Surgical Strikes On Surgical Wards: The Systematic Destruction of the Syrian Health System
It was unclear whether the jets had Russian or Syrian pilots, but their target was entirely unambiguous. On June 8th of this year, Al-Bayan hospital in Northern Aleppo was struck in a series of air-strikes conducted by government and allied forces. Ten people were killed and nine newborns had to be removed from their incubators due to damage in the neonatal wing of the hospital. After this initial strike, emergency personnel arrived at the scene. At this point, the jets returned, circling back for a second strike on the first responders.
This kind of chilling scene has played out across Syria again and again. Before the uprising began in 2011, Syria had one of the strongest health systems in the Middle East. The country had an average life expectancy of 76 years, with a drug industry that could meet 90% of all needs with domestic production. After a grueling five years of civil war, the damage to health infrastructure has been profound. 60% of hospitals and 38% of primary care facilities have been destroyed or damaged. The drug industry meets only 20% of needs and that number is decreasing.
The war in Syria has vastly increased the health burden associated with traumatic injuries, non-communicable diseases (NCDs), infectious diseases, and mental illness. The aforementioned health risks are directly or indirectly caused by the horrors of war, but are further amplified by the health infrastructure that is in need of recovery itself. Over 50% of doctors have left the country, and in Aleppo – formerly known as the largest city in Syria – over 95% of the doctors are gone; only about thirty are left. Aleppo has borne the brunt of the regime’s strikes. On September 28, 2016, two of Aleppo’s hospitals, M2, and the much-larger M10, were incapacitated by government forces.
According to the NGO Physicians for Human Rights (PHR), from March 2011 to June 2016 there were 382 attacks on 269 different medical facilities, 90% of which were perpetrated directly by the regime or its allies. In this same period, 757 medical personnel were killed and thousands have been forced to flee the country.
In conflicts such as the Syrian Civil War, attacks on medical facilities are seen by the international community as particularly reprehensible. The Geneva Conventions of1949, along with subsequent treaties, not only serve as the basis of the modern rules of warfare, but also underscore the importance of Medical Neutrality. This principle essentially states that medical personnel and infrastructure must not be attacked, civilians must not be prevented from seeking and receiving care, and medical personnel must offer care regardless of their allegiance.
The principle of Medical Neutrality is so important because attacking medical personnel amplifies the misery in which people in war zones live. Yet despite the recent resolution, four out of five permanent members of the UNSC (all except China) are part of coalitions that perpetrate deliberate attacks on civilians. The US, UK, France, and of course, Russia have supported attacks in Saudi Arabia, Yemen, Sudan, and Syria.
In war, there are no legally permissible situations when a medical site may be attacked, except for under three very strict criteria. Firstly, medical personnel must be acting directly to help one side in a non-humanitarian way, such as storing weapons or hiding forces. Secondly, the collateral damage to civilians must be proportional to its military advantage. And thirdly, ample warning must be given before the attack with a reasonable time limit for personnel and civilians to get to safety. The Syrian regime’s attacks meet none of these conditions.
Hospital attacks during war have been documented since the 1990s and earlier, in Afghanistan, Rwanda, Somalia, the former Yugoslavia, and countless others. Yet Syria is different than all of these in both frequency and kind. According to Amnesty International, targeting hospitals is now a central component of the Russian/Syrian strategy. Medecins Sans Frontieres (MSF), a medical non-profit operating hospitals in the region, has stated that targeting medical personnel has become the “new normal”.
This is the chilling reality of the war in Syria: hospitals are not struck as collateral damage, but as the main target. The goal in some cases is to empty entire towns by destroying any access to care. Amnesty International has collected information on several attacks: In Anadan, a small town, the only working hospital was struck on February 2nd. As a result, all those who possessed the means to leave did so, with only those in dire need of care forced to stay behind. In February 2016, the regime targeted three medical facilities over the course of one week, leaving the town of Tel Rifaat without any working medical infrastructure. On December 25, 2016, the Baghdad Hospital in Hreitan was targeted, leaving it incapable of operating and eventually driving the town to desertion.
One of the more horrific aspects of these attacks is the ‘double tap’ strike. Similar to the attack on Al-Bayan hospital, jets first strike a hospital, then wait for first responders to arrive, and finally circle back to punish those who attempted to help the wounded.
In addition to what is already a dire situation, the result of the recent US election does not look any better for Syrian medical personnel. Throughout his campaign, Trump promised to do the two things that may cause even greater bloodshed: cooperating with Russia and ramping up bombing. Regarding the former, it’s likely that his foreign policy will focus increasingly on fighting ISIS while allowing Russia a freer hand to deal with the rebels. With respect to the latter, even if Trump claims that he would be targeting only ISIS, it’s painfully clear that bombing campaigns are impossible without considerable damage to civilians and infrastructure. Even if one makes the argument that Trump has been and will continue to moderate his positions, the President has the most leeway with foreign policy and war. Furthermore, there is a great deal of domestic support for ramping up bombing, so it is unlikely that he would go back on those promises any time soon.
As of now, neither ceasefire nor UNSC resolution has succeeded in bringing any relief to the Syrian people or to their health system. Out of desperation, MSF has stopped sharing the location of its hospitals, since it is more likely that they will be targeted than avoided by the regime. Yet despite the bloodshed thus far, the worst part of the conflict is that there is no end in sight.