Saturday, November 21, 2015

Attacks on Health Care in Syria — Normalizing Violations of Medical Neutrality? via #NEJM

Attacks on Health Care in Syria — Normalizing Violations of Medical Neutrality?

Michele Heisler, M.D., M.P.A., Elise Baker, B.A., and Donna McKay, M.S.
November 18, 2015DOI: 10.1056/NEJMp1513512
In July 2015, a 26-year-old pediatrician described to our team of Physicians for Human Rights (PHR) investigators his experiences in Aleppo, Syria's most populous city. When he was a medical student in 2012, government forces detained and severely beat him. He now works as an emergency medicine physician and surgery resident in a hospital that has twice been bombed by the Syrian government. He lives in fear of being killed by bombs on his way to work or while there. His family wants him to leave Syria as they did, but he explained, “It's our country, and if we leave, it will fall apart. At times, I think maybe I will leave and specialize and come back with better skills, but then I see how much the people need me. Maybe that's the biggest thing that's keeping me inside.”
Media coverage of Syria has focused on the exodus of refugees fleeing the sectarian warfare and the atrocities committed by the Islamic State.1 Less attention is paid to the Syrian government's destruction of hundreds of hospitals and clinics in opposition-controlled areas and deaths of doctors, nurses, and other medical personnel. Since the conflict began in 2011, PHR has documented the killings of 679 medical personnel, 95% of them perpetrated by government forces. Some personnel were killed in bombings of their hospitals or clinics; some were shot dead; at least 157 were executed or tortured to death.2
In July, a PHR team investigated the state of the health care system in eastern Aleppo.3 Though Aleppo does not reflect the worst of the destruction in Syria today, conditions there illustrate the consequences of these repeated attacks: the city's medical facilities have been attacked nearly 50 times since opposition groups gained control of eastern Aleppo in 2012. The government has rained rockets, missiles, and since 2013, “barrel bombs” (100-to- 1000-kg barrels filled with explosives, shrapnel, nails, and oil that are dropped from helicopters and break into thousands of fragments on impact) on homes and civilian infrastructure, including hospitals. The number of barrel-bomb attacks reached an all-time high between April and July 2015. These bombs, which obliterate everything they hit and inflict head-to-toe injuries on anyone in their large blast radius, have had a devastating impact on life in eastern Aleppo. Only a quarter of the city's 1.2 million residents remain, more than two thirds of the hospitals have stopped functioning, and roughly 95% of doctors have been killed or have fled.3
Aleppo also provides countless examples of courage and resilience among health workers, which are an important part of the narrative of the Syrian crisis. Despite 3 years of death and destruction, Aleppo's remaining residents have shown what a dedicated, resilient community can achieve. Health professionals have described how they've rebuilt a health care system that rivals any created in a war zone. The city's 10 functioning hospitals (down from 33 in 2010) vary in size and capacity, but the fact that the largest hospital has only 13 physicians indicates how understaffed the facilities are. The available equipment also varies widely, and a lack of functioning CT and MRI scanners makes it difficult or impossible to treat traumatic brain injuries. Yet the lead surgeon in an Aleppo trauma unit noted, “Maybe we are only a few physicians in a simple hospital and with simple equipment, but we save a lot of lives.”
The killing of health workers during conflicts is not new. Governments and armed groups have increasingly attacked medical institutions and people who have taken an oath to provide care (see International Humanitarian Law and Its Violations). Whether such acts are part of broader attacks in civilian areas or represent deliberate efforts to punish health workers, civilians, and fighters for presumed political affiliations, to scare doctors away from treating “enemies” or exposing evidence of war crimes, or to destroy vital infrastructure, they violate international humanitarian law.
Nowhere have such violations been as egregious as those committed by government forces in Syria — violations that are especially troubling given that Syria's President Bashar al-Assad is a physician. Disruption of health services has become a brutal weapon of war. Although almost all parties to the Syrian conflict are violating human rights and humanitarian law, the scope and scale of the government's assault on medical personnel and facilities are among the worst since the adoption of the modern Geneva Conventions.
When health care systems come under assault, the losses are far greater than the toll of health workers killed and hospital bricks and mortar demolished. Safe spaces for injured civilians to seek medical care are destroyed, and whole populations may be denied access to treatment. When these attacks are as widespread as they are in Syria, the consequences reverberate across the country and region.
All the doctors we interviewed who remain working in Aleppo explained that if they leave, people will die for lack of medical care. As they risked their lives to treat civilians, including colleagues, whose bodies were shattered by barrel-bomb attacks, these physicians expressed dismay at the international community's failure to enforce the Geneva Conventions. They emphasized that the main obstacle for medical personnel was lack of safety, and the main need was for protection. As one explained, “You must be safe to save others . . . If you kill the physician or destroy the hospital, the medicine doesn't benefit any people. The main problem is the inability to protect the staff.” In particular, all the physicians we interviewed emphasized the priority of stopping the barrel bombs. One told us, “If the barrels stop, doctors will come back. We just need to stop the barrels; it's the first and the last thing we need.”
These violations of international humanitarian law have been well documented in real time, yet the international response has been minimal. The United Nations (UN) Security Council — the international body mandated to protect civilians in conflict, enforce international humanitarian law, and refer cases to the International Criminal Court for investigation of possible war crimes — remains paralyzed by politics. It passed a single resolution in February 2014 demanding that all parties to the conflict end attacks on civilians and respect the principle of medical neutrality. Since then, it has watched attacks on civilians and medical facilities increase in Syria without taking further actions. We believe that governments and nongovernmental organizations should call out the Security Council for failing to maintain international peace and security and ensure accountability for perpetrators, and in the event of continued failure these organizations should demand a restructuring of the Council. In addition, individual governments can step up diplomatic pressure and consider imposing sanctions against violators.
If the international community does not mobilize to stop the attacks on Syria's medical professionals and infrastructure, civilians will continue to suffer and die. In addition, lasting peace cannot be achieved unless the perpetrators of these crimes are held accountable. The effects of these violations and absence of accountability will go far beyond Syria. The longer the international community fails to enforce humanitarian law, the greater the chance that these violations will become the “new normal” in armed conflicts around the world, eroding the long-standing norm of medical neutrality. Left unchecked, attacks on medical care will become a standard weapon of war.
Although the international community's failure to act has cost hundreds of thousands of lives, it's not too late to change course. As the global body with the most power to stop these attacks in the short term, the UN Security Council should enforce its resolution to protect civilians and civilian infrastructure. Effective protection of medical neutrality would save lives and is a necessary prerequisite to any effective peace process. Rebuilding Syria's health care system will take decades, but the physicians we interviewed stand ready to do it. They first need support from the international community to ensure that the right to provide and receive medical care is protected.


