Syria's Long Road to Recovery

“If someone wants to be treated, the family needs to bring the products from the black market,” anesthesiologist Mirvat Zakouour told me.

In late January, the hospital was operating at just 10% of its normal capacity, after having been bombed by Russian airstrikes on December 1, 2024, a week before Assad’s government collapsed and he fled the country. It wasn’t the first time a hospital was bombed, as the Assad regime and its ally, Russia, systematically targeted health infrastructure in opposition-held areas during Syria’s long civil war.

In addition to basic surgical and first aid supplies, the facility lacked enough ventilators, dialysis machines and functioning MRI and CT scanners to serve the growing number of patients finally able to access hospital care as travel between cities — especially from nearby, opposition-held Idlib — resumed.

The intensive care unit was also stretched thin, with only four operating rooms in use, and thus reserved for emergency surgery only.

But although the evidence of 14 years of fighting lay all around the hospital, doctors said the problem wasn’t primarily war damage or looting, but international sanctions. Mostly imposed by the United States and European Union, these sweeping measures, intended to isolate the Assad regime, severely restricted trade, froze assets and effectively blocked access to essential goods, including medical supplies.

Today, seven months after the regime was toppled, recovery is inching forward, but the process is slow and bureaucratic, with the lifting of sanctions, the unfreezing of aid and the resumption of medical imports tied to complex administrative hurdles. Among the hardest-hit sectors is Syria’s healthcare system, which the World Health Organization warns is at risk of further collapse without significant support. Even as President Donald Trump issued an executive order in late June, officially revoking U.S. sanctions on Syria as of July 1, it could take many years before Syria’s shattered health system is fully functional again.

For years, more than a dozen countries worldwide imposed sanctions that they claimed targeted Assad’s regime. In reality, they strangled everyday life for Syrian civilians. When Syrians stormed the presidential palace in Damascus, they found garages full of sports cars, plush carpets and luxury bags from designers like Louis Vuitton and Dior — symbols of an elite untouched by the suffering around them. The Assad family and its inner circle had dodged the sanctions and enriched themselves through illicit trade, particularly in an amphetamine-like pill called Captagon, while millions of Syrians slipped deeper into poverty.

By the time Assad fell, 90% of the country was living below the poverty line, up from 33% before the war. One in four Syrians was unemployed. Even as some two million refugees and internally-displaced Syrians have now returned home since December, millions more remain abroad, deterred by the country’s collapsed economy.

The sanctions also fueled a black market dominated by regime cronies and blocked access to essential goods, including medical supplies like the ones Zair needed for his surgery. The UN has found that life expectancy in Syria decreased sharply during the Assad years — at one point, by 20 years — due not only to the civil war but also the sanctions’ impact on public health.

U.S. sanctions against Syria were among the most far-reaching worldwide, beginning in 1979, when Washington designated the government of Hafez al-Assad (Bashar al-Assad’s father and direct predecessor as president) a state sponsor of terrorism, citing its refusal to support the U.S.-brokered peace plan between Israel and Egypt. Syria had backed Palestinian armed factions and remained defiantly outside the U.S. sphere of influence.

Sanctions deepened during the 2011 revolution, when the United States and European Union imposed targeted measures on Bashar al-Assad’s inner circle in response to the brutal repression of popular protests. What began as peaceful demonstrations for democracy soon turned bloody. The regime met chants with bullets, arresting and killing thousands. By the following year, parts of the opposition had taken up arms and the uprising spiraled into a grinding civil war that would splinter the country, draw in foreign powers — including the United States, which supplied weapons to parts of the opposition — and leave many millions displaced or dead.

But the most punishing restrictions came in 2019, with the passage of the U.S. Caesar Syria Civilian Protection Act. Named for a Syrian military defector who smuggled out tens of thousands of photos showing the torture and murder of detainees in Assad’s prisons, the Caesar Act effectively cut off any entity, governmental or private, from doing business with the regime. It wasn’t just a financial chokehold. It was meant as a moral line in the sand.

What made these sanctions so devastating was how entangled the regime was in everyday life. Nearly every hospital, aid agency and business had to interact with government institutions in some way, whether to import medicine, pay salaries or maintain infrastructure. That meant even humanitarian efforts aimed at helping civilians were often swept up in the sanctions net, discouraging international funding and paralyzing basic services.

While sanctions imposed by the European Union, UK, Japan and other countries hurt as well, they didn’t have the same chilling effect on humanitarian work that U.S. sanctions did, says Emmanuel Tronc, Syria Mission Country Director for the humanitarian group Swiss Church Aid and an expert on Syria sanctions. (Also known by its Swiss acronym HEKS/EPER, Swiss Church Aid has received funding from Switzerland’s government, which imposed sanctions in line with EU and United Nations measures.) By comparison, Tronc says, the blunt force and wide net of Washington’s measures deterred even aid organizations and businesses outside the U.S. from engaging in Syria.

