Research Article: Determining the scope of attacks on health in four governorates of Syria in 2016: Results of a field surveillance program

Date Published: April 24, 2018

Publisher: Public Library of Science

Author(s): Rohini J. Haar, Casey B. Risko, Sonal Singh, Diana Rayes, Ahmad Albaik, Mohammed Alnajar, Mazen Kewara, Emily Clouse, Elise Baker, Leonard S. Rubenstein, Alexander C. Tsai

Abstract: BackgroundViolent attacks on and interferences with hospitals, ambulances, health workers, and patients during conflict destroy vital health services during a time when they are most needed and undermine the long-term capacity of the health system. In Syria, such attacks have been frequent and intense and represent grave violations of the Geneva Conventions, but the number reported has varied considerably. A systematic mechanism to document these attacks could assist in designing more protection strategies and play a critical role in influencing policy, promoting justice, and addressing the health needs of the population.Methods and findingsWe developed a mobile data collection questionnaire to collect data on incidents of attacks on healthcare directly from the field. Data collectors from the Syrian American Medical Society (SAMS), using the tool or a text messaging system, recorded information on incidents across four of Syria’s northern governorates (Aleppo, Idleb, Hama, and Homs) from January 1, 2016, to December 31, 2016. SAMS recorded a total of 200 attacks on healthcare in 2016, 102 of them using the mobile data collection tool. Direct attacks on health facilities comprised the majority of attacks recorded (88.0%; n = 176). One hundred and twelve healthcare staff and 185 patients were killed in these incidents. Thirty-five percent of the facilities were attacked more than once over the data collection period; hospitals were significantly more likely to be attacked more than once compared to clinics and other types of healthcare facilities. Aerial bombs were used in the overwhelming majority of cases (91.5%). We also compared the SAMS data to a separate database developed by Physicians for Human Rights (PHR) based on media reports and matched the incidents to compare the results from the two methods (this analysis was limited to incidents at health facilities). Among 90 relevant incidents verified by PHR and 177 by SAMS, there were 60 that could be matched to each other, highlighting the differences in results from the two methods. This study is limited by the complexities of data collection in a conflict setting, only partial use of the standardized reporting tool, and the fact that limited accessibility of some health facilities and workers and may be biased towards the reporting of attacks on larger or more visible health facilities.ConclusionsThe use of field data collectors and use of consistent definitions can play an important role in the tracking incidents of attacks on health services. A mobile systematic data collection tool can complement other methods for tracking incidents of attacks on healthcare and ensure the collection of detailed information about each attack that may assist in better advocacy, programs, and accountability but can be practically challenging. Comparing attacks between SAMS and PHR suggests that there may have been significantly more attacks than previously captured by any one methodology. This scale of attacks suggests that targeting of healthcare in Syria is systematic and highlights the failure of condemnation by the international community and medical groups working in Syria of such attacks to stop them.

Partial Text: Acts of violence against healthcare facilities, transports, medical personnel, and patients are frequent but underreported in armed conflict [1–4]. Clinics, hospitals, private medical offices, and transports such as ambulances and supply trucks have been bombed, looted, blocked, or occupied worldwide [5–7]. Healthcare personnel and patients have been arrested, killed, maimed, tortured, interrogated, and blocked from receiving or providing care. Even bombings and shelling of hospitals sometimes go unreported, and other attacks, such as looting, obstructing passage at checkpoints, and threats to healthcare workers are usually not systematically tracked [8,9]. Attacks on health workers, facilities, and transports, and on the wounded and sick, violate international human rights law and international humanitarian law [10–12]. Recent resolutions from the United Nations (UN) Security Council and the UN General Assembly have reiterated the vital importance of protecting health during conflict and the need for data to track attacks [13,14]. It is well recognized, however, that no systematic data collection on attacks on healthcare services in conflicts has existed, though the World Health Organization (WHO) is beginning such an effort in 11 countries in 2017 based on a mandate from the World Health Assembly in 2012 [15,16]. Where data is collected on such attacks, definitions of what constitutes an attack vary considerably, and in many cases, only secondary data is collected [4].

We developed a standardized reporting questionnaire to document attacks on health in Syria based on a previously validated survey for tracking attacks on healthcare in Myanmar and grounded in the requirements of and definitions from international human rights and humanitarian law [36]. These laws demand that in times of armed conflict, combatants respect and protect the wounded and sick as well as health facilities, health workers, and transports; allow the flow of humanitarian aid; and refrain from punishing persons engaged in medical work in accordance with their ethical duties [11]. The questionnaire was adapted for use in Syria, using domains for attacks on facilities, health workers, transports, and patients, and underwent numerous iterations based on pilot data and feedback on accuracy, clarity, and conciseness from within the research team, as well as from data collectors and SAMS data managers based in Gaziantep, Turkey.

SAMS recorded 200 incidents of attacks on healthcare in 2016. Of those, 102 (51.0%) had completed reports on the Magpi application that allowed for more in-depth analysis. The attacks took place in the four northern governorates of Syria: Aleppo (n = 122), Idleb (n = 49), Homs (n = 17), and Hama (n = 12) from January 1, 2016, to December 31, 2016 (Table 1). Of these, we note that the majority involved aerial bombing of hospitals (91.5%; n = 183, including chemical bombs [n = 7]). Sixty-one percent (n = 122) of all attacks took place in Aleppo Governorate, of which 66.4%(n = 81) took place in Aleppo City.

This study confirms the large number of attacks on health, particularly on health facilities, consistent with both PHR’s and WHO/Health Cluster findings for the period covered. The 200 attacks SAMS found in a region with fewer than 200 hospitals is a tragic testament to the long-term destruction of the health system in Syria. Using a prospective surveillance methodology, we found that most of the incidents impacted multiple domains; killing or injuring patients and personnel as well as destroying transport capacities while targeting a hospital was frequent. We also found that the personnel and patient casualties consistently rose and fell with the frequency of hospital attacks over time. During the period covered, hospitals in the city of Aleppo suffered a significant portion of the attacks. Repeat attacks on hospitals were frequent and highlight the vulnerability of these facilities, especially larger centers, to bombardment, possibly because they are easily visualized and identified. Many other types of facilities, such as medical schools and blood banks, were also attacked or destroyed. While we identified primarily infrastructure attacks, many staff and patients were also killed or injured. On average, more than three people were killed in each incident involving at least one casualty.



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