work/resources/my-only-crime-was-that-i-was-a-doctor/Date: December, 2019Date accessed: March 10, 2021Google Scholar Research by Annsar Shahhoud based on interviews with health workers involved in torturing opposition activists in hospitals suggests the scale and systematic nature of atrocities committed under Syrian Government direction, which she describes as “medical genocide”.14Shahhoud A Medical genocide: mass violence and the health sector in the Syrian conflict (2011–2019). Master's thesis in Holocaust and Genocide Studies. University of Amsterdam, Amsterdam2020Google Scholar Syria largely faded from international headlines after the March 6, 2020, ceasefire between Russia and Turkey that ended a pro-government offensive in the northwest of Syria and reduced hostilities. However, the conflict and violence against civilians continue, with the country still a “living nightmare”.8UN NewsTen years on, Syrian crisis “remains a living nightmare”: UN Secretary-General.https://news.un.org/en/story/2021/03/1086872Date: March 10, 2021Date accessed: March 11, 2021Google Scholar In the northwest around Idlib, the conflict still smoulders against millions of trapped civilians. The Syrian Network for Human Rights' (SNHR) statistics for 2020 tell the picture: 1882 arbitrary arrests and 1734 violent civilian deaths including 326 children and 157 torture deaths.15Syrian Network for Human RightsStatistics of 2020.https://sn4hr.org/blog/category/charts/statistics-of-2020/Date: Jan 1, 2021Date accessed: March 10, 2021Google Scholar A UN Syrian Commission of Inquiry issued a damning report in September, 2020, accusing all conflict parties, domestic and foreign, of human rights violations.16UN Commission of Inquiry on SyriaNo clean hands—behind the frontlines and the headlines, armed actors continue to subject civilians to horrific and increasingly targeted abuse.https://www.ohchr.org/EN/HRBodies/HRC/Pages/NewsDetail.aspx?NewsID=26237&LangID=EDate: Sept 15, 2020Date accessed: March 10, 2021Google Scholar Arrests and forced disappearances, affecting more than 149 000 people since the conflict began in 2011,17Syrian Network for Human RightsStatistics of 2020: record of arbitrary arrests.https://sn4hr.org/blog/2021/01/01/arbitrary-arrests-2020/Date accessed: March 10, 2021Google Scholar represent a crime by the state and other conflict parties and continue to agonise countless Syrian families, yet receive little attention in political and global health discussions on Syria. The lives of most Syrians now are filled with hardship. IDPs and refugees live in deplorable conditions, harder than they have been at any time in the past decade. In Syria and refugee-hosting neighbouring countries, more than 23 million people need humanitarian assistance.18Norwegian Refugee CouncilThe darkest decade: what displaced Syrians face if the world continues to fail them.https://www.nrc.no/globalassets/pdf/reports/2021-darkest-decade/darkest-decade/the-darkest-decade.pdfDate: March, 2021Date accessed: March 10, 2021Google Scholar The vast majority of Syrian refugees live below the poverty line. Many refugees and IDPs are unable to return home because of fear of insecurity, reprisal, arrest, torture, or military draft, among other concerns, compounded by the Syrian Government's threats to identity and property.19Center for Operational Analysis and ResearchNew civil status law raises concerns over identity cards and HLP rights. Syria update vol. 4, no. 10.https://coar-global.org/wp-content/uploads/2021/03/Syria-Update-8-March-2021.pdfDate: March 8, 2021Date accessed: March 10, 2021Google Scholar In Syria, economic collapse, caused by various factors including war, government policies, financial woes in Lebanon, and US and EU economic sanctions,20Hubbard B Saad H Having won Syria's war, al-Assad Is mired in economic woes.The New York Times. Feb 23, 2021; Google Scholar has led to chronic shortages of essentials such as bread and fuel, widespread poverty, hyperinflation, and loss of livelihoods. The UN World Food Programme reports that 12·4 million people across Syria are food insecure.21World Food ProgrammeWFP Syria country brief.https://www.wfp.org/countries/syrian-arab-republicDate: January, 2021Date accessed: March 10, 2021Google Scholar The health needs in Syria after 10 years of conflict are vast, ranking third after food and protection needs.22UN Office for Coordination of Humanitarian AffairsSyrian Arab Republic 2021 needs and response summary.https://reliefweb.int/sites/reliefweb.int/files/resources/som_summary_2021.pdfDate: February, 2021Date accessed: March 10, 2021Google Scholar There are major women, child, and adolescent health challenges but inadequate interventions.23Akik C Semaan A Shaker-Berbari L Jamaluddine Z et al.Responding to health needs of women, children and adolescents within Syria during conflict: intervention coverage, challenges and adaptations.Confl Health. 