If EU sanctions were like a Swiss knife, Tronc says, U.S. sanctions were ​“atomic bombs” — making Syria’s once-robust healthcare system ground zero.

But not all experts see such distinctions. Michael Galant, a senior research associate at the Center for Economic and Policy Research, argues that humanitarian exemptions do little to mitigate the damage of sanctions.

“We have mountains of evidence that broad sanctions, such as those that have been imposed on Syria, severely harm civilians,” says Galant. ​“It’s like stealing someone’s money, depriving them of every source of income, and then telling them, ​‘Hey, at least it’s still legal for you to buy food.’”

And damage like this, Galant adds, can’t be described as collateral. Rather, it’s the mechanism by which sanctions are supposed to work, since while policymakers often claim sanctions are meant to pressure governments, their actual function is to punish civilian populations until they revolt.

“We’re not talking about some smart, targeted policy lever. This is really warfare by other means, and the effects can be comparable to that of war,” says Galant. ​“So exemptions are not bad, of course. It would be far worse if they didn’t exist, and it would be great if they were expanded. But really, their main function is to rhetorically cover for what is, in fact, a policy of deliberately targeting civilians. And that’s the logic of broad economic sanctions: to deliberately instill such suffering as to instigate regime change.”

But what’s more troubling is that the situation has continued even after the Assad regime fell, in an echo of the dynamic that played out in Afghanistan after the U.S. overthrew the Taliban in 2001. There, even after humanitarian licenses were granted, businesses and banks still stayed away, as the legal ambiguity and operational complexity of working in a sanctioned, politically volatile environment created a chilling effect. Today, the same chill surrounds Syria, where fear overrides formal exemptions.

Benjamin Fève, a senior research analyst with the consultant group Karam Shaar Advisory, argues that countries imposing broad sanctions should be held responsible for mitigating consequences like these.

“Sanctioning governments should intervene and provide guarantees to the healthcare sector, medical sector and private sector, telling them, ​‘No, you won’t be sanctioned if you supply or if you interact with the Syrian healthcare system,’” says Fève.

But in the absence of such guarantees, the burden has fallen on already collapsing institutions to navigate the legal minefield alone.

Staff at the Aleppo hospital have seen how those consequences play out on the job, as doctors scramble to make do with broken machines and limited medication, ambulances run on fumes and even routine medical procedures become logistical nightmares.

In January, just after liberation, about 4,000 patients a day crossed the hospital’s doors. Among the hospital’s 1,500 employees and volunteers were doctors and specialists who could theoretically perform any surgery, but lacked the most basic supplies, from bandages and anesthesia to blankets and cleaning supplies. Without lab equipment, the hospital had no capacity to run diagnostic testing, making it difficult for doctors — who in January were earning just $30 per month — to accurately diagnose diseases or tailor treatment.

Of their functioning equipment, the hospital had one MRI, three CT scanners, several X-ray machines and ultrasound capacity, according to hospital director Dr. Mahad Alhadj.

When these machines malfunction, said Dr. Fatima Douba, head of the emergency department, it can be difficult to impossible to access replacement parts, which may cost tens of thousands of dollars each and sometimes can only be imported from the United States.

In the dialysis wards, patients lay in silence, waiting. When I visited in January, the hospital had 40 dialysis machines, according to department head Dr. Hazem Azuz, but 11 were out of order. As a result, the hospital’s 200 dialysis patients, who should receive the treatment three times per week, could only access it once weekly.

“One is better than nothing,” said Azuz, his voice heavy with a resignation that spoke of countless days trying to do more with less.

“Sanctions are the main obstacle we face in getting this hospital back on track,” added Alhadj. ​“They stop international NGOs from implementing projects and helping us buy the equipment we lost in the war.”

All of this is also happening at a time when Syria’s medical needs are rising sharply, as years of war, displacement and institutional collapse have left the population more vulnerable than ever. Diseases that were once easily contained, like cholera, have made deadly returns, spreading in areas with poor sanitation and limited clean water. Malnutrition is rising among children as more than nine million Syrians, in a country of 24 million, have been left food insecure due to rising costs of living. And chronic illnesses like diabetes and cancer often go untreated due to the unavailability or prohibitive cost of medication.

The battered health system simply cannot keep up with the scale or complexity of these needs, leaving entire communities without access to care. Meanwhile, international funding cuts to aid organizations — which started with the Trump administration’s systematic dismantling of USAID—have sharply reduced their ability to respond.

Despite the mounting evidence of suffering, says Tronc, policymakers have been slow to address the purportedly unintended consequences of sanctions.

“How unintended can something be,” he asks, ​“when you are aware that it is happening?”