The first Geneva Convention in 1864 enshrined the principles that protect medical spaces and health workers from interference and attack during armed conflicts. Updated and enhanced, the four Geneva Conventions of 1949 have been ratified by 196 countries, including Syria, which also ratified Additional Protocol I. These require that all parties to a conflict protect and ensure the functionality of medical facilities, transport, and personnel; all parties to a conflict protect and ensure unbiased treatment for both wounded civilians and combatants; and medical personnel provide impartial care to both civilians and wounded combatants, in keeping with medical ethics. An attack targeting a medical facility would be legal only if all three of the following requirements are fulfilled:
1. The facility is being used to commit acts harmful to the enemy that are not related to the facility's humanitarian function.
2. The party attacking the facility planned a proportional attack, judging that all anticipated military advantage gained from the attack would be greater than the potential collateral damage to protected civilians and civilian objects.
3. The party attacking gave advance warning, allowing time for people to cease all acts harmful to the enemy, explain themselves if a mistake was made, or evacuate the wounded and sick.
An attack on a medical worker would be legal only if the worker were directly participating in hostilities.4
Since the 1990s, lack of respect for these protections has been well documented. In Afghanistan, the Democratic Republic of Congo, Rwanda, Somalia, and the former Yugoslavia, combatants have targeted civilians and in some cases entered hospitals to remove and execute patients. In Bahrain and Libya, physicians tending wounded civilian demonstrators have been arrested and tortured. In the past decade, serious attacks on medical neutrality have also occurred in combat areas in Afghanistan, Iraq, Ukraine, and Yemen. The October 3, 2015, U.S. Air Force bombing of a Médecins sans Frontières hospital in Kunduz, Afghanistan, leading to at least 30 deaths of patients and medical personnel, is but one recent example of such attacks.
Disclosure forms provided by the authors are available with the full text of this article at
This article was published on November 18, 2015, at


