In 2013 the outlook in Syria was bleak. But the reality is that everything can get worse.

In 2014, as the conflict entered its fourth year, the situation has deteriorated even further. There have been 200,000 fatalities, 1 million wounded, 3 million who have sought refuge across the borders, and over 7 million displaced: evidence of the brutality of the worst conflict in recent years. More than half of the country's population needs some form of humanitarian aid, including 5 million children.

Not only has the dynamic of violence increased, but access to aid has also been restricted. Needs are greater but the aid system is not meeting them. Today, Syria remains the most serious humanitarian crisis in the world. 

In 2014, indiscriminate bombings have continued in many parts of the country and in some cities like Aleppo they have been stepped up. Barrel bombs have left the city practically deserted. The opposition-controlled area is unrecognisable, with many of its neighbourhoods suffering destruction comparable only to World War II or Grozny in the 1990s. The barrels that have rained down have forced many residents to flee to Turkey or to areas controlled by the Islamic State that suffer significantly less from the daily onslaught of bombing. A significant number has even moved to the government-controlled area through the only practicable crossing point. 

In July 2014 alone, at least six hospitals in Aleppo were hit or affected by bombs. For some, like the sadly well-known Dar Al Shifa Hospital, it was the fourth time. In the summer, Sakhur Hospital, one of the most operative in the city of Aleppo, was hit three times. On 2 August an airstrike completely obliterated Al Huda Hospital in the west of Aleppo, killing at least 6 doctors and nurses and injuring another 15 people, including patients. Created by the English foundation SKT, this hospital provided the only neurosurgical service in the north of the country. MSF facilities have not been spared the bombing either: the advanced medical centre near Aleppo has been damaged three times in recent months. 

The health system has disintegrated. Outbreaks of measles and polio are having a cruel impact on children and are a symptom of public health deterioration. Health priorities are changing as the war drags on because there are fewer people around to be wounded, and those who are still there are suffering from collapsed health, economic, family and social systems. Even if the violence decreases in the medium term, basic needs are greater, and the medical conditions observed are more severe and more widespread throughout Syria.

The inability of humanitarian organizations, including our own, to offer and deliver basic services to communities that are struggling to survive is evident. Not only is violence taking its toll, but communicable and vaccine-preventable diseases are also, chronic diseases are leaving a trail of untold suffering, women are giving birth in abject conditions, and the mental health has been affected across the board.

The refugees are an unprecedented social and economic pressure on local communities that host them and on national health systems and social welfare, job markets, etc. Not even a sprawling city like Istanbul, with nearly 18 million inhabitants, can make the massive influx of Syrian migrants invisible. The situation in Jordan and Lebanon is worse, where the proportion of refugees per capita is a full 20% of the population. Refugees who opted for Iraq have had even worse luck as they have been involved in the same war in recent months.

The awful situation has reached a point where there is a consensus that is not publicly spoken very much, but is repeated: the victory of neither side is a real possibility, nor a desirable outcome. Only despair and shame remain. Bombing by the international coalition is claiming civilian lives, while a desperate population looks on as nobody does anything to at least stop the indiscriminate barrel bombing.

It is shameful that in the three years of the conflict, Europe has given shelter to fewer refugees than Lebanon, Jordan and Turkey in a single day. It is shameful to see the politicians who believe that Syrians will stop trying to cross the Mediterranean since 'maritime rescue services encourage' the adventure of getting on a precarious boat with hundreds of desperate others. It is shameful to see how the international community reacts only when its own interests are affected, such as the agreement to end chemical warfare and the reaction to the threat of oil concessions in northern Iraq.

Apparently Syrian civilians are not even worthy of a tiny gesture, other than passing on the responsibility to humanitarian aid organisations.