The Syrian government has intentionally targeted its own medical infrastructure, a violation of the Geneva Convention that has resulted in the near complete destruction of the country's modern preconflict health care system.
A country’s optimal health care infrastructure comprises state of the art facilities staffed by well-trained providers with access to authoritative and current health science information. Prior to the civil war, the Syrian Arab Republic was close to this goal; it had five functioning medical schools, a National Health and Medication Plan, and thirty-seven medical libraries.
During the decades preceding the Syrian civil war, access to and delivery of healthcare and healthcare information had steadily improved. According to the World Health organization, the life expectancy of the average Syrian in 2012 was 75.7 years, a leap from an average of 56 years in 1970. Pre-conflict health indicators amassed by the Syrian International Coalition for Health in 2012 noted substantial reductions in the death rate from all causes.
The civil war has reversed this trend; average life expectancy has fallen twenty years from the 2012 level. The United Nations now estimates that 12.2 million Syrians—including approximately six million children—require urgent humanitarian assistance. Understanding the on-the-ground medical realities of the Syrian conflict, and how they differ from previous conflicts, is vital for both effective allocation of United States and international resources, and the development of medical plans for the days after the civil war.
Throughout the history of modern conflicts, combatants have generally recognized medical personnel and facilities as non-combatants and spared them from attack. The Geneva Convention explicitly states that both military and civilian medical personnel exclusively assigned to medical duties must be respected and protected in all circumstances. Consequently, intentionally directing attacks against identifiable medical personnel and facilities constitutes a war crime.
My personal experience in Vietnam supports the idea that the Geneva Convention Rules were, by and large, followed even in intense modern warfare scenarios. The Viet Cong and North Vietnamese regulars avoided attacking adequately identified medical facilities, probably due to United States’ military hospitals’ routine treatment for wounded enemy combatants. In 1968, while serving with the 101st Airborne, my medics and I were delivering a medical civic action program (MEDCAP) in a remote village. As dusk approached, the village chief told me a Viet Cong platoon was approaching and requested we leave immediately as the platoon did not want to harm a MEDCAP team. Though we feared an ambushed, we left the village unharmed. On another occasion my medical platoon was assigned to help re-open the civilian hospital in Hue City, which had been devastated by the TET offensive. There, we treated the general civilian population that undoubtedly included many enemies and enemy sympathizers. Our proper identification ensured that we were never harmed or even threatened during that three-month assignment.
The Syrian conflict stands in sharp contrast to this model of healthcare during modern warfare. The Syrian healthcare system, public health infrastructure, and health information resources have been devastated by the ongoing civil war, especially in rebel held areas. Health care personnel, health care facilities, ambulances, manufacturers and suppliers of medical equipment and pharmaceuticals, including NGOs such as Doctors Without Borders, have been purposely and aggressively targeted on multiple fronts, primarily by the Syrian government. The Syrian government, which controls the skies, is responsible for 88 percent of recorded hospital attacks and 97 percent of medical personnel killed, with 139 deaths directly attributed to torture or execution. Rebel forces and ISIL have also been accused of targeting the health sector. In total, there have been 233 deliberate or indiscriminate attacks on 183 medical facilities.
Russia’s entrance into the air campaign has dramatically increased hospital and clinic bombings. In October 2015, the first full month of Russian involvement, twelve medical facilities were purposely targeted and bombed. Early in 2016, Russian bombs targeted three hospitals, killing many and depriving thousands of Syrians access to care.
The effects of these bombings have cumulated into a national health crisis. According to the World Health Organization, approximately two-thirds of Syrian hospitals and clinics have been rendered useless or destroyed by the war. Remaining medical facilities are understaffed, poorly equipped, undersupplied, and overwhelmed with trauma care. Restrictions on travel and sanctions have resulted in drug, medical supplies, and equipment shortages.
With a shattered infrastructure, both doctors and patients have suffered tremendously. Nearly 700 healthcare workers have been killed or injured, and a full half of the country’s physicians have been forced to flee the country. More than one million Syrians have been wounded or killed, leaving hundreds of thousands with poorly managed chronic disabilities and a tragic lack of access to basic medical services. Deaths from treatable diseases and wounds have skyrocketed. Aside from combat-related challenges, treatments for chronic cardiovascular and renal diseases, cancer, diabetes, and non-urgent routine medical interventions are severely interrupted. “Elective” follow-up care for wounds, amputee prosthetics, infections, and other conditions can no longer be a priority and rarely receive attention.
The large-scale displacement of the Syrian population, unsanitary conditions, and contaminated water supply is fueling a resurgence of once-extinct communicable diseases: polio, cholera, typhoid, hepatitis, and parasitic infections. The mental trauma inflicted by this nearly six-year long civil war on the civilian population is incalculable.
The Syrian American Medical Society has been actively facilitating the rotation health care volunteers in Syria, but its doctors -- Dr. Samer Atar among them -- are chronicling the horrors of the field and the severe inadequacies of the medical situation that has led to the loss of many savable lives.
Healthcare professionals are in many ways at a loss as to how the situation can be alleviated. Leonard Rubinstein, Director at the Bloomberg Center for Public Health and Human Rights at Johns Hopkins University, noted that the situation in Syria “is the worst concerted attack on healthcare in living memory… in places like Bosnia, Chechnya, Afghanistan, and the Gaza Strip, there has been nothing like what has happened in Syria.”
The United States has provided more than $6.5 billion in humanitarian aid since the start of the crisis. This financial effort supports the operations of the United Nations and NGOs to provide emergency relief to Syria and its neighbors, which have been overwhelmed with the burdens of refugee assistance and have periodically closed their borders due to terrorist attacks. Closed borders prevent international medical humanitarian organizations like Doctors Without Borders from treating wounded Syrians. Though unconfirmed, it is reported that the Israeli army has set up a field hospital along the Syrian border on the Golan Heights to treat wounded Syrians.
Though it is obvious that the Syrian crisis will not end soon, it is important to start thinking about the major international efforts that will be required to rebuild their public health and health care infrastructure. The Syrian medical community and supporting NGOs will have to shift from a crisis response mode to a strategic planning and recovery mode. The health sector that will be assembled to support this effort will require strong command and control to coordinate efforts, prioritize activities, and develop communication protocols that can accommodate an international task force. Critically important to this effort is the use of real time, open and free access to health information provided by the US National Library of Medicines (NLM) Disaster Information Management Research Center.
Throughout the history of warfare, the medical respondents, both military and civilian, have intentionally been spared from attack. Even during the intense combat of World War I and World War II, periodic truces had been called to allow medical teams to evacuate and treat the injured; not so in Syria. The Syrian government has purposefully and intentionally targeted their own medical infrastructure, including humanitarian volunteer teams. This violation of the Geneva Convention has resulted in the nearly complete destruction of a preconflict, modern Syrian health care system. The rebuilding of their devastated health structure will require a herculean effort by the international community, which should commit itself to decades of work.
Steven J. Phillips, MD is a Research Scientist at the National Institutes of Health National Library of Medicine. This article was originally published on the Fikra website.