From the Department of Internal Medicine, University of Michigan Medical School, and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (M.H.); and Physicians for Human Rights, New York (M.H., E.B., D.M.).

Friday, October 30, 2015

اسمي د/ ماجد..و انا طبيب سوري آخر ممن قتلوا أثناء أداء مهام عملهم

'My Name is Dr. Majed and I Am Another Syrian Doctor Killed During Duty'

'My Name is Dr. Majed and I Am Another Syrian Doctor Killed During Duty'

Posted: Updated: 
My name is Dr. Mohamad Majed Bari
My friends and patients called me Dr. Majed
I was a doctor not a terrorist
I saved lives while terrorists take lives away
I was killed when my car was targeted with a heat-seeking missile by a Syrian fighter jet
I bled to death
No emergency crew was able to reach me on time
The International Committee of the Red Cross and the UN are not allowed by the government in my hometown behind rebel lines
They stay away safe in the capital
They have to abide by the system's bureaucracy
The system does not protect me or my patients
There were no news reports of my death.
The reporters are all in Kobani
I was riding in an ambulance in Aleppo trying to save another life
Another three civilians were killed with me
They joined another 200,000 Syrians killed in my homeland
I was working with a humanitarian organization called Saving Lives!
I was killed while saving lives
"How Ironic," you may say but Syria is the land of ironies these days
Many of my colleagues left Aleppo because they were afraid about losing their lives.
Some of my friends were detained, tortured and killed just because they insisted on working as doctors
They swore to save lives
They were treated like criminals or even worse
We were told that the whole world respects our neutrality
We were told the Geneva convention guarantees our impartiality
We were told that being a doctor is like being an angel
You give from yourself to heal your patient
The regime did not respect any of that
The world did not rush to help us
We suffered in silence like my homeland
Some of my friends died drowning trying to flee on boat to a new land of hope
They were swallowed by unsympathetic waves of the Mediterranean sea
I stayed because it is my duty to save lives
I stayed because if I left who else will stay?
Who else will offer a hand of healing to a sobbing child pulled out of the rubble of her home destroyed by a barrel bomb?
Who else will vaccinate the children in my neighborhood so they don't have polio or measles?
Everyone left us to face our fate
We have no one but God
He is watching those who deserted us 
I guess He is testing them and testing us
I don't expect anyone to react to my death
I don't expect anyone to stop the killing in my hometown
I lost my faith in humanity
But I lived a fulfilling life and I don't regret a minute I had serving my patients
I will join another 560 Syrian doctors who were killed by the war criminals
My patients will miss me and so will my wife and two young children
I will miss what is left of my city and homeland
I will miss the courage of my colleagues who are still working
Saving lives as usual
I will miss their faith, their warmth and their humor
And I will miss the sounds of the barrel bombs
It is too silent here
It is too cold
It is too dark
It is too "un-Syrian"
Pray for me and for my homeland
Dr Majed Bari with his Newborn Child
My name: Dr. Majed Bari
Medical School: Aleppo University Medical School
Graduation: With honors
Date of my death:10/15/2014
Place of Death: Aleppo City, Castello road
Cause of Death: Heat-Seeking Missile
Reason of Death: Saving Lives
Zaher Sahloul is a Syrian-American critical care specialist who is the president of The Syrian American Medical Society, SAMS.

