Intended for healthcare professionals


“Thoroughly and deliberately targeted”: bombarded doctors in Syria hold on to hope for the future

BMJ 2019; 365 doi: (Published 17 June 2019) Cite this as: BMJ 2019;365:l4012
  1. Elisabeth Mahase
  1. The BMJ

Hospitals under attack are struggling to provide healthcare to a badly damaged Syria, reports Elisabeth Mahase

Feras Fares, a gynaecologist trained at Aleppo University, was going about his usual routine in a hospital in Idlib: he finished up surgery, spoke to the receptionist, checked the rota, and headed to get some rest in the call room. When he next opened his eyes all that he could see was white. An air strike had hit the hospital.

“I didn’t hear anything, I didn’t see anything, I didn’t hear any commotion—but everything was white, everything was dust. I tried to stand up, but I realised that my arm was injured,” Fares tells The BMJ, speaking from Gaziantep, near the Syrian border in Turkey.

He adds, “I saw that a part of our hospital had been totally destroyed: it was the ICU department. I had to check that everybody inside the hospital was leaving . . . even the patient that I had delivered [a baby to] one hour ago, she was trying to escape.”

Fares is now programme director at the Syrian Expatriate Medical Association (SEMA), which is based in Turkey. He left Syria in 2015, just a few months after surviving the attack, and he now regularly trains doctors still in Syria—normally remotely, but from time to time crossing the border back into his home country.

He says, “It was a really hard time, the hardest moment that I have seen. I’m always grateful, I tell myself that I have been born again: as we say in Arabic, Alhamdulillah [praise and thanks be to God].”

The new normal

It was not an isolated incident. Last year 257 attacks were recorded on hospitals, medical transportation, and healthcare workers in Syria, says the latest report from the Safeguarding Health in Conflict Coalition.1 Although these attacks are illegal under international law, they are becoming the new normal. At least 102 health facilities were damaged or destroyed, some being hit multiple times. In all, 88 health workers were killed, 75 injured, 13 kidnapped, and 28 arrested.

“The humanitarian and human rights context in Syria remains one of the worst globally,” says the report by a group of international non-governmental organisations including Doctors of the World, Physicians for Human Rights, the Johns Hopkins Center for Humanitarian Health, Save the Children, and World Vision.1

It continues, “As the crisis in Syria enters its ninth year, parties to the conflict have continued to disregard civilian life by perpetrating human rights abuses and violating international humanitarian law.”

Since the conflict began in 2011, nearly half of Syria’s pre-war population has been displaced, says the United Nations: 6.2 million internally and 5.6 million in other countries, including an estimated 4500 people displaced each day in 2018.23

Recent figures show that more than 13.2 million people in Syria—nearly three quarters of the estimated 18 million total population—are now in need of health assistance, and 83% of Syrians are living below the poverty line.2

But, despite the dire need of the people, the attacks on healthcare continue.

In a statement released this month the UN said that intensified hostilities throughout northern Hama and southern Idlib in late April and early May this year had led more than 150 000 people to flee the area in search of safety.

The increase in air strikes and shelling had left medical facilities “deeply affected”: within one week from 29 April to 5 May, 12 health facilities serving 112 000 people, including six hospitals, were put out of action.4

Unimaginable conditions

Len Rubenstein, chair of the Safeguarding Health in Conflict Coalition, says, “There really is no historic precedent we’re aware of where hospitals have been so thoroughly and apparently deliberately targeted as in Syria, and that has resulted in incredible death, incredible suffering, and of course denial of healthcare to people, including people who are wounded by these very kinds of bombings and missile attacks on hospitals.”

Working in “horrendous” conditions is taking a “terrible toll” on the doctors, he explains. Many are “traumatised” not only by the experiences they have lived through but because they cannot provide the kind of care they were trained to give.

“They suffer moral distress, as well as their own trauma over the course of the war,” says Rubenstein. “There have been a lot of efforts to put hospitals underground, put them in caves, to protect them from missile and aerial attacks—but that only goes so far, and the difficulties of working in those conditions are really quite unimaginable.”

Declan Barry, a paediatrician who worked for Médecins Sans Frontières (MSF) in Syria in 2013, recounts his time working in a converted chicken factory. Speaking to The BMJ, he says that there were moments he cannot forget.

“It was during a mass casualty event, and there were many people from a local village coming in,” he recalls. “I remember the team being very tired: there were a lot of tears. Our translator’s uncle came in and he was palliative . . . we were not going to be able to save his life.

“I can still picture [the translator’s] face when I was explaining to him what was going on. He had to explain to his family what I was saying. And he was also really worried about the rest of his family because he didn’t know where they were. I can picture the fear in his face, and then he was given the duty of being part of a medical team, and he was absolutely excellent.”

Although the attacks on healthcare in Syria seem to be unrelenting, the conflict itself is “beginning to wind down,” says the coalition, and the conversation is shifting towards “return and reconstruction.” As the Syrian government regains control of much of the country and involved parties consider the future, the lasting impact of the war will be seen most acutely in the health of its people.

Barry says, “You cannot have a population of that size not being able to access good quality, reliable healthcare for almost a decade and not expect massive consequences.

“There are all the consequences of the war itself—both the physical and rehabilitation needs of the people who were physically injured—but also the psychological impact of what it has been to live in a war for 10 years. So, the needs are going to be very significant in all areas of medicine and healthcare.”

A tool of deterrence

The displaced Syrians must not be forgotten, warns Barry. He has just returned to Ireland from Greece, where he coordinated an MSF team assisting refugees, many of whom had fled from Syria. He says that the refugees’ health needs are not being met by the international community.

“We are failing,” he says. “Holding people in containment there, pushing them into increased levels of ill health and suffering, is being used as a tool of deterrence against more people coming. That is absolutely disgraceful.”

He warns that the mental suffering created by the policies and living conditions he encountered on the Greek island of Lesbos was the worst he has seen in his MSF career, which has also taken him to Afghanistan and Libya.

“People’s health and healthcare cannot be used as a tool of deterrence for asylum seekers coming to Europe,” says Barry. “That is not an ethically acceptable way of deterring people. It’s really shocking, what is happening out there, and the level of denial that Europe tends to allow itself in its role in creating this suffering.”

Calls for solidarity

Many displaced Syrians still hold on to the hope that they will be able to return to their home country and show their children a land at peace.

Fares says, “I have two children, both born after the start of the war—one in 2013, one in 2018—and they know only that Syria is at war. We always have hope because we saw life in Syria before the crisis.”

For the moment, however, doctors and healthcare staff are risking their lives and battling on the front line to provide care to increasingly vulnerable people in an exceptionally hostile environment.

“I think that the most important thing is solidarity,” says Rubenstein. “These are your colleagues. And unfortunately, only a very small group of people in the medical community are raising their voices, to bring attention to what is happening to their governments and simply to show doctors and nurses in Syria that their colleagues abroad really care about them.

“In my conversations with doctors in Syria it really mattered to them that they knew they had international support. So, the more doctors in the UK and elsewhere who speak up and communicate their concern and apply whatever pressure is possible, the better.”

Rubenstein’s calls for solidarity come as two Nobel prize winning doctors have published an open letter condemning the Syrian and Russian governments for their attacks on healthcare and demanding immediate protection of Syria’s healthcare workers.5


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