2020; 14: 37Crossref PubMed Scopus (12) Google Scholar Coverage for required child immunisations has dropped considerably during the conflict years.24WHOSyrian Arab Republic: WHO and UNICEF estimates of immunization coverage: 2018 revision.https://www.who.int/immunization/monitoring_surveillance/data/syr.pdfDate: 2019Date accessed: March 11, 2021Google Scholar War-related injury prevalence is unknown, but much of the 30% disability prevalence in Syria—double the global average—is probably attributable to war injuries.25Humanitarian Needs Assessment Programme (HNAP) I SyriaSpring 2020 report series disability overview.https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/assessments/syria_disability_overview_-_hnap_spring_2020_report_series-1_final.pdfDate: 2020Date accessed: March 11, 2021Google Scholar This is a serious challenge in a country with limited rehabilitation services. The health system is fragmented into subnational disconnected systems in areas under control of different conflict actors and cannot meet the complex health needs of the population. Ratios of health-care workers and functional primary health-care centres are below emergency standards in 135 subdistricts, home to 12·2 million people.22UN Office for Coordination of Humanitarian AffairsSyrian Arab Republic 2021 needs and response summary.https://reliefweb.int/sites/reliefweb.int/files/resources/som_summary_2021.pdfDate: February, 2021Date accessed: March 10, 2021Google Scholar In areas reconciled with or recaptured by the Syrian Government after 2018, there is insufficient active rebuilding of the health system and widespread health inequalities.26Physicians for Human RightsObstruction and denial: health system disparities and COVID-19 in Daraa, Syria.https://phr.org/wp-content/uploads/2020/12/PHR_Obstruction-and-Denial_Health-System-Disparities-and-COVID-19-in-Daraa-Syria_Dec-2020.pdfDate: December, 2020Date accessed: March 10, 2021Google Scholar In northwest Syria, extremist groups infringe on health rights and medical practice.27Syrians for Truth and JusticeHTS stormed the free Hama Health Directorate and arrested doctors.https://stj-sy.org/en/1104/Date: Dec 19, 2018Date accessed: March 10, 2021Google Scholar Unsurprisingly, COVID-19 is reportedly rampant, but low testing capacity, the Syrian Government's securitisation of information flow about the number of COVID-19 cases and deaths, stigma around the virus, and reduced access to health care mean that reported cases are likely to represent only a small fraction of all cases.28Khattab A “It's like Judgment Day”: Syrians recount horror of an underreported COVID-19 outbreak.Newlines Magazine. Oct 11, 2020; https://newlinesmag.com/reportage/its-like-judgment-day-syrians-recount-horror-of-an-underreported-covid-19-outbreak/Date accessed: March 10, 2021Google Scholar There is a limited supply of COVID-19 vaccines in Syria through a reported Syria–Russia–Israel prisoner exchange deal and via the COVAX mechanism.29ReutersSyria says it has received COVID-19 vaccinations from “friendly country”.https://www.reuters.com/article/us-health-coronavirus-syria-vaccine-idUSKBN2AP1LADate: Feb 25, 2021Date accessed: March 11, 2021Google Scholar, 30Al-Khalidi S WHO preparing to deliver vaccines across Syria from April despite conflict.https://www.reuters.com/article/us-health-coronvirus-vaccine-syria/who-preparing-to-deliver-vaccines-across-syria-from-april-despite-conflict-idINKBN2A32V7Date: Feb 4, 2021Date accessed: March 11, 2021Google Scholar There are massive political, policy, and humanitarian shortcomings in the international response to a decade of conflict in Syria. UN Security Council failings have been admonished. Syria has received a large share of humanitarian funding over the years, but the UN Syria Humanitarian Response Plan 2020 was only 58% funded31OCHA ServicesSyria Humanitarian Response Plan 2020. Response plan/appeal snapshot for 2020.https://fts.unocha.org/appeals/924/summaryDate accessed: March 11, 2021Google Scholar and there have been concerns about aid diversion in previous years.32Human Rights WatchRigging the system: government policies co-opt aid and reconstruction funding in Syria.https://www.hrw.org/sites/default/files/report_pdf/syria0619_web4.pdfDate: June 28, 2019Date accessed: March 10, 2021Google Scholar Despite these shortcomings, three developments are encouraging. First is the emergence of local and diasporic leadership, with international support, of the humanitarian response, offering lessons for combining local innovation and remote management of humanitarian programming.33Duclos D Ekzayez A Ghaddar F et al.Localisation and cross-border assistance to deliver humanitarian health services in North-West Syria: a qualitative inquiry for The Lancet–AUB Commission on Syria.Confl Health. 