- About HHR
The humanitarian crisis in Syria is now in its sixth year. The rest of the world is barraged with alarming images and harrowing accounts of entire families, their homes, and their livelihoods persistently coming under attack. Amidst the overwhelming storm of brutality, a concerning pattern has emerged: the destruction of entire health systems, including the buildings themselves, health workers and medical supplies. Each of these components, and more, is needed to keep the whole system functional, and when these systems are destroyed, it is impossible to fulfill the human right to health.
The last pediatrician in Aleppo, Abu Abdulrahman, was killed in an airstrike on Al Quds hospital as the Syrian Civil War edged into its fifth year. The attack on Al Quds hospital is a single example of the active destruction of health care facilities and staff, a tactic of growing prevalence in conflicts that is particularly devastating in Syria.
While the availability of all resources is strained during times of war, the most basic necessities like clean water, food, and healthcare are most sorely missed. The laws of war, as defined by the Geneva Convention, demand the protection of civilians: one should not attack water supplies, foodstuffs, and hospitals. Intentionally targeting civilian objects and indiscriminate attacks are illegal:
In sieges and bombardments all necessary steps must be taken to spare, as far as possible, buildings dedicated to religion, art, science, or charitable purposes, historic monuments, hospitals, and places where the sick and wounded are collected, provided they are not being used at the time for military purposes.1
The destruction of healthcare facilities in the Syrian Civil War contravenes this international law with generally no repercussions. Syrian has seen many of these attacks, from the calculated shelling of hospitals to the indiscriminate use of barrel bombs and chemical warfare. Such attacks have contributed to rendering 446 health care facilities completely non-functional over the past six years.2 The use of indiscriminate, deadly weapons like barrel bombs against hospitals is especially egregious, as they cause terrible civilian injury and destroy the resources needed to treat it. Barrel bombs, employed exclusively by the Assad regime, are large, homemade explosives that are filled with “a number of scorching-hot items, including fuel, TNT, metal fragments, nails, ball bearings and shards of old machinery,” and are capable of inflicting bodily injury of incredible magnitude.3 Trauma from barrel bomb explosions lead overwhelmingly to death and amputation.
Of the 454 total documented medical facility attacks, over 67% have been attributed to Syrian government forces or Russian forces.4 The number of reported attacks on health facilities increased dramatically from just two in 2011 to 122 in 2015.5 An independent inquiry commissioned by the United Nations’ Human Rights Council declared in February 2016, “[of] the 33 hospitals open in Aleppo city in 2010, fewer than 10 are still functioning.”6 By the end of 2016, the last hospital in rebel-held East Aleppo was destroyed by airstrikes, leaving an estimated 250,000 residents without access to surgery or specialist care.7 Throughout the country, only 48% of health care facilities remain fully functional, representing a devastating drought in the availability of health care for civilians remaining in the country.8
The use of chemical weapons—namely mustard, chlorine, and sarin gases—has required Syrian hospitals to treat affected civilians throughout the conflict. In addition to responding to the April 2017 chemical attacks with military action, the United States has opened an investigation on a drone attack that targeted a hospital treating victims of the chemical weapon strike. United States military officials allege that after the sarin gas attack, a drone belonging to either Russia or Syria was seen returning to the area around the hospital that was later bombed.9 While this investigation is on-going, the destruction of a hospital treating patients of a chemical attack is especially disquieting.
As devastating as the destruction of physical medical facilities is the threat under which doctors remaining in Syria must practice. Since the beginning of the conflict in the 2011, 796 medical professionals have been killed—55% by shelling and bombing, 23% by shooting, 13% by torture, and 8% by execution.10 The overwhelming majority of the deaths were at the hands of the Assad regime, reflecting the Syrian government’s tactic of targeting of rebel-held hospitals. The number of health worker casualties is augmented by the Syrian Air Force’s practice of “double-tap” bombing, in which a target is attacked a second time after first responders have arrived. This strategy is deliberately designed to cripple health care systems, resulting in the destruction of multiple hospitals and the deaths of many physicians.11 Reports indicate that between 2012 and 2014, the number of medical personnel killed each year hovered around 180; that the number has been decreasing in more recent years may reflect a significantly diminished overall number of medical personnel remaining in Syria.
Doctors and nurses have been forced to withhold treatment under threat of violence. More than half of Syrian doctors have fled their homes for fear of persecution by the government; those who remain fear that their dedication to the equal treatment of all patients will put them in jail. After medical care “to opponents of the government” was deemed a criminal offence by the Assad regime, an estimated 250 doctors were arrested, interrogated, and tortured in 2011 alone.12 The threat of wrongful detainment is not limited to physicians operating in rebel-held zones; with the entrance of Daesh into the conflict, physicians must navigate the practice of medicine in an increasingly hostile environment. During a skirmish over al-Assad hospital in Deir al-Zour in May 2016, Daesh also took a number of medical staff hostage.13 Even though Assad’s troops regained control of the hospital, the fate of the hostages remains unclear.