Russian Warplanes Strike Medical Facilities in #Syria

Russian Warplanes Strike Medical Facilities in Syria

Physicians for Human Rights Says Russia’s Air Strikes Have Hit Three Facilities in Two Days 

New York, NY - 10/07/2015
Physicians for Human Rights (PHR) has confirmed that Russian air strikes damaged three medical facilities in Syria in two days, exacerbating an already dire situation for civilians living in areas where the health system has been systematically attacked by the Syrian government.
“Bashar al-Assad’s forces have been relentlessly attacking Syria’s health care system for the past four years and the Russian government is now following in their footsteps,” said Widney Brown, PHR’s director of programs. “These attacks are inexcusable. Claiming that the fight is against terrorists does not give any government the right to tear up the laws of war, which specifically protect health workers and facilities. With these actions, Russia is damaging hospitals, putting patients and medical staff at risk, and depriving civilians of life-saving access to health care.”
The Russian Ministry of Defense maintains that its air strikes are conducted with precise, guided munitions, which suggests that these three attacks were targeted at the medical facilities. Russia further maintains that it is targeting the self-declared Islamic State (IS), also called ISIS or ISIL. However, the three medical facilities are all located more than 30 miles from the nearest IS-controlled territory. Regardless of location or who the medical staff treat, targeting a medical facility is a war crime.
PHR has documented 307 attacks on medical facilities and the deaths of 670 medical personnel in Syria since the start of the conflict in March 2011 through the end of August 2015. Syrian government forces have been responsible for more than 90 percent of these attacks, each of which constitutes a war crime. PHR recently also called for a full and independent investigation of an attack on a Doctors without Borders clinic in Kunduz, Afghanistan.
PHR has confirmed the following incidents by Russian air strikes in Syria over the last week:
  • On October 2, a Russian warplane launched an air strike on the field hospital in Latamneh, in northern Hama governorate. The facility was damaged, and multiple medical staff members were injured. The Syrian government has previously attacked this facility with barrel bombs in June.
  • Also on October 2, a Russian warplane launched an air strike on an ambulance depot and emergency response center in Benin, in rural Idlib. Part of the facility was destroyed, at least two ambulances were seriously damaged, and the depot was temporarily put out of service. Reports indicate that two planes flew over the facility and launched strikes that fell around the depot before circling back and launching another strike, which landed inside the depot. The Syrian government previously attacked this facility with barrel bombs in April.
  • On October 3, a Russian warplane launched an air strike that damaged al-Burnas Hospital in northern Latakia, near the Turkish border. The hospital suffered minor material damage, but had to be evacuated. The hospital is the only one in the region with an obstetrics/gynecology unit and is now only able to provide some emergency services.
Russia has not acknowledged that their air strikes hit or damaged the medical facilities, but confirmed it was conducting air strikes in each of these locations when the attacks occurred.

Monday, March 2, 2015

Mysteries Surround Kids' Top Acquired Heart Disease "Kawasaki "

