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.
INTERNATIONAL HUMANITARIAN LAW AND ITS VIOLATIONS.
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 NEJM.org.
This article was published on November 18, 2015, at NEJM.org.
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.).