2019; (published online May 27.)https://doi.org/10.1186/s13031-019-0207-zCrossref PubMed Scopus (17) Google Scholar Second is the adoption of new measures regarding attacks on health care, such as the 2016 UN Security Council Resolution 2286 on protection of the wounded and sick, medical personnel, and humanitarian personnel in armed conflict, WHO's new Surveillance System of Attacks on Healthcare, and remote methods-based investigations of perpetrators of attacks.34Hill E Triebert C 12 hours. 4 Syrian hospitals bombed. One culprit: Russia.The New York Times. Oct 13, 2019; Google Scholar Although these measures have not prevented health-care attacks in Syria, they have created the framework to better protect health care in future conflicts. Third, there are some initiatives towards justice and accountability after years of impunity. Frustrated with the impasses at the UN Security Council, the UN General Assembly established the International, Impartial and Independent Mechanism to investigate and prosecute the most serious crimes under international law committed in Syria since March, 2011. European courts are prosecuting alleged perpetrators of atrocities on the basis of universal jurisdiction. A German court in Koblenz heard shocking testimonies from survivors of torture in Syria and convicted a former Syrian security agent of crimes against humanity, a landmark conviction on these grounds.35DW NewsGerman court hands down historic Syrian torture verdict.https://www.dw.com/en/german-court-hands-down-historic-syrian-torture-verdict/a-56670243Date: Feb 24, 2021Date accessed: March 10, 2021Google Scholar Also in Germany, a doctor from Syria was arrested in 2020 in relation to allegations of torture of a man who was detained by the Syrian Government after an anti-government protest.36Schuetze CF Hubbard B Syrian doctor accused of torture is arrested in Germany.The New York Times. June 22, 2020; Google Scholar While these developments are encouraging, the dire health and humanitarian situation in Syria calls for urgent actions. Paramount to us and to global health advocates is renewing the commitment to the people of Syria, confronting so-called Syria fatigue among politicians, donors, and stakeholders, urging a more robust global health response, and applying pressure on our respective governments and the UN to bring about policy change on Syria. There are extensive health challenges in Syria and we focus on four key actions to address some of them. First, health-care workers in Syria need to be safeguarded. Even in the face of health-worker shortages and the COVID-19 pandemic, more than 3360 health workers in Syria remain in detention or forcibly disappeared, with the majority of arrests by the Syrian Government.37Syrian Network for Human RightsAt least 3,364 health care personnel still arrested/forcibly disappeared, 98% by the Syrian Regime.https://sn4hr.org/wp-content/pdf/english/At_Least_3364_Health_Care_Personnel_Still_Arrested_Forcibly_Disappeared_en.pdfDate: Feb 27, 2021Date accessed: March 10, 2021Google Scholar The Syrian Government should release these health personnel immediately, as well as all political detainees, and all conflict parties should stop violations against health care. Second, the Syrian Government, the UN Security Council, and all conflict parties should ensure humanitarian access in Syria. Syria is among four countries where humanitarian access is severely constrained.38ACAPSCrisisInSightHumanitarian access overview.https://www.acaps.org/sites/acaps/files/products/files/20201214_acaps_humanitarian_access_overview_december_2020_0.pdfDate: December, 2020Date accessed: March 10, 2021Google Scholar In July, 2020, humanitarian delivery was reduced to one crossing in northwest Syria. By the end of 2021, the UN cross-border humanitarian delivery to non-government-controlled areas might stop, further jeopardising population health. Third, the international community should help mount a strong response to COVID-19 by providing personal protective equipment to health workers, developing health personnel capacity and infrastructure, including oxygen, providing COVID-19 vaccines, and supporting local health solutions,39MedGlobalResponding to the COVID-19 crisis in Syria: a five part approach through “Operation Breathe”.https://medglobal.org/wp-content/uploads/2021/03/Operation-Breathe-PDF-Report.pdfDate: March 5, 2021Date accessed: March 10, 2021Google Scholar building on existing WHO support. COVID-19-specific measures need also to be complemented by broader public health measures so that the response is comprehensive and sustainable.40Center for Operational Analysis and ResearchSyrian public health after COVID-19: entry points and lessons learned from the pandemic response.https://coar-global.org/syrian-public-health-after-covid-19/Date: March, 2021Date accessed: March 11, 2021Google Scholar Fourth, the ripple health and humanitarian effects of economic sanctions on the civilian Syrian population must be addressed. These measures are first steps towards helping to ease the suffering of the people of Syria. We are all members of The Lancet–American University of Beirut Commission on Syria. We declare no other competing interests.