2015-02-11-0130FeatureAmericanHeartMonthV2_Blog.jpgThe patient came in complaining of a high fever that had persisted for about a week.
He was a little boy, just a few months past his fourth birthday.
The whites of his eyes were red. The inside of his mouth was redder than usual. So were his lips; they also were cracked, with a little bleeding. The side of his neck was painfully swollen.
It was 1961, and Dr. Tomisaku Kawasaki of the Red Cross Hospital in Tokyo had never seen anything like it in his 10 years as a pediatrician. He couldn't find anything written about it.
A year later, he saw it again.
Within a few years, he'd seen it in about 50 children. He referred to it as GOK -- "God Only Knows."
The root of the problem turned out to be inflamed blood vessels. In extreme cases, it affected various organ systems, including the heart. It could even be fatal.
Once Dr. Kawasaki began documenting cases, he found more and more. He published a paper on it in 1967, in his native language, Japanese. An English version arrived in 1974, and American doctors soon began to recognize cases, too. "GOK" soon got a new name based on its documenter; thus the title, Kawasaki disease.
Today, we have a much greater understanding of this condition.
We know it manifests in a fever that lingers at least five days, and includes at least two of these symptoms: body rash, reddened and/or swollen hands and feet, and the symptoms evident in Dr. Kawasaki's initial patient -- bloodshot eyes, reddened tongue, reddened and cracking lips, and a swollen lymph node in the neck. There is no test for it, so doctors diagnose it after eliminating other possibilities and by observing those symptoms.
We know that heart problems develop in as many as 1 of 5 patients. Those problems can include aneurysms in the coronary arteries, or a weakened heart muscle. Those less than a year old are the most at risk for serious heart problems.
We know that it's rarely seen in kids over 8; the vast majority of cases (80 percent) are 5 years old or younger. We know it strikes more boys than girls (by about 2 to 1), and it strikes mostly in winter and early spring. We know it happens in Japan more than any other country, followed by Taiwan and Korea; in the United States, we know that most patients are children of Asian-American descent.
Best of all, we know how to treat it. Aspirin can reduce the fever, rash, joint swelling and pain, and also can help prevent the formation of blood clots. Severe heart problems can usually be avoided if a type of IV treatment is given soon enough.
But there's a lot we don't know, including two of the most important things:
  • What causes it?
  • How can we prevent it?
Lacking those answers, Kawasaki disease has become the leading cause of acquired heart disease among children in developed countries. Phrased another way, it is the No. 1 heart problem among kids born with a healthy heart in the United States and other, similar countries.
Clearly, this is a growing problem, and a challenge for cardiovascular researchers.
Earlier this month -- which also happens to be American Heart Month -- about 400 medical professionals from around the world gathered in Honolulu for four days of meetings about this illness. It was called the International Kawasaki Disease Symposium, an event that began in 1984 and is now held every three years.
2015-02-11-Dr.Kawasaki.jpgDr. Kawasaki himself made the trip to Hawaii from Japan. He turned 90 the day after the conference, but in an interview with Dr. Elliott Antman, the president of the American Heart Association, Kawasaki recalled his initial case with the clarity of someone he'd met only days before.
"I was very much impressed by the signs I had seen on his face," Kawasaki said. As he detailed the symptoms, he gestured often -- pointing to his eyes, making circles around his mouth, extending his tongue and tilting his neck. He later touched his heart.
With the aid of a translator, the conversation ventured from 1961 to 2015, from the first patient he saw to our current understanding of Kawasaki disease.
So far, data suggests that that Kawasaki disease is not hereditary or contagious. In fact, it's rare for more than one child in a family to develop it.
Investigators also believe it's caused by an infection. The mystery is whether it is just one strain, or multiple strains coming together.
Another mystery is the long-term effect. While most patients who are treated see their heart problems clear up within six weeks, there's not enough research on their chances of developing heart problems as adults.
"What I really want is to protect children from getting Kawasaki disease -- prevention, prophylaxis," Kawasaki said. "But in order to find a way to do that, we have to first identify the cause of Kawasaki disease and that is very difficult. We are not able to do that yet. But I understand that many excellent scientists are working very hard to find the cause of Kawasaki disease. Therefore, I really look forward to the day we are able to prevent it, or treat it also."
All of us at the American Heart Association want that, too, and are proud to be working toward it by hosting events such as the International Kawasaki Disease Symposium and funding research. We've invested more than $3.7 billion on treating, beating and preventing cardiovascular diseases, including $100 million annually since 1996. Only the federal government spends more.
The effort is there. Soon, the answers will be, too.
Program for IKDS 2015 signed to Dr. Elliott Antman by Dr. Tomisaku Kawasaki
  CEO, American Heart Association

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