This guest blog was co-authored by Dr. Rohini Haar of UC Berkeley; Dr. Naser AlMhawish, of the Assistance Coordination Unit in Turkey; Dr. Ahmad Tarakji, of the Syrian American Medical Society and Hannah Tappis and Leonard S. Rubenstein, of John Hopkins Bloomberg School of Public Health (full details below).
Disclaimer: The views, thoughts and opinions expressed by the bloggers are theirs alone and do not necessarily reflect the opinions, viewpoints or policies of Elrha.
It was March 15, 2011, 10 years ago, when massive protests calling for government reform spread across major cities in Syria. By 19 March, dozens of protesters were killed in Dar’aa, a southwestern city near the Jordan border, after police opened fire on them. By summer the protest movement evolved into a civil war, now with myriad actors, which continues today.
Even in the early years of the conflict, health workers were, as they often are, at the frontlines. By the nature of their work, they bore witness to the violent crackdown and cared for those who were wounded and sick. As politically active citizens, some were involved in the fight for better government. It was not long until fulfilling their duty to care for everyone led to accusations that health workers, even those who were not involved in the protests, were supporting the revolution. Within the year, doctors, nurses and others were among the thousands of Syrians who were arrested, detained, tortured, and killed. Soon thereafter, clinics and hospitals were shut down, attacked or bombed. In early 2015, as the Russian military joined the conflict, the scale of airstrikes that have targeted health facilities dramatically increased.
Protecting health care during armed conflict — a matter of law
When Henri Dunant and his colleagues wrote the first Geneva Conventions in 1864, the first and most sacred principle was the protection of civilians who care for the wounded and sick. And yet, this principle, further enshrined through numerous iterations of the Geneva Conventions, human rights doctrines on the right to health, and criminal law across the globe, was so clearly and brazenly violated from the start of the Syrian conflict.
Until now, there has been no accountability for these attacks, now numbering in the thousands, including more than 600 documented attacks on hospitals and other health facilities.
For over a decade, members of our research partnership (at UC Berkeley, Johns Hopkins University, the Assistance Coordination Unit and the Syrian American Medical Society) have worked on better documenting attacks on health across the globe.
The hope has been that in understanding the scope of these attacks, we could call attention to the plight of health workers and patients. We could strengthen advocacy for better protections and accountability.
In reporting on each attack, we asked what, where, when, why, who and what. What happened? Where and when did the attack take place? Who was hurt? Why and how did this happen?
The documentation methodology developed has informed reporting efforts aimed at raising awareness of international humanitarian law violations.
Understanding the human impact of health care attacks
While it continues to be critical to document the occurrence and characteristics of these attacks, we cannot continue to do so without considering the impacts on those who witness or survive them, their families and their communities.
For them, it was not a single and distinct incident of attack to be recorded. Each attack meant hours, months and years of damage, recovery and reconstruction.
There is an urgent need to understand how an attack impacts the victims, the larger health community and the public. What are the personal and professional experiences of health workers? How do attacks affect the services they provide and the system they work within? How do they affect medical and nursing student training, job placements and careers? Health worker’s physical, mental health and ability to care for others?
A hospital bombing might affect health access by disrupting the availability of different services or drive patients away from seeking care. But what specific services are especially impacted in reality? And what happens to the people who get services from those health workers and those hospitals and clinics? Do they get sicker? Do more die? Do they have the alternative of going elsewhere?
Data, data, data
In trying to get to those impacts, more and different kinds of data need to be collected, organized and analyzed. Our research, generously funded by Elrha’s Research for Health in Humanitarian Crises (R2HC) programme, is doing just this. We have collected data from myriad organizations and programmes about the (1) incidents of attacks and (2) health outcomes.
The health attacks data includes both information about attacks on healthcare and various other types of civilian violence that could impact health. The health indicators include information about health service availability, the utilization of these services, and larger public health outcomes such as the incidence of infectious diseases. We have been collecting, collating and cleaning these data to make sure they are comparable, assessing the quality and reliability of those datasets, and developing methods to link them over time and geography. We hope to understand how individual as well as frequent attacks can lead directly and indirectly to health outcomes.
This information, we hope, will be methodologically relevant for a research audience studying the consequences of other violations or in other contexts. But quantitative data alone will not answer our questions.
The value of conversation
We have already spent more than 40 hours speaking with current and former health workers, including nurses, community health workers, administrators and medical students and hearing stories about their experiences, how attacks affected their work, their families, their own health, and communities.
We will triangulate the quantitative data with the qualitative interviews to present a nuanced narrative of what attacks on health did to the Syrian health system and people, how the community responded, and what still needs to be done.
We will share our findings in coming months, not only on the impacts we identify, but also on the methods we learned to study them, and present recommendations on how data in conflict settings could be improved and harnessed.
Hopefully, understanding these impacts and supporting our health worker colleagues and our conflict-affected communities will bring us step closer to the ideal of achieving accountability for the decade of violence and support for the reconstruction that needs to be done.
Especially as Syria faces a deepening economic crisis and the world faces many more months of this global pandemic, supporting vital frontline health workers, patients and the entire public health community is all the more important.
Find out more about the study ‘Evaluating the public health impacts of attacks on health in Syria’ here.
This blog was co-authored by:
Dr. Rohini Haar, Adjunct professor at the School of Public Health at the University of California, Berkeley;
Ahmad Tarakji, a Syrian American thoracic surgeon in Fresno, CA and past president of the Syrian American Medical Society;
Dr. Naser AlMhawish, a displaced general surgeon from Syria and health surveillance coordinator for the Assistance Coordination Unit based in Gaziantep, Turkey;
Hannah Tappis, Senior Measurement, Evaluation and Learning Advisor at Jhpiego and associate faculty at the Center for Humanitarian Health at John Hopkins Bloomberg School of Public Health;
Leonard S. Rubenstein, Professor and Director, Program on Human Rights and Health in Conflict, Center for Public Health and Human Rights, Johns Hopkins
Want to read more about the experience of healthcare workers in Syria during the civil war? Read this opinion piece on Devex by Dr. Ahmad Tarakji, Dr. Naser Almhawish, Dr. Rohini Haar: