The impacts of explosive violence on healthcare infrastructure in Syria
By Chloe Squires on 4 Dec 2019
Since the Syrian conflict began in 2011, there has been no shortage of media coverage detailing events have unfolded in the region. A devastating part of this conflict has been the direct and purposeful targeting of hospitals and healthcare workers. This is often in clear violation of the Geneva Conventions. Both Russia and Syria have been accused of deliberately targeting hospitals and civilians as part of their bombing campaigns. Both states, however, have strenuously denied that such attacks are intentional, arguing instead that they are unfortunate collateral damage. Organisations such as The New York Times, Bellingcat, and Syrians for Truth and Justice have carried out extensive investigations into these claims, focusing on Idlib where hospitals were at the forefront of the conflict.
The persecution of healthcare professionals throughout Syria and the routine bombing of healthcare facilities has left a once functioning healthcare system devastated, without staff, supplies or equipment to carry out even the most basic of procedures in some areas. Healthcare facilities and personnel have increasingly become direct targets of violence. Physicians for Human Rights estimating at least 912 medical professionals have been killed in the conflict. Of the 782 health workers killed between March, 2011 and September 2016, it is estimated that shelling and bombing accounted for 426 (55%) deaths.
The operation of humanitarian assistance in rebel-held areas of Syria has been consistently obstructed or denied throughout the conflict. Unable to obtain government authorisation, organisations such as Médecins Sans Frontieres have been forced to establish underground medical networks which have been largely cut-off from official assistance channels. These efforts have remained unsuccessful at halting attacks on hospitals however, with the use of ‘bunker buster bombs’, many of which containing chemical agents, being utilised to decimate underground healthcare facilities, though data on such attacks remain unclear.
The World Health Organisation revealed via Twitter on 6 October 2016, that every hospital in Eastern Aleppo had by then been bombed at least once, with one of the main trauma hospitals in the region being hit 4 times in a 5-day period. With many healthcare professionals killed, kidnapped or displaced, eastern Aleppo was left with less than 30 doctors available for more than 270,000 people. The few functioning hospitals in eastern Aleppo were overwhelmed and struggling to respond. With few resources and healthcare personnel available, wounded patients were reported as being treated on the floor with few patients get the medical care they need.
It is not only stationary healthcare facilities which have been the direct targets of violent attacks. Ambulances have been repeatedly bombed, shot at, stolen, looted and obstructed as part of the war strategy, with 204 individual attacks involving 243 ambulances occurring in Syria between 2016 and 2017.
Attacks on ambulances have been designed to be particularly violent and explosive. In 40% of cases, ambulances have been rendered entirely inoperative. One of the tactics used to achieve such outcomes has become known as ‘double-tap attacks’, whereby one attack is followed by an air strike on the same area. The most common modality of attacks on ambulances in 2017 were air-to-surface missiles (making up 53% of ambulance attacks) and shelling (making up 31% of ambulance attacks). The use of cluster and barrel bombs and IEDs have also been routinely used, making up 13% of ambulance attacks in 2016. Attacks on ambulances increasingly thwarted the healthcare system, significantly restricting the ability to safely evacuate the wounded and provide medical aid. Thus, even the most basic of healthcare functions became increasingly reliant on external healthcare organisations.
Moreover, violence directed at the healthcare institutions in Syria has not failed to have a significant impact on healthcare workers as individuals, both Syrian citizens and external healthcare providers. In 2018 alone, Syrian health workers, facilities and transport faced 257 attacks (data is available for 253 of these cases). Of this number, 208 attacks utilized explosive weapons in some capacity, including 132 aerial bombs and 46 surface launched explosives, and a number of cases using hand grenades and landmines. 88 individual health workers were killed in Syria in 2018. 73 of these deaths were caused by explosive weapons, 45 of which were aerial bombs.
This ‘weaponisation of healthcare’ is not only prevalent in Syria. Rather, we are seeing a much wider and alarming trend in regard to the targeting of healthcare facilities and personnel in conflict, one which needs to be urgently investigated by the international community. In 2018 alone, the Safeguarding Health in Conflict Coalition documented that there had been a total of 973 attacks on healthcare professionals and facilities in 23 countries experiencing conflict. Out of this number, 272 attacks included the use of explosive weapons, including 27% surface launched explosives, 55% aerial bombs, and 10% improvised explosive devices.
The impact such violence has, particularly explosive violence due to the wide-area impacts, on civilians is devastating and long-lasting. Life expectancy in Syria dropped by over 20 years according to the Syrian Centre for Policy Research, from 75.9 years in 2010 to 55.7 in 2015. While according to the World Health Organisation (WHO) in 2018, more than 11.3 million people are in need of health assistance in Syria, including three million living with injuries or disabilities. Outcomes see a similar pattern in other areas impacted by such conflict. And, while the healthcare will be redeveloped when conflict ends, the harm continues. In Sri Lanka, almost a decade after the end of the civil war, AOAV recorded those injured in the violence who still had shrapnel embedded in their bodies; amputees who could not access prosthetics; and a healthcare system overburdened, under-staffed and unable to attract new healthcare professionals. The attacks on healthcare in Syria are likely to leave scars that will still be visible in the decades to come.
For more information on the reverberating health impacts in Syria from the use of explosive weapons, please see here.