Sharaa’s government has complied with some U.S. demands. And, in an apparent observation of how Trump has approached other countries in conflict — including by pressuring Ukraine to sign away much of its mineral wealth and proposing to build a ​“Trump Gaza” on the ruins of Palestinian land — Sharaa tried to entice Trump by offering access to Syria’s natural resources and an invitation to construct a $200 million Trump Tower in Damascus.

Following high-level meetings in the United Arab Emirates in April, Sharaa also reportedly engaged in secret talks with Israeli security and intelligence officials — encouraged by the Trump administration and mediated by the UAE — which pushed Syria to normalize relations with Israel and avoid future confrontations, even as Israel continued to carry out airstrikes on Syrian territory, including near Damascus. While Israeli officials have described the strikes on Syria as ​“preemptive” measures to contain unrest, critics say they’re designed to entrench Israeli military dominance at a time when Syria is too fractured to respond. Taken together with Israel’s recent attacks on other countries in the region — including Lebanon, Yemen and Iran — and its ongoing genocide in Gaza, these actions reflect a broader strategy of targeting nations in the region perceived as threats, often with backing from the United States.

On May 14, speaking to reporters in Riyadh, Trump announced his intention to lift sanctions, while describing Sharaa, who he’d just met, as ​“a young, attractive” and ​“tough guy” with a ​“strong past” — a Trumpian signal that a figure long considered untouchable was morphing into an ally.

Six days later, the EU followed suit, announcing that it was also lifting all sanctions on Syria, barring those based on security concerns.

And at the end of June, Trump made it official, issuing an executive order ending most U.S. sanctions (except those targeting individuals tied to terrorism, human rights abuses and drug trafficking), effective July 1.

Both the EU and U.S. have stressed that sanctions could be reinstated if Syria’s new leaders backtrack on democratic commitments.

Already there have been issues. In January, Sharaa’s new justice minister was revealed to have been involved in the execution of two women in 2015. Two months later, forces affiliated with Sharaa’s government were involved in the massacre of nearly 1,500 Alawites — a minority group the Assads belonged to. Sharaa condemned the killings and pledged to investigate, but human rights groups have voiced concerns about whether there will be true accountability. A recent Reuters investigation traced the chain of command from the attackers directly to men formerly in HTS and now serving in Syria’s new government alongside Sharaa.

Following Trump’s executive order, U.S. sanctions on Syria have been broadly suspended, including the temporary lifting of those under the Caesar Act. This goes well beyond previous humanitarian waivers, allowing for significant economic activity and investment. The shift is substantial and intended to enable real progress on Syria’s recovery, but is also reversible, raising questions of how these changes will translate into concrete improvements on the ground.

While Trump’s waivers and licenses represent temporary relief, permanently lifting the sweeping measures of the Caesar Act will require congressional approval — a hurdle that remains. And even if Congress ultimately does rescind the Caesar Act, the hardest part will still lie ahead, in the struggle to rebuild Syria’s shattered healthcare system.

And that points to a bigger-picture problem. Sanctions have long been justified as a tool to compel change by making a nation’s population feel the cost of its leaders’ decisions. When it came to Syria, that rationale was often stated bluntly: starve the regime of resources and eventually the people would turn against their rulers. But more than a decade in, the evidence suggests the opposite. Sanctions hollowed out Syria’s public institutions, tanked its economy and pushed millions of its people into desperate poverty — all while failing to dislodge the regime. If anything, sanctions narrowed the political space further, strengthening the grip of those in power and fueling a siege mentality among the public.

Now, with Assad gone, some in Washington argue that sanctions achieved their goal. But the circumstances of his fall tell a different story, shaped less by U.S. sanctions than the withdrawal of Russian and Iranian military support, a demoralized Syrian army and fragmentation of authority within the regime. The consequences of the sanctions remain, not as a symbol of accountability, but as a source of ongoing harm. In May, Trump referred to the measures as ​“brutal and crippling” — a rare admission from a U.S. president, made only after Syria’s new leadership signaled its willingness to realign. That moment of candor lays bare a deeper inconsistency: if these tools are so brutal, why is their impact on civilians only acknowledged once an enemy becomes a friend?

Michael Galant of the Center for Economic and Policy Research sees Syria not as an exceptional case but rather part of a broader U.S. strategy to use economic force as a tool of empire.

“The U.S. weaponizes its position as the global hegemon — its centrality in the global financial system,” Galant says, ​“in order to illegally coerce other country governments to either act in a certain way or fall, typically in order to further project U.S. power and further advance U.S. interests.”

Back in the brightly lit corridors of Aleppo University Hospital, recovery still comes in half measures. The regime has fallen, and sanctions may no longer be the law, but the system they hollowed out remains.

The scars left by sanctions that once aimed to punish a dictator continue to punish a country. For millions of Syrians, the end of the regime did not bring the end of suffering. It merely revealed how much of it was brought not just by war, but by policy crafted in distant capitals, and paid for in blood.