Health staff have been working underground and in makeshift hospitals in Syria throughout the conflict, and hospitals will be rebuilt following the end of the conflict. However, the future of Syrian health care cannot be secured without health staff to provide it and to educate future generations of health workers. The ongoing abduction of health workers further complicates a hostile environment for all personnel and for nongovernmental organizations (NGOs) on the ground in Syria. Médecins sans frontières (MSF) currently has 23 health care facilities throughout the country, despite the abduction and release of MSF staff in 2014.14 Conflict to the north of Syria in mid-2016, notably near the city of Azaz, forced the evacuation of one of their hospitals in May 2016. This hospital, Al Salamah, was the largest medical facility supported by MSF in Syria and previously served over 100,000 internally displaced civilians trapped before the Turkish border.15 The evacuation was a further depletion of health care provision for a particularly vulnerable population.
Healthcare in Syria is also severely impaired by the severely limited availability of medical supplies. A number of NGOs, including MSF, the International Rescue Committee, and the Syrian American Medical Society, receive supplies from humanitarian convoys sent by donor agencies and the United Nations. However, the armed forces on the ground prevent much of this from reaching the 12.8 million people requiring medical assistance, and the forces also obstruct medical evacuations.16
The thinning availability of health care has further devastated the thready pulse of civilian life. Depleted resources to treat chemical attacks and other trauma are a serious challenge, and it contributes to the 30% of trauma victims in Syria who suffer a permanent disability.17 Furthermore, the scars of living through a prolonged war will lead to mental health problems in the future. The future need for health care in the country will be immeasurably large, and yet there is now a generation that has been deprived of schooling, and will not be in a position to fulfil the need for health workers.
It is unknown how many Syrians have died directly due to the destruction of hospitals and health care centers, but reports estimate 70,000 people have died from a lack of health services, medicine, potable water, and proper sanitation.18 The calculated destruction of the health system is a complete violation that will have repercussions on health rights for generations to come.
Gina Li recently earned a BA with Honors in International Studies from the University of Chicago and currently works as a neuro-oncology research technologist at Northwestern University’s Feinberg School of Medicine. Email: firstname.lastname@example.org.
1. Convention (IV) respecting the Law and Customs of War on Land and its annex: Regulations concerning the Laws and Customs of War on Land, International Peace Conference (1907), Section II, Chapter I Means of injuring the enemy, sieges, and bombardments, Article 27. Available at https://ihl-databases.icrc.org/ihl/INTRO/195.
2. Office for the Coordination of Humanitarian Affairs, 2017 Humanitarian needs overview: Syrian Arab Republic, (Geneva: OCHA, 2017). Available at https://docs.unocha.org/sites/dms/Syria/2017_Syria_hno.pdf.
3. A. Masi, “The Syrian regime’s barrel bombs kill more civilians than ISIS and Al Qaeda combined,” International Business Times (August 18, 2015).
4. Physicians for Human Rights, Anatomy of a crisis: a map of attacks on health care in Syria (April 2017). Available at https://s3.amazonaws.com/PHR_syria_map/web/index.html.
5. Physicians for Human Rights, Findings as of December 2016 (December 2016). Available at https://s3.amazonaws.com/PHR_syria_map/findings.pdf.
6. United Nations Human Rights Council, Thirty-third session, Agenda item 4, UN Doc. No. A/HRC/33/55 (2016).
7. M. Chulov, K. Shaheen, and E. Graham-Harrison, “East Aleppo’s last hospital destroyed by airstrikes,” The Guardian (November 19, 2016).
8. Office for the Coordination of Humanitarian Affairs (see note 2).
9. Associated Press, “Pentagon looking into Russia’s role in Syrian chemical weapons attack,” ABC 7 (April 7, 2017).
10. Physicians for Human Rights (December 2016, see note 6).
11. T. McKelvey, “Drones kill rescuers in ‘double tap’, say activists,” BBC (October 22, 2013); Médecins sans frontières, “Syria: Double-tap bombing on MSF-supported hospital – hospital partially destroyed – patients under treatment died in transit,” (December 1, 2015); U. Bacchi, “Syria MSF hospital bombed: ‘Russian warplanes’ targeted rescuers with ‘second tap’ air strike,” International Business Times (February 18, 2016).
12. Syrian American Medical Society, Syrian medical voices from the ground: the ordeal of Syria’s health care professionals (February 2015). Available at https://www.sams-usa.net/wp-content/uploads/2016/09/Syrian-Medical-Voices-from-the-Ground_F.pdf.
13. “Syria conflict: IS ‘overruns hospital in Deir al-Zour’,” BBC (May 15, 2016).
14. Médecins sans frontières, Syria (last updated January 2017). Available at http://www.msf.org/en/syria.
15. L. Dearden, “ISIS advance in Syria: hospital evacuated and 100,000 feared displaced as militants move towards Azaz,” Independent (May 27, 2016).
16. Office for the Coordination of Humanitarian Affairs (see note 2).
18. I. Black, “Report on Syria conflict finds 11.5% of population killed or injured,” The Guardian (February 10, 2016).
Papers in Press
The Cholera Epidemic in Zimbabwe, 2008-2009; A Review and Critique of the Evidence
Nicholas Cuneo, Richard Sollom, and Chris Beyrer